Sarit Aschkenazi

Differential Regulation and Function of the Fas/Fas Ligand System in Human Trophoblast Cells

Abstract Trophoblast rejection, which is characterized by increased apoptosis, is mediated by T helper (Th)-1, or proinflammatory, cytokines, whereas Th-2, or anti-inflammatory, cytokines confer immune protection and facilitate implantation. We investigated the role of both types of cytokines on the expression and function of the Fas/Fas ligand (FasL) apoptotic pathway in trophoblast cells. First-trimester human trophoblast primary-culture cells as well as A3 and HTR/8 trophoblast cell lines were treated with proinflammatory cytokines such as interferon-γ (IFN-γ) and tumor necrosis factor α (TNFα) and with the anti-inflammatory cytokines interleukin (IL)-6 and IL-10. Sensitivity to Fas-mediated apoptosis was measured using an activating anti-Fas monoclonal antibody. Cell viability was evaluated using the MTT (3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyltetrazolium bromide) and CellTiter 96 assay. Fas/FasL mRNA and protein expression levels were determined using reverse transcription-polymerase chain reaction (RT-PCR) and Western blot analysis, respectively. Trophoblast cells normally express FasL, but low levels of Fas, and they are resistant to Fas-mediated apoptosis. IFN-γ and TNFα promote Fas expression and sensitivity, whereas IL-6 and IL-10 increase the resistance of trophoblast cells to Fas-mediated apoptosis. Furthermore, IL-10 treatment activates FLICE-like inhibitory protein (FLIP), a downstream inhibitor of Fas apoptotic signaling. Although trophoblast cells express Fas, susceptibility to Fas does not necessarily correlate with its expression. In this study, we demonstrate that Th-2 cytokines increase the resistance of trophoblast cells to Fas-mediated apoptosis either by inhibiting Fas expression or by inducing FLIP activation. This “trophoblast-cytokine-Fas/FasL triad” determines the ability of the Fas/FasL system to regulate trophoblast viability and, consequently, the success or failure of pregnancy.

Absence of estrogen receptor-β expression in metastatic ovarian cancer

Objective To evaluate the expression of estrogen receptor (ER)&agr; and ERβ mRNA and protein in normal ovarian tissue and primary and metastatic tumors. Methods Estrogen receptor &agr; and ERβ expression was studied in normal ovarian biopsies (n = 9) and primary (n = 8) and metastatic ovarian epithelial cancers (n = 8). Ovarian tissue was collected from surgical samples. Estrogen receptor &agr; and ERβ mRNA expression was compared by coamplification of the mRNA of the ERs. Expression was confirmed at the protein level by Western blot analysis using antibodies specific for each receptor. Results Among eight primary ovarian cancer samples, three had only ER&agr;, two had only ERβ, and three had both. All eight metastatic ovarian cancer tissues expressed only ER&agr; mRNA and protein. Biopsies from normal ovaries had ER&agr; and ERβ mRNA and protein. Two of the ovarian epithelial cancer samples were paired and showed the same results. Conclusion We found varying amounts of ER&agr; and ERβ in normal ovaries, lower levels of ERβ expression in ovarian epithelial cancer primary tumors, and only ER&agr; in metastatic tumors. Our findings indicate that a fundamental difference might exist between primary and metastatic cells, which could be caused by intrinsic or extrinsic factors that regulate ER gene expression.

Sling surgery for stress urinary incontinence in women: a systematic review and metaanalysis.

OBJECTIVE Understanding the long-term comparative effectiveness of competing surgical repairs is essential as failures after primary interventions for stress urinary incontinence (SUI) may result in a third of women requiring repeat surgery. STUDY DESIGN We conducted a systematic review including English-language randomized controlled trials from 1990 through April 2013 with a minimum 12 months of follow-up comparing a sling procedure for SUI to another sling or Burch urethropexy. When at least 3 randomized controlled trials compared the same surgeries for the same outcome, we performed random effects model metaanalyses to estimate pooled odds ratios (ORs). RESULTS For midurethral slings (MUS) vs Burch, metaanalysis of objective cure showed no significant difference (OR, 1.18; 95% confidence interval [CI], 0.73-1.89). Therefore, we suggest either intervention; the decision should balance potential adverse events (AEs) and concomitant surgeries. For women considering pubovaginal sling vs Burch, the evidence favored slings for both subjective and objective cure. We recommend pubovaginal sling to maximize cure outcomes. For pubovaginal slings vs MUS, metaanalysis of subjective cure favored MUS (OR, 0.40; 95% CI, 0.18-0.85). Therefore, we recommend MUS. For obturator slings vs retropubic MUS, metaanalyses for both objective (OR, 1.16; 95% CI, 0.93-1.45) and subjective cure (OR, 1.17; 95% CI, 0.91-1.51) favored retropubic slings but were not significant. Metaanalysis of satisfaction outcomes favored obturator slings but was not significant (OR, 0.77; 95% CI, 0.52-1.13). AEs were variable between slings; metaanalysis showed overactive bladder symptoms were more common following retropubic slings (OR, 1.413; 95% CI, 1.01-1.98, P = .046). We recommend either retropubic or obturator slings for cure outcomes; the decision should balance AEs. For minislings vs full-length MUS, metaanalyses of objective (OR, 4.16; 95% CI, 2.15-8.05) and subjective (OR, 2.65; 95% CI, 1.36-5.17) cure both significantly favored full-length slings. Therefore, we recommend a full-length MUS. CONCLUSION Surgical procedures for SUI differ for success rates and complications, and both should be incorporated into surgical decision-making. Low- to high-quality evidence permitted mostly level-1 recommendations when guidelines were possible.

Sexual Function is Related to Body Image Perception in Women with Pelvic Organ Prolapse

INTRODUCTION A previous study demonstrated that women seeking treatment for advanced pelvic organ prolapsed (POP) reported decreased self-perceived body image and decreased quality of life. AIMS To determine the relationship between: (i) sexual function and POP, (ii) self-perceived body image and POP; and (iii) sexual function and self-perceived body image in women with prolapse. METHODS After IRB approval, consecutive women with POP stage II or greater presenting for urogynecologic care at one of eight academic medical centers in the United States were invited to participate. In addition to routine urogynecologic history and physical examination, including pelvic organ prolapse quantification (POPQ), consenting participants completed three validated questionnaires: Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) to assess sexual function; Modified Body Image Perception Scale (MBIS) to assess self-perceived body image; Prolapse subscale of Pelvic Floor Distress Inventory (POPDI-6) to assess condition specific bother from POP. Pearsons correlations were used to investigate the relationship between independent variables. MAIN OUTCOME MEASURES Sexual function and modified body image score and its correlation with symptoms of POP. RESULTS Three hundred eighty-four participants with a mean age of 62 +/- 12 years were enrolled. Median POPQ stage was 3 (range 2-4). 62% (N = 241) were sexually active and 77% (N = 304) were post-menopausal. Mean PISQ-12, MBIS, and POPDI scores were (33 +/- 7, 6 +/- 5, 39 +/- 23, respectively). PISQ-12 scores were not related to stage or compartment (anterior, apical, or posterior) of POP (P > 0.5). Worse sexual function (lower PSIQ-12 scores) correlated with lower body image perception (higher MBIS scores) (rho = -0.39, P < 0001) and more bothersome POP (higher POPDI scores) (rho = -0.34, P < 0001). CONCLUSIONS Sexual function is related to a womans self-perceived body image and degree of bother from POP regardless of vaginal topography. Sexual function may be more related to a womans perception of her body image than to actual topographical changes from POP.

Systematic Review of Robotic Surgery in Gynecology: Robotic Techniques Compared With Laparoscopy and Laparotomy

The Society of Gynecologic Surgeons Systematic Review Group performed a systematic review of both randomized and observational studies to compare robotic vs nonrobotic surgical approaches (laparoscopic, abdominal, and vaginal) for treatment of both benign and malignant gynecologic indications to compare surgical and patient-centered outcomes, costs, and adverse events associated with the various surgical approaches. MEDLINE and the Cochrane Central Register of Controlled Trials were searched from inception to May 15, 2012, for English-language studies with terms related to robotic surgery and gynecology. Studies of any design that included at least 30 women who had undergone robotic-assisted laparoscopic gynecologic surgery were included for review. The literature yielded 1213 citations, of which 97 full-text articles were reviewed. Forty-four studies (30 comparative and 14 noncomparative) met eligibility criteria. Study data were extracted into structured electronic forms and reconciled by a second, independent reviewer. Our analysis revealed that, compared with open surgery, robotic surgery consistently confers shorter hospital stay. The proficiency plateau seems to be lower for robotic surgery than for conventional laparoscopy. Of the various gynecologic applications, there seems to be evidence that renders robotic techniques advantageous over traditional open surgery for management of endometrial cancer. However, insofar as superiority, conflicting data are obtained when comparing robotics vs laparoscopic techniques. Therefore, the specific method of minimally invasive surgery, whether conventional laparoscopy or robotic surgery, should be tailored to patient selection, surgeon ability, and equipment availability.

Venous thromboembolism prophylaxis in gynecologic surgery: A systematic review

OBJECTIVE: To comprehensively review and critically assess the available gynecologic surgery venous thromboembolism prophylaxis literature and provide clinical practice guidelines. DATA SOURCES: MEDLINE and Cochrane databases from inception to July 2010. We included randomized controlled trials in gynecologic surgery populations. Interventions and comparators included graduated compression stockings, intermittent pneumatic compression, unfractionated heparin, and low molecular weight heparin; placebo and routine postoperative care were allowed as comparators. METHODS OF STUDY SELECTION: One thousand two hundred sixty-six articles were screened, and 14 randomized controlled trials (five benign gynecologic, nine gynecologic oncology) met eligibility criteria. In addition, nine prospective or retrospective studies with at least 150 women were identified and provided data on venous thromboembolism risk stratification, gynecologic laparoscopy, and urogynecologic populations. TABULATION, INTEGRATION, AND RESULTS: Two reviewers independently screened articles with discrepancies adjudicated by a third. Eligible randomized controlled trials were extracted for these characteristics: study, participant, surgery, intervention, comparator, and outcomes data, including venous thromboembolism incidence and bleeding complications. Studies were individually and collectively assessed for methodologic quality and strength of evidence. Overall incidence of clinical venous thromboembolism was 0–2% in the benign gynecologic population. With use of intermittent pneumatic compression for benign major procedures, venous thromboembolism incidence was less than 1%. No venous thromboembolisms were identified in prospective studies of benign laparoscopic procedures. Overall quality of evidence in the benign gynecologic literature was poor. Gynecologic–oncology randomized controlled trials reported venous thromboembolism incidence (including “silent” venous thromboembolisms) of 0–14.8% with prophylaxis and up to 34.6% without prophylaxis. Fair quality of evidence supports that unfractionated heparin and intermittent pneumatic compression are both superior to placebo or no intervention but insufficient to determine whether heparins are superior to intermittent pneumatic compression for venous thromboembolism prevention. Combining two of three risks (aged 60 years or older, cancer, or personal venous thromboembolism history) substantially elevated the risk of venous thromboembolism. CONCLUSION: Intermittent pneumatic compression provides sufficient prophylaxis for the majority of gynecology patients undergoing benign surgery. Additional risk factors warrant the use of combined mechanical and pharmacologic prophylaxis.

Regulation of Fas Ligand Expression By Estrogen in Normal Ovary

Objective: The clinical significance of the Fas/Fas ligand (FasL) system in hormone-sensitive carcinomas such as breast and ovary has been reported. However, only a few studies have investigated the potential hormonal regulation of its expression. In this study, we evaluated the expression of FasL in normal ovarian tissue during the normal female reproductive cycle with the goal of identifying potential hormones that can regulate FasL expression. Methods: We used Western blot analysis to examine the expression of FasL in the rat ovary throughout the natural estrous cycle. We employed Western blot and reverse transcriptase-polymerase chain reaction to study hormonal regulation of FasL in human ovarian epithelial cells and normal ovarian tissues. Results: FasL protein expression levels change in the ovary during the female reproductive cycle. FasL protein appeared intensively in estrus, declined sharply in metestrous, further decreased to a very low level in diestrus, and was absent in proestrus. Because the protein expression pattern of FasL in the cycling ovary was similar to the estrogen receptor beta expression pattern, we examined the effect of estrogen on the level of FasL protein and found that estrogen indeed upregulates the expression of FasL protein and mRNA levels in ovarian epithelial cells as well as in normal ovarian tissues. Furthermore, we showed that the estrogen-induced increase in the FasL protein and mRNA levels could be abolished by 4-hydroxytamoxifen, which suggests that the observed increase in FasL expression was mediated by estrogen receptor. Conclusion: Our findings support the hypothesis that the expression of FasL in normal ovary is hormonally sensitive and could have a key role in the physiology of normal ovarian tissue.

Impact of hysterectomy on stress urinary incontinence: an identical twin study

OBJECTIVE This study uses the unique properties of twin research design to evaluate whether hysterectomy impacts stress urinary incontinence (SUI). STUDY DESIGN As part of the Evanston Twins Sister Study, we performed bivariate and multivariate analyses on 83 identical twin pairs discordant for hysterectomy. RESULTS In bivariate analysis, SUI was less common in women who had prior hysterectomy (P =0.028). Multivariate analysis suggested that SUI was significantly less common after hysterectomy (odds ratio [OR], 0.55, confidence interval [CI], 0.30 to 1.00). Exclusion of twin pairs with a history of pelvic floor defect surgery eliminated the statistical relationship between hysterectomy and SUI (OR, 0.79, CI, 0.4 to 1.40). CONCLUSION Hysterectomy, when analyzed with all cases, was associated with reduced SUI. When concurrent pelvic floor defect surgeries were excluded from the analysis, we found no relationship between hysterectomy and the risk of SUI afterward.

Sling surgery for stress urinary incontinence in women: A systematic review and meta-analysis

Traditional treatment options in women with stress urinary incontinence (SUI) include Burch urethropexy or pubovaginal slings. These procedures have become much less popular and less frequently performed with the development and increased use of synthetic midurethral slings (MUSs). These trends in practice have not been associated with dramatic improvements in outcomes, however, and up to a third of women require repeat surgery. Therefore, it is important to understand the comparative effectiveness of competing surgical repair procedures. The primary aim of this systematic review and meta-analysis was to compare objective and subjective cure rates in adult women with SUI treated with different surgical procedures. A systematic review was performed using the MEDLINE and Cochrane Central Register for Controlled Trials databases to obtain English-language comparative studies, cohort studies, and systematic reviews published from 1990 through April 2013 comparing a sling procedure for SUI to another sling or to Burch urethropexy. For evaluation of outcomes, only peer-reviewed randomized controlled trials with at least 12 months of follow-up were included. The minimum requirement for meta-analysis was at least 3 randomized controlled trials that compared the same surgeries for the same outcome and provided adequate efficacy and adverse event data. A random-effects model meta-analysis was used to estimate pooled odds ratios (ORs). Comparison ofMUS vs Burch urethropexy (open or laparoscopic):Meta-analysis of objective cure showed no significant difference between these 2 procedures (OR, 1.18; 95% confidence interval [CI], 0.73–1.89). There was also no difference between these 2 surgeries for outcomes of subjective cure, quality of life, or sexual function. Either an MUS or Burch procedure can be used. The choice should be based on potential adverse events and planned concomitant surgeries. Comparison of pubovaginal sling vs Burch urethropexy: Because the evidence favored pubovaginal slings for both subjective and objective cure, the authors recommended use of pubovaginal slings to maximize cure outcomes. Comparison of pubovaginal slings vs MUS: Meta-analysis of subjective cure favored MUS (OR, 0.40; 95% CI, 0.18–0.85). A meta-analysis for objective cure could not be performed because of inadequate data. Based on the subjective evidence for better cure, the authors recommended MUS. www.obgynsurvey.com | 586 Copyright

Nongenetic Factors Associated With Stress Urinary Incontinence

OBJECTIVE: To explore the role of hereditary and environmental factors on the development of stress urinary incontinence in a large cohort of identical and nonidentical twins. METHODS: This is a large, population-based, classic twin study of twin sisters recruited to complete a health survey at the worlds largest annual twins festival during 2003–2008. Concordance rates were calculated and structural equation models were used to estimate the contribution of genetic effects compared with environmental factors toward the development of stress urinary incontinence. RESULTS: Eight hundred eighty-two twin sister pairs (n=1,764), including 765 identical and 117 nonidentical twin sister pairs, completed the questionnaires. Sequential structural equation modeling revealed that common environmental factors contributed 77.6% (95% confidence interval [CI], 41.4–83.8; P<.001) of the variance and unique environmental factors contributed 20.9% (95% CI, 15.8–26.7; P<.001) of the variance. The effect of genetics was not statistically significant at 1.49% (95% CI, 0.0–38.8; P=.46). CONCLUSION: Female stress urinary incontinence is more a consequence of environmental risk factors than heredity. This epidemiologic insight should be considered in preventive health efforts. LEVEL OF EVIDENCE: II