Sarcoidosis with secondary recurrent right-sided chylothorax and chylous ascites in a Caucasian male patient.

Sarcoidosis is a rare multisystem autoimmune disease characterized by the presence of non-caseating granulomas in involved organs. We report a novel case of a 61-year-old Caucasian male with sarcoidosis presenting with recurrent chylothorax and chylous ascites. Pleural and ascitic fluid analysis revealed high triglyceride levels, consistent with chylothorax and chylous ascites, respectively. Common etiologies of chylous fluid such as thoracic duct surgical trauma, malignancy and infection were all excluded. Sarcoidosis was confirmed by the presence of non-caseating granulomas on a mediastinal lymph node biopsy. Conservative treatment with low-fat diet, prednisone, octreotide and multiple thoracenteses failed to effectively resolve the chylothorax. Surgical interventions with pleurodesis and thoracic duct ligation were performed, leading to the complete resolution of the chylous effusion and ascites.

In Vitro Fertilization in a Nulliparous Female Resulting in Placenta Increta and Postpartum Hemorrhage.

A 32-year-old female with unexplained infertility delivered a healthy male infant at 39 weeks 0 days gestational age; the pregnancy was facilitated by in vitro fertilization. Shortly after delivery, she was found to have a morbidly adherent placenta. Attempted removal resulted in postpartum hemorrhage and ultimately hysterectomy after attempting multiple fertility preserving methods to achieve hemostatic control. Pathology results revealed a diagnosis of a 0.1 cm placenta increta (Grade 2 placental villi invasion), the least common diagnosis within the placenta accreta spectrum (PAS). Likely due to the small point of trophoblastic invasion, the diagnosis and outcome were not foreseen. This case highlights the need for additional data collection and development of standardized guidelines for the diagnosis and management of PAS, given a patient's risk factors. Current research may be limited by stigmatization surrounding infertility and reproductive-altering surgeries (e.g. hysterectomy). Additionally, counseling in all stages of pregnancy is critical to achieving the best patient-centered outcomes.

Primary Small Cell Carcinoma of the Bladder.

A 64-year-old Caucasian man with a 20 to 25-pack-year cigarette smoking history presented to his primary care provider with the chief complaint of gross hematuria after experiencing three to four months of urinary frequency and urgency. His workup consisted of laboratory blood work, a renal/bladder ultrasound (US), a CT scan without contrast, cystoscopy with biopsy (with an attempted transurethral resection of bladder tumor), and a PET scan. He was diagnosed with stage T4 small cell carcinoma of the bladder (SCCB) shortly after seeking medical care with metastases to the liver, bone, and lymph nodes. There was no evidence of lung involvement. The patient's primary concerns included difficulty urinating and sustained hematuria. He underwent palliative radiotherapy and placement of bilateral nephrostomy tubes in order to preserve his quality of life. He also received a chemotherapy regimen consisting of cisplatin, etoposide, and atezolizumab. The patient underwent hospice care and died approximately six months after the presentation.

Endometrial Carcinoma: Role of Current and Emerging Biomarkers in Resolving Persistent Clinical Dilemmas.

OBJECTIVES: Type II and other high-grade endometrial carcinomas may challenge conventional treatment due to recurrence and metastatic spread and therefore are a persistent clinical dilemma. Effective targeted therapy for these is a goal for clinicians and researchers alike. METHODS: An extensive review of the literature has been performed for obtaining an in-depth understanding of the clinicopathological characteristics, etiologic factors, and molecular profile of these subsets of endometrial carcinoma. Progress made with current and emerging biomarkers for prognosis assessment and therapeutic targeting has been summarized. RESULTS: There has been a significant increase in research on potential biomarkers of endometrial cancer, and beneficial targeted therapies have been identified. CONCLUSIONS: Clinical trials are leading the charge for substantial gains toward personalized treatment of aggressive endometrial carcinoma subtypes.

Transcriptional differences between rhesus embryonic stem cells generated from in vitro and in vivo derived embryos.

Numerous studies have focused on the transcriptional signatures that underlie the maintenance of embryonic stem cell (ESC) pluripotency. However, it remains unclear whether ESC retain transcriptional aberrations seen in in vitro cultured embryos. Here we report the first global transcriptional profile comparison between ESC generated from either in vitro cultured or in vivo derived primate embryos by microarray analysis. Genes involved in pluripotency, oxygen regulation and the cell cycle were downregulated in rhesus ESC generated from in vitro cultured embryos (in vitro ESC). Significantly, several gene differences are similarly downregulated in preimplantation embryos cultured in vitro, which have been associated with long term developmental consequences and disease predisposition. This data indicates that prior to derivation, embryo quality may influence the molecular signature of ESC lines, and may differentially impact the physiology of cells prior to or following differentiation.

Expression profiles of cohesins, shugoshins and spindle assembly checkpoint genes in rhesus macaque oocytes predict their susceptibility for aneuploidy during embryonic development.

High frequencies of chromosomal anomalies are reported in human and non-human primate in vitro-produced preimplantation embryos. It is unclear why certain embryos develop aneuploidies while others remain euploid. A differential susceptibility to aneuploidy is most likely a consequence of events that occur before oocyte collection. One hypothesis is that the relative transcript levels of cohesins, shugoshins and spindle assembly checkpoint genes are correlated with the occurrence of chromosomal anomalies. Transcript levels of these genes were quantified in individual oocytes that were either mature (group 1, low aneuploidy rate) or immature (group 2, high aneuploidy rate) at retrieval, utilizing TaqMan-based real-time PCR. The transcript level in each oocyte was categorized as absent, below the median or above the median in order to conduct comparisons. Statistically significant differences were observed between group 1 and group 2 for SGOL1 and BUB1. There were more oocytes with SGOL1 expression levels above the median in group 1, while oocytes lacking BUB1 were only observed in group 1. These findings suggest that higher SGOL1 levels in group 1 oocytes could better protect against a premature separation of sister chromatids than in embryos derived from group 2 oocytes. The absence of BUB1 transcripts in group 1 was frequently associated with reduced expression of either mitotic cohesins or shugoshins. We hypothesize that ablation of BUB1 could induce mitotic arrest in oocytes that fail to express a complete complement of cohesins and shugoshins, thereby reducing the number of developing aneuploid preimplantation embryos.

Incidence of chromosomal mosaicism in morphologically normal nonhuman primate preimplantation embryos.

OBJECTIVE: To establish the exact rates of chromosomal mosaicism in morphologically normal rhesus macaque embryos by determining the chromosomal complement of all blastomeres. DESIGN: Retrospective rhesus monkey IVF study. SETTING: Academic laboratory and primate research center. PATIENT(S): Young fertile rhesus macaque females. INTERVENTION(S): Morphologically normal in vitro-produced rhesus macaque embryos were dissociated and cytogenetically assessed using a five-color fluorescent in situ hybridization assay developed for rhesus macaque chromosomes homologous to human chromosomes 13, 16, 18, X, and Y. MAIN OUTCOME MEASURE(S): The incidence and extent of chromosomal mosaicism in rhesus macaque preimplantation embryos. RESULT(S): Seventy-seven preimplantation embryos, displaying normal morphology and development, from 17 young rhesus macaque females were analyzed. Overall, 39 embryos (50.6%) were normal, 14 embryos (18.2%) were completely abnormal, and 24 embryos (31.2%) were mosaic. Of the 226 blastomeres analyzed in the mosaic group, 110 blastomeres (48.7%) were normal. CONCLUSION(S): The observed rate of mosaicism in good-quality rhesus embryos resembles previously documented frequencies in poor-quality human preimplantation embryos. A high incidence of mosaicism may limit the diagnostic accuracy of preimplantation genetic diagnosis.

Epigenetics: definition, mechanisms and clinical perspective.

A vast array of successive epigenetic modifications ensures the creation of a healthy individual. Crucial epigenetic reprogramming events occur during germ cell development and early embryogenesis in mammals. As highlighted by the large offspring syndrome with in vitro conceived ovine and bovine animals, any disturbance during germ cell development or early embryogenesis has the potential to alter epigenetic reprogramming. Therefore the complete array of human assisted reproductive technology (ART), starting from ovarian hormonal stimulation to embryo uterine transfer, could have a profound impact on the epigenetic state of human in vitro produced individuals. Although some investigators have suggested an increased incidence of epigenetic abnormalities in in vitro conceived children, other researchers have refuted these allegations. To date, multiple reasons can be hypothesized why irrefutable epigenetic alterations as a result of ART have not been demonstrated yet.

Mitochondria: determinants of stem cell fate?

Stem cells are traditionally classified as being either embryonic stem cells (ESCs) or somatic stem cells. Such a designation has now become blurred by the advent of ostensibly pluripotent cells derived from somatic cells, referred to as induced pluripotent stem cells. Mitochondria are the membrane bound organelles that provide the majority of a cell's chemical energy via their production of adenosine triphosphate. Mitochondria are also known to be vital components in many cell processes including differentiation and apoptosis. We are still remarkably uninformed of how mitochondrial function affects stem cell behavior. Reviewed evidence suggests that mitochondrial function and integrity affect stem cell viability, proliferative and differential potential, and lifespan. Mitochondrial status therefore has profound and as yet unexamined implications for the current drive to develop induced pluripotent stem cells as a therapeutic resource.

Rhesus macaque embryos derived from MI oocytes maturing after retrieval display high rates of chromosomal anomalies.

BACKGROUND: Rhesus macaque and human preimplantation embryos display similar rates of chromosomal abnormalities. The aim of this study was to determine whether embryos developing from MI oocytes that mature post-retrieval display more chromosomal anomalies than those embryos that are generated from oocytes that are at MII at the time of retrieval. METHODS: Rhesus macaque oocytes were obtained after hormonal ovarian stimulation. Immediately after retrieval, the oocytes were classified according to their maturational status. Following in vitro fertilization, Day 3 embryos with good morphology and development derived from oocytes maturing post-retrieval and those from oocytes that were mature at the time of retrieval were cytogenetically assessed using a five-color fluorescent in situ fluorescent hybridization assay developed for rhesus macaque chromosomes homologous to human chromosomes 13, 16, 18, X and Y. RESULTS: Blastomeres from 53 embryos were analyzed. Of the 27 embryos that developed from oocytes that were mature at collection, 18 embryos were chromosomally normal (66.7%), while from the 26 embryos that developed from oocytes that matured post-retrieval, only 9 embryos were chromosomally normal (34.6%). CONCLUSIONS: These results indicate that embryos developing from oocytes maturing post-retrieval display high rates of chromosomal abnormalities and have therefore a reduced developmental competence. As a result, the clinical relevance of using immature oocytes that are retrieved after stimulated cycles in human IVF warrants further investigation.

Chromosomal instability in rhesus macaque preimplantation embryos.

OBJECTIVE: To establish a relevant animal model to systematically investigate chromosomal instability in human oocytes and preimplantation embryos. DESIGN: Prospective rhesus monkey IVF study. SETTING: Academic laboratory, Oregon National Primate Research Center and Caribbean Primate Research Center. ANIMAL(S): Young rhesus macaque females. INTERVENTION(S): In vitro produced entire rhesus macaque preimplantation embryos were cytogenetically assessed using a five-color fluorescent in situ hybridization assay developed for rhesus macaque chromosomes homologous to human chromosomes 13, 16, 18, X, and Y, using human bacterial artificial chromosome probes. MAIN OUTCOME MEASURE(S): Chromosomal abnormality rates in preimplantation embryos from young rhesus macaque females were established. RESULT(S): Fifty preimplantation embryos, displaying good morphology and normal development, were analyzed from 11 young rhesus macaque females. Overall, 27 embryos (54%) were normal, 11 embryos (22%) mosaic, 3 embryos (6%) chaotic, 2 embryos (4%) aneuploid, 3 embryos (6%) haploid, and 4 embryos (8%) triploid. CONCLUSION(S): These data indicate that in vitro produced rhesus macaque and human preimplantation embryos exhibit similar numerical chromosomal aberrations. Rhesus macaques appear to be a suitable animal model for investigating the origin of chromosomal instability observed in human preimplantation embryos.

Challenges of primate embryonic stem cell research.

Embryonic stem (ES) cells hold great promise for treating degenerative diseases, including diabetes, Parkinson's, Alzheimer's, neural degeneration, and cardiomyopathies. This research is controversial to some because producing ES cells requires destroying embryos, which generally means human embryos. However, some of the surplus human embryos available from in vitro fertilization (IVF) clinics may have a high rate of genetic errors and therefore would be unsuitable for ES cell research. Although gross chromosome errors can readily be detected in ES cells, other anomalies such as mitochondrial DNA defects may have gone unrecognized. An insurmountable problem is that there are no human ES cells derived from in vivo-produced embryos to provide normal comparative data. In contrast, some monkey ES cell lines have been produced using in vivo-generated, normal embryos obtained from fertile animals; these can represent a "gold standard" for primate ES cells. In this review, we argue a need for strong research programs using rhesus monkey ES cells, conducted in parallel with studies on human ES and adult stem cells, to derive the maximum information about the biology of normal stem cells and to produce technical protocols for their directed differentiation into safe and functional replacement cells, tissues, and organs. In contrast, ES cell research using only human cell lines is likely to be incomplete, which could hinder research progress, and delay or diminish the effective application of ES cell technology to the treatment of human diseases.

Role of the mitochondrial genome in assisted reproductive technologies and embryonic stem cell-based therapeutic cloning.

Mitochondria play a pivotal role in cellular metabolism and are important determinants of embryonic development. Mitochondrial function and biogenesis rely on an intricate coordination of regulation and expression of nuclear and mitochondrial genes. For example, several nucleus-derived transcription factors, such as mitochondrial transcription factor A, are required for mitochondrial DNA replication. Mitochondrial inheritance is strictly maternal while paternally-derived mitochondria are selectively eliminated during early embryonic cell divisions. However, there are reports from animals as well as human patients that paternal mitochondria can occasionally escape elimination, which in some cases has led to severe pathologies. The resulting existence of different mitochondrial genomes within the same cell has been termed mitochondrial heteroplasmy. The increasing use of invasive techniques in assisted reproduction in humans has raised concerns that one of the outcomes of such techniques is an increase in the incidence of mitochondrial heteroplasmy. Indeed, there is evidence that heteroplasmy is a direct consequence of ooplasm transfer, a technique that was used to 'rescue' oocytes from older women by injecting ooplasm from young oocytes. Mitochondria from donor and recipient were found in varying proportions in resulting children. Heteroplasmy is also a byproduct of nuclear transfer, as has been shown in studies on cloned sheep, cattle and monkeys. As therapeutic cloning will depend on nuclear transfer into oocytes and the subsequent generation of embryonic stem cells from resulting blastocysts, the prospect of mitochondrial heteroplasmy and its potential problems necessitate further studies in this area.

Genotyping: the HLA system and embryo development.

The human major histocompatibility complex (MHC), in addition to its role in the regulation of cell-cell interactions in the immune response, also influences reproductive success. Human leukocyte antigen-G (HLA-G) is an MHC class I gene of particular interest in reproductive biology because of its specific expression on fetal cytotrophoblast cells, and its reported involvement both in protection of the developing fetus from destruction by the maternal immune response and in the prevention of maternal pre-eclampsia. HLA-G has 15 known alleles at the DNA level, and allelic frequency varies among ethnic groups. This study describes the results of an inaugural attempt to correlate an HLA-G genetic polymorphism with pregnancy outcome in a patient population undergoing IVF. The study group was composed of 102 Caucasian women. A maternal HLA-G genetic polymorphism was investigated by polymerase chain reaction (PCR) analysis of DNA collected from granulosa cells surrounding oocytes harvested for the IVF procedure. While no statistically significant correlation was identified in this initial study, larger studies examining DNA from trios of mother, father and offspring are planned.