AdultStemCell.com

Al K asked:


Ms. L wrote me:

Hello Dr. Kavokin,

I was reading some of your literature and found it to be quite informative. I have a question that perhaps you may be able to answer: If a woman’s ovarian cyst ruptures, (especially multiple cysts from PCOS) can these ruptured cysts become an infection?


Hi, MS. L

Short answer: anything can become infected. Though I do no think ruptured ovarian cyst becomes infected very often, did not hear about that. I will look more literature and probably place the answer on my website.

Sincerely,

Alex

OK. I looked the literature.

I didn’t do very extensive literature search. Should admit.
Anyway, some available books mention that ovarian cyst may become infected. However the infection is not described as the main complication in ovarian cyst rupture.

Also, I don’t remember that anybody told me otherwise. Maybe there is some specialized article that says: the condition happens in one point three percent of cases with Standard Deviation of half percent. I don’t know exact percentage. Need to look more. PubMed service did not give many abstracts on PCOS + infection.

Anyway.

So how would it look alike?

A young woman comes to ER. She is premenopausal. She complains on mild (or maybe severe) pain in her belly. ER Doctor takes history. The woman also mentions changes in her menstrual interval. Let’s say regular is 28 days. Last one was delayed.

Physician puts gloves, puts jelly on gloves. Then he puts his two fingers into the female vagina.
The other hand is on belly. Then he starts to palpate.

It is named pelvic exam. Modest name. Though in Russia it is named vaginal exam, which it is.

Is it a common type of exam? Depends. They usually send you to CT (computer tomography) scan if there is severe abdominal pain. Charge 1000. Boom.
Done.

Exclude the price. Exclude delay in reading (somebody should look and interpret what is going on). Exclude radiation. CT scan gives better picture than just poking your belly.

CT scan helps to diagnose abdominal pain of uncertain origin. You can really image what is going on. Though, there are cases when physical exam gives more clues. Physical exam must be performed always. Pelvic exam is somewhat a special one.

I remember how I performed a pelvic exam in medical school. It is actually difficult even just to insert two fingers into vagina first time.
Female Gynecologist asks me: “So, what do you feel?”
Patient goes the same, encourages me:
“What do you feel, what do you feel, do you feel it?”

I guess she felt a sort of museum artifact.
Heck, I did not feel anything.

Well. Actually I felt something – aside from uterus – something round. I would say 5 cm in diameter (would it be less I probably would not feel it at all) and semi-solid on touch. Also I saw that the patient grimaces. It is tender when I push hard.

It’s it. How to say that it was tuboovarian abscess (that it was) for sure, I don’t know.
You really need experience to perform this type of exam. Experienced gynecologist can tell almost precisely what is going on.

Let’s discuss that woman in ER. She will have tenderness on one side. Physician should be able to feel a mobile cystic mass.
(Cyst or rather cystis is Latin for bubble. Palpate is Latin for touch. It means you touch something and feel what it is).
What if the pain is severe? It often means that the cyst ruptured.
My impression is that modern ER orders CT scan right away. If you are not very sure what is going on, you will go from less expensive methods to more expensive and end up with CT anyway. Ruptured cyst causes significant pain. Here CT is indicated.

Alternatively they may order Ultrasound Exam. Transvaginal ultrasound uses the probe inserted into vagina. Ultrasound is cheaper than CT. Ultrasound visualizes cysts clearly. Though, ultrasound gives less information for excluding other pathology. Ultrasound is also safe from the radiation point of view.

In PCOS ultrasound shows increased number of small cysts in both ovaries. Usually more than five confirms the diagnosis.

Culdocentesis may give some useful information too. The name came from cul-de-sac. It’s French I guess. Cul-de-sac is one of the pouches in the pelvis. Centesis means: stick a needle and draw. These days it is considered an outdated method. But if you do not have other machines, it is very useful.

If the content is blood, the ruptured cyst was probably Corpus luteum cyst. If the content is purulent the ruptured thing was probably a tubo-ovarian abscess or other pelvic inflammatory disease (PID).
Other abnormal masses can rupture as well. Teratoma gives oily fluid, endometrioma gives “chocolate” old blood.

What is a follicle?

Female body is created for reproduction and childbearing. Oocyte is the start for a new human being in the ovaries. Several layers of specialized membranes surround an oocyte.

The membranes protect the oocyte, help in feeding and nurturing of this small cell.
One of layers has a beautiful name Zona pellucida. Pellucida means shiny in Latin.

When the oocyte matures, a small bubble (follicle) filled with special fluid is formed around.
In mid-cycle the follicle bursts and the oocyte goes first into peritoneal cavity, next into ovarian tubes (fallopian tubes). The tubes lead into uterus. Tubes, by the way, have special small hair-like things inside – fimbria. They beat in one direction. They propel the oocyte into uterus.

I remember I read somewhere that there are 11000 follicles. When a girl is born, there is no more multiplication of oocytes. After the birth the follicles sit dormant. When the female goes into her reproductive age, the follicles start to grow and mature (one by one).

Only 400 of them mature.

Yeah, it should be like this. Calculate. Average cycle is 28 days. So there are around 12 cycles a year. Women start to menstruate at 13-15 years old. The menopause is around 45-55 years. Total is 30-40 years

Multiply everything together. It should be around 400.

By the way, an interesting thought.

All those discussion about abortion and Stem Cell research.
Somewhere in nineteen century the baby was considered the baby when it was born. The church even struggled to admit anything like existence of cells etc. Rare baby actually survived beyond first year.
Heck, the hypothesis that human been consists of small cells was actually admitted widely not so long ago. Maybe hundred years ago. Then, all that research happened. People learned how the fetus is created and how it grows. Now the public idea is that fertilized oocyte is already the baby.

Have you seen any oocyte under microscope? Even a human hair near an oocyte looks like a skyscraper near a real human.

Now, if the public perception had shifted this way in several decades, shouldn’t we punish all women for that they recklessly loose 400 potential babies during lifetime. Isn’t it a crime?

Then, maybe we should punish every man for losing millions of sperms – also potential babies.
Where did this idea come from that fertilized oocyte is the baby and non-fertilized oocyte is not?
Shouldn’t we move the boundary a little bit earlier?
Need to think about that.

Anyway.

Ovarian follicle (follicle means small bubble in Latin) usually mature, rupture and release the oocyte that was in this follicle. Sometime the rupture delays. Then ovulation delayes. (Ovulation is rupture and release of the oocyte. Oocyte is the cell that eventually becomes the fetus after sperm gives the genetic material).

Normal cycle is divided into follicular phase (when the follicle grows) and luteal phase.
Luteum means yellow in Latin.

When the follicle ruptures (by the way rupture means burst or tearing), the oocyte goes out.

The cavity that left behind (remember it was small bubble) is filled with blood and special cells, producing hormones. These special cells grow in quantity and fill that cavity. These cells produce hormones that help the fertilized oocyte to attach and to grow in the uterus. Because they grow in quantity, they create a yellowish body in the ovary. It is literally yellowish. The name is Corpus Luteum (corpus=body, luteum = yellow).

This is normal cycle.

As we said, the follicle sometime doesn’t rupture (there is a bunch of reasons). A physician should sort out several different conditions. This is an abnormal cycle.
If follicle does not rupture it becomes the follicular cyst. Cyst also means bubble in Latin. There are actually plenty of different kinds of bubbles in medical Latin. Big ones and small ones. Normal and abnormal.

OK, the cyst did not rupture. Then what happens?

Well. If cyst doesn’t rupture, it usually resolves. That fluid inside the cyst is reabsorbed and the cyst collapses.

However, if the cyst ruptures, it causes acute pain. The pain comes from irritation of peritoneum (lining of peritoneal cavity) with blood and cyst content.

Why it is not painful when a regular follicle ruptures and releases the oocyte? Probably, a regular follicle is too small. In addition it doesn’t cause much bleeding.

In contrast the cyst is a really big bubble (sometime 5-10 cm in diameter). If it ruptures, it instantaneously release bunch of special fluid. Plus, there is significant bleeding because there are a lot of blood vessels around to feed.

Significant is of course relative.

For example, take 5-10-20 ml of blood from a patient vein in a hospital daily. He complains about the pain from the needle mostly.

But if you get the same 10 ml of blood into peritoneum… Wow.
You will cry. There are plenty of nerve endings. Peritoneum is too touchy-feely. Tender.

Besides, the cyst has high concentration of prostaglandins. Prostaglandins, in their turn, are mediators of inflammation. They should cause significant pain directly and indirectly.

From the other hand bleeding could be really significant. Then it becomes really dangerous.

A physician also should not miss an ectopic pregnancy. Doctor will order a pregnancy test for that. If an ectopic pregnancy starts to bleed, this is really really worrisome. It seems like your blood did not left your body. However the blood is in the abdominal cavity. It left the blood vessels. It is internal bleeding. You die quickly.

Polycystic ovarian syndrome is a little bit different animal actually. Here is some genetic predisposition.

Classically: an overweight young female presents with oligomenorrhea or amenorrhea, anovulation, acne, hirsutism, and or infertility.

What is what? Poly = many. Many, many, many men.
So PCOS means bunch of those bubbles in the ovaries. The follicles did not rupture on time, as they should. Oligo means a little. Meno is derived from menses. Rrhea means flow in Latin

So olygomenorrhea = flowing a little bit (less than it should).
A- is a prefix that means “No”. So, amenorrhea = no flow at all.
Hirsutism. I don’t remember where it came from, but means hairy or hairiness. Actually excessive hairiness.

Causes of PCOD or PCOS (disease or syndrome) are obesity, genetic predisposition and some other causes of Luteinizing hormone (LH) excess.

There is a self-amplifying cycle:

LH stimulates theca lutein cells. Theca means sort of capsule. Doesn’t really matter, just an anatomical term.
Those cells are special. They produce androstendione and testosterone. Androstendione and testosterone are actually male hormones. You know, bodybuilders use these hormones to get muscle bulk. You probably heard about those hormones. Sport doping uses testosterone.
So, athletes build their muscles and trash their liver.

Rumors say that a famous Hollywood actor used the hormones. Later he got liver transplant.
Though he always denied the use.

Anyway, female body converts androstendione into estrone (a weak estrogen). Fat cells do this. Estrone is a female hormone already.

Basically any body produces androgens (andros = man) and estrogens (female hormones). Just the proportion of those hormones makes us male or female.

The cycle happens in normal person as well.

The estrone stimulates pituitary secretion of LH.
Pituitary is a small gland in you brain. Pea Size.
It’s small, but it sooooo powerful.

Pituitary has another name – hypophysis. Hypo means down, phys means growth, so this gland is growing from below the rest of the brain. Pituitary gets bunch of connections from hypothalamus.
Hypothalamus means “below thalamus”.
These two areas of brain regulate almost all the hormone production in organism.

Higher levels in brain hierarchy regulate them.

Hypophysis gets a command. Then it produces some intermediate messengers and hormones.
The hormones go into blood and control whole body.

Hormones are like orders, like messages to the rest of the body.

Brain may give quick orders: Signals go through the nerves. It is like a phone order or cablegram.

Brain also regulates organism through the hormones. This is like a mail order.
Sort of if the brain sends letters by regular mail. The hypophysis is the Post Office in this case.

PCOS kicks in when a woman is obese. There are more fat cells to convert
androstendione to estrone. Estrone has such effect that it stimulates pituitary secretion of LH.
LH in its turn goes back to those theca lutein cells we discussed and turns them on again, to produce more androstendione, which is again converted into estrone.

Self-amplifying cycle

In addition, that increased level of testosterone causes the hirsutism (she becomes hairy like a male) and acne in female.
In a normal person this cycle is probably designed to support the development of fetus.
Estrogen helps placenta to grow. Placenta supports fetal growth.

However, in a person with PCOD the cycle is going out of normal control. In this case LH causes growth of the cysts in the ovaries.

Why?

Because the corpus luteum cyst is partially made by overgrowth of those theca lutein cells. LH stimulates theca lutein cells.

Also, women with PCOS have intolerance to glucose (sugar) and resistance to insulin.
It means there is a lot of insulin (hormone that helps to utilize glucose mainly).

However excessive insulin does not work. Either receptors to insulin do not work or something else, but the glucose is not utilized. Hence, energy inside the cells drops. Hence, a big pile of other problems mounts. As if it is Diabetes Mellitus. Diabetes is a different topic of discussion. For us, it is worthwhile to mention that people with diabetes are very much prone to any infection.

PCOS causes acanthosis nigricans also. Acantocytes are special skin cells.
Nigricans means black in Latin. That thing looks like thickened pigmented skin. When you touch it, it feels like velvet. Usually it happens in axilla, neck, below breast, in inner thigh and vulva. So, mostly all those places where skin folds.

The treatment for PCOS includes different medications: oral contraceptives, progesterone,
glucocorticoids, ketoconazole, spironolactone, cyproterone, flutamide, cimetidine, finasteride, ovarian wedge resection, laparascopic electoracutery, mechanical hair removal, etc.

All methods break the cycle of overproduction. The medications are either hormones themself or hormone-like substances that occupy receptor site and prevent regular hormone to work.

The medications act on different levels. Normal hormones have very complicated regulation. There are loops and feedbacks in the pathways.

To suppress a hormone production or action, you give similar hormone or another hormone or non-hormone at all, that goes to the feedback loop and breaks it and so on. It’s really long separate discussion.

Basically, you either decrease hormone production or shift ratio toward female hormones.

Another way, the best probably, is weight loss. No fat cells – no conversion of andrgoens etc… You can make conclusions yourself.
It’s the first line of treatment.

For a simple follicular ovarian cyst (not PCOS) doctor rules out ectopic pregnancy. Then he may send patient home and repeat pelvic exam in 6-8 weeks. Especially, if the cyst was small, less than five cm in diameter.

For larger cysts, doctor would order pelvic ultrasound.

Most follicular cyst will resolve on their own in six to eight weeks. Though, a physician may give oral contraceptives. Again, this suppresses stimulation of cyst by hormones from the hypophysis. The hormones are named gonadotropins.

If the cyst is still there after 6-8 weeks, a suspicion arises that the cyst maybe malignant. Then doctor orders other studies. CT scan. Physician may perform surgical procedures also. He looks what is this cyst really.

Corpus luteum cyst is usually not treated. However, oral contraceptives may be used.

Rupture of any kind of those cysts leads to another story. Acute pain, bleeding into peritoneum.
Sometime bleeding is very severe and is true emergency. You need also to distinguish other process in the abdomen. For example, appendicitis looks similar. You can treat mild case of non-complicated cyst rupture with just observation. Appendicitis almost always requires surgery.

There are many other problems arise. Surgeon scratches his head: what’s going on? Is this this or is this that? Here is the CT scan gives big advantage.

Now, going back to the question of Ms. L.

If the cyst was infected, I don’t’ see a reason why a ruptured cyst wouldn’t become infected.
Cyst content is very nutrient-rich. Remember? All those cells and their products are dedicated to feeding the oocyte (future baby). Should be very tasty for any bacteria.

Rupture may cause significant bleeding as well. This blood is also different from the blood in your vessels.

This blood is sitting in the pelvis, not moving, quickly clotting. Clotting prevents entry of white blood cells. “No flow” prevents entry of antibodies. Absence of flow prevents entry of other protective chemicals (complement etc).

So, it is very nutrient-rich media for bacteria growth.

They can go wild. Why not?
If a female had another pelvic infection before, that infection can flare up. In a normal person peritoneal cavity should be sterile. However, any gynecological or gastrointestinal infection may supply bacteria. Now, mix these bacteria with the content of the leaking cyst. It just destined to become infected.

Actually Ms. L later answered her own question in another e-mail. She had cysts multiple times and they became infected several times.

So, to answer the question:
Will the ruptured cyst become infected? Not necessarily. Rather not. Can it become infected?
Yes.

Simon Paisley asked:


Stem cells are currently used for treating some diseases, and offer hope of a future cure for many of today’s incurable diseases. Parents are now able to have blood or cells from the umbilical cord of their newborn child stored for the child’s future disease treatments. This article gives an overview of the process of stem cell storage.

Stem cell storage is becoming a more and more popular choice among parents of newborn children, and is relatively common in the USA. It is now becoming increasingly common in the UK. These cells have been used for bone marrow transplants since 1988. They may, in the future, offer a cure for many diseases for which there is presently no cure. Conditions and injuries such as heart disease, brain damage, deafness, blindness and diabetes. Even hair loss and missing teeth could be treatable in the future.

The idea behind storage of your child’s stem cells is that they will have a supply of compatible cell types to be used in the treatment of any disease, injury or condition that they might suffer from in the future. Obviously, this also depends on advances being made in medical procedures using these cells. If a cure for this condition has not been discovered by the time the child has developed it, then they are of no use for treatment purposes. The current range of conditions treatable with stem cells is relatively small, however, significant time and money is being put into this area of research and future cures seem to be highly likely.

The storage process begins at the birth of the child, using an umbilical cord blood collection kit supplied by the cord blood storage company. A healthcare professional (a phlebotomist, doctor, nurse etc.) collects blood from the umbilical cord using the collection kit. The process is painless for both mother and baby, and is completely harmless to both. The blood is then transported to the laboratory for processing by the technicians. In some laboratories the whole blood is frozen, but other laboratories extract the stem cells before freezing. The sample is frozen using liquid nitrogen at around minus 190 degrees Celsius, and can be stored in the storage tank at this temperature indefinitely. Some storage tanks use liquid phase nitrogen and some use vapour phase nitrogen. Vapour phase nitrogen appears to be increasingly popular as there has been some evidence of liquid phase nitrogen transferring infectious diseases from one sample to others.

Robert Wascher asked:


Congestive heart failure (CHF) is a serious and life-threatening illness that is associated with premature death. If one thinks of the heart as a pump, progressive damage to this pump’s muscle fibers results in decreased “pump efficiency,” which causes blood to, essentially, back-up within the vascular system under increased pressure. This increased back-pressure causes swelling of the entire body (edema), and particularly the lower extremities, the lungs, the liver, as well as within the heart itself. In more severe cases, CHF is associated with generalized weakness and profound shortness of breath.

The American Heart Association estimates that there are already more than 5 million Americans living with CHF, and that more than 550,000 new cases of CHF are diagnosed each year. Although mortality rates associated with CHF have improved dramatically over the past 30 years, the 5-year death rate associated with clinically significant CHF still approaches 50 percent.

As our population continues to grow older, on average, the incidence of CHF is expected to continue to rise. Although precise estimates are difficult to arrive at, the cost of caring for CHF is thought to be at least $33 billion per year in the United States alone.

There are several known major risk factors for CHF, including coronary artery disease and heart attack (myocardial infarction), uncontrolled high blood pressure (hypertension), diabetes, obesity, diseased heart valves, elevated cholesterol, and smoking. In most countries, coronary artery disease and myocardial infarction are the leading causes of CHF, and these two related risk factors account for approximately two-thirds of all CHF cases in the United States.

In adults, heart muscle fibers (cardiac myocytes) that have become damaged by chronic oxygen deprivation (myocardial ischemia) or oxygen loss (myocardial infarction) are essentially unable to regenerate themselves, and are gradually replaced by scar tissue that interferes with the heart’s pumping action. At the present time, the standard clinical management of heart injury due to ischemia or infarction includes the use of medications such as aspirin, ACE inhibitors, aldosterone antagonists, beta-blockers and nitrates. So-called “reperfusion strategies,” including coronary artery stent placement and coronary artery bypass graft (CABG) surgery may also be required in some patients. However, once the heart’s blood-pumping muscle fibers have become extensively replaced with non-contractile scar tissue (fibrosis), irreversible CHF develops, and only symptomatic management is possible at this point.

Recent animal studies, and limited clinical research studies in humans, have looked at the use of stem cell auto-transplantation into damaged hearts afflicted with CHF. Although mature cardiac myocytes cannot regenerate or reproduce following severe ischemia or infarction, primitive “pluropotential” stem cells in the bone marrow are thought to be potentially capable, under certain conditions, of metamorphosing, or differentiating, themselves into almost any type of specialized cell of the body, including cardiac myocytes. However, this transformation, from undifferentiated bone marrow stem cell into a highly differentiated and specialized cardiac muscle cell, does not occur naturally in the human body, at least not to any clinically significant degree. Therefore, as is also the case in other areas of stem cell research, the greatest challenge in this type of clinical research is in coaxing undifferentiated stem cells to morph into functional cardiac myocytes and to find a way to incorporate these new heart muscle cells into the damaged heart in such a way that they actually improve the damaged heart’s compromised pumping function. (These two challenges continue to vex clinical research into stem cell therapy, and particularly research into the use of adult patients’ own stem cells.)

Now, newly published clinical research in the Journal of the American College of Cardiology appears to have pushed the existing boundaries of so-called autologous stem cell transplantation in the treatment of CHF, and may represent a major advancement towards finding an enduring treatment, if not an eventual cure, for this increasingly common and disabling disease.

In this prospective interventional clinical study, 124 patients who had just experienced an acute myocardial infarction were evaluated with coronary angiograms, treadmill EKGs, 24-hour EKGs, and echocardiograms, among other cardiac studies. Half of this cohort of patient volunteers also underwent collection of their own (autologous) bone marrow cells, and injection of these bone marrow cells into the blocked coronary arteries that had caused these patients’ heart attacks. Both groups of patients were matched with each other in terms of baseline cardiac function and the extent of their myocardial infarctions. All 124 patients were then closely followed, at regular intervals, for 5 years. The results of this study were rather dramatic.

Within 3 months of bone marrow cell injection, significant improvement was noted in cardiac pumping efficiency (ejection fraction) of the bone marrow cell transplant patients, when compared to the patients who did not receive autologous intracardiac bone marrow cell transfusions. Moreover, on average, the total area of heart muscle death (infarction) following heart attack was 8 percent smaller in the patients who received the bone marrow cell transplants, when compared to the “control group” patients.

In the area of the “infarction zone” of the heart, a very significant 31 percent increase in cardiac contractility was observed in the patients who had undergone bone marrow cell transplant, suggesting that the infused bone marrow stem cells had actually incorporated themselves into the infarcted heart muscle, and had successfully transformed themselves into functional cardiac myocytes. When compared to the control group patients, the patients who had undergone autologous intracardiac bone marrow cell transplantation also experienced significantly improved exercise tolerance and a decreased risk of death throughout the 5-year observation period within this study. Furthermore, these highly significant improvements in cardiac function continued to remain stable and durable throughout the 5-year period of post-transplant observation of these patients. As the “treatment group” patients were infused with their own bone marrow cells, there were no episodes of rejection, and no major complications were reported with this novel treatment.

This small prospective pilot study strongly suggests that autotransplantation with stem cells contained in the bone marrow can significantly reduce the risk and extent of CHF following acute myocardial infarction. Not only does this therapy appear to be clinically effective, but it appears to be associated with a very low risk of complications, and it also side-steps the ongoing ethical debate that surrounds the use of more versatile, but more controversial, fetal stem cells.

Based upon the rather remarkable findings of this small clinical study, much larger multi-institution, prospective, randomized, controlled studies of autologous intracardiac bone marrow cell transplantation, following acute myocardial infarction, need to be performed. Fortunately, several such studies are already underway in the United States and Europe. I look forward to the long-term results of such studies, as I believe that they may have the potential to radically transform the management of coronary artery disease and acute myocardial infarction, and offer the best and most practical hope of reducing both the incidence of CHF and the mortality rate associated with CHF.

The information in this column is intended for informational purposes only, and does not constitute medical advice or recommendations by the author. Please consult with your physician before making any lifestyle or medication changes, or if you have any other concerns regarding your health.

cybernat10 asked:

Embryonic stemcell research

Gail Pruszkowski asked:


Science fiction fans who love Frank Herbert’s DUNE series will also enjoy HELLSTROM’S HIVE; the classic tale of a dystopian America threatened by a chilling enemy – insects. It’s a story of genetic manipulation that’s just as spellbinding today as it was in 1973 when it was first published and it’s even more relevant in the light of current debates on cloning and stem cell research.

Herbert based his novel on the 1971 film “The Hellstrom Chronicle” which won the 1971 Academy Award for Best Documentary. The narrator was Dr. Nils Hellstrom, a fictional scientist, who filmed the documentary to warn mankind that insects may one day be the dominant species on Earth. The film is out of print, but I understand it was beautifully photographed with stunning sequences of insect wars and mating practices.
 
In 2007 TOR Books published a new edition of HELLSTROM’S HIVE that’s well worth adding to your collection. The setting is Oregon in a dystopian America, where Dr. Nils Hellstrom is making ecological films on his farm. The Agency, an espionage branch of the government, believes Hellstrom is using his films as a cover while he builds an experimental new weapon. His farm is placed under surveillance, with the hope of stealing his metallurgical technology. The agency “watchers” are easily discovered and they soon disappear. The Agency then sends in their “A” team to find out what happened to their missing agents. 
 
Hellstrom has secretly established an underground society, designed on insect – hive principles. The captured agents are sent to the “vats,” where Hive members go at the end of their own lives to become food for the rest of the Hive. And his society is on the verge of a discovery that is more horrific than anything the government could imagine.
 
Herbert is adept at conveying all the senses and readers will experience every emotion along with the characters. His Hive members are also quite convincing with their insect’s survival instincts, lack of individuality and emotion. The scene is set so perfectly it becomes another character in the story. The suspense is riveting as events unfold. Written in a chillingly real style, interspersed with notes and diary excerpts, this gripping adventure is a story that will make your blood run cold. The tension escalates and the ending will keep you thinking long after you turn the last page.
 
Publisher: Tor Books (April 2007)
ISBN: 978-0-7653-1772-8
Pages: 336
Price: $14.95