Potential novel role of the human amniotic membrane as a sustainable hemostat.

OBJECTIVES: Acute hemorrhage can cause significant morbidity and mortality arising from trauma, bleeding disorders, surgical procedures, or obstetric complications. Surgical hemostasis methods may fail to stop acute bleeding due to the complex bleeding dynamics of each bleeding type. Therefore, developing safe and effective topical hemostatic agents remains crucial. The human amniotic membrane (hAM) has established clinical evidence of effectiveness in promoting wound healing and tissue regeneration. Despite its unique biological and immunologic properties and its structural composition of established hemostatic elements, the hemostatic role of hAM has not been yet explored. The present study aimed to investigate this potential role and to describe the development protocol and characterization of hAM-derived topical hemostat. METHODS: Surface electron microscope (SEM) imaging and Fourier transform infrared (FTIR) spectroscopy were used for characterization, and mouse models with induced peritoneal and tail wound bleeding were employed to evaluate the hemostatic effectiveness using physiological studies, in comparison to a chitosan-based combat-scale hemostat. RESULTS: The hAM hemostat showed a distinctive composition by SEM and FTIR. Applying equal masses of the hAM hemostat, the commercial hemostat, or a combination reduced peritoneal wound bleeding time to averages of 108.4, 86.2, and 76.8 s, respectively, compared to the control group (300 s). Tail wound bleeding times were similarly reduced with no significant difference between the hAM and the commercial hemostat (P values = 0.29, 0.34 in peritoneal and tail wounds, respectively). Neither hemostat affected coagulation time. CONCLUSION: This study describes a simple cost-effective preparation protocol for a hAM-based hemostatic agent. The long-recognized safety, sustainability, and immunotolerance advantages of hAM can establish superiority over commercial hemostats with reported safety concerns. Robust research validation in larger-scale bleeding models is required for wider applications and severe bleeding types.

Are embryonic stem cell markers and ALDH1A1 relevant in the context of breast cancer estrogen positivity?

BACKGROUND: Embryonic pluripotency markers are recognized for their role in ER- BC aggressiveness, but their significance in ER+ BC remains unclear. This study aims to investigate the prevalence of expression of pluripotency markers in ER+ BC and their effect on survival and prognostic indicators. METHODS: We analyzed data of ER+ BC patients from three large cancer datasets to assess the expression of three pluripotency markers (NANOG, SOX-2, and OCT4), and the stem cell marker ALDH1A1. Additionally, we investigated associations between gene expression, through mRNA-Seq analysis, and overall survival (OS). The prevalence of mutational variants within these genes was explored. Using immunohistochemistry (IHC), we examined the expression and associations with clinicopathologic prognostic indicators of the four markers in 81 ER+ BC patients. RESULTS: Through computational analysis, NANOG and ALDH1A1 genes were significantly upregulated in ER+ BC compared to ER- BC patients (p < 0.001), while POU5F1 (OCT4) was downregulated (p < 0.001). NANOG showed an adverse impact on OS whereas ALDH1A1 was associated with a highly significant improved survival in ER+ BC (p = 4.7e-6), except for the PR- and HER2+ subgroups. Copy number alterations (CNAs) ranged from 0.4% to 1.6% in these genes, with the highest rate detected in SOX2. In the IHC study, approximately one-third of tumors showed moderate to strong expression of each of the four markers, with 2-4 markers strongly co-expressed in 56.8% of cases. OCT-4 and ALDH1A1 showed a significant association with a high KI-67 index (p = 0.009 and 0.008, respectively), while SOX2 showed a significant association with perinodal fat invasion (p = 0.017). CONCLUSION: Pluripotency markers and ALDH1A1 are substantially expressed in ER+ BC tumors with different, yet significant, associations with prognostic and survival outcomes. This study suggests these markers as targets for prospective clinical validation studies of their prognostic value and their possible therapeutic roles.

The Role of Three-dimensional Printed Models in Women's Health.

Three-dimensional printing is an innovative technology that has gained prominence in recent years due to its attractive features such as affordability, efficiency, and quick production. The technology is used to produce a three-dimensional model by depositing materials in layers using specific printers. In the medical field, it has been increasingly used in various specialties, including neurosurgery, cardiology, and orthopedics, most commonly for the pre-planning of complex surgeries. In addition, it has been applied in therapeutic treatments, patient education, and training wof medical professionals. In the field of obstetrics and gynecology, there is a limited number of studies in which three-dimensional printed models were applied. In this review, we aim to provide an overview of three-dimensional printing applications in the medical field, highlighting the few reported applications in obstetrics and gynecology. We also review all relevant studies and discuss the current challenges and limitations of adopting the technology in routine clinical practice. The technology has the potential to expand for wider applications related to women's health, including patient counseling, surgical training, and medical education.

The potential role of the gingival crevicular fluid biomarkers in the prediction of pregnancy complications.

Early and minimally invasive methods are required to predict the risk of multiple adverse pregnancy outcomes. A potential technique with growing interest utilizes the gingival crevicular fluid (GCF), a physiological serum exudate found in the healthy gingival sulcus and in the periodontal pocket in inflammatory conditions. Analysis of biomarkers in the GCF is a minimally invasive method that can be feasible and cost-effective. The potential use of GCF biomarkers along with other clinical indicators in early pregnancy may provide reliable predictors of several adverse pregnancy outcomes, therefore, reducing both maternal and fetal morbidities. Various studies have reported that increased or decreased concentrations of different biomarkers in GCF are associated with a high risk of developing pregnancy complications. In particular, such associations have been commonly demonstrated with gestational diabetes, pre-eclampsia, and pre-term birth. However, limited evidence is available regarding other pregnancy complications such as preterm premature rupture of membranes, recurrent miscarriage, small for gestational age, and hyperemesis gravidarum. In this review, we discuss the reported association between individual GCF biomarkers and common pregnancy complications. Future research is required to provide more solid evidence of the predictive value of those biomarkers in estimating women's risk for each disorder.

Balancing Benefits and Risks of Indomethacin in the Management of Antenatal Bartter Syndrome: A Case Report.

Background: Bartter syndrome, a very rare inherited renal tubular disorder, characterized by urinary salt wastage, hypokalemia, polyuria, and metabolic alkalosis, may manifest antenatally as severe isolated polyhydramnios. Indomethacin is known to reduce salt wastage and subsequent polyhydramnios during pregnancy; however, it reduces the Ductus Arteriosus diameter among other potential complications, such as inhibition of gastrointestinal perfusion and increasing the risk of renal toxicity. Case: A 36-year-old multigravida presented with severe isolated polyhydramnios at 30 weeks of gestation. Based on a history of a previous pregnancy affected with Bartter syndrome, indomethacin was initiated. Amniotic fluid volume and Ductus Arteriosus diameter were monitored. As evidence lacks on optimal dose and duration of indomethacin, multiple-dose adjustments were made to reduce the amniotic fluid volume while maintaining normal Ductus Arteriosus diameter. Progressive polyhydramnios led to Cesarean section at 34+ weeks of gestation resulting in a healthy fetus diagnosed with Bartter syndrome in the early neonatal period. Conclusion: We share our experience in the adjustment of the dose and duration of Indomethacin therapy in the treatment of severe polyhydramnios associated with antenatal Bartter syndrome. Amniotic fluid index, Ductus Arteriosus diameter, and umbilical artery doppler work together as key indicators to guide the success and safety of the therapy.

The impact of an online intervention on the medical, dental and health sciences students about interprofessional education; a quasi-experimental study.

BACKGROUND: Interprofessional education (IPE) encompasses integration, communication, mutual trust and shared decision-making with a common goal of improved patient care and safety. Despite its crucial role, IPE has not gained its anticipated popularity. This study aims to determine the impact of an online educational intervention about IPE on medical, dental and health sciences students in the University of Sharjah (UoS). METHODS: This quasi-experimental research was conducted in three phases; a pre-intervention phase where the Readiness for Interprofessional Learning Scale (RIPLS) inventory was administered online to the medical, dental and health sciences students of UoS; an intervention phase where an online workshop was organized via Microsoft Teams®; and a post-intervention phase where RIPLS was used to gather the students' attitudes towards IPE. The independent t test was used to compare the responses between genders and junior and senior students. A paired sample t test was used to determine the impact of the intervention on the students' understandings and attitudes about IPE. RESULTS: Out of 800 invited students, 530 students responded to the pre-intervention RIPLS survey. A comparison of the pre-post intervention for the RIPLS subscales of teamwork and collaboration, professional identification, and professional roles showed a significant improvement of students' attitudes with p-values 0.03, 0.00 and 0.00, respectively. All workshop moderators scored a median of 4 or 5 to the essential elements of IPE during intervention except for a median of 3 for group dynamics. CONCLUSION: The present data, derived from the application of a brief online educational intervention, underpins the readiness and positive attitudes of undergraduate medical students towards IPE. The positive impact of online intervention necessitates the development of a structured and unified IPE curriculum to enhance the receptiveness and application of IPE in the medical field.

A microfluidic platform for dissociating clinical scale tissue samples into single cells.

The advancement of sample preparation techniques is essential for the field of cell-based therapeutics. To obtain cells suited for clinical applications, the entire process starting from acquiring donor tissue biopsy, all through cell transplantation into the recipient, should occur in an integrated, safe, and efficient system. The current laboratory approach for solid tissue-to-cell isolation is invasive and involves multiple incoherent manual procedures running in an open operator-dependent system. Such an approach provides a chain of events for systematic cell loss that would be unfavorable for rare cell populations such as adult and cancer stem cells. A few lab-on-chip platforms were proposed to process biological tissues, however, they were limited to partial tissue dissociation and required additional processing off-chip. Here, we report the first microfluidic platform that can dissociate native biological tissue into ready-to-use single cells. The platform can merge the successive steps of tissue dissociation, debris filtration, cell sieving, washing, and staining in one streamlined process. Performance of the platform was tested with diverse biological tissues and it could yield viable cells that were ready for on or off-chip cell culture without further processing. Microfluidic tissue dissociation using this platform produced a higher number of viable single cells (an average of 2262 cells/ml per milligram of tissue compared to 1233.25 cells/ml/mg with conventional dissociation).

Breast Cancer Risk with Progestin Subdermal Implants: A Challenge in Patients Counseling.

There is a steady global rise in the use of progestin subdermal implants, where use has increased by more than 20 times in the past two decades. BC risk has been reported with the older progestin only methods such as oral pills, injectables, and intrauterine devices, however, little is known about the risk with subdermal implants. In this review, we aim to update clinicians and researchers on the current evidence to support patient counseling and to inform future research directions. The available evidence of the association between the use of progestin subdermal implants and BC risk is discussed. We provide an overview of the potential role of endogenous progesterone in BC development. The chemical structure and molecular targets of synthetic progestins of relevance are summarized together with the preclinical and clinical evidence on their association with BC risk. We review all studies that investigated the action of the specific progestins included in subdermal implants. As well, we discuss the potential effect of the use of subdermal implants in women at increased BC risk, including carriers of BC susceptibility genetic mutations.

Monogenic leptin deficiency in early childhood obesity.

BACKGROUND: Early childhood obesity is a public health problem worldwide. It affects different aspects of physical and mental child's health. Identifying the etiologies, especially treatable and preventable causes, can direct health professionals toward proper management. Analysis of serum leptin levels and leptin gene mutations is a rapid and easy step toward the diagnosis of congenital leptin deficiency that is considered an important cause in early childhood obesity. OBJECTIVES: The aim of this study was to diagnose monogenic leptin deficiency in Egyptian children presenting with early onset obesity (EOO). METHODS: The current cross-sectional study included 80 children who developed obesity during the first year of life with BMI > 2 SD (for age and sex). The studied population was subjected to history taking, auxological assessment, serum leptin assay, and leptin gene sequencing. RESULTS: Ten cases had leptin deficiency (12.5%), while 18 cases showed elevated leptin levels (22.5%). Leptin gene variants in the coding region were identified in 30% of the leptin-deficient group: two novel homozygous disease-causing variants (c.104 T > G and c.34 delC) and another previously reported homozygous pathogenic variant (c.313C > T). CONCLUSION: Leptin deficiency is considered a significant cause of monogenic obesity in Egyptian children with early-onset obesity as the diagnosis of these patients would be a perfect target for recombinant leptin therapy.

Resistance of primary breast cancer cells with enhanced pluripotency and stem cell activity to sex hormonal stimulation and suppression.

Female sex steroid hormones have a fundamental role in breast cancer. Meanwhile, current evidence supports the contribution of breast cancer stem cells in carcinogenesis, metastasis, and resistance to cytotoxic chemotherapy. Nevertheless, the interaction between breast cancer stem cells with sex hormones or key hormonal antagonists remains elusive. OBJECTIVE: To investigate the effect of diverse sex hormonal stimulation and suppression regimens on the proliferation of a primary human breast cancer cells with stem cell activity. METHODS: Cells were exposed to estradiol, progesterone, letrozole, ulipristal acetate, or a combination of ulipristal acetate-letrozole, continually for 6 months. Additionally, nanoparticle-linked letrozole and ulipristal acetate formulations were included in a subsequent short-term exposure study. Phenotypic, pathologic, and functional characteristics of unexposed cells were investigated. RESULTS: The proliferation of breast cancer cells was comparable among all hormonal stimulation and suppression groups (P= 0.8). In addition, the nanoparticle encapsulated hormonal antagonists were not able to overcome the observed resistance of cells. Cell characterization showed a mesenchymal-like phenotype overexpressing three master pluripotency markers (Oct 4, SOX2, and Nanog), and 92% of cells were expressing ALDH1A1. Notably, the CD44 high/CD24 low cell population presented only 0.97%-5.4% over repeat analyses. Most cells lacked the expression of mesenchymal markers; however, they showed differentiation into osteogenic and adipogenic lineages. Upon transfer to serum-free culture, the long-term maintained mesenchymal-like cancer cells showed remarkable morphologic plasticity as they switched promptly into an epithelial-like phenotype with significant mammosphere formation capacity (P= 0.008). CONCLUSION: Breast cancer cells can develop a pluripotent program with enhanced stemness activity that may together contribute to universal resistance to sex hormonal stimulation or deprivation. Isolation and characterization of patient-derived breast cancer stem cells in large clinical studies is therefore crucial to identify new targets for endocrine therapies, potentially directed towards stemness and pluripotency markers. Such direction may help overcoming endocrine resistance and draw attention to breast cancer stem cells' behaviour under endogenous and exogenous sex hormones throughout a woman's reproductive life.

A Cost-Effective Method to Assemble Biomimetic 3D Cell Culture Platforms.

METHODS: We utilized the hAM to provide the biological and the three dimensional (3D) topographic components of the prototype. The 3D nano-roughness of the hAM was characterized using surface electron microscopy and surface image analysis (ImageJ and SurfaceJ). We developed additional macro-scale and micro-scale versions of the platform which provided additional shear stress factors to simulate the fluid dynamics of the in vivo extracellular fluids. RESULTS: Three models of varying complexities of the prototype were assembled. A well-defined 3D surface modulation of the hAM in comparable to commercial 3D biomaterial culture substrates was achieved without complex fabrication and with significantly lower cost. Performance of the prototype was demonstrated through culture of primary human umbilical cord mononuclear blood cells (MNCs), human bone marrow mesenchymal stem cell line (hBMSC), and human breast cancer tissue. CONCLUSION: This study presents methods of assembling an integrated, flexible and low cost biomimetic cell culture platform for diverse cell culture applications.

Stem cell applications for pathologies of the urinary bladder.

New stem cell based therapies are undergoing intense research and are widely investigated in clinical fields including the urinary system. The urinary bladder performs critical complex functions that rely on its highly coordinated anatomical composition and multiplex of regulatory mechanisms. Bladder pathologies resulting in severe dysfunction are common clinical encounter and often cause significant impairment of patient's quality of life. Current surgical and medical interventions to correct urinary dysfunction or to replace an absent or defective bladder are sub-optimal and are associated with notable complications. As a result, stem cell based therapies for the urinary bladder are hoped to offer new venues that could make up for limitations of existing therapies. In this article, we review research efforts that describe the use of different types of stem cells in bladder reconstruction, urinary incontinence and retention disorders. In particular, stress urinary incontinence has been a popular target for stem cell based therapies in reported clinical trials. Furthermore, we discuss the relevance of the cancer stem cell hypothesis to the development of bladder cancer. A key subject that should not be overlooked is the safety and quality of stem cell based therapies introduced to human subjects either in a research or a clinical context.

The effect of acute aromatase inhibition on breast parenchymal enhancement in magnetic resonance imaging: a prospective pilot clinical trial.

OBJECTIVE: The breast is highly hormonally sensitive especially to the sex steroid hormone estrogen. Both physiological and iatrogenic steroid hormone modifications could affect how the breast tissue may appear in breast imaging techniques. We hypothesized that estrogen deprivation therapy could reduce breast nonspecific enhancement on magnetic resonance imaging (MRI). METHODS: This study was a prospective pilot phase II clinical trial. The study was approved by Health Canada and the institutional research ethics board, and participants signed informed consent forms. Sixteen healthy postmenopausal women were enrolled, and 14 completed the study. Baseline breast MRI was done followed 1 month later by administration of a high-dose aromatase inhibitor (letrozole 12.5 mg/day) for 3 successive days before a second breast MRI. Background breast parenchymal enhancement was compared between the pretreatment and posttreatment studies. RESULTS: There was a statistically significant reduction of the average background breast enhancement after treatment with aromatase inhibitors compared with baseline MRI. Of particular interest, specific areas of benign breast enhancement were reduced after aromatase inhibitor treatment. No significant adverse effects were recorded using this relatively high dose of the aromatase inhibitors. CONCLUSIONS: This preliminary study provided evidence that aromatase inhibitors could reduce the parenchymal background enhancement of benign breast tissue during MRI and may improve the specificity of the technique.

Hormonal, follicular and endometrial dynamics in letrozole-treated versus natural cycles in patients undergoing controlled ovarian stimulation.

The objective of this study was to compare letrozole-stimulated cycles to natural cycles in 208 patients undergoing intrauterine insemination (IUI) between July of 2004 and January of 2007. Group I (n = 47) received cycle monitoring only (natural group), Group II (n = 125) received letrozole 2.5 mg/day on cycle days three to seven, and Group III (n = 36) received letrozole 5 mg/day on cycle days three to seven. There were no differences between the groups in endometrial thickness or P4 on the day of hCG. Estradiol levels had higher variation in the second half of the follicular phase in both letrozole-treated groups compared to the control group. Estradiol per preovulatory follicle was similar in both letrozole cycles to that observed in the natural cycles. LH was lower on the day of hCG administration in the letrozole 2.5 mg/day group vs. the natural group. In summary, letrozole results in some minor changes in follicular, hormonal and endometrial dynamics compared to natural cycles. Increased folliculogenesis and pregnancy rates were observed in the letrozole-treated groups compared to the natural group. These findings need to be confirmed in larger, prospective studies.

Aromatase inhibitors: potential reproductive implications.

MEDLINE, EMBASE, Scopus, and Web of Science databases literature search from inception to March 2009 was performed to identify published clinical trials and cohort, observational, and in vitro studies that evaluated the use of aromatase inhibitors in reproductive medicine for indications other than ovulation induction. Aromatase inhibitors are currently being investigated for breast cancer prevention in women at high risk. Aromatase inhibitors may be used for treatment of symptomatic myomas and endometriosis as an alternative to surgical intervention. Current evidence does not support the routine use of aromatase inhibitors for these conditions without prospective controlled trials. Aromatase inhibitor cotreatment can be used to prevent the initial estrogen flare effect of gonadotropin-releasing hormone agonist treatment to offer flexibility in initiating this therapy.

Aromatase inhibitors prevent the estrogen rise associated with the flare effect of gonadotropins in patients treated with GnRH agonists.

This was a preliminary study to determine the effect of aromatase inhibitors in preventing the flare induced by GnRH agonist (GnRH-a) in women with endometriosis (n = 9) or leiomyomata (n = 4) who were given letrozole on the first 5 days of the GnRH-a therapy. Serum LH and FSH levels showed the typical flare 1 day after the injection of the GnRH-a; however, E(2) declined immediately after letrozole administration and was notably suppressed at 1, 2, and 4 days after GnRH-a. No patients complained of clinical symptoms typical of the GnRH-a flare phenomenon.

Letrozole co-treatment in infertile women 40 years old and older receiving controlled ovarian stimulation and intrauterine insemination.

OBJECTIVE: To investigate the effect of a combination of letrozole and gonadotropins in advanced reproductive age infertile women who were treated with IUI. DESIGN: A retrospective case control study. SETTING: A private practice affiliated with an academic institute. PATIENT(S): Infertile women 40 years old and older who were treated with IUI and controlled ovarian hyperstimulation (COH) using either letrozole in combination with FSH (n = 90) or FSH alone (n = 69). MAIN OUTCOME MEASURE(S): Pregnancy rates (PR), mature follicles, serum levels of E(2), P, LH, endometrial thickness, rates of cycle cancellation, and FSH dose. RESULT(S): Pregnancy rates were comparable between the letrozole-FSH co-treatment group and the FSH alone group. Significantly fewer cycles were cancelled in the letrozole co-treatment group. The E(2) levels and the number of follicles were significantly higher in the FSH-only group. Serum levels of LH were significantly higher in the co-treatment group on cycle day 7. The P levels were significantly higher in the FSH alone group on the day of hCG administration. CONCLUSION(S): Letrozole co-treatment compared with using FSH alone has significantly modified the cycle characteristics without reducing PRs and could be of potential benefit in IUI cycles in older infertile women.

Droplet-scale estrogen assays in breast tissue, blood, and serum.

Estrogen is a key hormone in human reproductive physiology, controlling ovulation and secondary sexual characteristics. In addition, it plays an important role in the pathogenesis of breast cancer. Indeed, estrogen receptor antagonists and aromatase inhibitors (which block estrogen biosynthesis) are primary drugs used for treatment and prevention in at-risk populations. Despite its importance, tissue concentrations of estrogen are not routinely measured because conventional techniques require large samples of biopsies for analysis. In response to this need, we have developed a digital microfluidic method and applied it to the extraction and quantification of estrogen in 1-microliter samples of breast tissue homogenate (as would be collected with fine-needle aspiration), as well as in whole blood and serum. This method may be broadly applicable to conditions requiring frequent analysis of hormones in clinical samples (for example, infertility and cancer).