The HERA (Hyper-response Risk Assessment) Delphi consensus for the management of hyper-responders in in vitro fertilization.

PURPOSE: To provide agreed-upon guidelines on the management of a hyper-responsive patient undergoing ovarian stimulation (OS) METHODS: A literature search was performed regarding the management of hyper-response to OS for assisted reproductive technology. A scientific committee consisting of 4 experts discussed, amended, and selected the final statements. A priori, it was decided that consensus would be reached when ≥66% of the participants agreed, and ≤3 rounds would be used to obtain this consensus. A total of 28/31 experts responded (selected for global coverage), anonymous to each other. RESULTS: A total of 26/28 statements reached consensus. The most relevant are summarized here. The target number of oocytes to be collected in a stimulation cycle for IVF in an anticipated hyper-responder is 15-19 (89.3% consensus). For a potential hyper-responder, it is preferable to achieve a hyper-response and freeze all than aim for a fresh transfer (71.4% consensus). GnRH agonists should be avoided for pituitary suppression in anticipated hyper-responders performing IVF (96.4% consensus). The preferred starting dose in the first IVF stimulation cycle of an anticipated hyper-responder of average weight is 150 IU/day (82.1% consensus). ICoasting in order to decrease the risk of OHSS should not be used (89.7% consensus). Metformin should be added before/during ovarian stimulation to anticipated hyper-responders only if the patient has PCOS and is insulin resistant (82.1% consensus). In the case of a hyper-response, a dopaminergic agent should be used only if hCG will be used as a trigger (including dual/double trigger) with or without a fresh transfer (67.9% consensus). After using a GnRH agonist trigger due to a perceived risk of OHSS, luteal phase rescue with hCG and an attempt of a fresh transfer is discouraged regardless of the number of oocytes collected (72.4% consensus). The choice of the FET protocol is not influenced by the fact that the patient is a hyper-responder (82.8% consensus). In the cases of freeze all due to OHSS risk, a FET cycle can be performed in the immediate first menstrual cycle (92.9% consensus). CONCLUSION: These guidelines for the management of hyper-response can be useful for tailoring patient care and for harmonizing future research.

The HERA (Hyper-response Risk Assessment) Delphi consensus definition of hyper-responders for in-vitro fertilization.

PURPOSE: To provide an agreed upon definition of hyper-response for women undergoing ovarian stimulation (OS)? METHODS: A literature search was performed regarding hyper-response to ovarian stimulation for assisted reproductive technology. A scientific committee consisting of 5 experts discussed, amended, and selected the final statements in the questionnaire for the first round of the Delphi consensus. The questionnaire was distributed to 31 experts, 22 of whom responded (with representation selected for global coverage), each anonymous to the others. A priori, it was decided that consensus would be reached when ≥ 66% of the participants agreed and ≤ 3 rounds would be used to obtain this consensus. RESULTS: 17/18 statements reached consensus. The most relevant are summarized here. (I) Definition of a hyper-response: Collection of ≥ 15 oocytes is characterized as a hyper-response (72.7% agreement). OHSS is not relevant for the definition of hyper-response if the number of collected oocytes is above a threshold (≥ 15) (77.3% agreement). The most important factor in defining a hyper-response during stimulation is the number of follicles ≥ 10 mm in mean diameter (86.4% agreement). (II) Risk factors for hyper-response: AMH values (95.5% agreement), AFC (95.5% agreement), patient's age (77.3% agreement) but not ovarian volume (72.7% agreement). In a patient without previous ovarian stimulation, the most important risk factor for a hyper-response is the antral follicular count (AFC) (68.2% agreement). In a patient without previous ovarian stimulation, when AMH and AFC are discordant, one suggesting a hyper-response and the other not, AFC is the more reliable marker (68.2% agreement). The lowest serum AMH value that would place one at risk for a hyper-response is ≥ 2 ng/ml (14.3 pmol/L) (72.7% agreement). The lowest AFC that would place one at risk for a hyper-response is ≥ 18 (81.8% agreement). Women with polycystic ovarian syndrome (PCOS) as per Rotterdam criteria are at a higher risk of hyper-response than women without PCOS with equivalent follicle counts and gonadotropin doses during ovarian stimulation for IVF (86.4% agreement). No consensus was reached regarding the number of growing follicles ≥ 10 mm that would define a hyper-response. CONCLUSION: The definition of hyper-response and its risk factors can be useful for harmonizing research, improving understanding of the subject, and tailoring patient care.

Retrograde root canal retreatment with pre-bent ultrasonic files. A retrospective outcome study.

AIM: To assess retrospectively the clinical and radiographic outcomes of retrograde root canal retreatment (RRR) and to identify possible prognostic factors that may affect the outcome. METHODOLOGY: Clinical records and radiographs were collected from patients who had undergone RRR between 2009 and 2016 and had a 1-year follow-up. All surgical procedures were performed by a single endodontist. The RRR technique involved minimal root-end resection and maximal length retrograde preparation using pre-bent ultrasonic files. Outcomes were categorized as complete, incomplete, uncertain or unsatisfactory healing based on clinical and radiographic findings. The complete and incomplete healing cases were pooled and considered as successes, while uncertain and unsatisfactory cases were considered failures. Prognostic factors were analysed using univariate analysis and multivariate logistic regression. RESULTS: In total, 575 patients with 721 teeth were included. The overall success rate was 91.8%. None of the prognostic factors (including age, gender, size of periapical radiolucency and isthmus presence) had a significant influence on the outcome (P > 0.05). Univariate analysis revealed tooth type had a significant influence on outcome (P = 0.008) with mandibular incisors having a significantly lower success rate (71.4%). Multivariate analysis using logistic regression revealed that the only variable with a significant association to the outcome was retrograde preparation length (P = 0.016, odds ratio = 1.299 (1.050, 1.607), C.I. = 95%)), i.e. the longer the retrograde preparation, the better the outcome. CONCLUSIONS: Retrograde root canal retreatment was successful in 91.8% of cases. This predictable success rate was achieved while minimizing root-end resection and maximizing retrograde canal preparation length.

Incidence of microcracks in maxillary first premolars after instrumentation with three different mechanized file systems: a comparative ex vivo study.

OBJECTIVES: The objective of this study is to determine the potential for microcracks in the radicular dentin of first maxillary premolars using three different mechanized endodontic instrumentation systems. METHODS: Eighty extracted maxillary first premolars with two root canals and no externally visible microcracks were selected. Root canal instrumentation was performed with either the ProTaper file system, the WaveOne primary file, or the self-adjusting file (SAF). Teeth with intact roots served as controls. The roots were cut into segments and examined with an intensive, small-diameter light source that was applied diagonally to the entire periphery of the root slice under ×20 magnification; the presence of microcracks and fractures was recorded. Pearson's chi-square method was used for statistical analysis, and significance was set at p < 0.05. RESULTS: Microcracks were present in 30 and 20 % of roots treated with the ProTaper and WaveOne systems, respectively, while no microcracks were present in the roots treated with the SAF (p = 0.008 and p = 0.035, respectively). Intact teeth presented with cracks in 5 % of the roots. The intensive, small-diameter light source revealed microcracks that could not be detected when using the microscope's light alone. CONCLUSIONS: Within the limitations of this study, it could be concluded that mechanized root canal instrumentation with the ProTaper and WaveOne systems in maxillary first premolars causes microcracks in the radicular dentin, while the use of the SAF file causes no such microcracks. CLINICAL RELEVANCE: Rotary and reciprocating files with large tapers may cause microcracks in the radicular dentin of maxillary first premolars. Less aggressive methods should be considered for these teeth.

The effects of caffeine on heart rate variability in newborns with apnea of prematurity.

OBJECTIVE: Apnea of prematurity is a common complication in premature newborns and caffeine is a widespread medication used to treat this complication. Caffeine may have adverse effects on the cardiovascular and central nervous system, yet its effects on the autonomic nervous system modulation of heart rate have not been studied in premature newborns, which was the objective of our study. STUDY DESIGN: We prospectively studied 21 premature newborns who were treated with caffeine. We analyzed heart rate variability by power spectral density and by dynamic nonlinear analyses methods. RESULT: There were no changes in heart rate, blood pressure or the autonomic nervous system tone following administration of caffeine, nor were the nonlinear dynamical properties of the system altered by caffeine. CONCLUSION: Caffeine does not have detrimental effects on heart rate variability, heart rate or blood pressure in conventional doses given to premature newborns.

The effects of meperidine and epidural analgesia in labor on maternal heart rate variability.

BACKGROUND: Epidural and parenteral opioid analgesia are two common methods of pain relief in labor that may influence the autonomic nervous system. However, these effects on laboring women have not yet been adequately studied. The aim of our study was to assess the effects of these two methods of analgesia on autonomic nervous system modulation of maternal heart rate variability in laboring women. METHODS: A prospective observational study was conducted on 64 laboring women; 33 received epidural analgesia with bupivacaine and fentanyl and 31 intravenous meperidine and promethazine. Power spectral analysis and nonlinear methods were applied to digitized electrocardiograms performed before and after administration of analgesia, to assess maternal heart rate variability and autonomic equilibrium. RESULTS: Maternal heart rate significantly increased in women who received meperidine compared to those who had epidural analgesia. There was a significant increase in the low-frequency to high-frequency ratio (3.7+/-3.9 vs. 1.8+/-1.6, P<0.05), and a significant decrease of high-frequency spectral power in women who had meperidine compared to those who received epidural analgesia (163+/-91 vs. 98+/-100 ms(2)/Hz, P<0.05). CONCLUSIONS: Meperidine caused an autonomic nervous system shift towards sympathetic activation with abolition of respiratory sinus arrhythmia high-frequency spectral band. Conversely epidural analgesia had no significant effect on autonomic nervous system control of heart rate.

Inhibiting Hdm2 and ubiquitin-activating enzyme: targeting the ubiquitin conjugating system in cancer.

The ubiquitin conjugating system represents a rich source of potential molecular targets for cancer and other diseases. One target of great interest is the RING finger ubiquitin ligase (E3) Hdm2/Mdm2, which is frequently overexpressed in cancer and is a critical E3 for the tumor suppressor p53. For those 50% of tumors that express wild-type p53, agents that inhibit Hdm2 have great potential clinical utility. We summarize our ongoing efforts to identify inhibitors of Hdm2 E3 activity by high-throughput screening of both defined small molecules and natural product extracts. Employing a strategy using both enzymatic and cell-based assays, we have identified inhibitors that block the E3 activity of Hdm2, activate a p53 response, preferentially kill p53-expressing cells, and have the capacity to differentially cause death of transformed cells. Therefore, screening for inhibitors of Hdm2 ubiquitin ligase activity through in vitro assays represents a powerful means of identifying molecules that activate p53 in cancer cells to induce apoptosis. We also discuss the potential of inhibitors of ubiquitin-activating enzyme (E1) that were discovered during these screens. E1 inhibitors may similarly serve as the basis for novel therapeutics. Additionally, they represent unique tools for providing new insights into the ubiquitin conjugating system.

RING-dependent tumor suppression and G2/M arrest induced by the TRC8 hereditary kidney cancer gene.

TRC8/RNF139 and von Hippel-Lindau (VHL) both encode E3 ubiquitin (Ub) ligases mutated in clear-cell renal carcinomas (ccRCC). VHL, inactivated in nearly 70% of ccRCCs, is a tumor suppressor encoding the targeting subunit for a Ub ligase complex that downregulates hypoxia-inducible factor-alpha. TRC8/RNF139 is a putative tumor suppressor containing a sterol-sensing domain and a RING-H2 motif essential for Ub ligase activity. Here we report that human kidney cells are growth inhibited by TRC8. Inhibition is manifested by G2/M arrest, decreased DNA synthesis and increased apoptosis and is dependent upon the Ub ligase activity of the RING domain. Tumor formation in a nude mouse model is inhibited by TRC8 in a RING-dependent manner. Expression of TRC8 represses genes involved in cholesterol and fatty acid biosynthesis that are transcriptionally regulated by the sterol response element binding proteins (SREBPs). Expression of activated SREBP-1a partially restores the growth of TRC8-inhibited cells. These data suggest that TRC8 modulation of SREBP activity comprises a novel regulatory link between growth control and the cholesterol/lipid homeostasis pathway.

Standard vs atraumatic Whitacre needle for diagnostic lumbar puncture: a randomized trial.

In order to define the impact of needle type on post-lumbar puncture headache (PLPH), we performed a prospective, randomized trial comparing the incidence of PLPH in patients undergoing lumbar punctures (LPs) with traumatic vs atraumatic 22-gauge needles. Fifty-eight patients underwent 85 LPs. The incidence of PLPH was 36% in the traumatic vs 3% in the atraumatic group (p = 0.002).

A field guide to ubiquitylation.

The capacity for exquisite regulation of ubiquitylation provides eukaryotic cells with a means to fine-tune both protein function and levels. This complex set of processes affects myriad proteins and potentially impacts all cellular processes. Ubiquitylation is brought about through multienzyme processes, with specificity conferred primarily by interactions of substrates with specific ubiquitin protein ligases (E3s) in association with ubiquitin conjugating enzymes (E2s). Regulation of ubiquitylation occurs at multiple levels, including E2-E3 interactions, substrate recognition, chain elongation, binding of ubiquitin to conserved motifs and deubiquityation. This review presents the fundamentals of the ubiquitin conjugating system.

The use of dextromethorphan to treat repetitive self-directed scratching, biting, or chewing in dogs with allergic dermatitis.

OBJECTIVE: To evaluate the efficacy of oral dextromethorphan in dogs with a repetitive behavior problem (self-licking, self-chewing, and self-biting associated with chronic allergic dermatitis). ANIMALS: Fourteen dogs with chronic allergic dermatitis were enrolled in the study. Twelve dogs completed the study. PROCEDURE: The dogs were treated for 2 weeks each with dextromethorphan (2 mg/kg BID) and placebo in a randomized, double blind, crossover designed study. A dermatology score, including an assessment of affected areas of the integument and the level of self-directed behavior, was generated before and following each 2-week phase of the study. Owners were required to record daily the amount of time they spent with their dog and the amount of time that the dog was observed to be engaged in any of the specified self-directed behaviors. RESULTS: The percent of the observed time that the dogs were reported to be involved in self-directed behaviors was significantly less during the 2-week active drug treatment phase. The pruritus score component of the dermatology score also was significantly less during the active treatment phase. In addition, a dermatologist-rated global assessment was more favorable in 11 of 12 dogs following the active treatment phase. CONCLUSIONS: Dextromethorphan significantly reduces the percentage of time that allergic dogs spend self-licking, self-chewing, and self-biting. CLINICAL RELEVANCE: Dextromethorphan may be a useful adjunct in the management of self-directed behaviors associated with allergic dermatitis and possibly in other repetitive behaviors as well.

Transcriptional coregulator SNURF (RNF4) possesses ubiquitin E3 ligase activity.

SNURF/RNF4 has been implicated in transcriptional regulation and growth inhibition in a RING finger-dependent fashion. In this work, we show that SNURF mediates its own ubiquitination in vitro in a ubiquitin-conjugating enzyme (E2)-selective manner: SNURF acts as an E3 ligase with UbcH5A and B, HHR6B (RAD6B), E2-25K, MmUbc7 and UbcH13, but not with UbcH3, UbcM4, MmUbc6 or E2-20K. In contrast, the well-characterized RING E3, AO7, functions only with members of the UbcH5 family. Furthermore, depending on the E2 used, the ubiquitin modification manifests as mono- or multi-ubiquitination. Mutation of conserved cysteine residues within the RING finger motif of SNURF abolishes the ubiquitination in vitro and in intact cells. Size fractionation of murine embryonal carcinoma F9 cell proteins shows that the majority of endogenous SNURF resides in salt-resistant > or =500-kDa complexes, suggesting that SNURF functions as a RING component in a multiprotein complex. Taken together, SNURF/RNF4 functions as an E3 ligase and this activity is closely linked to its transcription regulatory functions.

Assay for ubiquitin ligase activity: high-throughput screen for inhibitors of HDM2.

An assay for the autoubiquitination activity of the E3 ligase HDM2 (Mdm2) was developed and adapted to a high-throughput format to identify inhibitors of this activity. The assay can also be used to measure the activity of other E3s and may be useful in finding both inhibitors and activators of a wide range of different ubiquitin ligases.

Perceptions of nurses with regard to doctor-patient communication.

The objective of this study was to evaluate nurses' perceptions of communication between doctors and patients with cancer, AIDS and rheumatoid arthritis. A cross-sectional study was conducted with 741 nurses in 12 hospitals. Nurses received a self-questionnaire that included questions on personal value and attitudes. The answers were used in constructing affective variables (religious beliefs, attitude towards death, paternalism). The prevalence of explicit communication in 'nurse perception of doctor-patient communication' in the case of cancer was 4.5%, with AIDS 30%, and with rheumatoid arthritis 41.8%. When the value of communication was evaluated, it became evident that the likelihood of a nurse perceiving explicit communication in reference to a diagnosis of cancer was 6.5 time greater when communication was considered to be of greater value (CI 95% 2.6-6.6). For nurses who accept the possibility of death, the likelihood of perceiving explicit communication in the case of AIDs was 7.4 times greater than for nurses who deny this possibility (CI 95% 3.7-14.7), and when nurses displayed a deeply religious attitude, the likelihood of perceiving explicit communication was 80% greater than for nurses without this attitude (CI 95% 1.1-2.9). Nurses participate actively in the process of attending to patients with cancer and other disabling illnesses. Thus, there is a need for health professionals who provide compassionate attention, which will improve the various interrelationships between nurses and patients.

Sonographic nuchal markers for Down syndrome are more common but less ominous in gestations with a male fetus.

OBJECTIVE: A change in the normal male-to-female ratio has been reported in some autosomal trisomies (i.e., trisomy 21 or trisomy 18). The objective of the present study was to evaluate the male-to-female ratio in pregnancies with sonographic nuchal markers for Down syndrome. METHODS: The results of amniocenteses performed for isolated nuchal markers for Down syndrome were grouped by fetal sex and by maternal age. The male-to-female ratio in normal and trisomic gestations was compared. RESULTS: 584 fetal karyotypes were available for analysis. A significantly higher male-to-female ratio was observed. More affected gestations were observed in association with a female fetus. These differences were mainly attributed to the group of patients younger than 35 years that represents more than 80% of our study population. No difference was observed in pregnancies of patients older than 35 years of age. CONCLUSIONS: In patients younger than 35 years, sonographic nuchal markers for Down syndrome are more frequent (but apparently less ominous) in gestations with a male fetus. If the gender is known, counseling can be modified to include such differential risks.

The tumor autocrine motility factor receptor, gp78, is a ubiquitin protein ligase implicated in degradation from the endoplasmic reticulum.

gp78, also known as the tumor autocrine motility factor receptor, is a transmembrane protein whose expression is correlated with tumor metastasis. We establish that gp78 is a RING finger-dependent ubiquitin protein ligase (E3) of the endoplasmic reticulum (ER). Consistent with this, gp78 specifically recruits MmUBC7, a ubiquitin-conjugating enzyme (E2) implicated in ER-associated degradation (ERAD), through a region distinct from the RING finger. gp78 can target itself for proteasomal degradation in a RING finger- and MmUBC7-dependent manner. Importantly, gp78 can also mediate degradation of CD3-delta, a well-characterized ERAD substrate. In contrast, gp78 lacking an intact RING finger or its multiple membrane-spanning domains stabilizes CD3-delta. gp78 has thus been found to be an example of a mammalian cellular E3 intrinsic to the ER, suggesting a potential link between ubiquitylation, ERAD, and metastasis.

Screening for neural tube defects.

Neural tube defects are separated into two main categories: (1) abnormalities of the skull and brain (anencephaly, acrania, and encephalocele) and (2) malformations of the spine (meningomyelocele or spina bifida). The cause of neural tube defects is not always clear, and include chromosomal abnormalities, single gene mutations, maternal disease, or maternal exposure to teratogens. Mostly the disorder emerges as a multifactorial trait. Routine screening for neural tube defects was introduced in the United Kingdom in the mid-1970s and the United States in the mid-1980s. The use of screening has resulted in a marked decline in the frequency of neural tube defects diagnosed at birth.

Timing of testicular sperm retrieval procedures and in vitro fertilization-intracytoplasmic sperm injection outcome.

OBJECTIVE: To compare the outcome of IVF-intracytoplasmic sperm injection (ICSI) using testicular spermatozoa obtained on the day of ovum pick-up (OPU) or on the day before OPU. DESIGN: Retrospective study. SETTING: An IVF clinic in a university hospital. PATIENT(S): Forty-seven IVF-ICSI cycles using testicular spermatozoa in 28 couples with the male partner suffering from nonobstructive azoospermia. INTERVENTION(S): Sperm retrieval was performed either on the OPU day (23 cycles in 19 patients; group A) or on the day before OPU (24 cycles in 15 patients; group B). Testicular sperm aspiration (TESA) was performed and followed by testicular sperm extraction (TESE) if no spermatozoa could be found. MAIN OUTCOME MEASURE(S): The presence of motile spermatozoa at the time of ICSI and fertilization and clinical pregnancy rates. RESULT(S): A similar proportion of motile spermatozoa (60.9% vs. 62.5%), fertilization rate (61.7% vs. 58.9%), and clinical pregnancy rate per transfer (34.8% and 29.2%) were obtained for groups A and B, respectively. CONCLUSION(S): Testicular sperm retrieval can be performed on the day before OPU without compromising success. Considerable medical and practical advantages may be offered by further advancement of testicular sperm retrieval procedures to 48 hours before OPU. This approach should thus be further evaluated.