The human embryonic genome is karyotypically complex, with chromosomally abnormal cells preferentially located away from the developing fetus.

STUDY QUESTION: Are chromosome abnormalities detected at Day 3 post-fertilization predominantly retained in structures of the blastocyst other than the inner cell mass (ICM), where chromosomally normal cells are preferentially retained? SUMMARY ANSWER: In human embryos, aneuploid cells are sequestered away from the ICM, partly to the trophectoderm (TE) but more significantly to the blastocoel fluid within the blastocoel cavity (Bc) and to peripheral cells (PCs) surrounding the blastocyst during Day 3 to Day 5 progression. WHAT IS KNOWN ALREADY: A commonly held dogma in all diploid eukaryotes is that two gametes, each with 'n' chromosomes (23 in humans), fuse to form a '2n' zygote (46 in humans); a state that remains in perpetuity for all somatic cell divisions. Human embryos, however, display high levels of chromosomal aneuploidy in early stages that reportedly declines from Day 3 (cleavage stage) to Day 5 (blastocyst) post-fertilization. While this observation may be partly because of aneuploid embryonic arrest before blastulation, it could also be due to embryo 'normalization' to a euploid state during blastulation. If and how this normalization occurs requires further investigation. STUDY DESIGN, SIZE, DURATION: A total of 964 cleavage-stage (Day 3) embryos underwent single-cell biopsy and diagnosis for chromosome constitution. All were maintained in culture, assessing blastulation rate, both for those assessed euploid and aneuploid. Pregnancy rate was assessed for those determined euploid, blastulated and subsequently transferred. For those determined aneuploid and blastulated (174 embryos), ICM (all 174 embryos), TE (all 174), Bc (47 embryos) and PC (38 embryos) were analyzed for chromosome constitution. Specifically, concordance with the original Day 3 diagnosis and determination if any 'normalized' to euploid karyotypes within all four structures was assessed. PARTICIPANTS/MATERIALS, SETTING, METHODS: All patients (144 couples) were undergoing routine preimplantation genetic testing for aneuploidy in three IVF clinical settings. Cleavage-stage biopsy preceded chromosome analysis by next-generation sequencing. All patients provided informed consent. Additional molecular testing was carried out on blastocyst embryos and was analyzed for up to four embryonic structures (ICM, TE, Bc and PC). MAIN RESULTS AND THE ROLE OF CHANCE: Of 463/964 embryos (48%) diagnosed as euploid at Day 3, 70% blastulated (leading to a 59% pregnancy rate) and 30% degenerated. Conversely, of the 501 (52%) diagnosed as aneuploid, 65% degenerated and 35% (174) blastulated, a highly significant difference (P < 0.0001). Of the 174 that blastulated, the ratio of '(semi)concordant-aneuploid' versus 'normalized-euploid' versus 'other-aneuploid' embryos was, respectively, 39%/57%/3% in the ICM; 49%/48%/3% in the TE; 78%/21%/0% in the PC; and 83%/10%/5% in the Bc. The TE karyotype therefore has a positive predictive value of 86.7% in determining that of the ICM, albeit with marginally higher aneuploid rates of abnormalities (P = .071). Levels of abnormality in Bc/PC were significantly higher (P < 0.0001) versus the ploidy of the ICM and TE and nearly all chromosome abnormalities were (at least partially) concordant with Day 3 diagnoses. LIMITATIONS, REASONS FOR CAUTION: The results only pertain to human IVF embryos so extrapolation to the in vivo situation and to other species is not certain. We acknowledge (rather than lineage-specific survival, as we suggest here) the possibility of other mechanisms, such as lineage-specific movement of cells, during blastulation. Ethical considerations, however, make investigating this mechanism difficult on human embryos. WIDER IMPLICATIONS OF THE FINDINGS: Mosaic human cleavage-stage embryos can differentiate into a euploid ICM where euploid cell populations predominate. Sequestering of aneuploid cells/nuclei to structures no longer involved in fetal development has important implications for preimplantation and prenatal genetic testing. These results also challenge previous fundamental understandings of mitotic fidelity in early human development and indicate a complex and fluid nature of the human embryonic genome. STUDY FUNDING/COMPETING INTEREST(S): This research was funded by Organon Pharmaceuticals and Merck Serono by grants to W.G.K. W.G.K. is also an employee of AdvaGenix, who could, potentially, indirectly benefit financially from publication of this manuscript. R.C.M. is supported by the National Institute of General Medical Sciences of the National Institutes of Health under award number R35GM133747. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. D.K.G. provides paid consultancy services for Care Fertility. TRIAL REGISTRATION NUMBER: : N/A.

Practices of family physicians and pediatricians in administering poliovirus vaccine.

BACKGROUND: When the Advisory Committee on Immunization Practices added the sequential schedule to the poliovirus vaccine (PW) recommendations in 1997, primary care physicians expressed concern about its implementation. This study examines the practices and factors influencing the administration of sequential, oral, or inactivated PW schedules by family physicians and pediatricians. METHODS: A random sample of Ohio family physicians and pediatricians was surveyed between January and April 1998. Primary outcome measures included physicians' awareness of the 1997 recommendations, their recommendations to parents and caregivers, administration of current PW options, and the factors influencing their practices. RESULTS: All physicians who immunize children (n = 263) reported awareness of the 1997 PW recommendations. Family physicians were more likely to recommend and administer oral polio vaccine than pediatricians (50% and 63% vs 17% and 28%; P < .001). Pediatricians were more likely to recommend and administer the sequential schedule than family physicians (66% and 67% vs 31% and 28%; P < .001). Choice of sequential schedule was related to the risk of vaccine-associated paralytic poliomyelitis and liability (P < or = .05). Choice of an all oral polio vaccine schedule was related to cost of inactivated PW and increased number of injections (P < or = .05). One hundred eighty-two physicians (69%) indicated that they personally discuss PW options with parents or caregivers; only 41% have them read the required vaccine information sheets. CONCLUSIONS: Differences exist between family physicians' and pediatricians' implementation of the 1997 PW recommendations. Physician choice of PW schedule is influenced by the risk of vaccine-associated paralytic poliomyelitis, increased number of injections, liability concerns, and vaccine cost. Physicians need to inform parents of vaccine benefits and risks to comply with federal regulations.

Treatment of bleb hypotony after phacoemulsification with autologous blood.

Hypotony from an inadvertent filtration bleb developed in the eye of a 66-year-old woman 1 year after phacoemulsification cataract surgery. The hypotony was treated with an autologous blood injection over the previous phacoemulsification incision. This technique successfully treated the hypotony without additional ocular surgery. The authors report an effective alternative treatment for hypotony induced by an inadvertent filtration bleb.

Uterine and ovarian conservation in advanced small cell carcinoma of the ovary.

BACKGROUND: The decision to recommend removal or conservation of a normal ovary and uterus in a young woman with advanced ovarian cancer is difficult and controversial. CASE: A 21-year-old patient with a large-cell variant of small-cell carcinoma of the ovary stage IIIc underwent optimal debulking surgery with preservation of the normal appearing uterus and opposite adnexa followed by aggressive multi-agent chemotherapy. She is menstruating normally and is free of disease, more than 2 years since completion of chemotherapy. CONCLUSION: In selected cases, conservation of the uninvolved ovary and uterus in patients with advanced-stage, small-cell carcinoma of the ovary may not compromise survival.

Cancer in thyroid nodules. A community hospital survey.

There is little available evidence of the efficiency of preoperative screening for cancer in solitary thyroid nodules in the community hospital setting, and limited composite data for comparison. A three-year survey was made in a 480 bed community hospital to determine the percentage cancer index (PCI) found in patients operated on for solitary thyroid nodules. Cancer was diagnosed in ten of 153 patients with a PCI of 6.5%. For comparison, an extensive literature review revealed a mean PCI ranging from 13.8% to 27.9%, depending on the preoperative selection process. Periodic surveys of PCI in solitary nodules in community hospitals would yield pertinent information in relation to the general "state of the art" and encourage attainment of a PCI as high as feasible.

Membranoproliferative glomerulonephritis with dense intramembranous alterations. A clinicopathologic study.

Two major categories of membranoproliferative glomerulonephritis (MPGN) designated type 1 and 2 MPGN are currently recognized, largely on the basis of characteristic morphologic and immunofluorescence features. In contrast to experience reported from outside the United States, type 2 MPGN has been observed rather infrequently in this country. In a retrospective clinicopathologic study, 24 kidney specimens obtained from 10 children and young adults including seven females and three males (mean age: 13 years) with type 2 MPGN were identified using light, immunofluorescence, and electron microscopy. The histopathologic findings were related to the clinical course of each patient. When initially seen all patients had hematuria and proteinuria, three were nephrotic, and five were mildly hypertensive. A single patient was mildly azotemic. Eight patients had experienced an upper respiratory ifnection preceding their illness, although only one patient had evidence of a streptococcal pharyngitis. During a period of follow-up averaging 10 years, eight patients were nephrotic at some time during their illness and seven were persistently so. Hypertension was a major problem in eight patients and renal function declined markedly within a year of its onset in five. Persistence of the nephrotic syndrome from early onset of the disease, especially when associated with hypertension, was an additional sign of poor prognosis. Four patients developed chronic renal failure and three received one or more renal allografts. Histologic evidence of recurrent disease was found in allografts from the three patients as early as 7 months after transplantation in the absence of clinical features indicative of recurrent glomerulonephritis. It is concluded that type 2 MPGN is a chronic progressive renal disease of unknown etiology and pathogenesis which chiefly afflicts children and young adults. Hypertension and the early and persistent presence of the nephrotic syndrome suggest a poor prognosis. The disease appears to be largely unresponsive to conventional forms of therapy. The disease recurs with great frequency in allografts, often in the absence of clinical evidence of recurrent glomerulonephritis.

Temporal arteriography and immunofluorescence as diagnostic tools in temporal arteritis.

Nineteen patients with polymyalgia rheumatica and/or temporal arteritis were classified by degree of clinical and arteriographic abnormality, biopsy grade of arteriosclerosis, and giant cell arteritis (GCA). Temporal arteriograms were very sensitive in detecting abnormal arteries. However, the assumption of some previous studies, that certain angiographic abnormalities are synonymous with GCA, was not supported, since biopsies from distal sites in a Class I and a Class II arteriogram revealed only arteriosclerosis. Class III arteriograms correlated with proximal biopsies of GCA. Immunofluorescent staining was negative in all cases.

Immunofluorescent studies on the trabecular meshwork in open-angle glaucoma.

The trabecular meshwork of eyes with open-angle glaucoma has been demonstrated to have an increase in gamma globulin and plasma cells, raising the question of an immunogenic mechanism in this disorder. In the present study, however, immunofluorescence assays on the trabecular meshwork of eyes with open-angle glaucoma were negative for specific immunoglobulins and for complement components that would result specifically from an antigen-antibody reaction. The study fails to provide any evidence in support of an immunogenic mechanism in open-angle glaucoma.

Apparent recurrence of progressive systemic sclerosis in a renal allograft.

A young woman with progressive systemic sclerosis (PSS) and renal failure who received a renal transplant from her mother suffered accelerated loss of allograft function in the absence of hyperacute rejection or severe hypertension. A biopsy specimen and pathologic examination of the transplanted organ showed a fluorescent antibody pattern and vascular changes that were indistinguishable from those in the patient's native kidneys. This clinical sequence is a departure from the relative success of renal transplantation in the few previously reported cases of PSS where it has been used as therapy for renal failure.

The kidney in progressive systemic sclerosis: immunohistochemical and antibody elution studies.

Immunologic studies were performed on 11 renal specimens from seven patients with progressive systemic sclerosis (PSS). Two patients had the chronic renal lesions of PSS and five had acute PSS renal disease. One of the latter patients underwent renal transplantation after developing acute renal failure with recurrence of lesions in the allograft. The lesions in the allograft were morphologically indistinguishable from the renal lesions of acute PSS. Immunofluorescence microscopy revealed vascular localization of IgM along with early and late acting complement components C1Q, C4, and C3 in all specimens including the allograft. Fibrinogen localization was observed in the vasculature of patients with the acute form of the disease. Antiglobulin, detected by fluorescein-labeled, heat-aggregated gamma-globulin, was also present in vascular lesions from two of the specimens; Eluates of four of the kidneys including the allograft contained antinuclear antibodies. In addition, antiglobulin activity was present in eluates from three of the four kidneys, The findings suggest that (1) renal vascular lesions in PSS may result from injury via immune complexes composed of nuclear antigens and antibody, (2) the predominance of IgM in the vascular lesions may reflect the presence of rheumatoid factor in the immune complexes, and (3) a similar pathogenetic mechanism may have resulted in allograft failure following renal transplantation of a patient with PSS.

Renal transplantation between HL-A haploidentical donor-recipient pairs: functional and morphological evaluation.

Fifty-nine recipients received renal allografts from an HL-A haploidentical family member. Immunogenicity of the incompatible haplotype was measured by skin grafts exchanged within each family when possible, and renal allograft recipients were assigned prospectively to two groups depending on the skin graft survival time (Group 2A greater than 15 days; Group 2B less than 15 days). If skin grafts could not be accomplished, the patients were place in an unclassified group, Group 2. Renal function at one and 2 years following engraftment did not differ between the two groups. Mixed lymphocyte stimulation of recipient lymphocytes by mitomycin-treated donor lymphocytes also was comparable in the groups. Histopathological evaluation by light, immunofluorescence, and electron microscopy at least 6 months following allografting did not distinguish between the groups. The only differentiating characteristic was that Group 2A patients did not experience their primary rejection episode until an average of 18 days following transplantation, whereas Groups 2B and unclassified 2 had their initial primary rejection episode at average days 9 and 5, respectively. In our clinical program, matching for HL-A halotypes continues to be the best predictor for long-term renal function in consanguineous renal transplantation.

Focal glomerular sclerosis: contrasting clinical patterns in children and adults.

In a retrospective clinicopathological study, 48 kidney biopsy specimens from 16 children (mean age, 7 years) and 17 adults (mean age, 33 years) with histological evidence of focal glomerular sclerosis (FGS) were examined using light, immunofluorescence and electron microscopy. The histopathological findings were related to the clinical course of each patient. At the clinical onset of the disease, the nephrotic syndrome was seen more commonly in children (12/16) than adults (7/17), while the incidence of both hypertension (children 1/16 versus adults, 9/17) and renal insufficiency (children, 0/16 versus adults, 7/17) was greater in adults. Despite a shorter average follow-up, (adults 3 10/12 years versus children, 7 years), the incidence of hypertension (adults, 13/17 versus children, 7/16) and renal functional impairment (adults, 13/17 versus children, 3/16) remained greater in the adult patients. One child and three adults died in renal failure while two adults underwent transplantation and on requires regular dialysis therapy. Nine of 15 pediatric patients treated with corticosteroids experienced partial or complete remission in either their nephrotic syndrome or level of urine protein excretion, while just 3 of 6 adult patients treated with corticosteroids experienced a partial remission, but never became protein-free. There was an excellent correlation in all patients between the degree of functional renal impairment and the extent of glomerular and nonglomerular histopathological damage in the kidney. It is concluded that in the adults, FGS represents a more severe and progressive disease process and is less responsive to therapy.

IgA nephropathy.

From a series of 470 specimens of renal tissue examined by immunofluorescence microscopy, 20 specimens were identified and studied in detail from patients without evidence of systemic disease in which IgA was the predominant localizing immunoglobulin. All patients presented with hematuria which was recurrent or persistent, often being exacerbated by upper respiratory infection. Most of the group pursued a benign clinical course with little evidence of decline in renal function. Histopathologic changes in renal biopsy specimens of most of the group consisted of a proliferative glomerulonephritis of variable intensity. Characteristic alterations were seen by electron microscopy which included the presence of electron-dense deposits within the mesangium, the hilar regions of the glomerulus and the basement membrane of Bowman's capsule. Evidence for activation of complement by the alternate pathway at C3 was found with properdin localization in 14 of 15 specimens and with the absence of detectable Clq and C4 in 15 specimens studied for these early acting components. It is concluded that the combined clinical, morphologic and immunologic findings warrant consideration of IgA nephropathy as a distinct clinicopathologic entity.

Nuclear localization of immunoglobulins in renal biopsies of patients with lupus nephritis.

Immunofluorescent evaluation of renal biopsies from 19 patients with lupus nephritis revealed nuclear localization of immunoglobulins (IgG and IgM) in 6 patients. Homogeneous, nuclear rim and speckled patterns of nuclear localization were observed. The extent of localization varied, with only occasional nuclei fluorescing in 1 case, whereas approximately 50% of the nuclei exhibited fluorescence in the most extreme case. The phenomenon of nuclear localization of immunoglobulins was not observed in immunofluorescent studies of 225 renal biopsies from patients with conditions other than lupus nephritis. The possibility that nuclear localization of immunoglobulins occurred artifactually in the 6 patients was considered and was discounted by determining antinuclear antibody titers on serum obtained concurrently with the renal biopsy Nuclear localization was not confined to areas of histologically evident parenchymal destruction, indicating that antinuclear antibodies do not react only with nuclear antigens after tissue breakdown, but may gain access to intracellular antigens prior to cell dissolution.