Establishment and initial implementation of the Australasian Pelvic Floor Procedure Registry

INTRODUCTION AND HYPOTHESIS

Stress urinary incontinence (SUI) and pelvic organ prolapse (POP) are common pelvic floor disorders (PFDs). Owing to significant adverse events associated with mesh-related pelvic floor procedures (PFPs) in a proportion of the surgically treated population, and deficits in collection and reporting of these events, the Australian Government identified an urgent need for a tracking mechanism to improve safety and quality of care. The Australasian Pelvic Floor Procedure Registry (APFPR) was recently established following the 2018 Senate Committee Inquiry with the aim of tracking outcomes of PFP involving the use of devices and/or prostheses, with the objective of improving the health outcomes of women who undergo these procedures. This paper will describe the APFPR's aims, development, implementation and possible challenges on the way to its establishment.

METHODS

The APFPR has been developed and implemented in accordance with the national operating principles of clinical quality registries (CQRs). The minimum datasets (MDS) for the registry's database have been developed using a modified Delphi process, and data are primarily being collected from participating surgeons. Patient recruitment is based on an opt-out approach or a waiver of consent. Patient-reported outcome measures (PROMs) providing additional health and outcome information will be obtained from participating women to support safety monitoring of mesh-related adverse events.

RESULTS

Currently in the Australasian Pelvic Floor Procedure Registry (APFPR) there are 32 sites from various jurisdictions across Australia, that have obtained relevant ethics and governance approvals to start patient recruitment and data collection as of January 2023. Additionally, there are two sites that are awaiting governance review and five sites that are having documentation compiled for submission. Seventeen sites have commenced patient registration and have entered data into the database. Thus far, we have 308 patients registered in the APFPR database. The registry also published its first status report and a consumer-friendly public report in 2022.

CONCLUSIONS

The registry will act as a systematic tracking mechanism by collecting outcomes on PFP, especially those involving devices and/or prostheses to improve safety and quality of care.

Electronic properties of the interface between p-CuI and anatase-phase n-TiO2 single crystal and nanoparticulate surfaces: A photoemission study

We present a study of the growth of the p-type inorganic semiconductor CuI on n-type TiO2 anatase single crystal (101) surfaces and on nanoparticulate anatase surfaces using synchrotron radiation photoemission spectroscopy. Core level photoemission data obtained using synchrotron radiation reveal that both the substrate (TiO2) and the overlayer (CuI) core levels shift to a lower binding energy to different degrees following the growth of CuI on TiO2. Valence band photoemission data show that the valence band maximum of the clean substrate differs from that of the dosed surface which may be interpreted qualitatively as due to the introduction of a new density of states within the band gap of TiO2 as a result of the growth of CuI. The valence band offset for the heterojunction n-TiO2p-CuI has been measured using photoemission for both nanoparticulate and single crystal TiO2 surfaces, and the band energy alignment for these heterojunction interfaces is presented. With the information obtained here, it is suggested that the interface between p-CuI and single crystal anatase-phase n-TiO2 is a type-II heterojunction interface, with significant band bending. The measured total band bending matches the work function change at the interface, i.e., there is no interface dipole. In the case of the nanoparticulate interface, an interface dipole is found, but band bending within the anatase nanoparticles remains quite significant. We show that the corresponding depletion layer may be accommodated within the dimension of the nanoparticles. The results are discussed in the context of the functional properties of dye-sensitized solid state solar cells.

Subspecialty adnexal ophthalmological examination using telemedicine

We studied the clinical outcome of examination of a group of patients with adnexal (eyelid and orbit) conditions. Seventeen patients with adnexal problems were assessed by an ophthalmologist at a distance using telemedicine, and then subsequently by an ophthalmologist in a face-to-face consultation. Measurements such as palpebral aperture, levator muscle function and eyelid skin crease position were recorded. The clinical outcomes from both consultations were recorded independently by the consultants and then compared. The study showed that certain adnexal conditions, such as congenital and involutional ptosis, could be accurately assessed using telemedicine, but that other conditions, such as socket problems in patients who had a previous enucleation or those with non-specific ocular pain with less clear-cut features, were better assessed in a face-to-face consultation. Overall, teleconsultations appeared to be suitable for the assessment of uncomplicated ptosis but not for less well defined conditions. Other factors, such as family dynamics and language problems, also limited the usefulness of the technique.

Validation and development of fluorescence two-dimensional differential gel electrophoresis proteomics technology

Fluorescence two-dimensional differential gel electrophoresis (2-D DIGE*) is a new development in protein detection for two-dimensional gels. Using mouse liver homogenates (control and paracetamol (N-acetyl-p-aminophenol, APAP)-treated), we have determined the quantitative variation in the 2-D DIGE process and established statistically valid thresholds for assigning quantitative changes between samples. Thresholds were dependent on normalised spot volume, ranged from approximately 1.2 fold for large volume spots to 3.5 fold for small volume spots and were not markedly affected by the particular cyanine dye combination or by multiple operators carrying out the dye labelling reaction. To minimise the thresholds, substantial user editing was required when using ImageMaster 2D-Elite software. The difference thresholds were applied to the test system and quantitative protein differences were determined using replicate gels of pool samples and single gels from multiple individual animals (control vs treated in each gel). Throughout, the differences revealed with a particular cyanine dye combination were mirrored almost without exception when the dye combination was reversed. Both pool and individual sample analyses provided unique data to the study. The inter-animal response variability in inbred mice was approximately nine times that contributed by the 2-D DIGE process. A number of the most frequently observed protein changes resulting from APAP-treatment were identified by mass spectrometry. Several of these can be rationalised based on available data on the mechanism of APAP hepatotoxicity but others cannot, indicating that proteomics can provide further insights into the biochemical basis of APAP toxicity.

NMR study of a heterochiral DNA hairpin:impact of L-enantiomery in the loop

We carried out a structural study of the DNA heterochiral strand d (AGCTTATCAT(L)CGATAAGCT), -AT(L)C-, where T(L) (L thymine ) replaces T (natural D-thymine). -AT(L)C- is a structural analog of -ATC- that belongs to a strong topoisomerase II DNA cleavage site and which has been shown to resolve into a hairpin structure with a stem formed by eight Waston-Crick base-pairs and a single residue loop closed by an A.C sheared base-pair. Although - AT(L)C-, like its parent -ATC-, folds into a hairpin structure at low and high DNA concentrations it displays a lower stability (Tm of 56 degrees C versus 58.5 degrees C). Several NMR features in -AT(L)C- account for the disruption of the A.C pairing in the loop and a weakening of the C.G base-pair stability at the stem-loop junction. For instance, the exchange of the loop imino protons with solvent is accelerated compared with the natural oligonucleotide -ATC-. The higher flexibility of the heterochiral loop is confirmed by the results of NMR restrained molecular dynamics. In the calculated final structures of -AT(L)C-, the T10(L) residue moves the A9 and C11 residues away, thus preventing the loop closure through a C.A sheared base-pair and the achievement of a good base-base or sugar-base stacking. Actually, most of the stabilizing interactions present in -ATC- are lost in the heterochiral - AT(L)C- explaining its weaker stability.

Quantitative proteomic analysis of mouse liver response to the peroxisome proliferator diethylhexylphthalate (DEHP)

Peroxisome proliferators (PPs) are a diverse group of chemicals that cause hepatic proliferation, suppression of apoptosis, peroxisome proliferation and liver tumours in rodents. The biochemical response to PPs involves changes in the expression of peroxisomal beta-oxidation enzymes and fatty acid transport proteins such as acyl-CoA oxidase and liver fatty acid binding protein. The response to PPs is mediated by the peroxisome proliferator-activated receptor alpha (PPARalpha) and the livers of PPARalpha-null transgenic mice do not develop tumours in response to PPs. In order to identify the molecular pathways underlying the adverse effects of PPs in rodent liver, we carried out two-dimensional differential gel electrophoresis to provide quantitative proteomic analyses of diethylhexylphthalate (DEHP)-treated wild-type or PPARalpha-null mouse livers. Since tumourigenesis is both PP- and PPARalpha-dependent, analyses were focused on these changes. Fifty-nine proteins were identified where altered expression was both PPARalpha- and PP-dependent. In addition, six proteins regulated by the deletion of PPARalpha were identified, possibly indicating an adaptive change in response to the loss of this receptor. The proteins that we identified as being regulated by PPARalpha are known to be involved in lipid metabolism pathways, but also in amino acid and carbohydrate metabolism, mitochondrial bioenergetics and in stress responses including several genes not previously reported to be regulated by PPARalpha. These data provide novel insights into the pathways utilised by PPs and may assist in the identification of early markers rodent nongenotoxic hepatocarcinogenesis.

Validation and development of fluorescence two-dimensional differential gel electrophoresis proteomics technology

Fluorescence two-dimensional differential gel electrophoresis (2-D DIGE*) is a new development in protein detection for two-dimensional gels. Using mouse liver homogenates (control and paracetamol (N-acetyl-p-aminophenol, APAP)-treated), we have determined the quantitative variation in the 2-D DIGE process and established statistically valid thresholds for assigning quantitative changes between samples. Thresholds were dependent on normalised spot volume, ranged from approximately 1.2 fold for large volume spots to 3.5 fold for small volume spots and were not markedly affected by the particular cyanine dye combination or by multiple operators carrying out the dye labelling reaction. To minimise the thresholds, substantial user editing was required when using ImageMaster 2D-Elite software. The difference thresholds were applied to the test system and quantitative protein differences were determined using replicate gels of pool samples and single gels from multiple individual animals (control vs treated in each gel). Throughout, the differences revealed with a particular cyanine dye combination were mirrored almost without exception when the dye combination was reversed. Both pool and individual sample analyses provided unique data to the study. The inter-animal response variability in inbred mice was approximately nine times that contributed by the 2-D DIGE process. A number of the most frequently observed protein changes resulting from APAP-treatment were identified by mass spectrometry. Several of these can be rationalised based on available data on the mechanism of APAP hepatotoxicity but others cannot, indicating that proteomics can provide further insights into the biochemical basis of APAP toxicity.

Proteomic analysis of differential protein expression in primary hepatocytes induced by EGF, tumour necrosis factor alpha or the peroxisome proliferator nafenopin

Peroxisome proliferators are nongenotoxic rodent-liver carcinogens that have been shown to cause both an induction of hepatocyte proliferation and a suppression of apoptosis. Both epidermal growth factor (EGF) and the peroxisome proliferator nafenopin induce DNA replication in primary rat hepatocyte cultures, but apparently through different signalling pathways. However, both EGF and nafenopin require tumour necrosis factor alpha (TNFalpha) signalling to induce DNA replication. By examining proteins isolated from rat primary hepatocyte cultures using two-dimensional gel electrophoresis and mass spectrometry, we found that proteins showing an altered expression pattern in response to nafenopin differed from those showing altered expression in response to EGF. However, many proteins showing altered expression upon stimulation with TNFalpha were common to both the EGF and nafenopin responses. These proteome profiling experiments contribute to a better understanding of the molecular mechanisms involved in the response to peroxisome proliferators. We found 32 proteins with altered expression upon stimulation with nafenopin, including muscarinic acetylcholine receptor 3, intermediate filament vimentin and the beta subunit of the ATP synthase. These nonperoxisomal protein targets offer insights into the mechanisms of peroxisome proliferator-induced carcinogenesis in rodents and provide opportunities to identify toxicological markers to facilitate early identification of nongenotoxic carcinogens.

Sustained ex vivo and in vivo transfer of a reporter gene using polyoma virus pseudocapsids

Properties of a virus-like artificial gene delivery vehicle, synthesised from recombinant major coat protein of mouse polyoma virus, have been explored. The protein, VP1, self assembles into protein spheres, or 'pseudocapsids, which can bind and transfer DNA into cells in vitro and in vivo. Here, the ability of pseudocapsids to carry DNA into a complex cell system (ex vivo organ cultures of rabbit cornea) or whole animals (mice) has been assessed. Evidence from histochemical and PCR experiments indicate that pseudocapsids stimulate uptake and stable maintenance of marker DNA in nondividing corneal cells as efficiently as a recombinant adenovirus. In athymic and immunocompetent mice, gene transmission occurs with no apparent adverse effects on the animals. In the presence of pseudocapsids, the marker gene was transferred to a range of organs, including the brains of animals, following peripheral or intranasal administration. In immunocompetent mice, significant long-term transcriptional expression (at least 22 weeks) was observed with pseudocapsids, a period significantly longer than observed with DNA alone (several weeks only), again with no obvious adverse effects. This study demonstrates that pseudocapsids from the murine virus, polyoma, constitute a novel transfer agent for long-term gene therapeutic applications in tissues or whole animals.

Principles for Sustainable Governance of the Oceans

Pressures being exerted on the ocean ecosystems through overfishing, pollution, and environmental and climate change are increasing. Six core principles are proposed to guide governance and use of ocean resources and to promote sustainability. Examples of governance structures that embody these principles are given.

MerMade: an oligodeoxyribonucleotide synthesizer for high throughput oligonucleotide production in dual 96-well plates

We have designed and constructed a machine that synthesizes two standard 96-well plates of oligonucleotides in a single run using standard phosphoramidite chemistry. The machine is capable of making a combination of standard, degenerate, or modified oligos in a single plate. The run time is typically 17 hr for two plates of 20-mers and a reaction scale of 40 nM. The reaction vessel is a standard polypropylene 96-well plate with a hole drilled in the bottom of each well. The two plates are placed in separate vacuum chucks and mounted on an xy table. Each well in turn is positioned under the appropriate reagent injection line and the reagent is injected by switching a dedicated valve. All aspects of machine operation are controlled by a Macintosh computer, which also guides the user through the startup and shutdown procedures, provides a continuous update on the status of the run, and facilitates a number of service procedures that need to be carried out periodically. Over 25,000 oligos have been synthesized for use in dye terminator sequencing reactions, polymerase chain reactions (PCRs), hybridization, and RT-PCR. Oligos up to 100 bases in length have been made with a coupling efficiency in excess of 99%. These machines, working in conjunction with our oligo prediction code are particularly well suited to application in automated high throughput genomic sequencing.

Natural history of recurrent erosion syndrome--a 4 year review of 117 patients

AIMS/BACKGROUND

Recurrent erosion syndrome encompasses a group of mixed aetiologies for which there are a number of methods of management which may influence the course of the disease.

METHODS

The outcomes of a cohort of patients initially treated with topical lubricants were studied. 117 consecutive patients presenting over 1 year with a history of recurrent erosions were enrolled, baseline characteristics were documented, and treatment with lubricants was initiated. Patients were surveyed 4 years later inquiring about symptoms and treatments required.

RESULTS

A total of 94 (80%) of the initial cohort were contacted. The mean age was 44 years and the sex distribution was 44 males to 50 females. The mean period of follow up was 48 months. 55 (59%) were still symptomatic with attacks occurring at a median frequency of 60 days. 13 patients (24%) complained of an episode at least every week and 28 patients (51%) suffered at least every month. The median pain score (analogue scale of 1-10) was 2.5. Seventy five per cent (n = 21) of patients with epithelial basement membrane dystrophy (EBMD) were symptomatic compared with those with a traumatic aetiology among whom 46% (n = 28) were symptomatic. This difference was significant (p = 0.02). Those with EBMD were more likely to be continuing to use topical lubricants than the trauma group.

CONCLUSION

Patients with a traumatic aetiology are less likely to suffer chronic recurrent erosion syndrome than those with EBMD.

Lipaemia retinalis: a question of chylomicrons?

Lipaemia retinalis is a rarely described condition which occurs in certain types of both primary and secondary hyperlipidaemia. It presents with a striking fundal appearance. We report 7 cases of lipaemia retinalis and ocular manifestations in hyperlipidaemia which presented over a 12 year period to our hospitals. These illustrate the different presentations and stages of the disease, and other fundal abnormalities seen in hyperlipidaemia.

Purification and characterization of endogenous peptides extracted from HLA-DR isolated from the spleen of a patient with rheumatoid arthritis

We have purified HLA-DR from the spleen of a patient with rheumatoid arthritis. The patient had Felty's syndrome and was heterozygous for the DR4Dw4 antigen. We have isolated endogenous peptides from purified HLA-DR molecules. The peptides were purified by reverse phase HPLC and the major peaks were subjected to N-terminal sequencing. The peptides were derived from a variety of proteins: human serum albumin, human erythroid protein 4.1, 60S ribosomal proteins L31 and L35, VCAM-1, human immunoglobulin lambda chain and cathepsin-S. A peptide corresponding to the sequence of human serum albumin (HSA) residues 106-120 was synthesized and shown to bind to HLA-DR4Dw4 (IC50 = 1.41 microM). We have confirmed and refined current ideas about the structural motif for the binding of peptides to HLA-DR and HLA-DR4Dw4.

Management of impotence due to spinal cord injury using low dose papaverine

Erectile dysfunction is a common complication of spinal cord injury. Of the 68 spinal cord injured men in whom treatment with papaverine was initiated a therapeutic dosage was determined in 50 (74%). Papaverine was injected into the base of one corpora cavernosum. The dose started at 3 mg and was increased at weekly or longer intervals until an effective dose was determined. There were 15 (30%) men with tetraplegia and 35 (70%) men with paraplegia. The dosage of papaverine did not relate to the level or extent of injury. Doses of 12 mg or less were used in 56% of patients. Low dose papaverine is a safe and effective means of restoring erections in spinal cord injured men.

A comparison of rhodamine 123 accumulation and efflux in cells with P-glycoprotein-mediated and MRP-associated multidrug resistance phenotypes

Rhodamine 123 (Rh123) is a fluorescent dye which locates in the mitochondria of cells. It is a substrate for P-glycoprotein (Pgp) and can, therefore, be used as a molecular probe in studies of the multidrug resistance (MDR) phenotype. However, not all MDR cells overexpress Pgp. In some, the MDR phenotype is associated with expression of an alternative transporter molecule, the multidrug resistance-associated protein (MRP). We have studied the accumulation and efflux of Rh123 in MDR cells having both Pgp-mediated and MRP-associated phenotypes. In the mouse tumour parental cell line, EMT6/P, Rh123 accumulates rapidly to reach plateau levels by 90 min. Confocal microscopy confirms a localisation to the mitochondria. In the MDR subline, EMT6/AR1.0, which overexpresses Pgp and which is 10-fold resistant to Rh123 cytotoxicity, accumulation is dramatically reduced. Efflux of Rh123 from both resistant and parental lines is rapid but can be inhibited by reduced temperature or by the presence of cyclosporin A (5 micrograms/ml). Efflux from the parental line is probably due to the presence of very low, but detectable, levels of Pgp but the existence of other mechanisms cannot be ruled out. In contrast, the human lung cancer parental cell line COR-L23/P, and its MRP-associated (but Pgp-negative) MDR subline, COR-L23/R (which is 23-fold resistant to Rh123 cytotoxicity), accumulate Rh123 at similar rates for the first 30 min. The curves then diverge so that, at 180 min, the resistant cells contain only 70% of the Rh123 of parental cells. Confocal microscopy demonstrates a similar distribution of fluorescence in resistant and parental cells. Essentially no efflux of Rh123 occurs from parental cells, whereas 70% of the content is lost from resistant cells over a period of 150 min. Such efflux may again be inhibited by reduced temperature but cyclosporin A (5 micrograms/ml) has little effect. These observations should be borne in mind when interpreting Rh123 efflux data in terms of MDR mechanisms.

Galactorrhea: a complication of spinal cord injury

Galactorrhea, a secretion of milk or milk-like products from the breast in the absence of parturition, has been reported to occur in women with spinal cord injuries in association with amenorrhea and hyperprolactinemia. Four cases of galactorrhea in association with spinal cord injury are reported. Galactorrhea developed in four spinal cord injured women who had thoracic paraplegia. The onset of galactorrhea was from one month to five months after injury. Although the onset of galactorrhea may have been related to prescribed medications in all four cases, insufficient data exist to draw conclusions. The three women whose galactorrhea persisted declined treatment and galactorrhea continuing for more than two years in one instance. We conclude that galactorrhea with or without amenorrhea may develop after a spinal cord injury and that spinal cord injured women may have an enhanced sensitivity to medication-induced galactorrhea.

Increasing the proliferative capacity of muscular dystrophy myoblasts

Temperature-sensitive immortalized neural cells may be utilized to produce genetically engineered neural transplants. We have used a similar approach with mdx myoblasts. Control and mdx myoblasts were immortalized with a recombinant retrovirus that effects the expression of a temperature-sensitive simian virus 40 large T antigen. The resultant cells divide indefinitely at 34 degrees C, but differentiate at 38 degrees C, both morphologically and immunocytochemically. Polymerase chain reaction analysis of RNA confirmed the presence of the dystrophin point mutation in the mdx cells and its absence in the control cells. A similar approach may be useful for the proliferation, modification, and reimplantation of autologous cells from patients with degenerative and dystrophic disorders such as Duchenne muscular dystrophy.