Outcome of human amniotic membrane wrap around neurorrhaphy in high radial nerve injury - a case report following monkey bite.

INTRODUCTION: Peripheral nerve injury due to animal bite is a rare phenomenon. Most animal bites are from dogs. Monkey bites constitute a common risk, second only to dog bites, among travelers. Peripheral nerve injuries may occur due to a combination of monkey's strong jaws and sharp long teeth penetrating deep into the soft tissues. Such injuries are associated with increased perineural fibrosis. Human amniotic membrane (HAM) wrap around the nerve repair site reduces fibrotic response, prevents adhesions and scar formation thereby improving outcome. We report a case of "High Radial nerve palsy due to monkey bite, treated by neurorrhaphy with HAM wrap". METHOD: A 3-year old boy presented with wrist drop, and inability to extend the fingers and thumb of his right dominant hand, following a monkey bite over the distal arm. The diagnosis of high radial nerve injury was corroborated by high frequency ultrasound and electrodiagnostic studies. On exploration the radial nerve was found to be transected. An end to end repair was performed, with HAM wrap around the neurorrhaphy. RESULTS: Wrist dorsiflexion recovered at 2.5 months followed by active finger and thumb extension at 4 months with no infection or immune rejection. CONCLUSION: Nerve regeneration in our patient occurred at a faster rate as compared to the conventional 1 mm/day. This could be attributed to decreased perineural fibrosis, improved neurotropism due to the HAM wrap and neuronal plasticity in young brain in addition, the patient being a small child having better regenerative ability in comparison to an adult.

A randomized trial study on the effect of amniotic membrane graft on wound healing process after anal fistulotomy / Ensaio clínico randomizado sobre o efeito do enxerto de membrana amniótica sobre o processo de cicatrização após fistulotomia anal

Abstract Objective Human amniotic membrane (HAM) used as a wound coverage for more than a century. The aim of this study is to evaluate the efficacy of amniotic membrane on wound healing and reduce post-operative complication. Study design Randomized clinical trial study. Place and duration of study Surgery Department, Shahid Faghihi Hospital, Shiraz, in the period of between Sep. 2014 and Nov. 2015. Methodology 73 patients with anal fistula were divided into two groups. The patients suffered from simple perianal fistula (low type) without any past medical history. Fistulotomy were performed for all of them and in interventional group HAM were applied as biologic dressing. Their wound healing improvement was evaluated post-operative in two groups. Results From 73 patients participated in the study, 36 patients were in control group and 37 patients were in intervention group. According to the analysis of images taken from the wound, the rate of wound healing was 67.39% in intervention group and 54.51% in control group (p < 0.001). Discharge, pain, itching and stool incontinency was lower in intervention group. Analysis of pathology samples taken from the wound showed no differences between two groups. Conclusion HAM application could lead to improvement of wound healing and reduced post-operative complications. In conclusion, HAM may act as a biologic dressing in the patients with anal fistula.

Resumo Objetivo Membrana amniótica humana (MAH) tem sido usada para cobrir feridas por mais de um século. O objetivo deste estudo é avaliar a eficácia da membrana amniótica na cicatrização de feridas e reduzir complicações pós-operatórias. Desenho do estudo Ensaio clínico randomizado. Local e duração do estudo Departamento de Cirurgia, Shahid Faghihi Hospital, Shiraz, Irã, entre setembro de 2014 a novembro de 2015. Método 73 pacientes com fístula anal foram divididos em dois grupos. Os pacientes sofriam de fístula perianal simples (tipo baixo) sem histórico médico prévio. A fistulotomia foi realizada em todos eles e no grupo intervenção, MAH foi aplicada como curativo biológico. A melhora da cicatrização foi avaliada no período pós-operatório em dois grupos. Resultados De 73 pacientes que participaram do estudo, 36 pacientes eram do grupo controle e 37 pacientes do grupo intervenção. De acordo com a análise das imagens da ferida, a taxa de cicatrização foi 67,39% no grupo intervenção e 54,51% no grupo controle (p < 0,001). Secreção, dor, prurido e incontinência fecal foi menor no grupo intervenção. A análise das amostras patológicas retiradas da ferida não mostrou diferenças entre os dois grupos. Conclusão A aplicação de MAH pode levar à melhoria da cicatrização de feridas e reduzir as complicações pós-operatórias. Em conclusão, a MAH pode atuar como um curativo biológico nos pacientes com fístula anal.

Connexin 43 is overexpressed in human fetal membrane defects after fetoscopic surgery.

OBJECTIVE: We examined whether surgically induced membrane defects elevate connexin 43 (Cx43) expression in the wound edge of the amniotic membrane (AM) and drives structural changes in collagen that affects healing after fetoscopic surgery. METHOD: Cell morphology and collagen microstructure was investigated by scanning electron microscopy and second harmonic generation in fetal membranes taken from women who underwent fetal surgery. Immunofluoresence and real-time quantitative polymerase chain reaction was used to examine Cx43 expression in control and wound edge AM. RESULTS: Scanning electron microscopy showed dense, helical patterns of collagen fibrils in the wound edge of the fetal membrane. This arrangement changed in the fibroblast layer with evidence of collagen fibrils that were highly polarised along the wound edge but not in control membranes. Cx43 was increased by 112.9% in wound edge AM compared with controls (p < 0.001), with preferential distribution in the fibroblast layer compared with the epithelial layer (p < 0.01). In wound edge AM, mesenchymal cells had a flattened morphology, and there was evidence of poor epithelial migration across the defect. Cx43 and COX-2 expression was significantly increased in wound edge AM compared with controls (p < 0.001). CONCLUSION: Overexpression of Cx43 in the AM after fetal surgery induces morphological and structural changes in the collagenous matrix that may interfere with normal healing mechanisms. © 2016 The Authors. Prenatal Diagnosis published by John Wiley & Sons, Ltd.

Cryopreserved human amniotic membrane and a bioinspired underwater adhesive to seal and promote healing of iatrogenic fetal membrane defect sites.

INTRODUCTION: We investigated the ability of cryopreserved human amniotic membrane (hAM) scaffold sealed with an underwater adhesive, bio-inspired by marine sandcastle worms to promote healing of iatrogenic fetal membrane defects in a pregnant swine model. METHODS: Twelve Yucatan miniature pigs underwent laparotomy under general anesthesia at 70 days gestation (term = 114 days). The gestational sacs were assigned to uninstrumented (n = 24) and instrumented with 12 Fr trocar, which was further randomized into four different arms-no hAM patch, (n = 22), hAM patch secured with suture (n = 16), hAM patch with no suture (n = 14), and hAM patch secured with adhesive (n = 9). The animals were euthanized 20 days after the procedure. Gross and histological examination of the entry site was performed for fetal membrane healing. RESULTS: There were no differences in fetal survival, amniotic fluid levels, or dye-leakage from the amniotic cavity between the groups. The fetal membranes spontaneously healed in instrumented sacs without hAM patches. In sacs with hAM patches secured with sutures, the patch was incorporated into the swine fetal membranes. In sacs with hAM patches without sutures, 100% of the patches were displaced from the defect site, whereas in sacs with hAM patches secured with adhesive 55% of the patches remained in place and showed complete healing (p = 0.04). DISCUSSION: In contrast to humans, swine fetal membranes heal spontaneously after an iatrogenic injury and thus not an adequate model. hAM patches became incorporated into the defect site by cellular ingrowth from the fetal membranes. The bioinspired adhesive adhered the hAM patches within the defect site.

Carcinoma de células escamosas de la conjuntiva en adultos jóvenes inmunocompetentes / Squamous cell carcinoma of the conjunctiva observed in immunocompromised young adults

Se presentan dos casos de pacientes jóvenes VIH negativos, clínicamente inmunocompetentes, sin antecedentes de exposición actínica prolongada ni riesgo ocupacional, con diagnóstico de carcinoma escamoso de conjuntiva. Presentación inusual en este tipo de lesión que se caracteriza por ser más frecuente a partir de la sexta década de vida, en personas expuestas a las radiaciones ultravioletas o con inmunocompromiso. Su incidencia varía entre 0,13 y 1,9 casos por 100 000 habitantes y ocupa el segundo lugar en frecuencia de los tumores malignos oculares. Se realizó biopsia excisional amplia con margen de 5 mm, crioterapia en las márgenes de la lesión e injerto de membrana amniótica en ambos casos, sin recidiva tumoral en dos años de evolución.

Two cases of young HIV-negative clinically immunocompromised patients, with no history of prolonged actinic exposure or occupational risk, and diagnosed with squamous cell carcinoma of the conjunctiva were presented. This is an unusual presentation in this type of injury that is more frequent after 60 years of age in people exposed to ultraviolet radiation or immunocompromised. Its incidence ranges 0,13 to 1,9 cases per 100,000 pop and ranks second infrequency of ocular malignancies. Excisional biopsy was performed with a 5 mm wide margin, cryotherapy in the borders of the lesion and amniotic membrane grafting were also performed in both cases, without tumor recurrence after two years of evolution.

Carcinoma de células escamosas de la conjuntiva en adultos jóvenes inmunocompetentes / Squamous cell carcinoma of the conjunctiva observed in immunocompromised young adults

Se presentan dos casos de pacientes jóvenes VIH negativos, clínicamente inmunocompetentes, sin antecedentes de exposición actínica prolongada ni riesgo ocupacional, con diagnóstico de carcinoma escamoso de conjuntiva. Presentación inusual en este tipo de lesión que se caracteriza por ser más frecuente a partir de la sexta década de vida, en personas expuestas a las radiaciones ultravioletas o con inmunocompromiso. Su incidencia varía entre 0,13 y 1,9 casos por 100 000 habitantes y ocupa el segundo lugar en frecuencia de los tumores malignos oculares. Se realizó biopsia excisional amplia con margen de 5 mm, crioterapia en las márgenes de la lesión e injerto de membrana amniótica en ambos casos, sin recidiva tumoral en dos años de evolución(AU)

Two cases of young HIV-negative clinically immunocompromised patients, with no history of prolonged actinic exposure or occupational risk, and diagnosed with squamous cell carcinoma of the conjunctiva were presented. This is an unusual presentation in this type of injury that is more frequent after 60 years of age in people exposed to ultraviolet radiation or immunocompromised. Its incidence ranges 0,13 to 1,9 cases per 100,000 pop and ranks second infrequency of ocular malignancies. Excisional biopsy was performed with a 5 mm wide margin, cryotherapy in the borders of the lesion and amniotic membrane grafting were also performed in both cases, without tumor recurrence after two years of evolution(AU)

A 29-gauge atraumatic needle for amniocentesis.

OBJECTIVE: To compare perforation characteristics of standard 22 G (0.7 mm) to 29 G needle (0.34 mm) for amniocentesis. METHODS: Seventeen human chorio-amnion membranes were perforated immediately after cesarean section using 22 G needle for spinal anesthesia and 29 G "pencil-point" needles for amniocentesis under in-vitro conditions. Area of perforation was determined using a microscope and volume of fluid leakage was measured over a period of 5 min. RESULTS: Membrane perforation with the 22 G needle resulted in a mean damaged area of 225,147.4 µm(2), a hole with a mean area of 50,154 µm(2) and amniotic fluid volume passage of 17.5 mL/5 min, whereas the 29 G needle generated a mean damaged area of 114,812.4 µm(2), a hole with an average area of 1382.5 µm(2) and volume passage of 0.28 mL/5 min. These differences were significant. CONCLUSION: The hole formed by membrane perforation with 29 G "pencil-point" needle for amniocentesis is 36 times smaller, and the amniotic fluid loss is 61 times less than that measured with the 22 G standard needle for spinal anesthesia. Significant reduction of complications following amniocentesis is expected with the 29 G needle.

Chick amniogenesis is mediated by an actin cable.

This study examined the process of chick amniogenesis to determine whether the actin cable mechanism operating during amnion wound repair is a recapitulation of developmental events. Staining of the developing amnion with fluorescein isothiocyanate-labeled phalloidin indicated the presence of an actin cable in the amniotic head fold, which persisted through to the closure of the amnion. Transmission electron microscopy of the developing amnion revealed linearly arranged actin microfilaments in the elongated cells at the leading edge of the amnion, adjacent to either side of a nodule of numerous cells at the point of midline fusion. A mesh of cytoplasmic actin filaments was seen dispersed throughout the accumulated cells of the nodule. Lamellapodia were absent suggesting that cell crawling is not involved in amniogenesis. Addition of an enzyme inhibitor of Rho, cell-permeable C3 transferase, to the surface of the developing amnion prior to closure appeared to inhibit amniogenesis at the early embryonic stages.

Zinc and magnesium ions synergistically inhibit superoxide generation by cultured human neutrophils--a promising candidate formulation for amnioinfusion fluid.

Oligohydramnios is often caused by the premature rupturing of membranes and subsequent intrauterine infections, such as chorioamnionitis, in which event oxidative stress is hypothesized to be closely associated with the damage to the fetal organs. The clinical efficiency of amnioinfusion using warmed saline in cases of premature rupture of membranes is still controversial, especially concerning the prognosis for the fetus. In the present study, we found that human amniotic fluid per se suppresses the release of superoxide from cultured human neutrophils, suggesting an acute or chronic shortage of amniotic fluid in cases of premature rupture of membranes can affect the shielding of intrauterine organs from oxidative stress. The aim of this study was to propose a formula of zinc and magnesium ions in saline for amnioinfusion, by assessing antioxidative activities. A combination of 5 microM zinc and 5mM magnesium in saline synergistically inhibited superoxide production by cultured human neutrophils, equivalent to human amniotic fluid. The intraperitoneal administration of this formula significantly improved the survival rate in a rat model of peritonitis compared to the saline control (46.7% vs. 10%). The combination of these metals with saline may thus be a promising formula for an amnioinfusion fluid with the capacity to protect fetal organs from oxidative stress.

Gestational age-dependent repair kinetics of microsurgical defects in monolayers of human amniocytes.

OBJECTIVES: There is paucity of data on the capacity of fetal membranes to repair surgical defects following trauma. We aimed at developing an in vitro model using monolayers of human amnion epithelial cells to study fetal membrane healing. METHODS: Term (n = 6) and preterm (n = 3) fetal membranes were collected at caesarean section. The amnion was digested twice in a trypsin solution. Amniocytes were seeded (250,000-750,000/ml) and incubated at 37 degrees C and 5% CO(2) and 21 or 5% O(2). A microsurgical injury was made centrally in the monolayers and the cultures were incubated for 48 h. Every 6 h, slides were fixed and immunohistochemical staining was performed to quantify proliferation at the site of the defect and centrally in the monolayer. The closure rate was evaluated by measuring the defect size every 6 h. RESULTS: The closure rate of the defects was higher in preterm versus term cultures. Proliferation was significantly higher in the defect zone versus the peripheral zone, and also higher in the preterm group. CONCLUSION: We describe a new model for the study of fetal membrane healing and observed gestational age-dependent repair capacity of the amnion.

Partial amniotic carbon dioxide insufflation (PACI) during minimally invasive fetoscopic surgery: early clinical experience in humans.

BACKGROUND: The technical performance of minimally invasive fetoscopic surgery may be severely hindered by poor visualization of intra-amniotic contents. Partial amniotic carbon dioxide insufflation (PACI) allows the visual limitations of operating within the fluid environment to be overcome. PATIENTS AND METHODS: When amniotic fluid exchange failed to improve fetoscopic visualization, PACI was attempted during 37 fetoscopic procedures between 17 + 5 and 33 + 2 weeks of gestation. PACI was attempted with filtered carbon dioxide using a commercially available insufflator via one to three trocars that were percutaneously introduced into the amniotic cavity. The maximum pressure during PACI was limited by the maximum insufflation pressure (30 mmHg) generated by the insufflator. Improvement of fetoscopic visualization as well as technical, maternal, and fetal safety aspects surrounding PACI were analyzed. RESULTS: PACI could successfully be instituted in 36 of the 37 procedures. In one case, when in the presence of increased uterine tone the opening pressure exceeded the maximum insufflation pressure of the insufflator, the strategy was abandoned. In all cases where PACI could be instituted successfully, the approach offered far superior visualization of the fetoscopic procedure than would have been possible within amniotic fluid. Acute or chronic maternal or fetal complications were observed in only one case (intraoperative membrane rupture). CONCLUSION: PACI greatly improves fetal visualization during fetoscopic interventions when fetoscopy within fluid meets with difficulties. Continued assessment of its benefits, risks, and safety margins at specialist centers is required.

Comparative study of clinical characteristics of amniotic rupture sequence with and without body wall defect: further evidence for separation.

BACKGROUND: Amniotic rupture sequence (ARS) is a disruption sequence presenting with fibrous bands, possibly emerging as a result of amniotic tear in the first trimester of gestation. Our comparative study aims to assess whether there is a difference in the clinical pattern of congenital limb and internal organ anomalies between ARS with body wall defect (ARS-BWD) and ARS without BWD (ARS-L). METHODS: Among 1,706,639 births recorded between 1998 and 2006, 50 infants with a diagnosis of ARS were reported to the Polish Registry of Congenital Malformations. The information on 3 infants was incomplete, thus only 47 cases were analyzed. These infants were classified into groups of ARS-L (38 infants) and ARS-BWD (9 infants). RESULTS: The ARS-BWD cases were more frequently affected by various congenital defects (overall p < 0.0001), and in particular by urogenital malformations (p = 0.003). In both groups, limb reduction defects occurred in approximately 80% of cases; however, minor and distal limb defects (phalangeal or digital amputation, pseudosyndactyly, constriction rings) predominated in the ARS-L group (p = 0.0008). The ARS-L group also had a higher frequency of hand and upper limb involvement. CONCLUSIONS: This observation suggests that amniotic band adhesion in ARS-L takes place at a later development stage. Although limited by a small sample size, our study contributes to the growing evidence that both ARS entities represent two nosologically distinct conditions.

Transient chorioamniotic membrane separation after fetoscope guide laser therapy for twin-twin transfusion syndrome: a case report.

Chorioamniotic membrane separation (CMS) means that the close attachment of amniotic and chorionic membranes is disrupted, usually following the traumatic entry into the amniotic cavity including fetal therapy. We report a case of twin-twin transfusion syndrome receiving fetoscopic guide laser therapy at gestational age of 19 weeks with partial CMS detected at the fifth week (gestational age of 24 weeks) after surgery and resealed 1 week later. There was no more CMS noted till delivery at gestational age of 34 weeks 6 days. CMS after fetoscope surgery may reseal spontaneously.

Successful treatment of premature rupture of membranes after genetic amniocentesis by intra-amniotic injection of platelets and cryoprecipitate (amniopatch): a case report.

BACKGROUND AND OBJECTIVES: Iatrogenic premature rupture of membranes (PROM) occurs in approximately 1% of patients after genetic amniocentesis. If membranes do not seal spontaneously, fluid leakage through the vagina may cause infection and pregnancy loss. Intra-amniotic infusion of a platelet concentrate followed by a cryoprecipitate (amniopatch) is a possible therapeutic approach to restore the amnio-corial link and to facilitate the amniotic repair process. MATERIALS AND METHODS: The autologeous platelet concentrate was produced by apheresis (MCS+, Haemonetics) and contained a total amount of 48 x 10(9) platelets in a volume of 30 ml. The concentration of fibrinogen in our cryoprecipitate (20 ml) was 680 mg/dl. An amniocentesis was performed to apply the amniopatch. The platelet concentrate was administered first followed by the cryoprecipitate. RESULTS: We report the successful treatment of a 38-year-old woman with ruptured membranes after genetic amniocentesis in the 16th gestational week. Ten days after placement of the amniopatch we found a complete closure of the rupture, and in the 36th week of gestation the patient delivered a healthy infant by Caesarean section. CONCLUSIONS: Intra-amniotic injection of platelets and cryoprecipitate was a successful and safe therapy for PROM in this patient. Knowledge of the site of rupture is not necessary for the amniopatch, as platelets seem to find their way to the defect and seal it. We consider that amniopatch therapy for iatrogenic PROM is a possible therapeutic alternative for prolonging and preserving pregnancy and improving the fetal outcome.

A Rho-dependent actin purse-string is involved in wound repair in the early chick amnion following surgical puncture.

This study examined the mechanism of wound repair in the early chick amnion following surgical puncture. The chick amnion is a bilayered membrane with ultrastructural features similar to the human amnion, and thus may provide a model of the consequences of amnion puncture following first trimester amniocentesis in humans. Chick amnion was wounded on day 4-5 of incubation. The rate of wounding was measured as 40 microm2/minute by hourly measurements of wound area from initial wounding to a point where the wound appeared to be fully closed. Morphological changes were examined by scanning electron microscopy of amniotic membranes with the overlying chorionic membrane removed. Cells bordering the wound arranged themselves circumferentially during the healing period and eventually came together as a cellular pile up as the healing process was complete. The presence of an actin cable was revealed by fluorescein isothiocyanate-labeled phalloidin. The actin was circumferentially arranged around the wound margin and appeared within 10 minutes after wounding. Treatment of the amnion with the inhibitor of endogenous Rho, C3 exotransferase, inhibited actin cable formation, suggesting that formation of an actin cable within the amnion during wound healing is Rho dependent.

A histological study of fetoscopic membrane defects to document membrane healing.

OBJECTIVE: To evaluate the rate of spontaneous healing in human fetal membranes after fetoscopy. STUDY DESIGN: Membranes from patients that had undergone fetoscopic interventions and delivered in one of the two treatment centers were included in the study. The membranes were examined macroscopically for any remaining defects and if present, the size of the defect in chorion and amnion was measured. Subsequently, the defect was excised and stained with HE for histological evaluation. Additional immunohistochemical staining was performed with Ki-67, cytokeratin and vimentin. The proliferation index (percentage of proliferating cells) was calculated in amnion and chorion. RESULTS: Nineteen membrane defects were included in the study. The median time interval between invasive procedures and delivery was 60 days (range 3-112). All fetoscopic defects (n=19) could be identified in the gestational sac and in none spontaneous closure had occurred. Proliferation indices as measured by inmunohistochemistry were very low (median 2.8%, range 0-7%) in the chorion and 0% in the amnion. CONCLUSION: No evidence of spontaneous membrane healing was found after fetoscopic procedures, suggesting that the membrane defect normally persists until delivery. Absence of amniotic fluid leakage after invasive procedures may be based on mechanisms other than histologic membrane repair.

The effect on pregnancy rate of progesterone administration after manual reduction of twin embryos in dairy cattle.

Twin pregnancies are undesirable in dairy cattle as they increase the risk of abortion and have many negative effects on the profitability of the herd. The purpose of this study was to evaluate manual reduction of a twin embryo in dairy cows bearing unilateral twins. On day 34 of gestation, 33 cows were assigned to one of three treatment groups (n = 11 for each group): untreated cows (group control), amnion rupture (group AR), and amnion rupture plus treatment (intravaginal progesterone for 28 days) (group ART). A significantly higher (P = 0.0001) pregnancy loss rate was recorded in the AR group (100%, 11/11), than in the ART (54.5%, 6/11) and control (27.3%, 3/11) groups. In the ART group, one embryo survived amnion rupture and the cow bearing it had twins at parturition, while the remaining four cows delivered singletons. Our results suggest that the procedure of rupturing the amnion with progesterone supplementation may provide a satisfactory way for twin reduction in dairy cattle.

In vitro lesion repair by human amnion epithelial and mesenchymal cells.

OBJECTIVE: The purpose of this study was to compare wound healing by human amnion epithelial and mesenchymal cells from preterm and term placenta with the use of an in vitro lesion repair assay. STUDY DESIGN: Lesions were created in confluent monolayers of amnion epithelial and mesenchymal cells from preterm and term placentas. The repair was monitored by the measurement of the lesion area and the response to potential stimulants (platelet-derived growth factor, tumor necrosis factor-alpha, fibrinogen, and phorbol myristate acetate). Cell proliferation was detected with 5-bromodeoxyuridine staining. RESULTS: Lesion repair was complete within 40 hours in control epithelial cultures from preterm and term placenta but incomplete in mesenchymal cultures (preterm cells, 80%; term cells, 40%). Platelet-derived growth factor, tumor necrosis factor-alpha, fibrinogen, and phorbol myristate acetate did not accelerate repair in either cell type. CONCLUSION: An in vitro lesion repair assay revealed the differences in lesion repair capacity between amnion epithelial and mesenchymal cells and between mesenchymal cells from preterm and term placenta.