Unified Theory of TIs. GPRPL Consortium 5Dec25

Transcript

• 00:00Alright. Well, thank you so
• 00:01much. Let me just a
• 00:02brief introduction to myself. I'm
• 00:04a research scientist here at
• 00:05Yale University, Department of OB
• 00:07GYN.
• 00:08I've been here at Yale
• 00:09for thirty four years proudly,
• 00:11and I'm proud to be
• 00:12part of the GPRPL
• 00:14study.
• 00:15I have always been very
• 00:17enthusiastic about this study and,
• 00:18from the very beginning, wanted
• 00:19to be involved because this
• 00:21is what I deal with
• 00:22clinically.
• 00:23And I thought I would
• 00:24share,
• 00:25the work that we've been
• 00:27doing related to pregnancy loss,
• 00:29looking at the placenta,
• 00:30and how all these things
• 00:32in my mind,
• 00:33come together in a unifying
• 00:35hypothesis related to trophoblast inclusions,
• 00:38which I will introduce to
• 00:39you. I always like to
• 00:41start I'm, again, a physician
• 00:43scientist, so I take care
• 00:44of patients, do research.
• 00:46I always like to start
• 00:47off with my patients because
• 00:48I think it gives a
• 00:49context of what we're dealing
• 00:50with. So this is NH,
• 00:52at the time that I
• 00:53met her, a thirty year
• 00:54old G3P1,
• 00:55one stillbirth and two miscarriages,
• 00:57no living children. Her first
• 00:59loss here in twenty seventeen
• 01:01was thirty two weeks and
• 01:02two days
• 01:04of stillbirth. What was notable
• 01:05is the placenta was at
• 01:07the point
• 01:08one percentile,
• 01:09very small.
• 01:11This is from an outside
• 01:12institution.
• 01:13It was sent to me
• 01:14as a consult. The outside
• 01:15institution, the pathology basically just
• 01:17said normal placenta, normal karyotype,
• 01:20and she was told, these
• 01:21things happen. Just try again.
• 01:24So they did try again.
• 01:25Infertility is not their issue.
• 01:27They got pregnant again fairly
• 01:28easily.
• 01:29They had a sixteen week
• 01:30loss, now a miscarriage.
• 01:32At this point, the classic
• 01:34diagnosis by pathologists of products
• 01:36of conception, which has no
• 01:38information at all to it,
• 01:39we knew it was products
• 01:40of conception, so it's not
• 01:42helpful to have that as
• 01:43the diagnosis, but this is
• 01:44what they were told. And
• 01:45again, these things happen, try
• 01:47again.
• 01:48So they did, they got
• 01:49pregnant yet again and had
• 01:51at this point a twelve
• 01:52week miscarriage.
• 01:53Again, products of conception were
• 01:55diagnosed and they were simply
• 01:56told to try again. Well,
• 01:58as you can imagine, this
• 01:59was very frustrating, so they
• 02:01did find another resource and
• 02:02luckily found out about me,
• 02:04sent me their entire case
• 02:06for review, and I looked
• 02:07at all these placentas and
• 02:09found that there were no
• 02:10clots, no immune responses, no
• 02:12bacterial responses.
• 02:14So what is going on?
• 02:16Why have the has this
• 02:18couple had these three losses?
• 02:19So we'll get back to
• 02:20them in a minute, but
• 02:21let me pull back and
• 02:22just give an overview in
• 02:23terms of pregnancy losses.
• 02:25There are five million pregnancies
• 02:27a year in our country.
• 02:29There are four million liveborns
• 02:31approximately.
• 02:32That means that there are
• 02:33a million pregnancy losses. So
• 02:34that is a very large
• 02:35number.
• 02:37The majority of these are
• 02:38miscarriages, and we define these
• 02:40in our country as variable
• 02:42from country to country
• 02:43as a loss less than
• 02:45twenty weeks of gestation.
• 02:46And I'll point out in
• 02:47a few minutes that this
• 02:48is an arbitrary division. I
• 02:50don't think it's exactly the
• 02:51right place
• 02:52that we should have this
• 02:53division,
• 02:54but this is the way
• 02:55it is for us now.
• 02:56And we define losses a
• 02:58greater equal or greater than
• 03:00twenty weeks as a stillbirth,
• 03:01and there are about twenty
• 03:02three thousand in our country.
• 03:05One of the frustrating things
• 03:06about pregnancy losses is that
• 03:07for
• 03:08decades, the unexplained rate, in
• 03:10other words, the rate at
• 03:11which losses could not be
• 03:13explained and no cause could
• 03:15be attributed to them, has
• 03:16remained about constant, about thirty
• 03:18percent for years. So So
• 03:20we haven't really put a
• 03:21dent in this.
• 03:22And the question is, why
• 03:23is that? Why can't we
• 03:24figure out what's going on
• 03:25with these pregnancy losses?
• 03:27And I think the reason
• 03:29is
• 03:29simple.
• 03:30One is routine pathologic examination
• 03:33of the losses often doesn't
• 03:35reveal a pathologic problem, as
• 03:37these three cases
• 03:38show you, and current standard
• 03:41genetic analyses are not sufficient
• 03:43to find out a genetic
• 03:44reason.
• 03:45Now, of course, a routine
• 03:47thing is to get a
• 03:48karyotype and a microarray, for
• 03:50example,
• 03:51and many of my patients
• 03:52are very confused when they
• 03:53have a result that returns
• 03:55back as a normal karyotype
• 03:56or microarray,
• 03:58they feel that their
• 03:59pregnancy loss was not due
• 04:01to a genetic abnormality. But
• 04:03as we know, that is
• 04:04not true. Even if a
• 04:06karyotype and microarray are normal,
• 04:08there still obviously can be
• 04:09a genetic abnormality.
• 04:11And the reason is, is
• 04:12there are six billion DNA
• 04:14codes
• 04:15in our genome.
• 04:17And our goal for GPRPL
• 04:19is to try to solve
• 04:20this problem. So this is
• 04:21the underlying goal for our
• 04:23project and what brings us
• 04:24all together.
• 04:25In the meantime, while we're
• 04:27trying to figure that out,
• 04:28I have been asking myself
• 04:30for the last three decades,
• 04:31Is there another way to
• 04:32diagnose a genetic abnormality
• 04:35in a pregnancy?
• 04:36And obviously, one doesn't ask
• 04:38a question unless you have
• 04:39an answer for it. And
• 04:40I do believe there is
• 04:41a way to answer that.
• 04:44And the way to do
• 04:45it is by looking at
• 04:45the placenta and identify
• 04:48dysmorphic features in the placenta.
• 04:50Well, in order to teach
• 04:51you about dysmorphic features in
• 04:53the placenta, I just want
• 04:54to remind people about the
• 04:56normal structure of the placenta.
• 04:57Maybe it's familiar to many
• 04:59of you, but for those
• 05:00that aren't, I'm just going
• 05:01to give a very brief,
• 05:02embryologic overview here of ovulation,
• 05:05fertilization,
• 05:06early embryological
• 05:07development,
• 05:08and attachment of this blastocyst
• 05:10to the lining of the
• 05:12uterus, the endometrium.
• 05:14About nine days after fertilization,
• 05:16this is what a pregnancy
• 05:17looks like, the little embryo
• 05:19has now turned into a
• 05:20little three layer embryo,
• 05:22and the single layer of
• 05:23trophoblasts, which will become the
• 05:25placenta,
• 05:26have now differentiated into two
• 05:28different types of trophoblasts,
• 05:30the cytotrophoblasts,
• 05:31which is the stem cell,
• 05:32the inner layer, and the
• 05:34outer layer, the syncytiotrophoblasts,
• 05:37a multinucleoid
• 05:38cell that, for example, at
• 05:39this point in pregnancy is
• 05:41making large quantities of hCG.
• 05:44So this is what things
• 05:45look like at that point.
• 05:47If we jump ahead to
• 05:48the third trimester, for example,
• 05:51this is the overall structure
• 05:52of the placenta. The fetus
• 05:53would be up here, connected
• 05:55to its placenta through its
• 05:56umbilical cord. You can think
• 05:58of the placenta as the
• 06:00root system of a tree.
• 06:01So if you can see
• 06:02my hand, imagine my hand
• 06:04in a bucket of water
• 06:05with my fingers wiggling around,
• 06:07That's what the villus tree
• 06:08looks like. The water in
• 06:09this analogy is mom's blood,
• 06:11which is fountaining like a
• 06:13sprinkler system into the placenta.
• 06:15Let's dive down and look
• 06:17at a little more detail
• 06:18the structure of the villus
• 06:20trophoblasts here. So if we
• 06:22pull out one of these
• 06:23single villi, the fingers that
• 06:25I just showed you, and
• 06:26you cut a knife through
• 06:27it, you start to see
• 06:29the cellular structure of the
• 06:30villus and you see the
• 06:32same exact cells that I
• 06:33showed you before.
• 06:35The inner layer, the cytotrophoblast,
• 06:37is the stem cell, the
• 06:38proliferative cell, and the outer
• 06:40layer, the syncytiotrophoblast.
• 06:42You can consider this the
• 06:44working cell of the placenta,
• 06:46makes all the hormones, mediates
• 06:47transports, and things like that.
• 06:50This is a diagram. This
• 06:52is what a third trimester
• 06:53cross section of chorionic villi
• 06:55would look like. The white
• 06:57space is where mom's blood
• 06:58would be, the skin covering,
• 07:00if you will, of the
• 07:01fingers of the trophoblast layer,
• 07:03and you can see the
• 07:04fetal capillaries with the fetal
• 07:06red blood cells inside.
• 07:08Now, anybody who has done
• 07:10pediatrics or has had a
• 07:11baby or knows anything about
• 07:13what happens in labor and
• 07:14delivery room after delivery,
• 07:16you know that the first
• 07:18thing that we do when
• 07:19we look at a newborn
• 07:20baby is try to identify
• 07:22dysmorphic
• 07:23features.
• 07:24Why do we do that?
• 07:25Because this is the easiest
• 07:26way, just with a visual
• 07:28inspection,
• 07:29to give a hint that
• 07:30there might be a genetic
• 07:31abnormality.
• 07:32In this diagram, you can
• 07:34see trisomy twenty one at
• 07:35the top, trisomy eighteen in
• 07:37the middle, and trisomy thirteen
• 07:38at the bottom. These are
• 07:40pretty obvious and just from
• 07:42the dysmorphic features of these
• 07:43newborns, you can make these
• 07:45diagnoses.
• 07:46However,
• 07:47on the left are much
• 07:49more subtle developmental problems, dysmorphic
• 07:51features, in this case of
• 07:53hand development.
• 07:54And in these cases, these
• 07:55children have normal karyotypes,
• 07:57but they have genetic abnormalities.
• 07:59In fact, the genetic abnormalities
• 08:02to lead to polydactyly
• 08:03in these abnormal hand developments
• 08:05are quite interesting.
• 08:06They relate to the three-dimensional
• 08:08structure of the DNA
• 08:10of the ninety nine percent
• 08:11of the six billion codes
• 08:13that don't code for any
• 08:14genes that we know of.
• 08:16So this is just a
• 08:16little hint of the complexity
• 08:18of the genome.
• 08:20Now, just as newborn babies
• 08:22can be looked at for
• 08:23dysmorphic features, the placenta can
• 08:25also be looked at for
• 08:27dysmorphic features. And the placenta,
• 08:29as I pointed out, is
• 08:30like the root system, again,
• 08:31my hand in the bucket
• 08:32of water. Here's a diagram
• 08:34of the branching structure of
• 08:36the placenta, and most of
• 08:38the placenta basically forms by
• 08:40branching outward to create its
• 08:42structure.
• 08:43The dysmorphic feature we see
• 08:45in the placenta
• 08:47is an abnormal
• 08:48infolding.
• 08:49We call it an invagination.
• 08:52This is a diagram to
• 08:53the right. This is the
• 08:54real picture to the left.
• 08:55Let me focus on the
• 08:56diagram.
• 08:57It looks like someone has
• 08:58taken their finger and pushed
• 09:00inward to bend the bilayer
• 09:02inward. That's not what is
• 09:03happening. What is actually happening
• 09:05is there are too many
• 09:08cytotrophoblasts,
• 09:09these pink cells.
• 09:10Too much cell proliferation.
• 09:13Just continue to remember that
• 09:15as we go through this
• 09:16presentation here. On the left,
• 09:18you can see the piling
• 09:20up of all these cytotrophoblasts
• 09:21in this focal area, and
• 09:23that bends the bilayer inward.
• 09:26If the knife happens to
• 09:28randomly cut across one of
• 09:29these invaginations,
• 09:31like this SS cut here,
• 09:33it creates
• 09:34what we call a trophoblast
• 09:36inclusion.
• 09:37Truphoblast
• 09:38invaginations
• 09:39and inclusions are the dysmorphic
• 09:41features of the placenta.
• 09:43So,
• 09:44and again, just to highlight
• 09:46this, and I'll show you
• 09:46a three-dimensional reconstruction of this
• 09:48in a minute, this is
• 09:49actually the same structure,
• 09:52just happens to be moving
• 09:53in and out of the
• 09:54plane of the section. So
• 09:54this invagination is continuous
• 09:56with this cross section of
• 09:57this trophoblast inclusion. That's And
• 10:00you are sure. Go for
• 10:02the questions. So you get
• 10:03this
• 10:04excessive proliferation of cells. Why
• 10:05wouldn't they bulge outwards? Why
• 10:07does it always invaginate?
• 10:08Oh, what a good question.
• 10:10Well, it has to do
• 10:11with mechanical engineering and physics.
• 10:14So it depends on which
• 10:16side has more cells. I'm
• 10:17gonna give you an analogy.
• 10:19If you remember the hundred
• 10:20meter dash in the Olympics
• 10:21last summer, you know how
• 10:23they stagger all the runners
• 10:24in different places on the
• 10:25track. You can think of
• 10:27the cytotrophoblast
• 10:28lane here as a longer
• 10:31lane,
• 10:32and this is the outer
• 10:33lane of the tract, and
• 10:34this is the inner lane.
• 10:35So if there is more
• 10:37material on this side, it
• 10:38has to bend in this
• 10:39direction. If there was more
• 10:41material on the blue side,
• 10:43it would bend outward. And
• 10:44I will show you an
• 10:45example of that. So it
• 10:46just depends on the, basically,
• 10:49the kinetics
• 10:50of which layer has more
• 10:51cells in it. Either the
• 10:53inner layer or the outer
• 10:54layer determines which way things
• 10:56bend.
• 10:57Great, insightful question. Thank you.
• 10:59Now, I will just highlight
• 11:01some more pictures of invaginations
• 11:03from other placentas.
• 11:05And this last one on
• 11:06the lower right, if anybody
• 11:07knows dermatology,
• 11:08you might remember something called
• 11:10an epidermal inclusion cyst. Sometimes
• 11:12it appears as a little
• 11:13bump on someone's face. That's
• 11:15from an invagination
• 11:17of the squamous
• 11:18lining of the skin, and
• 11:20then the skin continues to
• 11:21grow but inside of the
• 11:23dermis, basically. And this is
• 11:25like an epidermal inclusion cyst.
• 11:27Again, if the knife happens
• 11:29to cut across any of
• 11:30these invaginations,
• 11:32it appears as trophoblast
• 11:34inclusions.
• 11:35Well, one of the questions
• 11:36that I'm always asked is,
• 11:37Well, gee, are you the
• 11:38only one who sees this?
• 11:40Are you the first one
• 11:41to have seen this? Have
• 11:42other people seen this before?
• 11:44Are you living in a
• 11:45fantasy world? What's going on
• 11:46with you, Harvey? So I
• 11:47just wanna highlight a little
• 11:49history here that these were
• 11:51first seen in the eighteen
• 11:53hundreds.
• 11:54For those of you who
• 11:55read German, I'm gonna translate
• 11:56this. This is a Google
• 11:58translate here. Syncytial Geschwasellen
• 12:01are syncytial tumor cells. And
• 12:04here's an actual photo micrograph
• 12:06from eighteen ninety seven of
• 12:08a microscopic view of a
• 12:09placenta of a pregnancy loss
• 12:11in this journal.
• 12:13And the article, the title
• 12:15of the article is Malignant
• 12:16Deciduomas.
• 12:17You can kind of get
• 12:18that. They didn't know exactly
• 12:20what was going on. And
• 12:21this was in the journal
• 12:23of
• 12:24Gebir Stalin, which I think
• 12:25is gynecology,
• 12:27maybe pregnancy, and gynecology.
• 12:29You can see that gynecology
• 12:30still exists as a word
• 12:32here in this journal. So
• 12:33this is really the first
• 12:34publication I was able to
• 12:35find of it. There was
• 12:37a fantastic
• 12:38volume in nineteen twenty one
• 12:40that looked at twelve hundred
• 12:42cases as part of the
• 12:43Carnegie collection.
• 12:45Look at these pictures. These
• 12:46are exactly the same as
• 12:47the tropholastic inclusions I just
• 12:49showed you back in nineteen
• 12:51twenty one. And what I
• 12:52like especially about this
• 12:55reference is that they describe
• 12:57the exact characteristics of tropholass
• 12:59inclusions here. They say there
• 13:01are numerous points of the
• 13:03syncytium that invade.
• 13:05They are lined by two
• 13:06layers of cells, just like
• 13:07I showed you, which are
• 13:09often filled with dense masses
• 13:10of small round cells. So,
• 13:12that is the definition
• 13:14of a trophoblast inclusion.
• 13:16Now, the word trophoblast inclusion
• 13:18was actually coined in this
• 13:19paper in nineteen sixty four
• 13:21by Boyd and Hamilton.
• 13:23The title of their paper
• 13:24was Stromal trophoblastic
• 13:26buds. And we do not
• 13:27write this way anymore, but
• 13:28I love that they describe
• 13:30the creation of these in
• 13:32this paper, and then they
• 13:33have a little asterisk under
• 13:35their title, stromal trophoblastic
• 13:37buds, and they say, The
• 13:38question of a suitable term
• 13:40for the trophoblastic
• 13:42inclusions
• 13:43has given us some concern.
• 13:45So their parenthetic comment here,
• 13:47in fact, has become the
• 13:48name of these things and
• 13:49it started in nineteen sixty
• 13:51four. As I pointed out
• 13:53before, they did something cool
• 13:54in this paper. They did
• 13:56three d reconstruction.
• 13:57They did serous sections of
• 13:59multiple sections of these placentas
• 14:01with the trophoblast inclusions.
• 14:03And in the top left,
• 14:04you can see the three
• 14:05d reconstruction,
• 14:07and it points out again
• 14:09that these inclusions are nothing
• 14:11more than invaginations
• 14:12from the surface with sort
• 14:13of bulbous ends to them.
• 14:15And if you cut through
• 14:16the bulb, it appears as
• 14:18a trophoblast inclusion.
• 14:20Okay. So that's the history
• 14:22of it. What causes it?
• 14:23And this will this will
• 14:25actually answer a little bit
• 14:26Hugh Taylor's insightful question there.
• 14:29It wasn't a plant. I
• 14:30did not ask him to
• 14:31ask that question, just FYI.
• 14:34So what causes these trophoblast
• 14:35inclusions? Well, to understand what
• 14:37causes them, you have to
• 14:39go back to the basic
• 14:40structure of the placenta.
• 14:42And I have mentioned a
• 14:43couple times, and I'm going
• 14:44to highlight this, that the
• 14:45placenta,
• 14:46the villi are lined by
• 14:48two layers of cells, the
• 14:49cytotrophoblast,
• 14:50the stem cell, and the
• 14:52syncytiotrophoblast.
• 14:53And I was lucky enough
• 14:54when I did my postdoctoral
• 14:56research fellowship at University of
• 14:57Pennsylvania with Jerry Straus, just
• 14:59by serendipity,
• 15:01I assure you it was
• 15:02by accident,
• 15:03I discovered the relationship of
• 15:05the cytotrophoblasts
• 15:06and the syncytial trophoblasts by
• 15:07looking at these cells in
• 15:09culture, and what I saw
• 15:10on time lapse movies is
• 15:12that these single cytotrophoblasts
• 15:14in culture over a period
• 15:15of four days
• 15:16moved, aggregated,
• 15:18the membranes broke down, and
• 15:20they formed syncytia.
• 15:21Up to that point, people
• 15:23thought that syncytial trophoblasts were
• 15:25formed by a process called
• 15:26endoreduplication,
• 15:28which means that the nuclei
• 15:30divide and divide, but we
• 15:31showed in this paper that
• 15:33they actually form by fusion
• 15:35of the cytotrophoblasts.
• 15:36Taking that insight into the
• 15:38placenta itself, we can now
• 15:40look at the bilayer and
• 15:41answer Hugh Taylor's question in
• 15:43more scientific detail.
• 15:45These cytotrophoblasts
• 15:46have two choices in life.
• 15:47They either proliferate
• 15:49or if they differentiate,
• 15:51they fuse with the overlying
• 15:52layer. And there's kinetic constants
• 15:55for proliferation and fusion.
• 15:57And depending, again, as I
• 15:59said before, but now highlighted
• 16:00in this publication,
• 16:02if the proliferation
• 16:03rate of the cytotrophoblast
• 16:05is greater than two times
• 16:07the fusion rate, it bends
• 16:09inward. That forms the invagination.
• 16:12If the fusion rate is
• 16:13greater than the
• 16:15proliferation rate, it branches outward.
• 16:19That's called branching morphogenesis.
• 16:21And this is how the
• 16:22placenta normally forms.
• 16:24If the rate is exactly
• 16:25equal where proliferation equals two
• 16:28times the fusion rate, there's
• 16:29just a lengthening
• 16:30of the bilayer. So these
• 16:32are the three kinetic constants
• 16:34that explain the whole growth
• 16:36of the placenta.
• 16:37So up until this point,
• 16:40what I basically had seen
• 16:42clinically through my clinical experience
• 16:44is that trophoblast inclusions
• 16:46are associated with pregnancy losses
• 16:48and, as I'll show you
• 16:49in a few minutes, very
• 16:51small placentas.
• 16:52So
• 16:53here is a paper that
• 16:54we recently published in Reproductive
• 16:56Sciences in twenty twenty three
• 16:58where we looked at the
• 17:00causes of pregnancy losses between
• 17:02six weeks and forty three
• 17:04weeks. I've created what's called
• 17:06a density plot here of
• 17:08the different
• 17:09pathologies that were identified in
• 17:10these losses. There were almost
• 17:12thirteen hundred of them. And
• 17:14you can see that the
• 17:15dominant
• 17:16cause of pregnancy loss in
• 17:18the first and certainly second
• 17:20trimester
• 17:21are dysmorphic or associated with
• 17:22dysmorphic chorionic villi, which we've
• 17:25interpreted are due to genetic
• 17:27abnormalities. Of course,
• 17:29the reason I'm so excited
• 17:30about the gPRPL study is
• 17:32I would like to validate
• 17:33this. This is currently a
• 17:35hypothesis
• 17:36based on the visualization of
• 17:38trophoblast inclusions. So this is
• 17:39the entire
• 17:41population.
• 17:42I can show you the
• 17:43same data in a pie
• 17:44chart, and you can see
• 17:45that about seventy one percent
• 17:47of all pregnancy losses have
• 17:49trophoblast inclusions,
• 17:50and then there are some
• 17:51other causes which are here
• 17:53in these other pieces of
• 17:54the pie.
• 17:55If we focus just on
• 17:56miscarriages,
• 17:57again, defined as pregnancy losses
• 17:59less than twenty weeks, and
• 18:01look at the pie chart
• 18:02for that, eighty six percent
• 18:04are associated with trophoblast inclusions.
• 18:08And if we look at
• 18:10stillbirths now, greater than twenty
• 18:12weeks, twenty weeks and greater,
• 18:14here is what the pie
• 18:15chart looks like here.
• 18:17Now the causes are slightly
• 18:18different. Genetics is still quite
• 18:20a bit at thirty percent,
• 18:21but small placentas
• 18:23are thirty three percent and
• 18:25cord accidents are about fifteen
• 18:26percent.
• 18:27But what's interesting is that
• 18:29if you look at just
• 18:30the third trimester, and this
• 18:31is where I think we
• 18:32should, from now on, have
• 18:34the division of miscarriages and
• 18:35stillbirths,
• 18:36this is a U shaped
• 18:37curve and this is the
• 18:38inflection point right at the
• 18:40end of the second trimester.
• 18:41I believe that all first
• 18:43trimester and second trimester losses
• 18:45really are very similar, and
• 18:47it's the third trimester that
• 18:49diverge and are quite different.
• 18:51But what's interesting when you
• 18:52look at the pie chart
• 18:53of that, now you can
• 18:54see that thirty six percent
• 18:56of stillbirths are due to
• 18:57small placentas, only sixteen percent
• 19:00genetics,
• 19:01and twenty one percent cord
• 19:02accidents. However, when you look
• 19:04at the causes for small
• 19:05placentas,
• 19:06the majority of the small
• 19:08placentas are due to genetic
• 19:10abnormalities.
• 19:11Okay, well, this has all
• 19:12have been just an introduction
• 19:14to go back to our
• 19:15patient here, which is setting
• 19:16up this whole discussion.
• 19:18So, let's look at NH
• 19:19again and see what we
• 19:20found.
• 19:21I found an average of
• 19:23one point seven trophoblast inclusions
• 19:26per slide in her thirty
• 19:27two week loss. And you
• 19:29may say, That's not really
• 19:30that much, but normal is
• 19:31zero point one. So this
• 19:33is seventeen times normal, and
• 19:35this is a classic example
• 19:37of a small placenta associated
• 19:39with trophoblast inclusions.
• 19:41Her sixteen week loss had
• 19:42three point five per slide
• 19:44or thirty five times normal,
• 19:46and her twelve week loss
• 19:48had ninety times normal the
• 19:50number of trophoblast inclusions.
• 19:52So as you can see,
• 19:53there seems to be a
• 19:54dose response curve. And if
• 19:56we plot out on the
• 19:57y axis the number of
• 19:59trophoblasts inclusions per slide is
• 20:01some
• 20:02metric of how many there
• 20:04are, you can see that
• 20:05there is a crude relationship
• 20:07between the severity of the
• 20:09genetic problem with tetraploidy, for
• 20:11example, having the most, then
• 20:13triploidy less, trisomies less, pregnancy
• 20:16losses with apparently normal karyotypes,
• 20:18and finally, stillbirths, and then
• 20:21at the extreme left,
• 20:23normal pregnancies.
• 20:26So if we then plot
• 20:27the three losses of the
• 20:29patient NH on this, you
• 20:30can see it fits this
• 20:31curve very well. Here's her
• 20:33twelve week loss that had
• 20:34the most number of inclusions,
• 20:35her sixteen week had less,
• 20:37and her thirty two week
• 20:39loss had the least.
• 20:40Basically, the more trophoblast inclusions,
• 20:43the earlier the pregnancy loss.
• 20:45So, frankly, for many years,
• 20:47I'm a practical person. I
• 20:48simply used the presence of
• 20:50trophoblast inclusions as a check
• 20:52engine light
• 20:53but really didn't do much
• 20:54else with it. Can I
• 20:55can I,
• 20:57comment on one thing? We
• 20:58just had one case two
• 21:00weeks ago in NICU,
• 21:02has a triple priority,
• 21:04and it's a twenty six
• 21:05week end of delivery.
• 21:07So you might look at
• 21:08that back in that percentage.
• 21:09If that's possible, it's somewhere.
• 21:12I'm sure it's somewhere. And
• 21:13do me a favor, Yong
• 21:14Wei. I appreciate. Just send
• 21:16me an email with the
• 21:17MR number, and I will
• 21:18definitely look at that. That's
• 21:20fantastic. Yeah. I appreciate. And
• 21:21for anybody listening, wherever you
• 21:23are in the country, if
• 21:24you have pregnancy losses that
• 21:26you do not know why
• 21:27they've occurred or patients with
• 21:29multiple losses, and especially if
• 21:31they're stillbirths and can't be
• 21:32part of GPRPL,
• 21:33I would be very happy
• 21:34to look at them. So,
• 21:36frankly, I was minding my
• 21:37own business at this point
• 21:39just looking at pregnancy losses
• 21:40and being a clinician
• 21:42and using the presence of
• 21:43triple s inclusions as this
• 21:44marker
• 21:45when, unfortunately,
• 21:47in nineteen ninety eight, Wakefield
• 21:48publishes now, in my opinion,
• 21:50infamous,
• 21:51unfortunately, recently resurrected
• 21:54paper here showing that the
• 21:55MMR vaccine was, in his
• 21:57opinion, the cause of autism.
• 21:59And because of that, people
• 22:01started believing
• 22:02that their children's
• 22:04autism was due to the
• 22:05MMR vaccines that they were
• 22:07given when these children were
• 22:08younger. And so not surprisingly
• 22:10in this country, these people
• 22:12started suing their doctors, their
• 22:14pediatricians, and vaccine makers.
• 22:17You know, as we all
• 22:18know, the Wakefield paper was
• 22:19retracted and shown to be
• 22:21completely fraudulent, but that hasn't
• 22:23stopped people from still believing
• 22:25this. Well, at this point,
• 22:27and one of the things
• 22:28I do in my life,
• 22:29because I'm one of the
• 22:30few people who looks at
• 22:31placentas,
• 22:32is that I look at
• 22:34cases
• 22:35of legal cases
• 22:37that either plaintiff's attorneys or
• 22:38defense attorneys,
• 22:40have to try to help
• 22:41them figure out why there
• 22:42was a pregnancy complication or
• 22:44loss. And in this case,
• 22:46I was asked by a
• 22:46number of defense attorneys
• 22:48to look at the placentas
• 22:49from these children and see,
• 22:51could there be another explanation
• 22:52for this children's autism?
• 22:55Well,
• 22:56I will just quote Louis
• 22:57Pasteur,
• 22:58December seventh eighteen fifty four,
• 23:01In the fields of observation,
• 23:03chance favors only the prepared
• 23:05mind. And luckily, because I
• 23:06have been doing for years
• 23:08work on pregnancy losses and
• 23:10looking at trophoblast inclusions,
• 23:12when I looked at these
• 23:13placentas of children with autism,
• 23:15I found trophoblast inclusions, and
• 23:17I said to myself,
• 23:19wow, I think this might
• 23:20be, in fact, genetic and
• 23:21not due to the MMR
• 23:23vaccine,
• 23:24which at the time was
• 23:25novel because really people did
• 23:27believe it was due to
• 23:28the MMR vaccine.
• 23:29So what do you do
• 23:30when you're posed with this,
• 23:32problem? Well, you do research.
• 23:34So the first thing we
• 23:35did is a retrospective study,
• 23:36which we published in two
• 23:38thousand and seven, and although
• 23:39it was a small study,
• 23:41we did show a statistically
• 23:42significant difference between placentas from
• 23:44children with proven autism
• 23:47and those that were controls
• 23:48in this particular study. Well,
• 23:50retrospective studies are flawed,
• 23:53and obviously, I wanted to
• 23:54do a prospective study, but
• 23:56it's very challenging
• 23:58to do a prospective study
• 24:00of children with autism.
• 24:02Their incidence is two percent
• 24:04at most, and it's very
• 24:05hard to follow these kids
• 24:07and then get all the
• 24:08placentas, and not all placentas
• 24:10are sent to pathology.
• 24:11So I was really, for
• 24:12four years, in a complete
• 24:14stagnation with this project. But
• 24:16luckily, on the front page
• 24:17of The New York Times
• 24:18in November first of twenty
• 24:19ten,
• 24:21in the left top corner
• 24:22was an article that was
• 24:23titled At the Age of
• 24:24Pick a Boo in Therapy
• 24:26to Fight Autism.
• 24:27And this was a article
• 24:29about a study
• 24:31that was looking at placentas
• 24:32of children with autism.
• 24:34And I will challenge you
• 24:35to find another article on
• 24:37the front page of the
• 24:38New York Times that has
• 24:39the word placenta in it.
• 24:40It is a rare occurrence.
• 24:42So I was very struck
• 24:44by this, and I immediately
• 24:45contacted the people at the
• 24:47MIND Institute at UC Davis,
• 24:49and I said, look, I
• 24:51would love to look at
• 24:52the placentas that you are
• 24:54collecting for your reasons.
• 24:56As an aside, they believe
• 24:57the cause of autism were
• 24:59pesticides
• 25:00in the Sacramento,
• 25:01you know,
• 25:02area of California.
• 25:04I didn't really, you know,
• 25:05acknowledge that. It didn't matter
• 25:07to me what they thought
• 25:08the cause was. I just
• 25:09wanted to look at the
• 25:09placentas,
• 25:10and they begrudgingly eventually did
• 25:12send me two hundred and
• 25:14seventeen cases.
• 25:15And there
• 25:16were a hundred and seventeen
• 25:18kids at risk for autism
• 25:20and high risk families and
• 25:22a hundred controls.
• 25:23And without going through the
• 25:24details of this paper here
• 25:26because of time,
• 25:27this just graphically shows you
• 25:29that there were far more
• 25:30trophoblast inclusions in the at
• 25:32risk population on the left
• 25:34compared to the controls. And
• 25:35in fact,
• 25:36no control placenta had more
• 25:38than an average of point
• 25:40five trophoblast inclusions per slide.
• 25:42You might remember the numbers
• 25:43I showed you before.
• 25:45And this is the plot
• 25:46of those cases on the
• 25:47same graph I showed you
• 25:48before. Here are the normal
• 25:50placentas with an average of
• 25:51point one, and that's where
• 25:52we get that data from.
• 25:54And the at risk placentas
• 25:55from these families had an
• 25:57average of point five. So
• 25:58it's not that much more,
• 26:00but remember, if you have
• 26:01too many trophoblast inclusions,
• 26:03you're a pregnancy loss. So
• 26:05these are children that were
• 26:06born but had something going
• 26:08on with them.
• 26:09Well, my question for myself
• 26:11was, and again, I'm gonna
• 26:12go back to Hugh Taylor's
• 26:14question, why are the tissues
• 26:15bending one way or the
• 26:16other?
• 26:17Why is bending of the
• 26:19placenta and invaginations
• 26:21related to autism? So I
• 26:23started investigating
• 26:24autism a little bit, what
• 26:25was known about the brains
• 26:26of children with autism.
• 26:28And what's interesting among many
• 26:29things of children with autism,
• 26:31people with autism,
• 26:32their brains are actually folded
• 26:34more at a microscopic
• 26:35level. Here is,
• 26:37Margaret Bowman's work at Harvard
• 26:39who has shown at a
• 26:40microscopic level, the brains of
• 26:42these children are folded more,
• 26:43and here's an MRI study
• 26:45on the left showing that
• 26:47the macroscopic
• 26:48level of the brains are
• 26:49also folded more. So my
• 26:51thought was, well, maybe this
• 26:52has to do with folding.
• 26:54Maybe that's really the source
• 26:55of the problem here. And
• 26:57then I was very struck
• 26:58by this article that was
• 26:59published in twenty thirteen.
• 27:01This was a pulmonologist
• 27:02who was seeing children with
• 27:04autism that had pulmonary problems.
• 27:06She was doing bronchoscopies
• 27:08looking at the bronchial tree,
• 27:10and what she showed
• 27:11on the left, the normal
• 27:12bronchial tree looks like this.
• 27:14The bronchial trees of children
• 27:16with autism
• 27:17were more folded, more branched,
• 27:20different than the normals.
• 27:22So the question is, is
• 27:24this, in fact, a global
• 27:26increase of folding,
• 27:27and why would there be
• 27:28any advantage? Why would you
• 27:30want to have more folding?
• 27:32And I would like to
• 27:33propose, this is a hypothesis,
• 27:35it's hard to prove these
• 27:36things, that there actually is
• 27:38a benefit to folding, and
• 27:39I'd like to share that
• 27:40with you in a hypothesis
• 27:42I call the pelvis skull
• 27:44conflict hypothesis.
• 27:45I presented this in twenty
• 27:47fifteen at the Institute Society
• 27:48for Evolutionary Medicine.
• 27:50And what I was pointing
• 27:52out is that our babies'
• 27:55skull sizes,
• 27:56head sizes,
• 27:58are the largest compared to
• 28:00any other primate compared to
• 28:02the pelvic outflow. So here
• 28:03we are in the lower
• 28:04right corner, Homo sapiens,
• 28:07and we have maximized
• 28:09the amount of space
• 28:11that we can pack brain
• 28:12into. In other words, we
• 28:14cannot make the heads of
• 28:16babies any bigger. The only
• 28:18way to get increased intelligence
• 28:20is to actually have more
• 28:21folding. And as it is
• 28:22now,
• 28:23our brains are the most
• 28:25folded primate brain that exists.
• 28:27So, again,
• 28:29why is that? Well, because
• 28:30I think there's more computing
• 28:32power when you have more
• 28:33folded brains, and there's evidence
• 28:35of that. There are genetic
• 28:37conditions that lead to complete
• 28:39severe developmental disabilities
• 28:42and brain development intelligence, and
• 28:44they're associated with poorly folded
• 28:46brains. You can think of
• 28:47the normal population here.
• 28:49Autism seems to have increased
• 28:51folding,
• 28:52and we know that there
• 28:54is an association of intelligence
• 28:56with autism.
• 28:57I'm not gonna name some
• 28:58names, but just think of
• 28:59some carmakers that you know
• 29:01who are very intelligent
• 29:02and are on the spectrum,
• 29:04and maybe people who are
• 29:05computer people and engineers and
• 29:07work at MIT and other
• 29:08things like that. So I
• 29:09think that the evolutionary pressure
• 29:11that we're looking at here
• 29:13is for increased intelligence
• 29:15that when it's too severe
• 29:17leads to something that we
• 29:18call autism.
• 29:20Now, in evolution, there is
• 29:22no free lunch. There is
• 29:24something called antagonistic
• 29:25pleiotropy,
• 29:26and I call this collateral
• 29:28damage, basically. That's my interpretation
• 29:30of this. If there are
• 29:32genes that are trying to
• 29:33make us more intelligent,
• 29:35there might be some collateral
• 29:37damage to that and negative
• 29:38impact.
• 29:39And one of the things
• 29:40that I was really struggling
• 29:42with during the years of
• 29:43doing this research is how
• 29:45is it possible
• 29:46that trophoblast inclusions in the
• 29:48placenta could
• 29:50lead to pregnancy loss?
• 29:52It didn't seem logical to
• 29:53me. And even when there
• 29:54are hundred times the number
• 29:56of trophoblast inclusions that there
• 29:58should be, and this is
• 29:59from a paper where I
• 30:00actually plotted out on a
• 30:02map form on the right
• 30:03here where the trophalescent inclusions
• 30:05are, you can see that
• 30:06there are very, very few
• 30:07of them in the whole
• 30:09spectrum
• 30:10of the placenta.
• 30:11So in my opinion,
• 30:13these inclusions are not affecting
• 30:15affecting the function of the
• 30:16placenta whatsoever.
• 30:17So the question
• 30:19is, what organ could be
• 30:20deleteriously
• 30:21affected by increased folding? And
• 30:24I'd like to do a
• 30:25thought experiment with you, kind
• 30:27of a knockout experiment with
• 30:29the whole body at this
• 30:30point. So if you imagine
• 30:31a fetus and we are
• 30:33in the uterus, we're not
• 30:34outside the uterus, but if
• 30:35you imagine we're in the
• 30:36uterus, my question is, what
• 30:38is necessary for life, not
• 30:41high quality life, just existence?
• 30:43Well, you can remove the
• 30:45entire GI tract without any
• 30:46problem in a fetus. You
• 30:47don't need it. You have
• 30:48the placenta.
• 30:49You can remove the entire
• 30:51GU system. It's unnecessary.
• 30:53You can remove the liver,
• 30:54the spleen, and the pancreas.
• 30:55They're not necessary.
• 30:57You can remove the lungs.
• 30:58Unfortunately, they're very clear clinical,
• 31:00Potter syndrome as an example,
• 31:02where the lungs don't ever
• 31:04develop, and you can exist
• 31:05in the uterus.
• 31:06Unfortunately, you don't need the
• 31:08brain or head, and we
• 31:09know lots of people who
• 31:10are ex vivo that is
• 31:12the case, and that's not
• 31:13necessary either.
• 31:14So sorry, I couldn't help
• 31:16it.
• 31:17But there is one last
• 31:18organ that is completely necessary
• 31:21for life, and that is
• 31:22the heart. And in fact,
• 31:23the heart is the only
• 31:26essential organ. Now, what's interesting
• 31:28about the heart is that
• 31:29it's formed by complex
• 31:31folding.
• 31:33That is how the heart
• 31:34is made.
• 31:36And it is very susceptible
• 31:38to abnormal folding, and abnormal
• 31:40folding leads to pregnancy loss.
• 31:43Here's just an example of
• 31:45an amazing paper that looked
• 31:47at the details of embryonic
• 31:49heart development between three point
• 31:50five and eight weeks of
• 31:52human development.
• 31:53And this is just one
• 31:54of their figures. It's too
• 31:55complex for me to even
• 31:57follow what was going on
• 31:58with these hearts. But in
• 31:59general, what I gained from
• 32:01this paper is that it's
• 32:02extremely complex,
• 32:04and it takes very accurate
• 32:05folding to make a heart.
• 32:07And also, once the heart
• 32:09starts at four weeks after
• 32:10fertilization,
• 32:11it continues to grow every
• 32:12day. It is beating at
• 32:14a hundred and fifty beats
• 32:15a minute, and it's getting
• 32:17larger. It's like building an
• 32:19airplane in midair while it's
• 32:20flying. That is a very
• 32:22sophisticated problem. So in my
• 32:24opinion,
• 32:25what I think is happening
• 32:26with these pregnancy losses is
• 32:28that they're related to abnormal
• 32:30heart folding.
• 32:31And
• 32:32I think that
• 32:33increased abnormalities of folding,
• 32:36as shown by this graph,
• 32:37are related to earlier losses,
• 32:39which is reflected in just
• 32:41the statistics of looking at
• 32:43pregnancy losses.
• 32:44As anybody who is a
• 32:45reproductive endocrinologist
• 32:47knows, extremely high number of
• 32:49empty sac losses
• 32:51probably in the first week
• 32:52or two, and I think
• 32:53those are simply
• 32:54an embryonic or simply an
• 32:56embryo that never had a
• 32:57heart that started. It didn't
• 32:58even start. If it starts
• 33:00at four weeks and then
• 33:01fails right away, then we
• 33:03have very early losses. And
• 33:04although we have a million
• 33:06miscarriages,
• 33:07I think we actually have
• 33:09even more losses before this
• 33:10period of time that we
• 33:11don't even know about. Right?
• 33:13I agree. Not even appreciated.
• 33:15And, again, what is the
• 33:16critical organ that's necessary? What
• 33:18do we look at when
• 33:19we define that you have
• 33:21a pregnancy?
• 33:21It's, of course, a heartbeat,
• 33:23right? That's what we're looking
• 33:24for. So I think that
• 33:25this is really where
• 33:27the answer is.
• 33:29The final piece of this
• 33:30puzzle that I'd like to
• 33:31share with you is an
• 33:32enigma that I've had. I've
• 33:34showed you that the number
• 33:35one cause of stillbirth is
• 33:36a small placenta.
• 33:37How could genetics relate to
• 33:39small placentas?
• 33:40Well,
• 33:41I think that it relates
• 33:42back to the heart, and
• 33:44that when you have an
• 33:45abnormal heart, the heart does
• 33:47not pump as well, has
• 33:48poor cardiac output, and does
• 33:51not literally blow up the
• 33:52placenta
• 33:53like a bicycle pump normally.
• 33:56So if you have a
• 33:57bicycle pump that is too
• 33:58small, and this is completely
• 34:00hypothetical, there is no evidence
• 34:02to support this at all.
• 34:03Although, Hugh, you'll remember the
• 34:05grant we submitted for our
• 34:07stillbirth
• 34:08included trophoblast inclusions, EPV, and
• 34:10looking at detailed heart structure.
• 34:13So I think that we're
• 34:14on the right track. Now
• 34:15is there evidence in the
• 34:16literature to support this? Well,
• 34:17there certainly is. Here's, for
• 34:19example, an article that said,
• 34:21among the few studies reported,
• 34:23several of these have noted
• 34:25smaller placentas in newborns with
• 34:26congenital heart disease.
• 34:28And Miriam Hamburger,
• 34:31who, Yong Hui, you had
• 34:32quoted one of her papers
• 34:33early in our study years
• 34:35ago. You might remember this
• 34:36paper that you,
• 34:38shared with everybody.
• 34:39What she showed, and I
• 34:41talked to her about this
• 34:42work, she said in the
• 34:43mouse,
• 34:44not all small placentas are
• 34:45associated with congenital heart disease,
• 34:47but all cases of congenital
• 34:49heart disease have a small
• 34:50placenta. So I think that's
• 34:52an interesting observation.
• 34:53So my question and
• 34:55final hypothesis
• 34:57to think about for the
• 34:58group here is are there
• 34:59common genes responsible for all
• 35:01these things? Trophoblast inclusions, abnormal
• 35:04folding, increased folding in the
• 35:06brain, dysmorphia features in embryos,
• 35:08pregnancy losses, abnormal hearts, are
• 35:11there common genes?
• 35:12And Miriam Hamburger, again, and
• 35:14this is the paper that
• 35:15you cited for us, young
• 35:16Weez, she said placental defects
• 35:18correlate strongly with abnormal brain,
• 35:21heart, and vascular development in
• 35:23these embryonic lethal mouse mutants.
• 35:25So that, I think, is
• 35:27where we are headed with
• 35:28gPRPL.
• 35:29I will just end with
• 35:30one final study that we're
• 35:32just hopefully finishing soon. Cindy
• 35:34Ortonau at
• 35:36University of Washington Washington University
• 35:38in Saint Louis, sorry.
• 35:40She looks at the brain
• 35:41heart connection.
• 35:43I asked her to look
• 35:44at if I could look
• 35:45at the placentas
• 35:46from her cases
• 35:48of congenital heart disease and
• 35:50abnormal brain development, and we
• 35:52have shown that there's a
• 35:54significant increase of tropholast inclusions
• 35:56in the placenta of children
• 35:58with congenital heart disease. So
• 36:00I think the unifying hypothesis
• 36:02might be that there are
• 36:03shared genes related to congenital
• 36:05heart disease,
• 36:06folding morphogenesis,
• 36:07branching morphogenesis,
• 36:09pregnancy loss, intelligence,
• 36:11developmental
• 36:12disabilities such as autism.
• 36:14And what I'm hoping is
• 36:16that in our studies, we
• 36:17can identify some of these
• 36:19common genes.
• 36:20Now this work is done
• 36:21with many, many, many people
• 36:23involved, including, of course, the
• 36:24GPR
• 36:25group right here, the trophoblast
• 36:27inclusion group, my pregnancy loss
• 36:29group, and Cindy Ortonau's group
• 36:31at
• 36:32University of Washington. I'd like
• 36:33to acknowledge them. And for
• 36:35anybody who is interested in
• 36:36any details of what I've
• 36:38talked about, please feel free
• 36:39to email me or go
• 36:40to my lab site here
• 36:42at yale, klein and labs
• 36:43dot yale dot edu. And,
• 36:44again, I put this out
• 36:45to anybody who has any
• 36:47patients with pregnancy loss. I
• 36:48would welcome very much looking
• 36:50at those cases and helping
• 36:51you with them. Thank you
• 36:53very much for letting me
• 36:54share my work with you
• 36:55today.
• 37:00Thank you, Hugh. Hey, Warwick.
• 37:02Amazing.
• 37:04Well How do you bring
• 37:05it all together?
• 37:07I like a lot of
• 37:08quote,
• 37:09Harvey.
• 37:10That's a
• 37:11history. I I have a
• 37:13how you're looking for, sort
• 37:15of what would be the
• 37:16next step to for this
• 37:18study.
• 37:19How many of for case
• 37:21you have fresh,
• 37:23percent store in
• 37:26minus eighty or or or
• 37:28liquid nitrogen, would you able
• 37:29to do the RNA expression
• 37:31study?
• 37:33Yeah. Unfortunately,
• 37:35my relationship with my patients
• 37:38is and, actually, COVID is
• 37:39partly it's interesting. Before COVID,
• 37:42I saw very few pregnancy
• 37:43loss patients because they had
• 37:45to physically be in Connecticut
• 37:46or come to Yale to
• 37:47see me.
• 37:48COVID opened up the opportunity
• 37:50for me to start seeing
• 37:51patients all over the world,
• 37:52literally.
• 37:53So I now have a
• 37:55reputation that really draws from
• 37:57all over, and the negative
• 37:59is that my patients
• 38:01are seeking me out after
• 38:02they've tried to get answers
• 38:04locally.
• 38:05And when they can't get
• 38:05an answer locally, they find
• 38:07me, like the first case
• 38:08I showed you. And those
• 38:10cases, the placentas are fixed
• 38:12in formalin.
• 38:13So that is why in
• 38:14the very beginning of this,
• 38:16study,
• 38:17I was so grateful
• 38:19that the Yale Genomic Center
• 38:20and Monkel, I have to
• 38:22thank him and his whole
• 38:23team and everybody,
• 38:24you know, who was involved
• 38:26with this, to figure out
• 38:28how to actually do decent,
• 38:29not fantastic, but decent genomic
• 38:31analysis of paraffin embedded tissue
• 38:34because it is very difficult
• 38:36to get that fresh loss
• 38:37on these patients as we
• 38:38know. So that's, I think,
• 38:40the limiting factor. If there's
• 38:41a way for anybody to
• 38:42figure out how to solve
• 38:43that,
• 38:44yes. We should try to
• 38:45do it. But I I
• 38:46go where the light bulb
• 38:47is shining at night, you
• 38:48know, the old adage of
• 38:49the old man losing the
• 38:50keys. You know? You look
• 38:51where the light bulb is
• 38:52shining. That's always been my
• 38:54philosophy.
• 38:56Harvey, to date, I mean,
• 38:57of the ones of your
• 38:58specimens
• 38:59that have been
• 39:00sequenced, have the ones that
• 39:02have shown some evidence of
• 39:04mutation been particularly extreme in
• 39:06the number of inclusions they've
• 39:08had, or are there any
• 39:09correlation there?
• 39:10Well, it's interesting you asked
• 39:12that. Every patient that I
• 39:14have submitted to GPRPL
• 39:16has truffle blast inclusions. That
• 39:17is the that is the
• 39:18criteria.
• 39:19Huge variability.
• 39:21There is a variability.
• 39:23Conclusions. I thought what you
• 39:24were gonna ask was something
• 39:25slightly different, so I,
• 39:27just allow me this,
• 39:29to change your question slightly.
• 39:31Have we even found any
• 39:33genetic genes in my two
• 39:34hundred or so patients? And
• 39:36I'm gonna let Monkel speak
• 39:37to that. He and Andrew
• 39:39and I meet, you know,
• 39:40every few weeks to go
• 39:41over my patients.
• 39:43And,
• 39:44you know, there have been
• 39:45some that we have found
• 39:46some answers. I'm surprised still
• 39:49at how few we have
• 39:50found answers to, but I'm
• 39:52hoping
• 39:53that we will find them
• 39:54and continued analysis will work.
• 39:56Michael, do you wanna jump
• 39:57in and give me an
• 39:57overview
• 39:59of that? So so one
• 40:00of the analysis on the
• 40:01to do list, okay, the
• 40:03a low hanging fruit is
• 40:04to ask the question of
• 40:06a lot of genes are
• 40:07expressed in the placenta and
• 40:08the, you know, the placenta
• 40:10material. So, you know, the
• 40:12the first low hanging fruit
• 40:13is a direct genetic influence.
• 40:15So genes that cause disease
• 40:17and are also important in
• 40:19the expression in,
• 40:21placenta. Like, Hugh, you remember
• 40:23when I, when we presented
• 40:24the NIH, one of them
• 40:25were a gene that was
• 40:27very important for vascular
• 40:29vascularization
• 40:31of the of the placenta.
• 40:32So it's not only important
• 40:34placenta, but it's, you know,
• 40:35important in general too. But,
• 40:37you know, but it does
• 40:39cause a big problem early
• 40:40development. So so I think
• 40:42the next low hanging fruit
• 40:44is asking the questions, okay,
• 40:46we know these genes cause,
• 40:48you know, severe diseases or
• 40:50these are strong candidates, one
• 40:51or the other, one of
• 40:52the what are their expression
• 40:54levels like? And we can
• 40:55go one further,
• 40:56Harvey, because
• 40:57in preparing the stillbirth grant
• 40:59last year yeah.
• 41:01Still still the trauma of
• 41:02chasing
• 41:04chasing signatures,
• 41:06you know, one hour before
• 41:07submissions. It's still burned in
• 41:09my head. But one one
• 41:11of the things that,
• 41:12that the field has done,
• 41:14you know, and this is
• 41:15my gonna be my question
• 41:17to you, Harvey, because it's
• 41:18related to what Yonghui said
• 41:19is they've done some really
• 41:21great single nuclei work. So
• 41:23frozen placenta. And because
• 41:26of the property you're saying,
• 41:27it's very similar to,
• 41:29to muscle fibers. You have
• 41:30multiple nuclei sharing the same
• 41:32cytoplasm.
• 41:35So single nuclei work really
• 41:36well in that, and they've
• 41:37done some single nuclei that
• 41:39was published about a year
• 41:40and a half ago in
• 41:40Nature Genetics.
• 41:42So one of the cool
• 41:43things we could do, you
• 41:45know what I mean,
• 41:46if,
• 41:47if,
• 41:48you know, you can correct
• 41:50me if I'm wrong.
• 41:51You know, in preparing it,
• 41:53I think Lina and I,
• 41:55know that
• 41:56Yale has a placenta
• 41:58biobank or something like that.
• 42:00And
• 42:01and if there are some
• 42:03that you know what I
• 42:03mean? That are you know
• 42:06you know how you had
• 42:07that model, Harvey, of, you
• 42:08know, the three possibilities. Normal
• 42:10is in the middle, and
• 42:11this can happen. This can
• 42:12happen. If we can get
• 42:13examples of that, and we
• 42:14can ask the question of,
• 42:16is there
• 42:17gen a genetic signature? If
• 42:19we did single nuclei sequencing
• 42:21I don't have the money.
• 42:21I'm hoping someone this call
• 42:23does, they can pay for
• 42:23it.
• 42:24If we did single nuclei
• 42:26sequencing on,
• 42:27placentas
• 42:28from this,
• 42:29then we can use, for
• 42:31example, the publication Nature's Genetics.
• 42:33This is how this is
• 42:34how healthy placenta should behave.
• 42:37We can create our own
• 42:38controls and ask that question
• 42:39of you know what I
• 42:40mean? But the genetic signature
• 42:42could be in response
• 42:44or it could be the
• 42:45driver, but it will still
• 42:46be a genetic signature. And
• 42:47it will give us more
• 42:49of a feel for that
• 42:51mechanism behind what you were
• 42:52saying. You know what I
• 42:53mean? Or just say, you
• 42:54know, what is the genetics
• 42:55behind that mechanism. For some
• 42:57of that mechanism could be
• 42:58purely as you, I think,
• 42:59hinted Harvey. It could be
• 43:01purely physical, but it could
• 43:03be a physical thing, and
• 43:04then there's a genetic response
• 43:06to it or vice versa,
• 43:08you know, a chicken egg.
• 43:09But it'd be a cool
• 43:10thing we could do. You
• 43:11know what I mean? Since,
• 43:12you know,
• 43:14it's only become available, this
• 43:16technology, to do something like
• 43:17that. I'd like to try
• 43:18on that before the FFPE.
• 43:20But but me saying this,
• 43:22I I we would need
• 43:23money to do this, but
• 43:25it'd be an awesome question
• 43:26to ask, you know, based
• 43:27on your presentation, Harvey.
• 43:29Thank you. That sounds awesome.
• 43:31But my question was really
• 43:32more the ones you've that
• 43:33we have found some mutations
• 43:34in the samples you do
• 43:36have, were they, you know,
• 43:37were they just loaded with
• 43:38inclusions? Were they the real
• 43:39extremes?
• 43:41Right. So I have to
• 43:42admit I haven't done that
• 43:43because
• 43:45and, again,
• 43:46Andrew, I don't see him
• 43:47on the call, and Monkel
• 43:48and Ira. I I would
• 43:49love to sit down and
• 43:51actually, at some point, collect
• 43:53all of the cases that
• 43:55I have, you know, pathology
• 43:57on and I've looked at.
• 43:58What are the genetic results
• 44:00that we've gotten? There aren't
• 44:01that many. That's why I
• 44:02was hoping Oh, it's not
• 44:03many. But if what if
• 44:04what if those you know,
• 44:05one we found was the
• 44:07one that had, you know,
• 44:08hundred times more occlusions. We
• 44:09might have found that connection
• 44:10already. Okay. That's true. That's
• 44:12a good point. I've always
• 44:14looked, and you can tell
• 44:15where I'm going with this.
• 44:17I've always been asking and
• 44:19wondering the genes that are
• 44:20found. Could they have something
• 44:21to do with folding, with
• 44:23bending?
• 44:23What's interesting, Piezo one
• 44:26is a, you know, a
• 44:27touch bending,
• 44:29you know, gene. So that's
• 44:31kind of interesting. And that's
• 44:32the first one we found,
• 44:34right, of one of my
• 44:35families.
• 44:36And I think that's really
• 44:38interesting. So, yeah, that is
• 44:39always going to be my
• 44:40mind. The other thing I
• 44:41wanna bring up is that,
• 44:43two things. One is if
• 44:45you play a little game
• 44:46with yourself and ask the
• 44:47question, what does morph embryology
• 44:50do? What what creates morphology
• 44:52structure?
• 44:53It turns out that the
• 44:54number one tool in the
• 44:55toolbox
• 44:56is tissue folding, either invagination
• 44:59or branching morphogenesis.
• 45:00I mean, that's ninety percent
• 45:02of everything we are, from
• 45:03the first neurofold
• 45:04to all the branching organs.
• 45:06So how many genes do
• 45:08you think control that? Cell
• 45:10proliferation,
• 45:11fusion,
• 45:12bilayer, you know, deformation.
• 45:15That's everything. There probably
• 45:17thousands and thousands of genes
• 45:18that are involved with that
• 45:19process since that is the
• 45:21dominant tool that's in the
• 45:22toolbox.
• 45:26Yep.
• 45:27Well, there was a good
• 45:28model for maybe someone knows
• 45:30on this call. You you
• 45:30know what I mean? A
• 45:31genetics approach to doing this
• 45:33is to to do a
• 45:34CRISPR knockout screen. So if
• 45:36you if you know what
• 45:38phenotype you want, then you
• 45:39can ask the question, if
• 45:40I knock out that gene,
• 45:41does that phenotype vary? You
• 45:43know what I mean? So
• 45:44it it it's a question
• 45:45we can ask now because
• 45:47of our genetic toolbox that
• 45:48we can ask if the
• 45:49question is which genes that
• 45:51contribute to that. But you
• 45:53find the one that you
• 45:54know, you start with the
• 45:55one that has the best
• 45:56correlation with the inclusions, and
• 45:57that's the one we knock
• 45:58out first. Mhmm.
• 46:01Is there such thing as
• 46:02a Piazza one knockout, though?
• 46:03It just I think we
• 46:04don't exist without that gene.
• 46:06Right? I can't imagine. Do
• 46:07we? Is there a person
• 46:09that exists without that gene?
• 46:12Not sure. I'm not sure
• 46:13if there's a mouse model
• 46:14we eat on. So Yeah.
• 46:15Most of these, we knock
• 46:16it out. It's probably embryonic
• 46:17lethal. Yeah. Exactly.
• 46:19I would imagine that you
• 46:21know, because the first neurofold
• 46:22of creation of the heart
• 46:23is dependent on folding. So,
• 46:25you know Maybe we'd have
• 46:26to knock knock it out.
• 46:27We have to recreate whatever
• 46:29mutation we find in the
• 46:30patients that may recreate the
• 46:32same phenotype in the mouse.
• 46:34Mhmm. Mhmm. But one thing
• 46:35you could do, like, in
• 46:36some of these papers, if
• 46:37it's embryonic lethal
• 46:39or, yeah, important for early
• 46:40development, you can have a
• 46:41conditional knockout. You go, okay.
• 46:43We believe it's because of
• 46:44this tissue, and then then,
• 46:46you know, prove it via
• 46:48conditional knockout. Knock it out
• 46:49just in placenta.
• 46:51Yeah.
• 46:52But either knock it out
• 46:53just in placenta or, again,
• 46:55if we have a phenotype
• 46:56that maybe not a complete
• 46:58same, you know, null mutation
• 47:00phenotype that's a that's a
• 47:03based on just a mutation
• 47:04that makes it somehow
• 47:05function differentially, we could recreate
• 47:08that in the mouse model,
• 47:09see if we can recreate
• 47:11the phenotype.
• 47:14Alright. Again, I wanna thank
• 47:15everybody for your time. Please
• 47:16feel free to contact me,
• 47:18individually
• 47:19by email, either clinically or
• 47:21research, and, of course, Mankel,
• 47:24Ira, Hugh, you know, John,
• 47:25we I'm here, and I'm
• 47:27very excited to continue to
• 47:28work on this project with
• 47:29all of you. Yeah. Yeah.
• 47:30But definitely, thanks for the
• 47:32idea, Hugh. So,
• 47:33Harvey, we can follow-up on
• 47:34it if you want Andrew
• 47:36to do an analysis or
• 47:37one of your students analysis.
• 47:38Because I know you have
• 47:39the spreadsheet with some of
• 47:41those things quantitated. We could,
• 47:42you know, combine the two
• 47:44things.
• 47:45Absolutely.
• 47:46Worth done.
• 47:48Alright. Great. Thanks, Harvey. Thank
• 47:50you, everybody.
• 47:51See you. Thank you, everyone.