Continence, quality of life and depression following surgical repair of obstetric vesicovaginal fistula: a cohort study.

OBJECTIVE: We evaluated residual incontinence, depression, and quality of life among Malawian women who had undergone vesicovaginal fistula (VVF) repair 12 or more months previously. DESIGN: Prospective cohort study. SETTING: Fistula Care Centre in Lilongwe, Malawi. POPULATION: Women who had undergone VVF repair in Lilongwe, Malawi at least 12 months prior to enrolment. METHODS: Self-report of urinary leakage was used to evaluate for residual urinary incontinence; depression was evaluated with the Patient Health Questionnaire-9; quality of life was evaluated with the King's Health Questionnaire. MAIN OUTCOME MEASURES: Prevalence and predictors of residual incontinence, quality of life scores, and prevalence of depression and suicidal ideation. RESULTS: Fifty-six women (19.3%) reported residual urinary incontinence. In multivariable analyses, predictors of residual urinary incontinence included: pre-operative Goh type 3 [adjusted risk ratio (aRR) 2.82; 95% confidence interval (CI) 1.61-5.27) or Goh type 4 1.08-2.78), positive postoperative cough stress test (aRR = 2.42; 95% CI 1.24-4.71) and the positive 1-hour postoperative pad test (aRR = 2.20; 95% CI 1.08-4.48). Women with Goh types 3 and 4 VVF reported lower quality of life scores. Depressive symptoms were reported in 3.5% of women; all reported residual urinary incontinence. CONCLUSIONS: While the majority of women reported improved outcomes in the years following surgical VVF repair, those with residual urinary incontinence had a poorer quality of life. Services are needed to identify and treat this at-risk group. TWEETABLE ABSTRACT: Nearly one in five women reported residual urinary incontinence at follow up, 12 or months after vesicovaginal fistula repair.

Use of a postoperative pad test to identify continence status in women after obstetric vesicovaginal fistula repair: a prospective cohort study.

OBJECTIVE: Determine whether a 1-hour pad test at discharge can identify continence status within 120 days of obstetric vesicovaginal fistula (VVF) repair. DESIGN: Prospective cohort study. SETTING: Fistula Care Centre in Lilongwe, Malawi. POPULATION: Women with VVF who underwent repair between January 2012 and December 2014. METHODS: Data on demographics, obstetric history, physical exam findings, operative management, postoperative findings, and follow up evaluations were collected on women with VVF repair. MAIN OUTCOME MEASURES: Sensitivity, specificity, positive and negative predictive values (PPV and NPV), and a receiver operating curve (ROC) were calculated to assess the utility of using a discharge pad test at three thresholds to identify women likely to be continent at follow up. RESULTS: After VVF repair, 346 women had a 1-hour pad test performed at the time of hospital discharge and completed follow up within 120 days of repair. Of these, 79.8% (n = 276) were completely continent, whereas 20.2% (n = 70) had some degree of incontinence. The sensitivity and specificity of a negative 1-hour pad test at predicting continence is 68.1% and 82.9%, respectively. With this prevalence, a negative pad test at a 1.5-g threshold demonstrates a high predictive value (PPV = 94.0%, 95% CI 90.0-96.9) in detecting women with continence after repair. CONCLUSIONS: At the 1.5-g threshold, a negative pad test at discharge identifies 94% of women who will remain continent after VVF repair. Adding the pad test to fistula care can identify women who are likely to remain continent and may not need further therapies in settings where resources are limited and follow up after repair is difficult. TWEETABLE ABSTRACT: A negative pad test after repair is associated with continued continence at follow up.

Association between parity and fistula location in women with obstetric fistula: a multivariate regression analysis.

OBJECTIVE: To compare primiparous and multiparous women who develop obstetric fistula (OF) and to assess predictors of fistula location. DESIGN: Cross-sectional study. SETTING: Fistula Care Centre at Bwaila Hospital, Lilongwe, Malawi. POPULATION: Women with OF who presented between September 2011 and July 2014 with a complete obstetric history were eligible for the study. METHODS: Women with OF were surveyed for their obstetric history. Women were classified as multiparous if prior vaginal or caesarean delivery was reported. The location of the fistula was determined at operation: OF involving the urethra, bladder neck, and midvagina were classified as low; OF involving the vaginal apex, cervix, uterus, and ureters were classified as high. MAIN OUTCOME MEASURES: Demographic information was compared between primiparous and multiparous women using chi-squared and Mann-Whitney U-tests. Multivariate logistic regression models were implemented to assess the relationship between variables of interest and fistula location. RESULTS: During the study period, 533 women presented for repair, of which 452 (84.8%) were included in the analysis. The majority (56.6%) were multiparous when the fistula formed. Multiparous women were more likely to have laboured <1 day (62.4 versus 44.5%, P < 0.001), delivered a live-born infant (26.8 versus 17.9%, P = 0.026), and have a high fistula location (37.5 versus 11.2%, P < 0.001). Multiparity [adjusted odds ratio (aOR) = 4.55, 95% confidence interval (CI) 2.27-9.12)] and history of caesarean delivery (aOR = 4.11, 95% CI 2.45-6.89) were associated with development of a high fistula. CONCLUSIONS: Multiparity was common in our cohort, and these women were more likely to have a high fistula. Additional research is needed to understand the aetiology of high fistula including potential iatrogenic causes. TWEETABLE ABSTRACT: Multiparity and caesarean delivery were associated with a high tract fistula in our Malawian cohort.

Tract formation and axon fasciculation of molecularly distinct peripheral neuron subpopulations during leech embryogenesis.

In leech, the central projections of peripheral sensory neurons segregate into specific axonal tracts, which are distinguished by differential expression of surface antigens recognized by the monoclonal antibodies Lan3-2 and Lan4-2. Lan3-2 recognizes an epitope expressed on axons that segregate into three distinct axon fascicles. In contrast, the Lan4-2-positive axons selectively project into only one of the Lan3-2-positive axon tracts. These observations provide evidence for a hierarchy of guidance cues mediating specific pathway formation in this system. Since the Lan3-2 antibody has been shown to perturb this process and since, as shown here, the Lan3-2 and Lan4-2 antigens are closely molecularly interrelated, these antibodies may help define molecules and epitopes mediating neuronal recognition and axonal guidance.

Disparity in neurotransmitter release probability among competing inputs during neuromuscular synapse elimination.

Competition among the several motor axons transiently innervating neonatal muscle fibers results in an increasing disparity in the quantal content and synaptic territory of each competitor, culminating in the permanent loss of all but one axon from neuromuscular junctions. We asked whether differences in the probability of neurotransmitter release also contribute to the increasing disparity in quantal content among competing inputs, and when in the process of competition changes in release probability become apparent. To address these questions, intracellular recordings were made from dually innervated neonatal mouse soleus muscle fibers, and quantal content and paired-pulse facilitation were evaluated for each input. At short interpulse intervals, paired-pulse facilitation was significantly higher for the weaker input with the smaller quantal content than the stronger input with the larger quantal content. Because neurotransmitter release probability across all release sites is inversely related to the extent of facilitation observed after paired-pulse stimulation, this result suggests that release probability is lower for weak compared with strong inputs innervating the same junction. A disparity in the probability of neurotransmitter release thus contributes to the disparity in quantal content that occurs during synaptic competition. Together, this work suggests that an input incapable of sustaining a high release probability may be at a competitive disadvantage for synaptic maintenance.

Multimorphic growth cones in the embryonic medicinal leech: relationship between shape changes and outgrowth transitions.

Comparative studies of growth cone morphology may provide insight into the mechanisms underlying motility and navigation in vivo. Here we analyzed the morphology of a unique set of growth cones in the embryonic medicinal leech, Hirudo medicinalis. The comb or C-cell is a transient cell found as a bilateral pair in each midbody segment. Early in development, from embryonic day (E)7 to E11, each C-cell adds and orients about 70 parallel growth cones that remain relatively nonmotile until E12 when rapid process outgrowth is initiated. Individual C-cells from E10 to E14 were injected with Lucifer yellow and growth cones were traced with a camera lucida. Growth cone morphology was quantified from the drawings. Lamellar regions increased in area with age and change in extension rate. Young, relatively nonmotile growth cones had numerous short filopodia in many orientations, while at highly motile stages filopodial number decreased, length increased, and orientation became more restricted in the direction of outgrowth. Thus, while filopodia were distributed symmetrically, such that the average filopodial angle was predictive of the direction of outgrowth at all stages, younger (relatively nonmotile) growth cones project more filopodia in many directions than do older more motile growth cones. These results suggest that: (1) alterations in morphology may reflect developmentally regulated changes in extension and the local environment, (2) these growth cones maintain a large area for environmental sampling as they increase extension rate, even as filopodia become more restricted in orientation, and (3) C-cell growth cones might progressively alter their affinity for local cellular cues as they initiate rapid and directed outgrowth. The C-cell of embryonic leech may provide a relatively simple system in which to test these ideas experimentally.

Initial formation and secondary condensation of nerve pathways in the medicinal leech.

Invertebrates have proved to be important experimental systems for examining questions related to growth cone navigation and nerve formation, in large part because of their simpler nervous systems. However, such apparent simplicity can be deceiving because the final stereotyped patterns may be the result of multiple developmental mechanisms and not necessarily the sole consequence of the pathway choices of individual growth cones. We have examined the normal sequence of events that are involved in the formation of the major peripheral nerves in leech embryos by employing (1) an antibody directed against acetylated tubulin to label neurons growing out from the central nervous system, (2) the Lan3-2 antibody to label a specific population of peripheral neurons growing into the central nervous system, and (3) intracellular dye filling of single cells. We found that the mature pattern of nerves was characterized by a pair of large nerve roots, each of which branched into two major tracts. The earliest axonal projections did not, however, establish this pattern definitively. Rather, each of the four nerves initially formed as discrete, roughly parallel tracts without bifurcation, with the final branching pattern of the nerve roots being generated by a secondary condensation. In addition, we found that some of the nerves were pioneered in different ways and by different groups of neurons. One of the nerves was established by central neurons growing peripherally, another by peripheral neurons growing centrally. These results suggest that the formation of common nerves and neuronal pathfinding in the leech involves multiple sets of growth cone guidance strategies and morphogenetic mechanisms that belie its apparent simplicity.

Sprouting and connectivity of embryonic leech heart excitor (HE) motor neurons in the absence of their peripheral target.

The rhythmic pumping of the hearts in the medicinal leech, Hirudo medicinalis, is neurogenic and mediated by a defined circuit involving identified interneurons in a central pattern generator (CPG) and segmentally iterated motor neurons that drive the heart muscle. During early embryogenesis, presumptive heart excitor (HE) motor neurons extend many axon branches into the body wall; they later innervate the heart while retracting the supernumerary peripheral axons, and only much later in development receive synaptic input from the central pattern generator (Jellies, Kopp and Bledsoe (1992) J. Exp. Biol., 170, 71-92.). In this study, HE motor neurons were deprived of an early interaction with the heart by surgical ablation of a circumscribed portion of body wall including the heart primordium. Anatomical and electrophysiological data were obtained using intracellular techniques to examine the hypothesis that peripheral interactions with the developing heart provide instructive cues for the final differentiation of these neurons. Target-deprived HE motor neurons continued to extend multiple axons in ventral, lateral and dorsal body wall throughout late embryonic and into postembryonic stages and they extended anomalous axons within the CNS. This resembles the early embryonic growth of HE motor neurons before heart tube differentiation. Furthermore, HE motor neurons deprived of heart contact exhibited tonic activity similar to the situation during early development before they are contacted by the CPG interneurons. In contrast, sham-operated and contralateral HE motor neurons oscillated normally. These results suggest that heart tube contact is specifically required for at least some aspects of HE development and provide a framework in which to identify cell-cell interactions that are involved in matching neurons and targets to generate behaviorally relevant neural circuits.

Ultrastructure of an identified array of growth cones and possible substrates for guidance in the embryonic medicinal leech, Hirudo medicinalis.

The oblique muscle organizer (Comb- or C-cell) in the embryonic medicinal leech, Hirudo medicinalis, provides an amenable situation to examine growth cone navigation in vivo. Each of the segmentally iterated C-cells extends an array of growth cones through the body wall along oblique trajectories. C-cell growth cones undergo an early, relatively slow period of extension followed by later, protracted and rapid directed outgrowth. During such transitions in extension, guidance might be mediated by a number of factors, including intrinsic constraints on polarity, spatially and temporally regulated cell and matrix interactions, physical constraints imposed by the environment, or guidance along particular cells in advance of the growth cones. Growth cones and their environment were examined by transmission electron microscopy to define those factors that might play a significant role in migration and guidance in this system. The ultrastructural examination has made the possibility very unlikely that simple, physical constraints play a prominent role in guiding C-cell growth cones. No anatomically defined paths or obliquely aligned channels were found in advance of these growth cones, and there were no identifiable physical boundaries, which might constrain young growth cones to a particular location in the body wall before rapid extension. There were diverse associations with many matrices and basement membranes located above, below, and within the layer in which growth cones appear to extend at the light level. Additionally, a preliminary examination of myocyte assembly upon processes proximal to the growth cones further implicates a role for matrix-associated interactions in muscle histogenesis as well as process outgrowth during embryonic development.

Glial growth factor rescues Schwann cells of mechanoreceptors from denervation-induced apoptosis.

Golgi tendon organs and Pacinian corpuscles are peripheral mechanoreceptors that disappear after denervation during a critical period in early postnatal development. Even if regeneration is allowed to occur, Golgi tendon organs do not reform, and the reformation of Pacinian corpuscles is greatly impaired. The sensory nerve terminals of both types of mechanoreceptors are closely associated with Schwann cells. Here we investigate the changes in the Schwann cells found in Golgi tendon organs and Pacinian corpuscles after nerve resection in the early neonatal period. We report that denervation induces the apoptotic death of these Schwann cells and that this apoptosis can be prevented by administration of a soluble form of neuregulin, glial growth factor 2. Schwann cells associated with these mechanoreceptors are immunoreactive for the neuregulin receptors erbB2, erbB3, and erbB4, and the sensory nerve terminals are immunoreactive for neuregulin. Our results suggest that Schwann cells in developing sensory end organs are trophically dependent on sensory axon terminals and that an axon-derived neuregulin mediates this trophic interaction. The denervation-induced death of mechanoreceptor Schwann cells is correlated with deficiencies in the re-establishment of these sensory end organs by regenerating axons.

Development of segment- and target-related neuronal identity in the medicinal leech.

The rhythmic pumping of the paired heart tubes in the medicinal leech Hirudo medicinalis offers an excellent system for studying the development of a simple behavior in terms of its neuronal and muscular components. The present experiments examined the development of identified heart excitor (HE) motor neurons during normal embryogenesis. Using intracellular impalements and dye-filling, we found that the HE motor neurons could be identified at an early stage of development and that they initially elaborated axonal arborizations in inappropriate target fields in the ventral body wall. These inappropriate projections were retracted as those at the appropriate target (developing heart tube muscle) extended. This remodelling occurred at least 4 days before the HEs acquired the adult phenotype of being driven to fire action potentials in a rhythmic pattern. Although the HEs exhibited centrally driven rhythmic oscillations late in embryogenesis, at earlier stages they exhibited largely a tonic discharge interrupted by bursts of inhibitory potentials in a periodic, but not a rhythmic, pattern. We also found what appeared to be non-rhythmic HE homologs in anterior and posterior segments where HE neurons have not been previously described. These homologs may project along similarly patterned guidance cues early in development, since they are at first indistinguishable from the definitive HEs, but they continued to elaborate both lateral and medial body wall projections over the same period that definitive HEs were expanding their arborizations over the developing heart tube and retracting their body wall projections. In both adult and embryonic leeches the homologs exhibited mostly tonic activity that was interrupted by pronounced, but non-rhythmic, hyperpolarizing postsynaptic potentials. Thus, there appears to be early segmental specification directing the final phenotype of the iterated neuron that, in most segments, becomes the HE motor neuron.

Developmental regulation of a glycolipid epitope on actively extending growth cones and central and peripheral projections in the medicinal leech.

The monoclonal antibody, A2B5, that recognizes vertebrate gangliosides also recognizes embryonic cells in the medicinal leech (Hirudo medicinalis) in a spatially and temporally regulated way. Furthermore, A2B5-positive glycolipids could be isolated from embryonic leeches. Early in development A2B5 labeled axon tracts within the central nervous system coincident with the initial growth of axons, while later in embryogenesis, A2B5 also labeled the forming peripheral nerves. This central and peripheral staining disappeared during the latter third of embryogenesis. A2B5 also labeled the growing tips of an identified myo-organizing cell. This cell, the C-cell, projects an array of parallel processes and exhibits a discrete transition in the rate of growth cone extension (J. Jellies, and W. B. Kristan, Jr. 1991. Dev. Biol. 148, 334-354.). A2B5 failed to recognize the relatively non motile growth cones of the C-cell during early embryogenesis. The C-cell growth cones began to exhibit A2B5 labeling as they became more rapidly extending and this labeling persisted throughout the later motile phase of C-cell growth. In addition to its widespread distribution on embryonic (but not mature) cellular processes, A2B5 also labeled the mitotic profiles of dividing cells in all tissues. Thus, the A2B5 epitope may be presented intracellularly, or both intra- and extracellularly. When glycolipids were extracted from embryonic leeches, partitioned by elution from a silicic acid column, and analyzed using high-performance thin-layer chromatography, at least one of the major glycolipid bands was resorcinol-positive, consistent with presentation of sialic acid residues. The fraction enriched for the resorcinol-positive band was recognized by A2B5 on dot blots, as was ganglioside GQ1b. While potential mechanisms remain to be examined, on the basis of the distinct distribution of the A2B5 epitope and our finding of A2B5-positive glycolipids in leech embryos, we suggest that complex polar glycolipids may play a role in the extension of cellular projections in the medicinal leech.