Anatomic considerations for posterior iliac crest bone procurement.

PURPOSE: The aim of this study was to identify the relative anatomic locations of relevant vital structures at risk for injury during posterior iliac crest bone graft procurement. MATERIALS AND METHODS: Twenty-one cadavers yielded 39 intact posterior ilia for dissection. The posterior superior iliac spine (PSIS) was used as the primary reference landmark. Measurements were made to the medial branch of the superior cluneal nerves, the superior branch of the middle cluneal nerves, the sciatic notch, and the superior gluteal vessels. Distances from the spinal midline to the superior cluneal nerves were recorded. RESULTS: The average distances from the PSIS to the superior and middle cluneal nerves, greater sciatic notch, and superior gluteal vessels were 5.7 cm (standard deviation, 1.22 cm), 6.55 cm (standard deviation, 1.53 cm), 5.3 cm (standard deviation, 0.71 cm), and 5.4 cm (standard deviation, 0.95 cm), respectively. The most medial superior cluneal nerve was identified at 3.0 to 4.9 cm from the PSIS in 23% of cases, at 5.0 to 6.9 cm from the PSIS in 61.5% of cases, and farther than 7.0 cm from the PSIS in 15.4% of cases. CONCLUSIONS: This study illustrates that the most medial superior cluneal nerve is often closer to the PSIS than previously described and the same holds true for the greater sciatic notch and superior gluteal vessels. Knowledge of the anatomic locations of these important structures should allow the surgeon to avoid or decrease the complication rate of bone procurement from the posterior ilium.

Comparable efficacy and lower cost of PBSC mobilization with intermediate-dose cyclophosphamide and G-CSF compared with plerixafor and G-CSF in patients with multiple myeloma treated with novel therapies.

Studies comparing the efficacy and cost of stem cell mobilization with intermediate-dose CY (ID-CY) and G-CSF against plerixafor and G-CSF, specifically in multiple myeloma (MM) patients treated in the novel therapy era, are not available. Eighty-eight consecutive patients undergoing mobilization with ID-CY (3-4 g/m(2)) and G-CSF (n=55) were compared with patients receiving plerixafor and G-CSF (n=33). Compared with plerixafor, ID-CY use was associated with higher median peak peripheral blood CD34+ cell count (68 vs 160 cells/µL, P<0.001), and CD34+ cell yield on day 1 of collection (6.9 × 10(6) vs 11.7 × 10(6) cells/kg, P<0.001). Total CD34+ cell yield was significantly higher in the ID-CY patients (median collection 16.6 × 10(6) vs 11.6 × 10(6) cells/kg; P<0.001). ID-CY use was associated with significantly more frequent episodes of febrile neutropenia (16.3% vs 0%; P=0.02), intravenous antibiotic use (16.3% vs 3%; P=0.03) and hospitalizations (P=0.02). The average total cost of mobilization in the plerixafor group was significantly higher compared with the ID-CY group ($28 980 vs $22 504.8; P=0.001). Our data indicate robust stem cell mobilization in MM patients treated with novel agents, with G-CSF and either ID-CY or plerixafor. When compared with plerixafor, ID-CY-containing mobilization was associated with significantly lower average total mobilization costs.

Identifying environmental drivers of insect phenology across space and time: Culicoides in Scotland as a case study.

Interpreting spatial patterns in the abundance of species over time is a fundamental cornerstone of ecological research. For many species, this type of analysis is hampered by datasets that contain a large proportion of zeros, and data that are overdispersed and spatially autocorrelated. This is particularly true for insects, for which abundance data can fluctuate from zero to many thousands in the space of weeks. Increasingly, an understanding of the ways in which environmental variation drives spatial and temporal patterns in the distribution, abundance and phenology of insects is required for management of pests and vector-borne diseases. In this study, we combine the use of smoothing techniques and generalised linear mixed models to relate environmental drivers to key phenological patterns of two species of biting midges, Culicoides pulicaris and C. impunctatus, of which C. pulicaris has been implicated in transmission of bluetongue in Europe. In so doing, we demonstrate analytical tools for linking the phenology of species with key environmental drivers, despite using a relatively small dataset containing overdispersed and zero-inflated data. We demonstrate the importance of landcover and climatic variables in determining the seasonal abundance of these two vector species, and highlight the need for more empirical data on the effects of temperature and precipitation on the life history traits of palearctic Culicoides spp. in Europe.

Impacts of climate, host and landscape factors on Culicoides species in Scotland.

Culicoides biting midges (Diptera: Ceratopogonidae) vector a wide variety of internationally important arboviral pathogens of livestock and represent a widespread biting nuisance. This study investigated the influence of landscape, host and remotely-sensed climate factors on local abundance of livestock-associated species in Scotland, within a hierarchical generalized linear model framework. The Culicoides obsoletus group and the Culicoides pulicaris group accounted for 56% and 41%, respectively, of adult females trapped. Culicoides impunctatus Goetghebuer and C. pulicaris s.s. Linnaeus were the most abundant and widespread species in the C. pulicaris group (accounting for 29% and 10%, respectively, of females trapped). Abundance models performed well for C. impunctatus, Culicoides deltus Edwards and Culicoides punctatus Meigen (adjusted R(2) : 0.59-0.70), but not for C. pulicaris s.s. (adjusted R(2) : 0.36) and the C. obsoletus group (adjusted R(2) : 0.08). Local-scale abundance patterns were best explained by models combining host, landscape and climate factors. The abundance of C. impunctatus was negatively associated with cattle density, but positively associated with pasture cover, consistent with this species' preference in the larval stage for lightly grazed, wet rush pasture. Predicted abundances of this species varied widely among farms even over short distances (less than a few km). Modelling approaches that may facilitate the more accurate prediction of local abundance patterns for a wider range of Culicoides species are discussed.

Dental appliances with inadequate occlusal coverage: a case report.

A case is presented which illustrates the occlusal problems that can develop when a dental appliance such as a temporomandibular splint with incomplete occlusal cover is worn for a reasonable length of time. As in this case, the selective over-eruption of posterior teeth not incorporated in the appliance can lead to the development of an anterior open bite and an increased overjet. A simple orthodontic method to correct the iatrogenic malocclusion through the re-intrusion of the over-erupted teeth is shown and the importance of providing long-term dental appliances with full occlusal contact is discussed.

Using the Cambridge Neuropsychological Test Automated Battery (CANTAB) to assess the cognitive impact of electroconvulsive therapy on visual and visuospatial memory.

BACKGROUND: The cognitive impact of electroconvulsive therapy (ECT) is rarely measured systematically in everyday clinical practice even though patient and clinician acceptance is limited by its adverse affect on memory. If patients are tested it is often with simple paper and pencil tests of visual or verbal memory. There are no reported studies of computerized neuropsychological testing to assess the cognitive impact of ECT on visuospatial memory. METHOD: Twenty-four patients with severe depression were treated with a course of bilateral ECT and assessed with a battery of visual memory tests within the Cambridge Neuropsychological Test Automated Battery (CANTAB). These included spatial and pattern recognition memory, pattern-location associative learning and a delayed matching to sample test. Testing was carried out before ECT, during ECT, within the week after ECT and 1 month after ECT. RESULTS: Patients showed significant impairments in visual and visuospatial memory both during and within the week after ECT. Most impairments resolved 1 month following ECT; however, significant impairment in spatial recognition memory remained. This is one of only a few studies that have detected anterograde memory deficits more than 2 weeks after treatment. CONCLUSIONS: Patients receiving ECT displayed a range of visual and visuospatial deficits over the course of their treatment. These deficits were most prominent for tasks dependent on the use of the right medial temporal lobe; frontal lobe function may also be implicated. The CANTAB appears to be a useful instrument for measuring the adverse cognitive effects of ECT on aspects of visual and visuospatial memory.

Percutaneous sperm retrieval in secondary azoospermia.

INTRODUCTION: Males presenting for assisted reproduction after vasectomy have a high chance of normal spermatogenesis and of successful surgical sperm retrieval. We aimed to evaluate simple percutaneous methods of retrieving sperm for intracytoplasmic sperm injection in males with secondary azoospermia due to previous vasectomy. PATIENTS AND METHODS: We analyzed a series of post-vasectomy males who presented for sperm retrieval between 1999 and 2005 and who were not being considered for vasal reconstruction as their primary method of re-establishing their fertility. RESULTS: All 132 men had sperm retrieved successfully, 97% with percutaneous methods. In seventy-five percent of the couples intracytoplasmic sperm injection was done, with a total number of 184 cycles being performed. The clinical pregnancy and live birth rates were 25 and 24%, respectively. There were no significant scrotal haematomas, and only 2 patients had postoperative pain after percutaneous sperm retrieval that required analgesia for more than 2 days. CONCLUSION: We have shown that percutaneous sperm retrieval, where normal spermatogenesis is assumed, is successful in all men following vasectomy. Percutaneous methods of retrieving epididymal or testicular sperm are inexpensive, simple and could replace open techniques in men who are not considering vasal reconstruction following vasectomy.

Ameloblastoma: a rare nasal polyp.

Ameloblastoma is an odontogenic neoplasm of enamel organ type tissue which does not undergo transformation to the point of enamel formation. We present the second case in the English literature of maxillary ameloblastoma that presented with nasal obstruction and rhinorrhoea, and the first to be excised using a combined maxillotomy and endoscopic ethmoidectomy. The patient had no previous dental history. The unusual presenting symptoms, as well as the highly destructive nature of these lesions when arising in the maxilla, make them worthy of consideration in the differential diagnosis of nasal and maxillary masses. We discuss the clinical features, pathology and management of these lesions and review the literature.

Identification of viable embryos in IVF by non-invasive measurement of amino acid turnover.

BACKGROUND: IVF is limited by low success rates and an unacceptably high multiple pregnancy rate. These outcomes would be improved significantly if a single embryo of high viability could be replaced in each treatment cycle, but widespread acceptance of such a policy is hindered by the lack of predictive factors for embryo selection. We have conducted a retrospective clinical study of a novel non-invasive method of embryo selection based on the depletion/appearance of amino acids in the culture medium. METHODS: Fifty-three cycles of IVF treatment using ICSI were studied. Embryos were cultured for 24 h in 4 microl drops of medium containing a physiological mixture of 18 amino acids. The spent medium was analysed for amino acid content by high performance liquid chromatography. RESULTS: The turnover of three amino acids, Asn, Gly and Leu, was significantly correlated with a clinical pregnancy and live birth. These correlations were independent of known predictors, such as female age, basal levels of FSH, embryo cell number and embryo morphological grade. CONCLUSIONS: Non-invasive assay of amino acid turnover has the potential to improve significantly the prospective selection of the most viable embryos, or single embryo, for replacement in an IVF cycle.

Cloning, sequencing, expression and allelic sequence diversity of ERG3 (C-5 sterol desaturase gene) in Candida albicans.

The C-5 sterol desaturase gene (ERG3), essential for yeast ergosterol biosynthesis, was cloned and sequenced from Candida albicans by homology with the Saccharomyces cerevisiae ERG3. The ERG3 ORF contained 1158bp and encoded 386 deduced amino acids. The clone was used to transform a gal1 mutant derived from the Darlington strain of C. albicans, using galactose selection. The Darlington strain is known to lack Delta(5,6) sterols, i.e. to have an erg3 phenotype (Howell, S.A., et al., 1990. J. Appl. Bacteriol. 69, 692-696). The transformant (CDTR1) contained six tandem integrated ERG3GAL1 repeats, had double the abundance of ERG3 transcript found in the host strain, and synthesized ergosterol, a Delta(5,6) sterol.The Darlington strain was noted to have an abundance of ERG3 transcript. Both ERG3 alleles in Darlington were cloned and sequenced in order to look for changes that might explain the erg3 phenotype. One allele, called Dar-2, contained a stop codon in place of tryptophan-292. The other ERG3 allele, called Dar-1, had changes in three amino acids, two of which were conserved in three fungal and one plant species. EcoRI genomic fragments containing ERG3 from the Dar-1 allele and from B311, the wild-type strain, were inserted into the plasmid pRS316 and used to transform a Saccharomyces cerevisiae erg3,ura3 mutant using uracil selection. The 4.1kb ERG3 fragments from the B311 and Dar-1 both contained 1. 4kb 5' and 1.5kb 3' flanking sequences around the coding region. Transformants with ERG3 from B311 but not from Dar-1 showed restored ergosterol synthesis. One or more of these three deduced amino acids in the Dar-1 allele of ERG3 appeared critical for function.

A 3 year retrospective review of intrauterine insemination, using cryopreserved donor spermatozoa and cycle monitoring by urinary or serum luteinizing hormone measurements.

Insemination with donor spermatozoa is an integral part of infertility treatment. For the last 3 years in our unit, intrauterine insemination with donor spermatozoa (IUID) has been used in preference to vaginal insemination. In this retrospective study, patients were offered an initial course of five single intrauterine inseminations with cryopreserved donor spermatozoa and treatment was then reviewed. A total of 389 patients received 1465 inseminations. In all, 1119 cycles were monitored using luteinizing hormone serum analyses and 346 cycles using the urine home test kits. The clinical pregnancy rate per insemination for the cycles monitored by the serum assay was 18.0% (202/1119) compared with the urine cycles (13.7%, 46/346) (P <05). The pregnancy loss rate was not significantly different (14.4%, 29/202 and 21.7%, 10/46) (serum and urine cycles respectively). The viable clinical pregnancy rate was significantly higher (P <03) for the serum cycles than for the cycles using the urinary monitoring (15.5%, 173/1119 and 10.4%, 36/346 respectively). The cycles monitored by serum assay had a significantly higher cumulative viable clinical pregnancy rate (P <0001) of 70.2% after nine inseminations compared with the urine monitored cycles of 54.8%. The majority of patients opted for the serum cycles, with a minority self-selecting the urine cycles mainly for travelling convenience. The explanation for the significant differences between the viable clinical pregnancy rates per insemination and the cumulative viable clinical pregnancy rates may be due to the sensitivity of the urine home test kit or the patients' interpretation of the result.

Mechanism of fluconazole resistance in Candida krusei.

The mechanisms of fluconazole resistance in three clinical isolates of Candida krusei were investigated. Analysis of sterols of organisms grown in the absence and presence of fluconazole demonstrated that the predominant sterol of C. krusei is ergosterol and that fluconazole inhibits 14alpha-demethylase in this organism. The 14alpha-demethylase activity in cell extracts of C. krusei was 16- to 46-fold more resistant to inhibition by fluconazole than was 14alpha-demethylase activity in cell extracts of two fluconazole-susceptible strains of Candida albicans. Comparing the carbon monoxide difference spectra of microsomes from C. krusei with those of microsomes from C. albicans indicated that the total cytochrome P-450 content of C. krusei is similar to that of C. albicans. The Soret absorption maximum in these spectra was located at 448 nm for C. krusei and at 450 nm for C. albicans. Finally, the fluconazole accumulation of two of the C. krusei isolates was similar to if not greater than that of C. albicans. Thus, there are significant qualitative differences between the 14alpha-demethylase of C. albicans and C. krusei. In addition, fluconazole resistance in these strains of C. krusei appears to be mediated predominantly by a reduced susceptibility of 14alpha-demethylase to inhibition by this drug.

Fluconazole resistance associated with drug efflux and increased transcription of a drug transporter gene, PDH1, in Candida glabrata.

Sequential Candida glabrata isolates were obtained from the mouth of a patient infected with human immunodeficiency virus type 1 who was receiving high doses of fluconazole for oropharyngeal thrush. Fluconazole-susceptible colonies were replaced by resistant colonies that exhibited both increased fluconazole efflux and increased transcripts of a gene which codes for a protein with 72.5% identity to Pdr5p, an ABC multidrug transporter in Saccharomyces cerevisiae. The deduced protein had a molecular mass of 175 kDa and was composed of two homologous halves, each with six putative transmembrane domains and highly conserved sequences of ATP-binding domains. When the earliest and most azole-susceptible isolate of C. glabrata from this patient was exposed to fluconazole, increased transcripts of the PDR5 homolog appeared, linking azole exposure to regulation of this gene.

Isolation and characterization of fluconazole- and amphotericin B-resistant Candida albicans from blood of two patients with leukemia.

Infections with fluconazole-resistant Candida albicans isolate have rarely been described in clinical settings other than oropharyngeal candidiasis in patients with late-stage AIDS. We report on two patients with leukemia who developed fungemia caused by fluconazole-resistant C. albicans after receiving fluconazole prophylaxis (400 mg/day) and empiric amphotericin B therapy (0.5 mg/kg of body weight per day). The fluconazole MICs for the isolates were > or = 64 micrograms/ml, and the isolates were resistant to other azoles and had membrane sterol changes consistent with a mutation in the delta 5,6-sterol desaturase gene. The lack of ergosterol in the cytoplasmic membrane of the fluconazole-resistant strains also imparted resistance to amphotericin B. Both patients were successfully treated with high-dose amphotericin B (1 to 1.25 mg/kg/day) and flucytosine (150 mg/kg/day).

Fluconazole resistance due to energy-dependent drug efflux in Candida glabrata.

We report on the mechanism of fluconazole resistance in Candida glabrata from a case of infection in which pre- and posttreatment isolates were available for comparison. The resistant, posttreatment isolate was cross-resistant to ketoconazole and itraconazole, in common with other azole-resistant yeasts. Resistance was due to reduced levels of accumulation of [3H]fluconazole rather than to changes at the level of ergosterol biosynthesis. Studies with metabolic or respiratory inhibitors showed that this phenomenon was a consequence of energy-dependent drug efflux, as opposed to a barrier to influx. Since energy-dependent efflux is a characteristic of multidrug resistance in bacteria, yeasts, and mammalian cells, we investigated the possibility that fluconazole resistance is mediated by a multidrug resistance-type mechanism. Benomyl, a substrate for the Candida albicans multidrug resistance protein, showed competition with fluconazole for efflux from resistance C. glabrata isolates, consistent with a common efflux mechanism for these compounds. By contrast, other standard substrates or inhibitors of multidrug resistance proteins had no effect on fluconazole efflux. In conclusion, we have identified energy-dependent efflux of fluconazole, possibly via a multidrug resistance-type transporter, as the mechanism of resistance to fluconazole in C. glabrata.

Orbital subperiosteal abscess and blindness complicating a minimally displaced zygomatic complex fracture.

A case of orbital subperiosteal abscess (SPA) complicating a minimally displaced zygomatic complex (ZMC) fracture is reported and the aetiology and management of this potentially life-threatening condition is discussed. The value of CT scanning in staging orbital infection and determining the site of the abscess and involved paranasal sinuses is emphasised. The correct interpretation of a lateral skull radiograph with the patient brow up may have lead to earlier diagnosis and treatment.

Anterior occipital cervical reconstruction with a free vascularized osteocutaneous graft: a case report.

Free vascularized osteocutaneous bone grafts are an unusual but effective method to reconstruct complex and extensive defects of skin and bone of the extremities due to trauma, tumor, or infections. Many recent publications support their utility in these situations. In distinction, little literature exists to document the use of free vascularized osteocutaneous flaps in the spine. This is likely due to the infrequent occurrence of concomitant skin and osseous defects that are not manageable by routine spinal and plastic surgical approaches. We recently managed a particularly challenging patient in whom six prior operations--three anterior and three posterior--to decompress and stabilize the occipital-cervical junction had failed. We used a free vascularized distal radius osteocutaneous flap for three purposes: to provide the patient with an optimal chance to obtain an extensive and critically important anterior occipital-cervical arthrodesis, to supply a stable soft tissue envelope for protection of a tenuous dural repair, and to reconstruct an atrophic and scarred posterior pharyngeal wall. We are unaware of any report to date that documents the use of a graft of this type in the spine. We wrote this brief article to document the indications for this operation, to illustrate the problems we encountered in this difficult reconstructive situation, and to report on the progress of our patient to date.