B. Dave

Distinct regional and subcellular localization of adenylyl cyclases type 1 and 8 in mouse brain.

Adenylyl cyclases (ACs) convert ATP to cAMP and therefore, subserve multiple regulatory functions in the nervous system. AC1 and AC8 are the only cyclases stimulated by calcium and calmodulin, making them uniquely poised to regulate neuronal development and neuronal processes such as learning and memory. Here, we detail the production and application of a novel antibody against mouse AC1. Along with AC8 immunohistochemistry, these data reveal distinct and partially overlapping patterns of protein expression in brain during murine development and adulthood. AC1 protein increased in abundance in the neonatal hippocampus from postnatal days 7-14. By adulthood, abundant AC1 protein expression was observed in the mossy fiber tract in the hippocampus and the molecular layer in the cerebellum, with diffuse expression in the cortex and thalamus. AC8 protein levels were abundant during development, with diffuse and increasing expression in the hippocampus that intensified in the CA1/CA2 region by adulthood. AC8 expression was weak in the cerebellum at postnatal day 7 and decreased further by postnatal day 14. Analysis of synaptosome fractions from the adult brain demonstrated robust expression of AC1 in the postsynaptic density and extrasynaptic regions, while expression of AC8 was observed in the presynaptic active zone and extrasynaptic fractions. These findings were confirmed with localization of AC1 and/or AC8 with PSD-95, tau, synaptophysin and microtubule-associated protein-2 (MAP-2) expression throughout the brain. Together, these data provide insight into the functional roles of AC1 and AC8 in mice as reflected by their distinct localization in cellular and subcellular compartments.

Adenylyl Cyclases 1 and 8 Initiate a Presynaptic Homeostatic Response to Ethanol Treatment

Background Although ethanol exerts widespread action in the brain, only recently has progress been made in understanding the specific events occurring at the synapse during ethanol exposure. Mice deficient in the calcium-stimulated adenylyl cyclases, AC1 and AC8 (DKO), demonstrate increased sedation duration and impaired phosphorylation by protein kinase A (PKA) following acute ethanol treatment. While not direct targets for ethanol, we hypothesize that these cyclases initiate a homeostatic presynaptic response by PKA to reactivate neurons from ethanol-mediated inhibition. Methodology/Principal Findings Here, we have used phosphoproteomic techniques and identified several presynaptic proteins that are phosphorylated in the brains of wild type mice (WT) after ethanol exposure, including synapsin, a known PKA target. Phosphorylation of synapsins I and II, as well as phosphorylation of non-PKA targets, such as, eukaryotic elongation factor-2 (eEF-2) and dynamin is significantly impaired in the brains of DKO mice. This deficit is primarily driven by AC1, as AC1-deficient, but not AC8-deficient mice also demonstrate significant reductions in phosphorylation of synapsin and eEF-2 in cortical and hippocampal tissues. DKO mice have a reduced pool of functional recycling vesicles and fewer active terminals as measured by FM1-43 uptake compared to WT controls, which may be a contributing factor to the impaired presynaptic response to ethanol treatment. Conclusions/Significance These data demonstrate that calcium-stimulated AC-dependent PKA activation in the presynaptic terminal, primarily driven by AC1, is a critical event in the reactivation of neurons following ethanol-induced activity blockade.

Challenges and Future Prospects for Tissue Engineering in Female Pelvic Medicine and Reconstructive Surgery

With advances in material engineering there is now a wide array of new materials for augmentation of tissue repairs in Female Pelvic Medicine and Reconstructive Surgery (FPMRS). However, clinical outcomes are discrepant and long term complications debilitating. In this manuscript, we describe the molecular and cellular host environments and biomechanical considerations that affect optimal integration of implant materials. There is growing interest in biodegradable scaffolds with cellular implants. It is thought that the cellular component could regenerate host tissue while the scaffold provides temporary mechanical properties. Current findings are promising, but detailed in vivo and long term testing is needed before clinical applications.

Changing Referral Patterns to Urogynecology

Objective The study aims to identify sources of and changes in referral patterns for pelvic floor disorders. Methods All new patient visits to urogynecology at our institution between January 2010 and December 2015 were identified. Patient demographics, referral source, insurance type, and visit diagnoses using ICD-9 codes were abstracted. ICD-9 codes were grouped into 18 urogynecologic diagnoses. Data were analyzed using SPSS (Version 20; Chicago, IL). Results Five thousand seven hundred ninety-nine new patient visits were included in the analysis. The mean age was 54 ± 17 years and 59% were Caucasian. Forty-four percent were referred by obstetrician/gynecologists (OB/GYNs), 32% by primary care providers (PCPs), 14% by self-referral, and 9% by other specialties. New patient visits increased overall by 280% over 6 years; self- and PCP referrals increased by 480% and 320%, respectively. In comparison, OB/GYN referrals increased by only 229%. Patients diagnosed with prolapse and stress incontinence were more likely to be referred by an OB/GYN (P < 0.001), whereas PCPs were more likely to refer for urinary tract infections (P < 0.005) and urgency urinary incontinence (P < 0.001) than OB/GYNs. Conclusions Demand for pelvic floor specialists is growing quickly, with PCP and self-referrals outpacing referrals from obstetrician-gynecologists to tertiary care urogynecology practices.

Anal penetrative intercourse as a risk factor for fecal incontinence

Objective The aim of the study is to investigate the relationship between anal penetrative intercourse (API) and pelvic floor symptoms, specifically, anal incontinence (AI). Methods This was an institutional review board–approved, cross-sectional, e-mail survey of women enrolled in the Illinois Womens Health Registry. Participants were anonymously queried about their sexual practices and the effects of these on bowel and bladder symptoms. Urinary symptoms were assessed using the urogenital distress inventory-6 and bowel symptoms with the fecal incontinence severity index (FISI). Results One thousand three women (mean age of 46 ± 15 years) completed the survey. Eighty percent were white, 56% were married, and 99% reported ever being sexually active. Thirty-two percent had API at least once, and 12% considered it “part of their sexual practice.” Sixty percent of the cohort reported a bothersome urinary symptom on the urogenital distress inventory-6, 70% reported AI on the FISI, and 15% reported fecal incontinence. Of women who engaged in API, 18% reported it changed their stool consistency, and 10% reported it caused AI. Having engaged in API within the last month was correlated with higher FISI scores (P = 0.05) and with fecal incontinence on the FISI (28.3% vs 14.4%; P = 0.01; odds ratio, 2.48). In addition, API was more commonly practiced among women who reported that vaginal intercourse caused dyspareunia (17% vs 12%, P = 0.05) or changes in bladder symptoms such as urgency or dysuria (44% vs 30%, P < 0.001). Conclusions Self-reported AI and FI (as measured by the FISI scores) are higher in women who have had API, and frequency of API may be important in determining the risk of bowel symptoms.

Mesh—Is Less More?

Due to safety concerns, the US Food and Drug Administration has placed a warning on the use of transvaginal mesh in pelvic organ prolapse (POP) repair.1 Studies like the one by Chughtai et al2 in this issue of JAMA Surgery are important because they provide important information regarding the incidence and timing of complications. Compared with other studies, their work is unique for 2 reasons. First, it focuses on clinically important mesh complications (those that require an intervention as opposed to asymptomatic erosions). Second, it includes a statewide database, which minimizes underreporting that occurs when patients change clinicians secondary to perceived complications. The authors compare the following 4 groups of surgical procedures that use varying amounts of mesh: (1) POP repair with transvaginal mesh and mesh stress urinary incontinence (SUI) sling, (2) POP repair with transvaginal mesh and no concurrent sling, (3) POP repair without mesh but with mesh sling, and (4) mesh sling alone. They conclude that there is a dose-response relationship between the amount of mesh used and the need for surgical intervention secondary to mesh erosion. This conclusion seems logical and is supported by the data, but its clinical applicability is limited because patients with SUI and POP often desire surgical correction for both problems. In other words, the population of groups 1 and 3 differs from that of groups 2 and 4. The authors’ hypothesis about the dose-dependent risk of mesh erosions is intriguing and warrants further investigation. Patients undergoing surgery for POP who have occult SUI would be a more ideal population in which to study this theory. These patients have underlying SUI that is unmasked when POP is reduced (ie, the urethra is unkinked) and are given the option of a concomitant vs staged procedure (the placement of mesh sling at the time of POP repair vs delayed placement in those who develop symptomatic SUI after POP repair). Does placing a sling at the same time as opposed to later increase the risk of mesh-related complications? A study answering this question would guide treatment decisions and reflect a scenario in which the dose response would be clinically important. The data reported in this article are limited by the contents of its database. The Current Procedural Terminology codes used to identify transvaginal prolapse repairs with mesh include other prosthetic grafts (biologic implants and nonmesh devices) that would dilute the denominator, underestimating the overall rate of mesh complications. In addition, the authors note that the number of laparoscopic sacrocolpopexies in the database was too few to include in the analysis. This limitation poses serious concern for the generalizability of the database. It has been well established that sacrocolpopexies have greater success than transvaginal mesh and fewer complications.3-5 The number of sacrocolpopexies has almost doubled yearly from 2008 to 2011, while the number of transvaginal mesh procedures has declined.6 Studying a population of patients undergoing sacrocolpopexies and midurethral slings for a dose-response mesh risk may be more reflective of current standards of practice.

Anal Sphincter Injuries After Operative Vaginal Versus Spontaneous Delivery-Is There a Difference in Postpartum Symptoms?

Objective The aim of this study was to determine whether there is a difference in pelvic floor symptoms between women who had obstetric anal sphincter injuries (OASIS) after an operative vaginal delivery versus those who had OASIS after a spontaneous delivery. Methods This was a secondary analysis of a prospective cohort study of women who sustained OASIS. Women were evaluated at 1 week postpartum and again at 12 weeks; at both of these visits, they completed a battery of validated questionnaires including a visual analog scale for pain, Patient Health Questionnaire 9 depression inventory, Fecal Incontinence Severity Index, Urogenital Distress Inventory 6, and Incontinence Impact Questionnaire 7. Results Two hundred sixty-eight women with OASIS were included in this analysis (194 operative vaginal, 74 spontaneous). Ninety-one percent of those with operative vaginal delivery had a forceps-assisted delivery. After multivariate regression, operative OASIS was independently associated with greater Urogenital Distress Inventory 6 scores (P = 0.02), Fecal Incontinence Severity Index scores (P = 0.04), and visual analog scale pain scores (P = 0.03) and higher rates of urgency urinary incontinence (P = 0.04), stress urinary incontinence (P = 0.02), and anal incontinence (P = 0.04) at 1 week postpartum. At 3 months postpartum, symptoms were no different between the groups. Conclusions Women who sustain OASIS secondary to operative vaginal delivery report more bothersome urinary symptoms and higher rates of anal incontinence immediately postpartum as compared with women with OASIS secondary to spontaneous delivery. These differences may resolve by 3 months postpartum.