Risk for transmission of Naegleria fowleri from solid organ transplantation.

Primary amebic meningoencephalitis (PAM) caused by the free-living ameba (FLA) Naegleria fowleri is a rare but rapidly fatal disease of the central nervous system (CNS) affecting predominantly young, previously healthy persons. No effective chemotherapeutic prophylaxis or treatment has been identified. Recently, three transplant-associated clusters of encephalitis caused by another FLA, Balamuthia mandrillaris, have occurred, prompting questions regarding the suitability of extra-CNS solid organ transplantation from donors with PAM. During 1995-2012, 21 transplant recipients of solid organs donated by five patients with fatal cases of PAM were reported in the United States. None of the recipients developed PAM, and several recipients tested negative for N. fowleri by serology. However, historical PAM case reports and animal experiments with N. fowleri, combined with new postmortem findings from four patients with PAM, suggest that extra-CNS dissemination of N. fowleri can occur and might pose a risk for disease transmission via transplantation. The risks of transplantation with an organ possibly harboring N. fowleri should be carefully weighed for each individual recipient against the potentially greater risk of delaying transplantation while waiting for another suitable organ. In this article, we present a case series and review existing data to inform such risk assessments.

Digital sculpting in surgery: a novel approach to depicting mesosigmoid mobilization.

BACKGROUND: The aim of the present study was to develop a unique anatomic replica of the mesocolon using digital graphical software in order to provide an educational template for mesosigmoidectomy. METHODS: The colon and mesocolon were fully mobilized from ileocecal to mesorectal levels in a cadaver. Both colon and mesocolon provided a template from which to generate a three dimensional replica in ZBrush. The model was deformed in ZBrush, to compare and contrast current and classic interpretations of mesosigmoidal topography. An animation was developed in which the replica was deformed to mimic operative mobilization. Contiguous shape changes were captured in two-and-a-half-dimensional (2.5D) screen snapshots. This was repeated for medial to lateral and lateral to medial mobilization of the mesosigmoid. RESULTS: Topographic differences between classic and current appraisals of mesocolic anatomy were evident in 2.5D format. Using the model generated, contiguous shape changes during mesosigmoidal mobilization (i.e., between the left mesocolon, mobile/apposed mesosigmoid, and mesorectum) were replicated in animation format. By extracting and compiling 2.5D screen grabs a pictorial chronology of mobilization was developed. CONCLUSIONS: Recent advances in mesocolic topography can be captured and rendered using advanced digital sculpting software with high-end graphics capabilities. This approach permits a depiction of contiguous changes in mesosigmoidal topography during mesosigmoidal mobilization. A compilation of images in either animation or screen grab format obviates the interpolation of shape changes required using standard educational approaches.

Application of EU tissue and cell directive screening protocols to anonymous oocyte donors in western Ukraine: data from an Irish IVF programme.

Anonymous oocyte donation in the EU proceeds only after rigorous screening designed to ensure gamete safety. If anonymous donor gametes originating from outside EU territory are used by EU patients, donor testing must conform to the same standards as if gamete procurement had occurred in the EU. In Ireland, IVF recipients can be matched to anonymous donors in the Ukraine (a non-EU country). This investigation describes the evolution of anonymous oocyte donor screening methods during this period and associated results. Data were reviewed for all participants in an anonymous donor oocyte IVF programme from 2006 to 2009, when testing consistent with contemporary EU screening requirements was performed on all Ukrainian oocyte donors. HIV and hepatitis tests were aggregated from 314 anonymous oocyte donors and 265 recipients. The results included 5,524 Ukrainian women who were interviewed and 314 of these entered the programme (5.7% accession rate). Mean age of anonymous oocyte donors was 27.9 years; all had achieved at least one delivery. No case of hepatitis or HIV was detected at initial screening or at oocyte procurement. This is the first study of HIV and hepatitis incidence specifically among Ukrainian oocyte donors. We find anonymous oocyte donors to be a low-risk group, despite a high background HIV rate. Following full disclosure of the donation process, most Ukrainian women wishing to volunteer as anonymous oocyte donors do not participate. Current EU screening requirements appear adequate to maintain patient safety in the context of anonymous donor oocyte IVF.

Who abandons embryos after IVF?

This investigation describes features of in vitro fertilisation (IVF) patients who never returned to claim their embryos following cryopreservation. Frozen embryo data were reviewed to establish communication patterns between patient and clinic; embryos were considered abandoned when 1) an IVF patient with frozen embryo/s stored at our facility failed to make contact with our clinic for > 2 yrs and 2) the patient could not be located after a multi-modal outreach effort was undertaken. For these patients, telephone numbers had been disconnected and no forwarding address was available. Patient, spouse and emergency family contact/s all escaped detection efforts despite an exhaustive public database search including death records and Internet directory portals. From 3244 IVF cycles completed from 2000 to 2008, > or = 1 embryo was frozen in 1159 cases (35.7%). Those without correspondence for > 2 yrs accounted for 292 (25.2%) patients with frozen embryos; 281 were contacted by methods including registered (signature involving abandoned embryos did not differ substantially from other patients. The goal of having a baby was achieved by 10/11 patients either by spontaneous conception, adoption or IVF. One patient moved away with conception status unconfirmed. The overall rate of embryo abandonment was 11/1159 (< 1%) in this IVF population. Pre-IVF counselling minimises, but does not totally eliminate, the problem of abandoned embryos. As the number of abandoned embryos from IVF accumulates, their fate urgently requires clarification. We propose that clinicians develop a policy consistent with relevant Irish Constitutional provisions to address this medical dilemma.

First Irish pregnancies after IVF with gestational carrier.

In this report, our early experience with screening, monitoring and coordinating IVF utilising gestational carrier treatment is described. Although congenital and iatrogenic etiologies for uterine factor infertility manifest distinctly different reasons for considering a gestational carrier approach, we outline a unified management strategy for both conditions. One patient had congenital absence of the uterus and proximal vagina (Mayer-Rokitansky-Kuster-Hauser syndrome variant), while another patient presented post-hysterectomy and adjuvant brachytherapy for invasive squamous cervical carcinoma. Conception was established for both patients, the first pregnancies to be achieved using an IVF/gestational carrier technique in Ireland. As demonstrated here, selected patients with at least one intact ovary who suffer from uterine factor infertility can be excellent candidates for IVF with embryo transfer to a carefully screened gestational carrier. The role of individual and group counselling is reviewed; professional legal advice is prudent in complex cases.

Blastocyst transfer for multiple prior IVF failure: a five year descriptive study.

Patients with recurrent IVF failure are generally regarded as having a poor prognosis, and when female age exceeds 35 yrs such patients face a particularly bleak outlook. This study reported on blastocyst transfer (BT) performed over a five-year interval in patients seeking "second opinion" after multiple failed IVF cycles. Clinical features and reproductive outcomes were compared between two sets of poor-prognosis IVF patients undergoing BT for the first time, the initial group underwent treatment in 2002 (n=66) and a second group presented five years later (n=392). The two clinical sets had no patients in common. The 2002 group had an average of 3.5 (+/- 1.1) prior failed IVF cycles at baseline, and mean (+/- SD) patient age was 36.4 (+/- 3.9) yrs. Average number of oocytes retrieved in this group was 10.4 (+/- 5.3) with a fertilisation rate of 58.8%. Although embryo arrest resulted in no transfer for 19 patients (28.8%), clinical pregnancy was achieved for 59.6% of transfers. Five years later, 392 patients underwent BT, but this group had an average of 4.5 (+/- 2.3) prior failed IVF cycles. Mean (+/- SD) female age was 36.0 (+/- 3.9) yrs, and the average number of oocytes retrieved in this group was 9.1 (+/- 5.4); the fertilisation rate was 59.5%. No blastocysts were available for transfer in 99 cases (25.3%); clinical pregnancy was achieved for 50.0% of transfers. The number of blastocysts transferred was similar in the two groups (1.6 vs. 1.3; p=0.06); the twinning rate rose slightly from 8.2% to 15.1% (p=0.12) despite an increased utilisation of single embryo transfer in 2007 (19.7% vs. 22.2%; p=0.40). Comparisons from 2002 and 2007 found no important differences between the two patient groups, except for a significantly higher rate of prior failed cycles in the 2007 group (p<0.001). This refractoriness was accompanied by a somewhat reduced blastocyst cryopreservation rate in 2007, compared to 2002 (27.6% vs. 29.5%; p=0.44). Clinical pregnancy rates are not adversely affected by application of BT in patients with multiple prior unsuccessful IVF cycles. For these patients, our data suggest that extended embryo culture and BT should be considered. Further controlled studies are needed to document more precisely the role of BT in this sub-set of refractory IVF patients.

Intercellular adhesion molecule-1 expression in endothelial cells is activated by cytomegalovirus immediate early proteins.

BACKGROUND: Human cytomegalovirus (HCMV) infection is associated with allograft vasculopathy and rejection. One potential mechanism is vascular injury from immunologically mediated processes. HCMV infection has been shown to increase the constitutive expression of intercellular adhesion molecule-1 (ICAM-1). The objective of this study was to determine the molecular basis of HCMV enhanced ICAM-1 gene expression in endothelial cells using human umbilical vein endothelial cells (HUVECs) as a model. METHODS: HUVECS were infected with HCMV virus and the level of ICAM-1 mRNA determined over time. HUVECS were then transiently transfected with plasmid constructs containing ICAM-1 and HCMV immediate early (IE) gene sequences and the effect of IE proteins on ICAM-1 promoter expression determined. Antibodies to cytokines known to be affected by HCMV IE proteins or to modulate ICAM-1 expression were added to determine if cytokines were mediating ICAM-1 expression. RESULTS: Infection of HUVECs with HCMV resulted in a rapid rise in ICAM-1 mRNA levels, suggesting that the viral IE proteins were involved in gene activation. The HCMV IE1 and IE2 proteins synergistically activated both transfected and endogenous ICAM-1 gene expression. The addition of antibodies to interleukin-1, tumor necrosis factor-a, transforming growth factor-beta, or interleukin-6 had no effect on the IE protein-mediated increase in ICAM-1 expression. Deletion analysis of the ICAM-1 gene promoter revealed that a minimum of 370 base pairs of 5' flanking sequences was required for maximal transactivation by IE proteins; mutation analysis showed that an NFkappaB site at base pairs -187 to -178 was not required for promoter activation. CONCLUSIONS: These results demonstrate that HCMV regulates the heterologous ICAM-1 gene promoter in endothelial cells not via cellular cytokine production, but rather by a direct effect of IE proteins, and supports a model in which HCMV IE gene products interact with ICAM-1 promoter elements to increase gene expression.

Vision beyond the resolution limit: aliasing in the periphery.

Pattern resolution is generally considered a prerequisite for spatial vision because details too fine to be resolved cannot be distinguished from a uniform field. However, our experiments using peripheral vision demonstrate that reliable pattern detection is possible for images far beyond the resolution limit. The visual percept which arises in this case is an illusion called aliasing in which the apparent spatial structure of the stimulus is quite different from that actually present. Aliasing begins at spatial frequencies just above the classical resolution limit, which is taken as evidence that peripheral resolution is limited by the coarse spacing of visual neurons rather than by increased size of their receptive fields. At a given eccentricity, the very finest pattern which produces aliasing has a spatial period which approaches the smallest anatomical dimension: the diameter of a single cone photoreceptor.

Urinary drainage following radical hysterectomy for cervical carcinoma - a pilot comparison of urethral and suprapubic routes.

Twenty-four patients who underwent radical hysterectomy and pelvic node dissection for cervical carcinoma were randomized in a pilot study to compare continuous postoperative drainage by urethral and suprapubic catheters. There were no statistically significant differences in either the duration of continuous catheter drainage before the return of spontaneous voiding or the incidence of urinary tract infection in the two groups. Power calculations reveal that 628 patients require to be entered into each arm of a future study in order to be able to detect the former difference should it exist (alpha = 0.05, beta = 0.2, difference = 16% of one s.d.) and 41 in the latter (alpha = 0.05, beta = 0.2, 92.9% urethral group had UTI, 70% suprapubic group had UTI). We conclude that differences in these objective measures of catheter efficacy and morbidity between the groups, if they exist, are clinically irrelevant. On this basis we suggest that individual gynaecological oncologists should continue to use whichever method of catheter drainage best suits their clinical practice.

Normal high-resolution cerebral 99mTc-HMPAO SPECT scans in symptomatic neonates exposed to cocaine.

Vascular constriction is said to account for a variety of clinical effects of cocaine. High-resolution 99mTc-hexamethylpropylene amine oxime single photon emission computed tomographic (SPECT) scans, which measure cerebral blood flow, were used to determine whether neonatal brain perfusion deficits are present in newborns with confirmed cocaine exposure. Normal, age-appropriate SPECT scans were found in 21 babies. Conventional neuroimaging was also performed when possible. All but one of the 14 magnetic resonance imaging (MRI) scans and one computed tomographic scan were normal. One MRI showed a mild delay in myelination. All but four neonates had behavioral or electroencephalographic abnormalities, and microcephaly was found in five of 21. The normal neonatal SPECT scans contrast with findings in adult cocaine users, which typically report abnormal findings of cerebral hypoperfusion. This study identifies a unique lack of corresponding cerebral vascular pathology in symptomatic neonates. It raises the possibility that many of these children can escape significant ischemic injury.

Modification of the furanacryloyl-L-phenylalanylglycylglycine assay for determination of angiotensin-I-converting enzyme inhibitory activity.

Angiotensin-I-converting enzyme (ACE, EC 3.4.15.1) plays a central role in the regulation of blood pressure in man. The objective of this study was to evaluate and modify the furanacryloyl-L-phenylalanylglycylglycine (FAPGG) assay method for quantification of ACE activity. The fixed time conditions developed for assay of ACE activity were as follows: 0.8 mM FAPGG, 175 + or - 10 units l(-1) ACE, incubation at 37 degrees C for 30 min and enzyme inactivation with 100 mM ethylenediaminetetra-acetic acid (EDTA). Hydrolysis of FAPGG to FAP and GG was quantified by measuring the decrease in absorbance at 340 nm. It was shown that increasing the level ACE activity in the assay from 155 to 221 + or - 15 units l(-1) resulted in a corresponding increase in the apparent IC(50) value for Captopril from 9.10 to 39.40 nM. Similar trends in the apparent IC50 values for a whey protein hydrolysate were obtained. The results demonstrate the requirement for carefully controlling ACE activity levels in the assay in order to obtained comparable and reproducible values for the inhibitory potency of ACE inhibitors.

Isolation of deoxyribonucleic acid (DNA) from saliva and forensic science samples containing saliva.

Saliva and saliva-stained materials were examined as potential sources of deoxyribonucleic acid (DNA) for DNA analysis and identity testing. In this paper, the authors demonstrate that DNA was isolated and DNA banding patterns suitable for DNA typing were obtained from fresh saliva and various saliva-stained materials, such as envelopes, buccal swabs, gags, and cigarettes. Furthermore, DNA and DNA banding patterns were obtained from actual forensic evidentiary samples containing mixed saliva/semen stains. The DNA banding patterns obtained from saliva or saliva-stained material were indistinguishable from the patterns obtained from blood or hair from the same individual. Intact DNA was readily isolated and DNA banding patterns were obtained from saliva stored at -20 degrees C and dried saliva stains stored under varying conditions. We conclude that saliva and saliva-stained material can be good sources of DNA for analysis and for DNA typing in certain forensic settings.

The association between the development of weighing technology, possession and use of weighing scales, and self-reported severity of disordered eating.

The aim of this study is to investigate David Healy's hypothesis that the development of weighing technologies significantly contributes to the development of anorexia nervosa. A newly developed questionnaire and the EAT-26 were used to investigate these ideas. The key results from this study are that a positive correlation between EAT-26 scores and the frequency of weighing (p ≤ 0.001), and that group differences were also found between the control group and those with an EAT-26 score of 20 or above on weighing scale ownership (p = 0.017), the type of scale owned (p = 0.002) and whether people weighed themselves often (p ≤ 0.001); indicating that those with a higher EAT-26 score were more likely to own weighing scales, own digital weighing scales, and weigh themselves more often. These results suggest that the increased precision and usage of weighing technologies may potentially be a causal factor in disordered eating, and as such, this idea can be extended to suggest the hypothesis that frequent and precise weighing of anorexic patients in therapy may actually be counter-productive.

First Irish delivery following sequential, two-stage embryo and blastocyst transfer.

BACKGROUND: The timing of embryo transfer (ET) after in vitro fertilisation (IVF) remains controversial, and there are no reliable guidelines available to prospectively identify which patients would benefit from either day-3 or blastocyst transfer. While blastocyst transfer is generally favoured over day-3 transfers, very few IVF patients get both in the same treatment cycle. CASE DESCRIPTION: We report on a 35.5-year-old female with tubal factor infertility who underwent IVF, which included transfer of a fresh day-3 embryo and a thawed blastocyst frozen at day 6. Transfer occurred on two separate days (days 3 and 6) in a two-stage/dual catheter fashion and resulted in a healthy term singleton livebirth. CONCLUSIONS: While combined day-3 and day-5 ET has been available elsewhere for several years, this is the first description of its successful application in Ireland and confirms the effectiveness of coordinated two-stage transfer in a single IVF treatment cycle.

First reported deliveries in Ireland using surgically retrieved sperm for non-obstructive azoospermia.

Couples presenting with male factor infertility comprise an important proportion of clinical reproductive endocrinology consultations. Indeed, a problem with the male is the only cause, or a contributing cause, of infertility in ~40% of infertility evaluations. Here we present the first published deliveries obtained from IVF utilising surgically retrieved sperm in Ireland; pregnancy and delivery are also described following transfer of cryopreserved/thawed embryos derived from such sperm. Finding no sperm from a semen analysis in a man without a vasectomy can be a devastating event, and substantially influences the scope of the reproductive endocrinology consultation. Successful treatment of non-obstructive azoospermia is possible without reliance on anonymous donor sperm.