Atoh1 null mice show directed afferent fiber growth to undifferentiated ear sensory epithelia followed by incomplete fiber retention.

Inner ear hair cells have been suggested as attractors for growing afferent fibers, possibly through the release of the neurotrophin brain-derived neurotrophic factor (BDNF). Atoh1 null mice never fully differentiate hair cells and supporting cells and, therefore, may show aberrations in the growth and/or retention of their innervation. We investigated the distribution of cells positive for Atoh1- or Bdnf-mediated beta-galactosidase expression in Atoh1 null and Atoh1 heterozygotic mice and correlated the distribution of these cells with their innervation. Embryonic day (E) 18.5 Atoh1 null and heterozygotic littermates show Atoh1- and BDNF-beta-galactosidase-positive cells in comparable distributions in the canal cristae and the cochlea apex. Atoh1-beta-galactosidase-positive but only occasional Bdnf-beta-galactosidase-positive cells are found in the utricle, saccule, and cochlea base of Atoh1 null mutant mice. Absence of Bdnf-beta-galactosidase expression in the utricle and saccule of Atoh1 null mice is first noted at E12.5, a time when Atoh1-beta-galactosidase expression is also first detected in these epithelia. These data suggest that expression of Bdnf is dependent on ATOH1 protein in some but does not require ATOH1 protein in other inner ear cells. Overall, the undifferentiated Atoh1- and Bdnf-beta-galactosidase-positive cells show a distribution reminiscent of that in the six sensory epithelia in control mice, suggesting that ear patterning processes can form discrete patches of Atoh1 and Bdnf expression in the absence of ATOH1 protein. The almost normal growth of afferent and efferent fibers in younger embryos suggests that neither fully differentiated hair cells nor BDNF are necessary for the initial targeted growth of fibers. E18.5 Atoh1 null mice have many afferent fibers to the apex of the cochlea, the anterior and the posterior crista, all areas with numerous Bdnf-beta-galactosidase-positive cells. Few fibers remain to the saccule, utricle, and the base of the cochlea, all areas with few or no Bdnf-beta-galactosidase-positive cells. Thus, retention of fibers is possible with BDNF, even in the absence of differentiated hair cells.

Partial behavioral compensation is revealed in balance tasked mutant mice lacking otoconia.

We describe for the first time behavioral tests which show that mammals with congenital absence of otoconia can learn a motor task that normally relies on gravity perception. The mouse mutation tilted (tlt) occurs in the otopetrin 1 gene (Otop1(tlt/tlt)) and eliminates an essential component necessary for the formation of otoconia. Our data show that even in the absence of otoconia, tlt mutant mice, like normal mice, learn to cross a bar suspended between two boxes and, with practice, improve their speed of crossing. Despite this learned compensatory skills, tlt mutant mice show balance impairments, such as falling from the bar, not observed in wild type (WT) or heterozygous (het) Otop1(+/)(tlt) littermates. The tlt mutant mice also use their tail as additional support, a behavior that is rarely exhibited in the control littermates. Interestingly, the Otop1(+/)(tlt) heterozygous littermates show in many aspects an intermediate phenotype between wild type and tlt mutant mice, suggestive of a gene dosage effect. Overall, these data support the notion that mammals can use other otic and extraotic receptors such as semicircular canals and limb proprioreceptors, respectively, to compensate for the absence of otoconia-mediated gravity perception in a balance task.

A time for change: for the road to excellence for health care professionals.

This article addresses the changes affecting all of health care. Change should first be driven by data--data are what will be used to make clinical and business decisions that will result in better quality care. Employees should be held accountable for results, and celebrations should be provided for these changes. Customers have needs and goals that must be met, and if we do not meet the needs, our competition will. Management must understand the principles of quality and must encourage growth in employees. To bring change to your health care organization, you must embrace and encourage change.

The Noble-Mengert-Fish operation-revisited: a composite approach for persistent rectovaginal fistulas and complex perineal defects.

OBJECTIVE: Our aims were to evaluate the full-thickness anterior rectal wall advancement flap in the treatment of primary and recurrent or persistent rectovaginal fistulas, evaluate the surgical exposure for composite repair of site-specific perineal defects, and categorize clinical manifestations of site-specific perineal defects caused by obstetric injury. STUDY DESIGN: This is a prospective study of all patients with fecal incontinence from rectovaginal septal defects and complex perineal obstetric injuries treated by the Noble-Mengert-Fish operation. RESULTS: Thirty-four patients were classified into groups on the basis of site-specific perineal defects. Anatomic success was 94.2%. Functional success was excellent in 76.5%, good in 14.7%, fair in 5.9%, and poor in 2.9%. CONCLUSION: The Noble-Mengert-Fish operation is effective for primary and recurrent or persistent rectovaginal fistulas. The circumanal surgical exposure permits concomitant repair of all perineal defects.

Peptides bind to eosinophils in the rat stomach.

BACKGROUND: An immunological role for eosinophils has been well established. However, roles for eosinophils in the physiological functions of the organs they populate are little explored. METHODS: Fixed, frozen, then vibratomed sections of rat stomach were exposed to biotinylated 1-17 gastrin (bG17), biotinylated gastrin-releasing peptide (bGRP), biotinylated neuromedin C (bNC), biotinylated vasoactive intestinal peptide (bVIP), and biotinylated substance P (bSP). Binding sites were identified using an avidin-biotin-glucose oxidase complex and tetranitroblue tetrazolium staining. RESULTS: bG17, bGRP, and bNC all bound to cells in the lamina propria and to a lesser extent in the submucosa. Neither bVIP nor bSP bound to cells in these sections. Stained cells were identified as eosinophils in the light microscope on the basis of their distribution and staining properties using the Luna stain for eosinophils and in the transmission electron microscope (TEM) on the basis of a light/TEM matching process. Plastic sections viewed in the light microscope showed that stain was localized to a granular component in the cytoplasm of the eosinophils. No other cell type, specifically neither mast cells nor plasma cells, stained. G17 competed for the bG17 binding site better than did NC. A competition study in which polyglutamic acid failed to compete with bG17 for the binding site, and the observation that bG17, bGRP, and bNC did not bind to other positively charged sites (e.g., collagen, red blood corpuscles), demonstrated that binding was not due to nonspecific electrostatic interactions alone. Binding of bG17 to a CCK(B)/gastrin-type receptor was ruled out when specific receptor antagonists failed to block binding. CONCLUSIONS: The particulate nature of the binding site suggests a secretory substance. If so, eosinophils might use that substance to destroy, neutralize, or control the activity of peptide hormones bound to it in the extracellular space.

The Vecchietti operation for constructing a neovagina: indications, instrumentation, and techniques.

The Vecchietti method is a surgical technique for the treatment of vaginal agenesis that constructs a dilation-type neovagina in 7-9 days. We have performed the Vecchietti operation on six patients. The method was applied to create a primary neovagina, to lengthen a surgically foreshortened vagina, and to reconstruct an obliterated neovagina with or without the presence of a uterus. Two patients underwent the conventional transabdominal approach, and four, laparoscopy. Follow-up was 7-39 months, and neovaginal depth was 8.0-10.6 cm. The anatomic and functional results in all patients were excellent.

The development of vestibulocochlear efferents and cochlear afferents in mice.

We have reinvestigated the embryonic development of the vestibulocochlear system in mice using anterograde and retrograde tracing techniques. Our studies reveal that rhombomeres 4 and 5 include five motor neuron populations. One of these, the abducens nucleus, will not be dealt with here. Rhombomere 4 gives rise to three of the remaining populations: the facial branchial motor neurons; the vestibular efferents; and the cochlear efferents. The migration of the facial branchial motor neurons away from the otic efferents is completed by 13.5 days post coitum (dpc). Subsequently the otic efferents separate into the vestibular and cochlear efferents, and complete their migration by 14.5 dpc. In addition to their common origin, all three populations have perikarya that migrate via translocation through secondary processes, form a continuous column upon completion of their migrations, and form axonal tracts that run in the internal facial genu. Some otic efferent axons travel with the facial branchial motor nerve from the internal facial genu and exit the brain with that nerve. These data suggest that facial branchial motor neurons and otic efferents are derived from a common precursor population and use similar cues for pathway recognition within the brain. In contrast, rhombomere 5 gives rise to the fourth population to be considered here, the superior salivatory nucleus, a visceral motor neuron group. Other differences between this group and those derived from rhombomere 4 include perikaryal migration as a result of translocation first through primary processes and only then through secondary processes, a final location lateral to the branchial motor/otic efferent column, and axonal tracts that are completely segregated from those of the facial branchial and otic efferents throughout their course inside the brain. Analysis of the peripheral distribution of the cochlear efferents and afferents show that efferents reach the spiral ganglion at 12.5 dpc when postmitotic ganglion cells are migrating away from the cochlear anlage. The efferents begin to form the intraganglionic spiral bundle by 14.5 dpc and the inner spiral bundle by 16.5 dpc in the basal turn. They have extensive collaterals among supporting cells of the greater epithelial ridge from 16.5 dpc onwards. Afferents and efferents in the basal turn of the cochlea extend through all three rows of outer hair cells by 18.5 dpc. Selective labeling of afferent fibers at 20.5 dpc (postnatal day 1) shows that although some afferents are still in early developmental stages, some type II spiral ganglion cells already extend for long distances along the outer hair cells, and some type I spiral ganglion cells end on a single inner hair cell. These data support previous evidence that in mice the early outgrowth of afferent and efferent fibers is essentially achieved by birth.

Ligature carrier specifically designed for transvaginal sacrospinous colpopexy.

A new ligature carrier designed for sacrospinous colpopexy permits bite acquisition to be performed under direct surgical visualization within the confines of the pararectal space. In addition, it permits ample penetration of the sacrospinous ligament through the coccygeus muscle, without restriction of suture type, size, or number of sutures per bite. As part of site-specific reconstructive pelvic surgery, we have performed sacrospinous colpopexy using this ligature carrier in 71 patients with genital prolapse. We have encountered no operative complications from the use of this ligature carrier.

The incidence of low-pressure urethra as a function of prolapse-reducing technique in patients with massive pelvic organ prolapse (maximum descent at all vaginal sites).

OBJECTIVE: Our aims were to compare several prolapse-reducing techniques during urodynamic evaluation and prospectively evaluate their usefulness in identifying the incidence of low urethral closure pressure in continent patients with massive prolapse. STUDY DESIGN: This preoperative, prospective, repeated-measures urodynamic study evaluated the maximum urethral closure pressure with the use of four different techniques in 30 consecutive continent patients with grade 4 prolapse at all vaginal sites. Twenty patients with grade 0 prolapse served as the control group. All patients from the prolapse group underwent surgical treatment and were followed up clinically for a minimum of 1 year. RESULTS: Use of the Scopette (Birchwood Laboratories, Eden Prairie, Minn.) reduction technique to reduce the prolapse in a linear orientation during multichannel urodynamics revealed a 56% incidence of low-pressure urethra and an overall genuine stress urinary incontinence of 83% in patients with massive pelvic organ prolapse but without clinical urinary incontinence. CONCLUSIONS: There may be an increased indication for sling urethropexy in patients with massive prolapse.

Development of midbrain and anterior hindbrain ocular motoneurons in normal and Wnt-1 knockout mice.

The effect of homozygotic Wnt-1-/- mutations on the development of ocular motoneurons was examined with the lipophilic dye DiI and compared to control and phenotypic wild-type mouse embryos. A piece of DiI-soaked filter paper was inserted into the orbit, the midbrain, or rhombomere 5 of the hindbrain in six paraformaldehyde-fixed litters (10.5, 12.5, and 14.5 days postcoitum) containing Wnt-1, Wnt+/-, and Wnt-1+/+ individuals and three control litters. We labeled all ocular motoneurons retrogradely and all relevant nerves anterogradely in all control and phenotypic wild-type animals. In all phenotypically identified Wnt-1-/- mutants we could always label the abducens nerve and motoneurons and the optic fibers to the thalamus, but we were unable to label oculomotor or trochlear nerves or motoneurons. In addition to Wnt-1 knockout mutants, we also labeled mice from the WZT9B transgenic line carrying a lacZ reporter gene driven by the Wnt-1 gene enhancer. In these embryos we tested for co-localization of Wnt-1 expression in biotinylated dextran amine-labeled ocular motoneurons using a newly developed technique. In younger embryos we obtained evidence for co-localization of the beta-galactosidase reaction product derived from lacZ gene activity in some retrogradely filled oculomotor motoneurons and adjacent to other oculomotor and the trochlear motoneurons. Acetylcholine esterase, a marker of early differentiating cholinergic neurons, showed a similar topology with respect to the lacZ reaction product. Thus, at least some future oculomotor motoneurons express Wnt-1, whereas others and the trochlear motoneurons caudal to the ventral midbrain expression of Wnt-1 may be exposed to the short range diffusion of the Wnt-1 gene product. Thus, the Wnt-1-/- mutation precludes formation or survival of midbrain and anterior hindbrain neurons, including oculomotor and trochlear motoneurons.

Carboxyfluorescein and biotin neuromedin C analogues: synthesis and applications.

Two neuromedin C (NC) analogues were constructed by Fmoc synthesis and in situ coupling of 4(5)-carboxyfluorescein or biotin to the N-terminus. Both displayed full agonism in an amylase release assay and cross-reacted fully with a NC-specific antiserum. Biotin NC functioned in a streptavidin-capture ELISA. Carboxyfluorescein NC was used to probe receptor localization in rat stomach. Specific NC binding sites, which did not interact with substance P, angiotensin I, or neurokinin A, were labeled in the antrum. Identity of NC binding sites was confirmed by microautoradiography. The specifically labeled cells were all found in the lamina propria and at least some of cells were identified as eosinophils.

Fiber pathways and positional changes in efferent perikarya of 2.5- to 7-day chick embryos as revealed with DiI and dextran amines.

The differentiation of facial motoneurons and inner ear (octaval) efferents was examined in chicken embryos by applying DiI or dextran amines to the cut VII/VIII nerve (peripheral label) or to the basal/floor plate of rhombomeres 4/5 (central label). Central labeling found axons of these efferent neurons to leave the brain as early as 2.5 days of incubation. Peripheral labeling identified cell bodies ipsilaterally in rhombomeres 4 and 5 at 2.5 days. Central labeling at 3.5 days showed these fibers to have fully segregated into separate pathways to the facial nerve and the inner ear and that the octaval efferent axons had reached the otocyst wall. By 3.5 days many peripherally labeled octaval efferent somata were found in the floor plate and by 5 days they were found bilaterally. At 6 days, selective peripheral labeling of either the VIIth or VIIIth nerve showed that the contralateral population consisted of octaval efferents and central label applied to the floor plate of rhombomeres 4/5 identified fibers that entered the octaval nerve via the facial root and entered the vestibular sensory epithelia. Together these data suggest an initial mingling of two different motoneuron populations (facial and octaval) in rhombomeres 4/5 and a subsequent segregation by differential migration. Our data also find a much earlier arrival of octaval efferent axons at the otic vesicle than previously described and suggest a contralateral migration of many octaval efferents beginning shortly after their axons reach the facial nerve root.

Pelvic relaxation of the posterior compartment.

Relaxation of the posterior compartment may involve the upper, middle, and/or lower portion of the posterior vaginal wall and result in a variety of disorders including enterocele, rectocele, and perineal defects. When symptomatic, singly, or in combination with other abnormalities, they deserve full evaluation and surgical correction. Their management and technical considerations for repair and prevention of recurrence are outlined including fecal incontinence.

DiI reveals a prenatal arrival of efferents at the differentiating otocyst of mice.

We have reinvestigated the time of arrival of efferent fibers at the developing otocyst of mice employing diffusion of the lipophilic dye DiI in fixed tissue. In contrast to almost all previous reports, our data indicate a prenatal arrival of efferent fibers. A few efferent fibers were found to enter the eighth nerve root at embryonic day (ED) 10 1/2. Retrogradely labelled efferent cell bodies were at this stage coextensive with those of the facial motor nucleus, but started to segregate by ED 12. In contrast to retrogradely labelled facial motor neurons, labelled efferent neurons were bilaterally distributed in the hindbrain with a few projecting to both otocysts as early as ED 12. Anterograde labelling from the brain showed efferent fibers in the vestibular ganglion by ED 11. Invasion of the future vestibular sensory epithelia started by ED 12. Growth cones of efferent fibers had also reached the future cochlear sensory epithelium but invasion was only achieved by a few filopodia at this stage. The early arrival of efferents at the future sensory epithelia demonstrated here may allow an as yet unexplored interaction of efferent fibers with the proliferating and/or differentiating hair cells.

Surgery for pelvic floor disorders.

By careful observation of the physical findings in the patient complaining of one of the disorders of genital prolapse, it should be possible to discern the origin of the symptoms and therefore to devise an appropriate treatment that would remedy by reconstruction all of the signs of anatomic weakness. The goals of reconstructive surgery are three: to relieve the symptoms, to restore the anatomy to normal, and to restore the function to normal. When any element of weakness in the pelvic floor is found to be sufficient to produce symptoms that warrant repair, it is the responsibility of the surgeon to identify all the sites of weakness, so that all may be repaired at the same time, sparing the patient the expense, pain, and inconvenience of future readmission for further surgery. These weaknesses all relate to deficiencies of the six major organ systems that are involved in the support of the female pelvis, which may be damaged singly or in any combination. There are various types of cystocele, each of which must be carefully excised if an appropriate surgical treatment is to be given. This may involve correction of cystocele, enterocele, rectocele, prolapse of the uterus, and posthysterectomy prolapse of the vaginal vault. With enterocele, it is possible to correlate the four common types of enterocele with their location, which in turn correlates directly with their treatment. The prevention of complications is emphasized along with the treatment of certain mechanical complications easily recognized at the time of surgery.

Fertility retention in the patient with genital prolapse.

There are several treatments from which to choose for the patient with symptomatic uterine prolapse who wishes to retain fertility. Transabdominal construction of a sacrocervical "ligament" with transplanted fascia lata femoris is a useful solution to this problem. The technique is described.