Mohamed Satti

First analysis of the secretome of the canine heartworm, Dirofilaria immitis

BackgroundThe characterization of proteins released from filariae is an important step in addressing many of the needs in the diagnosis and treatment of these clinically important parasites, as well as contributing to a clearer understanding of their biology. This report describes findings on the proteins released during in vitro cultivation of adult Dirofilaria immitis , the causative agent of canine and feline heartworm disease. Differences in protein secretion among nematodes in vivo may relate to the ecological niche of each parasite and the pathological changes that they induce.MethodsThe proteins in the secretions of cultured adult worms were run on Tris-Glycine gels, bands separated and peptides from each band analysed by ultra mass spectrometry and compared with a FastA dataset of predicted tryptic peptides derived from a genome sequence of D. immitis.ResultsThis study identified 110 proteins. Of these proteins, 52 were unique to D. immitis . A total of 23 (44%) were recognized as proteins likely to be secreted. Although these proteins were unique, the motifs were conserved compared with proteins secreted by other nematodes.ConclusionThe present data indicate that D. immitis secretes proteins that are unique to this species, when compared with Brugia malayi. The two major functional groups of molecules represented were those representing cellular and of metabolic processes. Unique proteins might be important for maintaining an infection in the host environment, intimately involved in the pathogenesis of disease and may also provide new tools for the diagnosis of heartworm infection.

Congenital hernia of cord: an often misdiagnosed entity

Congenital hernia of the cord, also known as umbilical cord hernia, is an often misdiagnosed and under-reported entity, easily confused with a small omphalocele. It is different from postnatally diagnosed umbilical hernias and is believed to arise from persistent physiological mid-gut herniation. Its incidence is estimated to be 1 in 5000. Unlike an omphalocele, it is considered benign and is not linked with chromosomal anomalies. It has been loosely associated with intestinal anomalies, suggesting the need for a complete fetal anatomical ultrasound evaluation. We present a case of a fetal umbilical cord hernia diagnosed in a 28-year-old woman at 21u2005weeks gestation. The antenatal and intrapartum courses were uncomplicated. It was misdiagnosed postnatally as a small omphalocele, causing unwarranted anxiety in the parents. Increased awareness and knowledge of such an entity among health professionals is important to prevent unwarranted anxiety from misdiagnosis, and inadvertent bowel injury during cord clamping at delivery.

The Effect of the 39-Week Initiative on Intrauterine Demise: One Hospital's Experience [254].

INTRODUCTION: Published studies have shown mixed results regarding the risks of intrauterine fetal demise after implementation of guidelines for reduction of nonmedically indicated deliveries before 39 weeks of gestation. Our objective was to describe the variation in rates of intrauterine fetal demise in a high-risk patient population after implementation of guidelines eliminating nonmedically indicated deliveries before 39 weeks of gestation. METHOD: This was a retrospective chart review of patients with intrauterine fetal demise delivering at or beyond 20 weeks of gestation or birth weight 350 g or more when the gestational age was unknown between March 4, 2012, and July 31, 2014, at Hurley Medical Center in Flint, Michigan. RESULTS: A total of 6,561 deliveries were performed during the study period. Group 1: 2,846 deliveries before implementation of the guidelines with 16 cases of intrauterine fetal demise. Group 2: 3,715 deliveries after the guidelines with 29 cases of intrauterine fetal demise. Despite a small sample size, the most concerning observation is that the rate of intrauterine fetal demise between 37 and 39 weeks of gestation increased from 0.35 to 1.35 per 1,000 births after implementation of the guidelines. CONCLUSION: In our institute, the rate of stillbirth has increased since implementation of and strict adherence to guidelines for the elimination of elective induction of labor or cesarean delivery before 39 weeks of gestation were instituted. This is a disturbing trend that needs further evaluation, especially in medical centers caring for a high-risk pool of patients for whom all medical indications are not covered by the lists of approved indications.

Modified natural cycle for embryo transfer using frozen-thawed blastocysts: A satisfactory option

OBJECTIVEnTo describe pregnancy outcomes of frozen-thawed blastocysts cycles using modified natural cycle frozen embryo transfers (NC-FET) and down-regulated hormonally controlled frozen embryo transfers (HC-FET) protocols.nnnSTUDY DESIGNnThis retrospective cohort study included all patients undergoing either modified NC-FET or down-regulated HC-FET using frozen-thawed day 5 embryos. Cycles with donor blastocysts were excluded. Four hundred twenty eight patients underwent a total of 493 FET cycles. Patients with regular menses and evidence of ovulation underwent modified NC-FET. These patients were given hCG 10,000 IU IM on the day of LH-surge. Vaginal progesterone (P4) was started two days later and blastocyst transfer was planned seven days after detecting the LH surge. Anovulatory patients and some ovulatory patients underwent down-regulated HC-FET. These patients were placed on medroxy-progesterone acetate (10mg) for 10days to bring on menses and were also given a half-dose of GnRH-agonist (GnRH-a) on the third day of medroxy-progesterone acetate. Exogenous estradiol was initiated on the third day of menses. Once serum E2 levels reached >500pg/mL and endometrial lining reached >8mm, intramuscular (IM) P4 in oil was administered. Blastocyst FET was planned 6days after initiating P4. The primary outcomes included clinical pregnancy and delivery rates.nnnRESULTSnThere were 197 patients in the modified NC-FET protocol and 181 in the down-regulated HC-FET protocol. Mean age (years), day-3 FSH levels (mIU/mL) and percentage of patients with male factor infertility were significantly higher and mean BMI (kg/m2) was significantly lower in modified NC-FET compared to HC-FET, respectively. Analysis of the first cycle pregnancy outcomes revealed no significant differences in clinical pregnancy rate (54.3% vs. 52.5%) and delivery rate (47.2% vs. 43.6%) between modified NC-FET and HC-FET. Logistic regression analysis showed age (OR=0.939, 95% CI 0.894-0.989, p=0.011), number of blastocysts transferred (OR=1.414, 95% CI 1.046-1.909, p=0.024), and the year of FET (OR=1.127, 95% CI 1.029-1.234, p=0.010) were significant factors impacting clinical pregnancy. An age analysis within three age groups (≤35, 36-39, ≥40) was performed, but no significant difference in clinical pregnancy was observed.nnnCONCLUSIONnOur data suggests that modified NC-FET protocol has comparable pregnancy outcomes to down-regulated HC-FET when utilizing frozen-thawed day 5 embryos.

Obstetric Outcome in Dichorionic Versus Trichorionic Triplet Pregnancies After IVF-ET [22H]

INTRODUCTION: To compare the obstetric outcome of dichorionic triplet and trichorionic triplet pregnancies following in vitro fertilization and embryo transfer (IVF-ET). METHODS: This is a retrospective cohort study that included 64 triplet pregnancies that occurred following IVF-ET in the period between 2007–2014 at our IVF unit. Patients were divided into 2 groups. Group 1 consisted of 27 patients who had 2 embryos transferred resulting in dichorionic triplet, while group 2 included 37 patients that had trichorionic triplet as a result of transferring 3 embryos. RESULTS: There were no significant differences in underlying etiology of infertility, maternal age (33.4±4.5 vs 33.2±3.7 years), BMI (25.7±7.0 vs 26.3±7.2 kg/m2), preterm birth rates (81.4% vs 90.6%), gestational age at birth (30±9 vs 33±4 weeks) and average birth weight (1890.9±823.7 vs 2054.8±741.5 grams) between group 1 and 2 respectively. The live birth rate after viability (completed 24 week gestation) was significantly lower in dichorionic triplet pregnancies compared to trichorionic triplet pregnancies (77.8% vs 97.3% P<.05). CONCLUSION: Our data suggests that dichorionic triplet pregnancy has lower chance to have live birth compared to trichorionic triplet pregnancy.

Selective Fetal Reduction Versus Expectant Management in Triplet Pregnancies After IVF-ET [20G]

INTRODUCTION: To compare the effect of selective fetal reduction procedure on obstetric outcome of triplets conceived after in vitro fertilization and embryo transfer. METHODS: This is a retrospective cohort study that included 64 triplet pregnancies that occurred in the period between 1/1/2007 to 12/31/2014 at our IVF unit. Patients were divided into 2 groups. Group 1 consisted of 15 patients who underwent a selective fetal reduction procedure, while group 2 included 49 patients who did not go for a fetal reduction procedure. The primary outcomes were: gestational age at delivery and average birth weight. RESULTS: There were no significant differences in underlying etiology of infertility, maternal BMI (26.1±6.3 vs 26.0±7.3 kg/m2), gestational age at birth (30.7±9.6 vs 32.1±5.9 weeks), incidence of preterm birth rate (83.3% vs 75.6%) and live birth rate after viability (80.0% vs 91.8%) between group 1 and 2 respectively. However, there were significant differences in maternal age (35.7±3.7 vs 32.6±3.9 years P<.01) and average birth weight (2671.3±887.4 vs 1813.9±631.4 grams P<.01) between group 1 and 2, respectively. CONCLUSION: Our data suggests that selective fetal reduction procedures can improve triplet pregnancy outcome by increase the average birth weight by 857.4 grams or 47%. Further studies with larger sample size are needed to guide patient counseling and decision regarding selective fetal reduction in triplet pregnancies.

The importance of fetal sex determination

The executive summary statement of a Joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal–Fetal Medicine, American Institute of Ultrasound in Medicine, American College of Obstetricians and Gynecologists, American College of Radiology, Society for Pediatric Radiology, and Society of Radiologists in Ultrasound Fetal Imaging Workshop reported that screening the fetal genitalia should be a part of the standard fetal sonographic examination only in cases of multiple gestations and when medically indicated. We report a case of a 39-year-old pregnant woman, G2P0Sab1, who was referred at 31 weeks and 3 days’ gestation to our Maternal– Fetal Medicine unit for consultation on her pregnancy, which was complicated by suspected fetal skeletal dysplasia and intrauterine growth restriction on the basis of sonography performed outside our unit. The patient had declined prenatal diagnosis and sonographic assessment for fetal sex earlier in her pregnancy. The sonograms obtained in our unit confirmed the diagnosis of severe intrauterine growth restriction, but skeletal dysplasia was not suggested. The sex of the fetus was not assessed, in accord with the patient’s request. Cesarean delivery was performed at 31 weeks and 6 days’ gestation for non-reassuring fetal testing and abnormal follow-up Doppler imaging of the umbilical cord. The neonate was small for its gestational age, weighing 1,120 grams. Most notably, the neonate was found to have abnormal genitalia and was diagnosed with a disorder of sex development (Figure 1). The parents experienced emotional distress in having to deal with the uncertainty about the infant’s sexual identity. Both obstetric and neonatal care providers were as stunned as the parents. The patient was discharged home on post partum day 4 without knowing the infant’s sex; the parents were thus unable to announce the sex to family and friends, which was extremely distressing. Chromosomal analysis, hormonal analysis, and radiologic studies eventually showed a male fetus with severe hypospadias and undescended testes. The sex of a neonate is very important to parents and families. This is often the first question asked after its delivery if the sex was unknown beforehand. Fetal sex carries both psychological and social implications. To parents, the prenatal knowledge of fetal sex is as important if not more important than screening for Trisomy 21. Of note, screening for Trisomy 21 is common and part of the standard of care in the United States. Moreover, cell-free fetal DNA screening is becoming more common, even in low-risk women; thus, if the sex is determined by that testing, confirmatory scanning for the genitalia should be warranted during the anatomy scan. Thus, more directed guidelines for the assessment of fetal sex during prenatal sonographic examination should be considered for pregnant patients in the United States. In conclusion, we propose that FIGURE 1. The neonate’s genitalia post partum day 2.

Should Prophylactic Anticoagulation Be Considered with Large Uterine Leiomyoma? A Case Series and Literature Review

Introduction. Uterine leiomyomas, also called uterine fibroids or myomas, are the most common pelvic tumors in women. They are very rarely the cause of acute complications. However, when complications occur they cause significant morbidity and mortality. Thromboembolic disease has been described as a rare complication of uterine leiomyomas. DVT is a serious illness, sometimes causing death due to acute PE. Cases. We report a case series of 3 patients with thromboembolic disease associated with uterine leiomyoma at Hurley Medical Center, Flint, Michigan, during 2015 and conduct a literature review on the topic. A literature search was conducted using Medline, PubMed, and PMC databases from 1966 to 2015. Conclusion. The uterine leiomyoma is a very rare cause of PE and only few cases have been reported. DVT secondary to uterine leiomyoma should be considered in a female presenting with abdominal mass and pelvic pressure, if there is no clear common cause for her symptoms. Thromboembolic disease secondary to large uterine leiomyoma should be treated with acute stabilization and then hysterectomy. Prophylactic anticoagulation would be beneficial for lowering the risk of VTE in patients with large uterine leiomyoma.