Heterogeneity in the progression of retinal pathologies in mice harboring patient mimicking Impg2 mutations

Biallelic mutations in interphotoreceptor matrix proteoglycan 2 (IMPG2) in humans cause retinitis pigmentosa (RP) with early macular involvement, albeit the disease progression varies widely due to genetic heterogeneity and IMPG2 mutation type. There are currently no treatments for IMPG2-RP. To aid preclinical studies toward eventual treatments, there is a need to better understand the progression of disease pathology in appropriate animal models. Toward this goal, we developed mouse models with patient mimicking homozygous frameshift (T807Ter) or missense (Y250C) Impg2 mutations, as well as mice with a homozygous frameshift mutation (Q244Ter) designed to completely prevent IMPG2 protein expression, and characterized the trajectory of their retinal pathologies across postnatal development until late adulthood. We found that the Impg2T807Ter/T807Ter and Impg2Q244Ter/Q244Ter mice exhibited early onset gliosis, impaired photoreceptor outer segment maintenance, appearance of subretinal deposits near the optic disc, disruption of the outer retina, and neurosensorial detachment, whereas the Impg2Y250C/Y250C mice exhibited minimal retinal pathology. These results demonstrate the importance of mutation type in disease progression in IMPG2-RP and provide a toolkit and preclinical data for advancing therapeutic approaches.

Molecular and behavioral consequences of Ube3a gene overdosage in mice

Chromosome 15q11.2-q13.1 duplication syndrome (Dup15q syndrome) is a severe neurodevelopmental disorder characterized by intellectual disability, impaired motor coordination, and autism spectrum disorder. Chromosomal multiplication of the UBE3A gene is presumed to be the primary driver of Dup15q pathophysiology, given that UBE3A exhibits maternal monoallelic expression in neurons and that maternal duplications typically yield far more severe neurodevelopmental outcomes than paternal duplications. However, studies into the pathogenic effects of UBE3A overexpression in mice have yielded conflicting results. Here, we investigated the neurodevelopmental impact of Ube3a gene overdosage using bacterial artificial chromosome-based transgenic mouse models (Ube3aOE) that recapitulate the increases in Ube3a copy number most often observed in Dup15q. In contrast to previously published Ube3a overexpression models, Ube3aOE mice were indistinguishable from wild-type controls on a number of molecular and behavioral measures, despite suffering increased mortality when challenged with seizures, a phenotype reminiscent of sudden unexpected death in epilepsy. Collectively, our data support a model wherein pathogenic synergy between UBE3A and other overexpressed 15q11.2-q13.1 genes is required for full penetrance of Dup15q syndrome phenotypes.

[Metastatic mechanisms of uterine malignancies and therapeutic consequences]

Malignancies of the uterus metastasize by direct invasion of neighboring structures, lymphatically or hematogenously. Endometrial and cervical cancers lymphatically spread to the pelvic and para-aortic lymph nodes. For endometrial cancer the depth of myometrial invasion, lymphosvascular space involvement (LVSI) and a microcystic, elongated and fragmented (MELF) glandular invasion pattern are predictors for lymph node metastases. Metastases to the pelvic lymph nodes occur in approximately 10 % of endometrial cancer patients and in 30 % of these cases the para-aortic lymph nodes are also involved. Sentinel lymph node biopsy is possible for clinical stage I endometrial cancer and early stages of cervical cancer but is not yet routine. The presence of LVSI is considered to be the strongest predictor of distant metastases, particularly if assessed by immunohistochemistry with antibodies against factor VIII-related antigen or CD31. Endometrioid and clear cell carcinomas can hematogenously metastasize to the lungs, bones, liver and brain and can rarely be manifested as a solitary metastasis. In contrast, serous carcinomas can show extensive peritoneal spread. To date molecular biomarkers cannot predict the occurrence of distant metastasis. Overexpression of P53, p16 and L1CAM have been identified as negative prognostic factors and are associated with the prognostically unfavorable serous tumor type. The metastatic spread of squamous cell cervical cancer is strongly associated with tumor volume. Microinvasive carcinomas have a very low rate of parametrial and lymph node involvement and do not require radical hysterectomy. In contrast, lymph node metastases occur in up to 50 % of bulky stages IB and II cervical cancers. Distant metastases can occur in the lungs, liver, bones and brain. Molecular biomarkers have not been shown to predict metastatic spread. In well-differentiated adenocarcinoma of the cervix the pattern of invasion is strongly predictive for the presence of lymph node metastases, irrespective of tumor size and depth of invasion.

Reproductive outcome after laparoscopic instillation of hyperosmolar glucose into unruptured tubal pregnancies

OBJECTIVE

To determine intrauterine and ectopic pregnancy rates after local instillation of 50% glucose into unruptured tubal pregnancies.

DESIGN

Retrospective cohort of 183 patients, who were observed for 16 to 108 months (median, 64 months).

SETTING

University hospital.

PATIENT(S)

One hundred eighty-three women who underwent laparoscopic instillation of hyperosmolar glucose for unruptured tubal pregnancies.

INTERVENTION(S)

Completion of questionnaires.

MAIN OUTCOME MEASURE(S)

Pregnancy rate, tubal recurrence rate.

RESULT(S)

A total of 124 women returned the questionnaire and had a desire for spontaneous conception. The conception rate and the intrauterine pregnancy rate were 79% and 73%, respectively. Seventy percent of all women with desire for spontaneous conception had live births. The rate of subsequent ectopic pregnancies was 12%. Tubal patency of the treated tube was demonstrated in 69% of 39 women at hysterosalpingography.

CONCLUSION(S)

The long-term prognosis for conception after laparoscopic instillation of hyperosmolar glucose for unruptured tubal pregnancy is favorable and comparable to that of other conservative treatments.

Ureteral complications with operative gynecologic laparoscopy

OBJECTIVE

The study assessed the incidence, diagnosis, management, and causes of ureteral injuries during major laparoscopic operations at our department in a 6-year period.

STUDY DESIGN

The study was a chart review of 790 consecutive major laparoscopic procedures in 711 patients (mean age 37.4 +/- 11.6 years, mean weight 64.3 +/- 29.1 kg).

RESULTS

There were four ureteral complications in three patients during or after laparoscopic operations: three of 711 patients (0.42%) and four of 790 procedures (0.38%). All three ureteral complications (one transection and a total of three ureterovaginal fistulas in two patients) occurred during laparoscopically assisted vaginal hysterectomies, for an incidence of 4.3%. There were no ureteral injuries in 291 salpingo-oophorectomies, 414 ovarian cystectomies, and 15 colposuspensions. Both delayed ureteral complications occurred in the lower segment of the ureter after laparoscopic bipolar coagulation and division of the cardinal ligament.

CONCLUSION

We conclude that in laparoscopic surgery the ureter is most at risk when the cardinal ligament is dissected and divided below the uterine vessels.

Laparoscopic instillation of hyperosmolar glucose vs. expectant management of tubal pregnancies with serum hCG < or = 2500 mIU/mL

OBJECTIVE

To compare expectant management with local instillation of 50% glucose solution for tubal pregnancies with a serum hCG level < or = 2500 mIU/mL.

DESIGN

Prospective, non-randomized, comparative clinical study.

SETTING

Two university departments.

PATIENTS

One hundred and twenty-eight patients with laparoscopically-confirmed tubal pregnancy and serum hCG < or = 2500 mIU/mL.

INTERVENTIONS

Eighty patients in Graz were treated with laparoscopic instillation of 50% glucose solution and 48 patients in Turku were followed expectantly.

MAIN OUTCOME MEASURES

Resolution of hCG excretion, need for further interventions.

RESULTS

Seventy-four of the 80 patients (92%) in the glucose group (32 of 33 with an initial hCG < or = 250 mIU/mL and 42 of 47 with hCG 251-2500 mIU/mL) and 36 of 48 (75%) patients in the expectant group (19 of 23 with an initial hCG < or = 250 mIU/mL and 17 of 25 with hCG 251-2500 mIU/mL) had resolution of the pregnancy with no further intervention (p=0.008, chi-square test, odds ratio 0.24).

CONCLUSIONS

Glucose instillation is superior to expectant management for patients with early tubal pregnancy.

[Iatrogenic vascular lesions in laparoscopic interventions in gynecology]

Injuries to major vessels in the course of gynecological laparoscopic surgery are rare but serious, life-threatening complications. We report on five iatrogenic vascular injuries during minimally invasive surgery that occurred between January 1991 and May 1996 in obstetrical-gynecological services in the Austrian province of Styria. The total vascular complication rate is 0.05%. As this data shows, the distal abdominal aorta and vena cava as well as the large pelvic vessels are especially susceptible to injury when the Veress needle and trocars are inserted into the abdomen. Surgical reconstruction of these five arterial lesions required a PTFE patch in one case and the resection of the damaged section of the artery and reanastomosis in a second case. The remaining lesions, as well as an associated injury to the pelvic vein in one case was corrected with direct suturing of the vessel. Pelvic circulation was completely restored in all patients and permanent damage was avoided.

Histopathology of the fallopian tube after local instillation of hyperosmolar glucose solution for unruptured tubal pregnancy

Because of an incomplete tubal abortion, salpingectomy was performed in a patient 12 days after glucose instillation into an ampullary tubal gestation. Serum hCG levels had progressively declined from 1.122 mIU/mL at first intervention to 37 mIU/mL at the second operation. Histopathology showed marked necrosis of trophoblastic tissue but no discernible damage of the tubal epithelium and tubal wall attributable to the hyperosmolar solution applied 12 days before. This case offers histopathologic evidence that intraluminal glucose instillation for treatment of unruptured tubal pregnancies does not lead to persisting damage of the tubal mucosa.

Intrauterine pregnancy in a patient with a sole remaining tube after local treatment of tubal pregnancy with hyperosmolar glucose

A spontaneous IUP occurred 8 months after laparoscopic instillation of hyperosmolar glucose solution into a tubal pregnancy in a patient with a sole remaining tube. This is the first unequivocal proof of intact tubal function after treatment of a tubal pregnancy with local hyperosmolar glucose.

Treatment of unruptured tubal pregnancy by laparoscopic instillation of hyperosmolar glucose solution

Sixty patients with unruptured tubal pregnancy were treated with local laparoscopic instillation of 50% glucose solution. This treatment was successful in 49 (98%) of 50 patients with an initial serum human chorionic gonadotropin level of less than or equal to 2500 mU/ml and in six (60%) of 10 with an initial level greater than 2500 mU/ml. No side effects were seen. The average hospital stay of patients who did not require a second intervention was 5.2 days (range 3 to 10). The average time between glucose instillation and the decline of serum human chorionic gonadotropin levels below the level of detectability was 21.3 (+/- 14.3) and 30.2 (+/- 10.9) days in patients with serum levels less than or equal to 2500 mIU/ml and greater than 2500 mIU/ml, respectively. Five patients (8%) underwent a second laparoscopy (n = 4) or laparotomy (n = 1) because of stable or increasing human chorionic gonadotropin levels and progressing clinical symptoms. We conclude that laparoscopic instillation of hyperosmolar glucose solution is safe, technically simple, and effective in the treatment of unruptured tubal pregnancies associated with a serum human chronic gonadotropin level less than or equal to 2500 mIU/ml.

Intrauterine pregnancy after treatment of tubal pregnancy with local and systemic prostaglandins in a patient with a single oviduct

A spontaneous intrauterine pregnancy occurred after instillation of prostaglandin-F2 alpha into the solitary tube and systemic prostaglandin administration for treatment of an ectopic gestation. This is the first unequivocal proof of intact function of the affected tube after non-surgical treatment of a tubal pregnancy with prostaglandins.

[Laparoscopy-assisted vaginal hysterectomy: initial experiences with an extrafascial technique]

This is a report on 4 cases of vaginal hysterectomy assisted by laparoscopy. The indications were dysfunctional hemorrhages, uterus myomatosus as well as 1 case of cervical intraepithelial neoplasia. Postoperatively, no complications were observed. It can therefore be concluded that with laparoscopic assistance the technical spectrum of hysterectomy can be enlarged. The disadvantage, if one can refer to it as such, implies the necessity of the gynecologist being a well-trained laparoscopist.

Conservative treatment of ectopic pregnancy with local injection of hyperosmolar glucose solution or prostaglandin-F2 alpha: a prospective randomised study

In a prospective randomised study, 31 patients with an unruptured tubal pregnancy were treated either with local and systemic prostaglandins or with local instillation of a hyperosmolar glucose solution. Prostaglandin therapy was successful in 13 of 15 patients and glucose therapy in 16 of 16. 9 women treated with prostaglandins had cramping abdominal pains postoperatively. No side-effects were noted in those treated with glucose. At subsequent hysterosalpingography 5 of 6 patients treated with prostaglandins and 7 of 8 treated with glucose had normal tubal configuration and patency. 3 patients treated with glucose later had a normal intrauterine pregnancy, demonstrably through the affected tube in 1 case. These results suggest that local instillation of hyperosmolar glucose solution is an option in the laparoscopic management of unruptured tubal pregnancies.