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Restoring vision to the blind – Science Magazine

Surveys consistently report that people fear total blindness more than any other disability, and currently the major cause of untreatable blindness is retinal disease. The retina, a part of the brain that extends into the eye during development, initiates vision by first detecting light with the rod and cone photoreceptors. Four classes of retinal neurons then begin the analysis of visual images. Defects in the optical media that transmit and focus light rays onto the retina (lens and cornea) can usually be dealt with surgically, although such treatments are not available in some parts of the world, resulting in as many as 20 to 30 million legally blind individuals worldwide. Untreatable retinal disease potentially causes legal or total blindness in more than 11 million people in the United States alone, but progress in treatments raises the possibility of restoring vision in several types of retinal blindness (1).

Retinal neurons comprise bipolar and horizontal cells, which are second-order neurons that receive signals from the photoreceptors in the outer retina. Third-order amacrine and retinal ganglion cells are activated in the inner retina by bipolar cells. Axons from the ganglion cells form the optic nerve and carry the visual message to the rest of the brain (see the figure). The cells most susceptible to blinding retinal disease are the photoreceptors and ganglion cells. Whereas progress has been made in combating blindness caused by photoreceptor degeneration, little can be done currently to address ganglion cell loss, such as occurs in glaucoma.

The approach that has been most successful in restoring photoreceptor loss that results in complete blindness is the use of retinal prosthetic devices, with two now approved for clinical use (2). These devices electrically stimulate either bipolar or ganglion cells. They require goggles that have a camera that converts visual stimuli into electrical stimuli that activate the device, which in turn stimulates the retinal cells. Several hundred of these devices have been implanted in blind or virtually blind individuals, 70 to 80% of whom report improvement in quality of life. For those who are completely blind, the ability to experience again at least some visual function is viewed as a miracle.

There are substantial limitations to the devices, however. The best visual acuity attained so far is poor (20/500) and visual field size is limited, but many improvements, mainly technical, are being developed and tested, including the potential use of electronic low-vision devices to increase visual field size and acuity (3). Retinal prostheses are not useful for patients who are blind because of loss of ganglion cells and/or the optic nerve, but prostheses that bypass the retina and stimulate more central visual structures, including the lateral geniculate nucleus (the intermediary between retina and cortex) and visual cortex, are being developed and tested in humans (4). There remain considerable technical issues, but preliminary data indicate that such devices are feasible.

A second approach to treat photoreceptor degeneration and potential blindness, now in the clinic, is gene therapy (5). This involves injecting a viral construct into the eye that contains a normal gene to replace an abnormal one. Success so far has been limited to the treatment of Leber congenital amaurosis (LCA) type 2, a rare form of retinitis pigmentosa in which the gene whose product is required to form the correct isomer of vitamin A aldehyde, the chromophore of the visual pigments, is mutated. Little of the correct isomer is made in LCA patients, resulting in substantial loss of photoreceptor light sensitivity. This is reversed when viral constructs encoding the normal gene are injected deep into the eye between the photoreceptors and pigment epithelium.

Two factors make this approach feasible in LCA: The genetic defect is monogenic, and many of the photoreceptors in the patients remain alive, although compromised. Thus, how broadly feasible gene therapy will be for treating the enormous range of inherited retinal diseases now known to exist (300) remains to be seen. But at least a dozen other gene therapy trials on monogenic inherited eye diseases similar to LCA are under way (6). Other methods to manipulate genes are now available, including CRISPR-mediated editing of retinal genes. So far, the experiments have been mainly on isolated cells or retinas, but these powerful techniques are likely to have eventual clinical applications.

A variation on the use of gene therapy techniques is optogenetics, in which light-sensitive molecules are introduced into non-photosensitive retinal cells. This approach holds much promise for restoring vision to totally blind individuals whose photoreceptors have been lost. Using viruses to insert genes encoding light-sensitive molecules into bipolar and ganglion cells, as well as surviving photoreceptor cells that are no longer photosensitive, has been accomplished in animals and shown to restore some vision (7). Again, technical issues remain: The cells made light-sensitive require bright light stimuli, and the light-sensitive cells do not adapt. That is, whereas photoreceptors normally allow vision over as much as 10 log units of light intensity, the cells made light-sensitive respond only to a range of 2 to 3 log units. Various methods to overcome these limitations are now being developed, and at least one clinical trial is under way. Experiments to make cortical neurons sensitive to light or other stimuli that better penetrate the skullmagnetic fields or ultrasound, for exampleare also being developed and tested in animals.

Other promising approaches to restore vision are being explored. In cold-blooded vertebrates, retinal cells (in fish) and even the entire retina (in amphibians) can regenerate endogenously after damage. Regeneration of retinal cells in zebrafish is now quite well understood (8). The regenerated neurons come from the major glial cell in the retina, the Mller cell. After retinal damage, Mller cells reenter the cell cycle and divide asymmetrically to self-renew and produce a progenitor cell that proliferates to produce a pool of cells capable of differentiating into new retinal cells that repair the retina.

A number of transcription factors and other factors identified as being involved in retinal regeneration in zebrafish have been shown to stimulate some Mller cell proliferation and neuronal regeneration in mice. Regenerated bipolar and amacrine cells, as well as rod photoreceptors, have so far been identified in mouse retinas, and these cells are responsive to light stimuli (9, 10). Further, cells postsynaptic to the regenerated neurons are activated by light stimuli, indicating that the regenerated neurons have been incorporated into the retinal neural circuitry. So far, the regenerative capacity of mammalian Mller cells is limited, but directed differentiation of specific types of neurons with a mix of factors appears to be a possibility. Regrowth of ganglion cell axons after the optic nerve is disrupted is also under active investigation, and although the number of axons regrowing is low (10%), those that do regrow establish synaptic connections with their correct targets (11). Therefore, endogenous regeneration is still far from clinical testing, but substantial progress has occurred.

The retina lines the back of the eye and consists of rod and cone photoreceptors, as well as four types of neuron: second-order bipolar and horizontal cells and third-order retinal ganglion cells (RGCs) and amacrine cells. Mller glial cells fill the spaces between the neurons. The pigment epithelium, critical for photoreceptor function, underlies the retina. Photoreceptors and RGCs are most susceptible to blinding retinal disease. Progress in combating photoreceptor degeneration has been made, but there are few strategies to address RGC loss.

A long-studied area of research is transplantation of retinal cells, particularly photoreceptors, into diseased retinas. In experiments with mice, transplanted postmitotic rod photoreceptor precursor cells derived from embryonic retinas or from stem cells appeared to integrate into diseased retinas in reasonable numbers and to be functional. A surprising and unexpected complication in the interpretation of these experiments was recently discovered. Rather than integrating into diseased retinas, the donor cells appear to pass material (RNA or protein) into remaining host photoreceptor cells, rejuvenating them, and these appear to be most of the functional cells (12). The current evidence suggests that only a small proportion of the donor cells integrate, but progress in overcoming this setback is being made.

More success has been reported with stem cells induced to become pigment epithelial (PE) cells, which provide essential support for photoreceptors. A number of blinding retinal diseases relate to the degeneration of the PE cells, and replacement using such cellsin a suspension or on a scaffoldis being actively pursued. PE cells do not need to integrate synaptically with retinal cells; they simply need to contact the photoreceptor cells. This is achieved when PE cells are placed between the retina and the back of the eye. Early clinical trials suggest that the transplants are safe, but retinal detachment, a serious complication, can occur and efficacy has yet to be shown (13).

The finding that donor photoreceptor cells can help diseased host retinal cells to recover function suggests that certain substances can provide neuroprotection. Indeed, a substantial number of such neuroprotective molecules have been shown to affect retinal disease progression, especially degeneration of photoreceptor cells. No one factor has been shown to be effective generally, but two have received much attention. One, ciliary neurotrophic factor (CNTF), promotes photoreceptor survival in light-induced photoreceptor degeneration and in several other models of retinal degeneration (14). Some evidence suggests that CNTF acts primarily on Mller cells, but how it works, and on what cells, is still unclear. The other factor, rod-derived cone viability (RDCV) factor, has received less research attention, but with recent industrial support, it is now being advanced to the clinic. Current evidence indicates that RCDV factor protects cones after rod degeneration.

Two of the most common retinal diseases in developed countriesage-related macular degeneration (AMD), the leading cause of legal blindness (visual acuity of less than 20/200), and glaucoma, the leading cause of total blindnessare not monogenic diseases, and so genetic treatments for them are not obvious. Attempts to understand the etiology of these diseases are under way, but currently their underlying causes are still unclear. A difficulty presented by AMD is that no animal model is readily available, because it is a disease of the fovea, which mediates high-acuity vision. Except for primates, other mammals do not possess this small critical retinal area. Whereas large primates are not feasible for extensive cellular or molecular studies, small primates such as marmosets that have a fovea are potential models but have not been used much to date.

Other approaches for restoring vision have been suggested and have even yielded some progress. From both normal humans and those with an inherited retinal disease, skin biopsy cells can be induced to form tiny retinal eyecups called organoids (15). Containing all retinal cell types, these structures could be a source of retinal cells for studying retinal disease development and possible therapies, as well as for cell transplantation. A fovea has not been observed in any organoid so far, but this is not beyond the realm of possibility. Another suggested approach is to surgically transplant whole eyes into blind individuals. This appears feasible, but whether there is sufficient optic nerve regrowth remains an open question.

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Restoring vision to the blind - Science Magazine

Ontario Announces First Phase of Research Projects to Fight COVID-19 – Government of Ontario News

Ontario Announces First Phase of Research Projects to Fight COVID-19Ontario-Based Solutions Contribute to the Global Effort against the Outbreak

Ontario is funding the following research on preventing, detecting and treating COVID-19. These projects focus on important areas of research, including vaccine development, diagnostics, drug trials and development, and social sciences.

A Randomized Open-Label Trial of CONvalescent Plasma for Hospitalized Adults with Acute COVID-19 Respiratory Illness (CONCOR-1)Donald Arnold, Principal InvestigatorMcMaster University

CONCOR-1 is a clinical trial that will collect blood plasma from individuals who have recovered from COVID-19, known as COVID-19 convalescent plasma. Convalescent plasma contains COVID-19 antibodies, proteins that help fight the virus. Convalescent plasma will be injected into patients currently fighting the infection, to test whether this is an effective treatment for the virus. This clinical trial will enrol patients 16 years of age and older admitted to hospital with COVID-19 and who require supplemental oxygen for respiratory illness.

Partners include 60 hospitals across Canada and three hospitals in New York City, the Canadian Blood Services and Hma-Qubec and the New York Blood Center.

Research and Deployment of Rapid High-Throughput Diagnostic Testing for COVID-19Marek Smieja, Principal InvestigatorSt Joseph's Healthcare Hamilton

This project will increase Ontario's COVID-19 testing capacity by deploying robotic liquid handling technology, specimen pooling, and efficient sample preparation, while reducing biological risk and ensuring reliable results. The Disease Diagnostics & Development group in the Research Institute of St Joe's Hamilton (RSJH) is collaborating with the Hamilton Regional Laboratory Medicine Program (HRLMP) and other clinical laboratories across the province to quickly develop, validate, and deliver high-throughput, COVID-19 testing, with the goal of testing up to 6,000 samples per lab daily.

Assay Development for SARS-CoV-2 Sero-SurveillanceJennifer Gommerman, Principal InvestigatorUniversity of Toronto

This study will provide a better understanding of the immune response to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19. This approach aims to measure the level and/or types of antibodies induced by SARS-CoV-2 infection in the blood of acute and convalescent patients. In addition, measuring these antibodies in the saliva of asymptomatic infected subjects identified through contact tracing will provide insights into what the early immune response to the virus looks like, and how this may correlate with clinical outcome. This knowledge, as well as the development of a robust serosurveillance platform, represents a powerful weapon in our fight against COVID-19.

Multivalent Antibody Scaffold to Deliver an Exceptionally Potent and Broad Antiviral Against SARS-CoV-2Jean-Philippe Julien, Principal InvestigatorThe Hospital for Sick Children

This project has the potential to develop a unique antibody-based molecule for protection and treatment against COVID-19. Molecular technology will allow these researchers to decipher the vulnerabilities of the virus with the goal of developing a potent and broad antiviral that neutralizes SARS-CoV-2 and prevents associated COVID-19 symptoms.

Developing Prophylactic Virus-Vectored Vaccines for COVID-19Byram Bridle, Leonardo Susta and Sarah Wootton (Co-Principal Investigators, University of Guelph); Darwyn Kobasa, National Microbiology Laboratory, Public Health Agency of Canada (Collaborator) University of Guelph

This research aims to develop a vaccination strategy for COVID-19. By developing avian avulavirus (AAvV-1) and adenovirus viral-vectored vaccines expressing the SARS-CoV-2 spike protein as a target antigen, researchers will test these vaccines in mice to identify a way to induce robust protective mucosal (respiratory, gastrointestinal and urogenital tract) and systemic immunity. Mucosal immunity plays a significant role in preventing pathogens from getting into the body. Systemic immunity clears any pathogens that bypass mucosal barriers. After optimization, these vaccines will be evaluated in a hamster challenge model at the National Microbiology Laboratory in Winnipeg.

The RAPID COVID Study - Application of Point-of-Care COVID-19 Testing to Optimize Patient Care, Resource Allocation and Safety for Frontline StaffDerek So, Principal InvestigatorUniversity of Ottawa Heart Institute

This study will determine the role of point-of-care testing (POC) as a tool to improve care of COVID-19 patients and conserve resources. A major obstacle facing hospitals during the COVID-19 outbreak is the inability to quickly diagnose who is infected with the virus. Delayed test results could mean that patients, who ultimately test negative, are treated for days utilising resources that could be better deployed elsewhere. An immediate diagnosis of COVID-19 among carriers could provide more expedient treatment, prevent clinical deterioration and help health care workers avoid unnecessary risk of exposure.

In collaboration with Spartan Biosciences, which has developed a novel point-of-care 45-minute bedside COVID-19 test, and a team of specialists from six centres in Ontario, this research will evaluate the efficacy of POC testing to determine when, how and to who it can be applied.

A Prospective, Observational Research Study on the Diagnosis of COVID-19 Infection from Stool Samples of Children and AdultsNikhil Pai, Jeff Pernica, Marek Smieja (Co-Principal Investigators)McMaster University

Through the development and use of a novel test to diagnose COVID-19 from stool samples, this team will assess up to 4,500 stool samples collected from outpatient clinics, emergency departments and inpatient wards across eight major Hamilton region hospitals and clinics. This work will improve COVID-19 disease detection in children and adults who lack respiratory symptoms, are asymptomatic, or are presumed to have "recovered" from past infection. The researchers hope to expand COVID-19 testing options across Canada and ultimately, better identify patients who carry high risk of community transmission than traditional respiratory testing alone.

Cellular Immuno-Therapy for COVID-19 Induced Acute Respiratory Distress Syndrome: The CIRCA-19 TrialDuncan Stewart, Principal InvestigatorOttawa Hospital Research Institute

Through a series of trials, this research will rapidly evaluate the safety and efficacy of using mesenchymal stromal/stem cells, or MSCs, to help treat patients with COVID-19 related acute respiratory distress syndrome (ARDS). Up to 25 percent of all patients admitted to hospital require admission to an intensive care unit, and as many as 40 percent develop severe difficulty breathing due to ARDS.

In total, 27 patients will undergo three sequential trials. The first trial, called the Vanguard study, is designed to quickly determine the optimal dosing strategy of MSCs derived from bone marrow to treat patients experiencing ARDS. The next two trials will use the optimal dose of cells determined by the Vanguard trial, but will administer MSCs derived from the umbilical cord, which is an abundant and readily available source.

Rapid Identification of Immunogenic and T-cell Epitopes to Enable Serologic Testing, Passive Immunotherapy, and Epitope Vaccine for COVID-19Shawn Li, Principal InvestigatorWestern University

To curb the COVID-19 outbreak caused by the SARS-CoV-2 virus, researchers are looking to solve three critical challenges as quickly as possible - detection, treatment, and vaccination. This project will address these challenges by developing a point-of-care blood test to identify infected individuals, including those without symptoms, devising strategies for the production of virus-neutralizing antibodies to treat the severely ill, and identifying viral epitopes to inform epitope-vaccine development.

The Impact of the Coronavirus Pandemic on Children with Medical Complexity Technology Dependency: A Novel Research Cohort StudyAudrey Lim, Principal InvestigatorMcMaster University

This study addresses how to effectively manage pediatric patients remotely by identifying the barriers and facilitators of virtual clinics. COVID-19 is placing strain on families of children with medical complexity, medical fragility and technology dependency. Many of these children are dependent on life sustaining technology such as tracheostomy, home mechanical ventilation, and/or enteral feeding tubes. Though accounting for less than 1 percent of all children in Ontario, this group is at increased risk of multiple and prolonged hospitalizations and poorer health outcomes. Normally, these children are seen at a hospital to address their multiple complex needs, however due to COVID-19, all in-person clinic appointments have been replaced by virtual clinics. Parental satisfaction with virtual clinic healthcare teams will also be assessed using a quality improvement tool developed for this study. This research has the potential to advance virtual medicine, beyond COVID-19.

Food Retail Environment Surveillance for Health and Economic Resiliency: FRESHER OntarioJason Gilliland, Principal InvestigatorWestern University

The Food Retail Environment Surveillance for Health & Economic Resiliency (FRESHER) project is a rapid response to the widespread closures of, and modified operating conditions for, many retail food outlets. The FRESHER project will examine the economic and social impacts of COVID-19 in Southwestern Ontario by identifying what businesses modified their operations, temporarily closed or permanently closed during the outbreak and how the outbreak has affected businesses and their employees. This study will help inform policies and programs that will maintain Ontario's food security, incentivize economic growth during the recovery period, and improve resiliency among businesses during future pandemics and emergencies.

Protective Immunity in Individuals Infected with COVID-19Ishac Nazy, Principal InvestigatorMcMaster University

The goal of this research is to determine the makeup, concentration, strength and viral properties of anti-SARS-CoV-2 antibodies to provide insights into the immune response of individuals infected with COVID-19. Working with Dr. Arnold (CONCOR-1 study on convalescent plasma therapy), this team will use samples from recovered patients to test whether antibodies exist, and if they are able to bind and neutralize the virus. This research will determine whether immunity is longstanding or if it wanes over time; and will inform researchers how immune-based treatments work to fight off the virus, including convalescent plasma or future vaccines.

Clinical Research on the Therapeutic Benefits of Annexin A5 in Severe COVID-19 PatientsClaudio Martin, Principal InvestigatorLawson Health Research Institute

There are currently no proven therapies to treat COVID-19. In the most severe cases, the disease is complicated by sepsis acute respiratory distress syndrome (ARDS), and multiorgan failure. Sepsis is a life-threatening condition caused by the body's response to an infection. While the body normally releases chemicals to fight an infection, sepsis occurs when the body's response to these chemicals is out of balance, triggering systemic inflammation that can damage multiple organs. Many critically ill COVID-19 patients develop sepsis 1-2 days before ARDS, suggesting that sepsis is a major contributor to the development of organ and respiratory failure.

This clinical trial will examine the effects of Annexin A5, in treating critically ill COVID-19 patients who develop sepsis. Annexin A5 is a human protein that has potent anti-inflammatory, anti-apoptotic (cell death prevention) and moderate anticoagulant (blood clot prevention) properties. The ultimate goal of the trial is to use Annexin A5 to treat sepsis and prevent respiratory and multi-organ failure.

Novel Coronavirus Antiviral Drug Discovery Using High-Throughput ScreeningJean-Simon Diallo, Principal InvestigatorOttawa Hospital Research Institute

Using a novel bio-sensor that detects drugs that disrupt the attachment of coronaviruses to cells, this research will test approximately 1,200 approved drugs to better understand their potential to prevent viral infection in cells and their ability to block the interaction between COVID-19 and its receptor. A second phase of this study will attempt to identify novel antivirals from a small (>220,000) molecule library.

Canada's COVID-19 Pandemic Response and Impact in Low-Income and Homeless or At-Risk for Homelessness Populations in Ottawa (Canada): A Mixed Method StudySmita Pakhale, Principal InvestigatorThe Ottawa Hospital Research Institute

Vulnerable populations face numerous social and health inequities that are exacerbated during times of crises. Lessons learned from previous public health crises suggest that inappropriate communication strategies jeopardize risk reduction for vulnerable populations. The objective of this research is to measure the impacts of COVID-19 public health emergency response efforts and communication strategies on Ottawa's low-income, homeless or at-risk for homelessness populations. The findings could help inform public health messaging strategies and pandemic approaches for vulnerable populations.

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Ontario Announces First Phase of Research Projects to Fight COVID-19 - Government of Ontario News

Umbilical Cord Stem Cell Therapy to Be Assessed in Severe COVID-19 – Pulmonology Advisor

Home Topics Lung Infection

The Food and Drug Administration (FDA) has approved a phase 1/2a study evaluating the use of umbilical cord mesenchymal stem cells for the treatment of patients with severe cases of coronavirus disease 2019 (COVID-19).

The multicenter, randomized, blinded, placebo-controlled SUCCESS (Systemic Umbilical Cord Cells to Ease Severe Syndrome) study will assess the efficacy and safety of umbilical cord mesenchymal stem cells provided by RESTEM, a cell-based therapeutics company, in hospitalized patients with severe COVID-19 (N=60). RESTEMs cells are grown from umbilical cord tissue through a proprietary process that rapidly replicates millions of doses.

The SUCCESS study will identify COVID-19 patients with acute respiratory distress syndrome (ARDS) who would best benefit from the therapy. Patient enrollment is expected to begin this week from Baptist Health South Florida and Sanford Health.

We are excited to launch this study and demonstrate the potential of our patented umbilical cord lining stem cell (ULSC) technology, said Dr. Rafael Gonzalez, senior vice president of research & development for RESTEM. Based on the properties of our cells and targeted treatments, our breakthrough technology has shown promise to help those suffering from COVID-19 complications.

Use of the novel therapy for COVID-19 was based on promising results in patients previously treated at the Miami Cancer Institute under the FDAs Emergency Use Authorization. Treatment with umbilical cord mesenchymal stem cells was associated with a reduction in both oxygen requirements and circulating inflammatory markers in 3 critically ill COVID-19 patients.

For more information visit sanfordhealth.org or baptisthealth.net.

This article originally appeared on MPR

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Umbilical Cord Stem Cell Therapy to Be Assessed in Severe COVID-19 - Pulmonology Advisor

Cells for Cells and Austrianova announce publication on novel method to produce stem cell exosomes – BioSpace

21 May 2020 - Austrianova and Cells for Cells have just jointly published a ground breaking, peer reviewed, scientific publication on a novel, cost and time-saving method to generate extra-cellular vesicles (EVs) from encapsulated Mesenchymal Stem Cells (MSCs). These EVs are known to mediate many of the therapeutic effects of stem cells. The authors show that Austrianovas proprietary Cell-in-a-Box encapsulation technology can be used to produce and deliver EVs from encapsulated MSCs, as demonstrated using Cells for Cells proprietary MSCs. The publication, which was co-authored with their academic partners, the University of the Andes, Chile and the University of Veterinary Medicine Vienna, Austria appeared in prestigious international journal Frontiers in Pharmacology (Front. Pharmacol., 21 May 2020 | https://doi.org/10.3389/fphar.2020.00679 https://www.frontiersin.org/articles/10.3389/fphar.2020.00679/full)

Currently, EVs have to be purified from cell culture conditioned media using tedious, costly and time-consuming protocols that are difficult to perform under Good Manufacturing Practices (GMP) conditions. The Cell-in-a-Box encapsulation technology allows efficient enrichment of EVs at high concentration since they are released from the encapsulated cells via the semipermeable pores, which selectively enable the release of small particles but not of the MSCs. Moreover, Cell-in-a-Box provides 3D culture conditions for the MSCs. The technology can be used in cell culture allowing GMP production. Alternatively, the encapsulated cells can be implanted into patients as a retrievable delivery device that shields the cells from clearance, whilst they continuously produce EVs, growth factors, hormones and other small therapeutically relevant molecules. Moreover, the EVs produced after encapsulation can themselves be used as drug-loaded delivery vehicles. This technology will be invaluable for the treatment of regenerative diseases and Inflammatory disease.

Maroun Khoury, CSO of Cells for Cells said this is a multifaceted project bringing together different expertise to support the burgeoning field of EV-based therapies. It will be interesting to test in the near future, the continuous release of EVs in a in vivo context. At a personal level, it was a great way to stay connected with colleagues that I met while living in Singapore .

Brian Salmons, CEO of Austrianova said we are pleased that these results representing the culmination of a long term project with our colleagues at Cells for Cells are finally publicly available. The encapsulation of stem cells as a means to produce exosomes using our Cellin-a-Box is an exciting technological breakthrough that is applicable for all stem cell types.

About Austrianova

Austrianova, part of the SG Austria Group, is a biotech company with a global footprint and headquarters in Singapore. Austrianova utilizes a novel and proprietary technology for the encapsulation of living mammalian (Cell-in-a-Box) and bacterial (Bac-in-a-Box) cells. Cellin-a-Box protects the encapsulated cells from rejection by the immune system, allows cells to be easily transported, stored and implanted at specific sites in patients. The technology, which has been proven safe and efficacious in clinical trials carried out in Europe, allows companies to develop any kind of cells as a one-for-all living pharmaceutical. Bac-in-a-Box is a similar protective device adapted for encapsulation of probiotic bacteria where it has human food and animal feed applications due to its ability to extend storage under lyophilized conditions and to protect encapsulated bacteria against destruction by stomach acid. Austrianova now also offers GMP4Cells that includes competitively priced Master Cell Bank and Working Cell Bank production as well as Fill and Finish services for cell therapy products (such as stem cell therapies, biologics produced from cells e.g. vaccines, antibodies, recombinant proteins etc).

About Cells for Cells

Cells for Cells is a Chilean biotechnological company dedicated to the research, development and commercialization of innovative cellular therapies, complying with high standards of scientific, technological and international quality, through manufacturing processes certified under ISO 9001: 2015. Each therapy is produced in our labs with GMP standards, being the first biotech company, with such high-quality standards at Latin American level. Our therapies are applied by duly certified specialists.

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World coronavirus Dispatch: Animal Stem Cell Therapy Market Size, Share, Statistics, Demand and Revenue; Forecast To 2025 – 3rd Watch News

Global Animal Stem Cell Therapy Market Growth Projection

The new report on the global Animal Stem Cell Therapy market is an extensive study on the overall prospects of the Animal Stem Cell Therapy market over the assessment period. Further, the report provides a thorough understanding of the key dynamics of the Animal Stem Cell Therapy market including the current trends, opportunities, drivers, and restraints. The report introspects the micro and macro-economic factors that are expected to nurture the growth of the Animal Stem Cell Therapy market in the upcoming years and the impact of the COVID-19 pandemic on the Animal Stem Cell Therapy . In addition, the report offers valuable insights pertaining to the supply chain challenges market players are likely to face in the upcoming months and solutions to tackle the same.

The report suggests that the global Animal Stem Cell Therapy market is projected to reach a value of ~US$XX by the end of 2029 and grow at a CAGR of ~XX% through the forecast period (2019-2029). The key indicators such as the year-on-year (Y-o-Y) growth and CAGR growth of the Animal Stem Cell Therapy market are discussed in detail in the presented report. This data is likely to provide readers an understanding of qualitative and quantitative growth prospects of the Animal Stem Cell Therapy market over the considered assessment period.

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Segment by Type, the Animal Stem Cell Therapy market is segmented intoDogsHorsesOthers

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Vital Information Enclosed in the Report

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World coronavirus Dispatch: Animal Stem Cell Therapy Market Size, Share, Statistics, Demand and Revenue; Forecast To 2025 - 3rd Watch News

The Economic Impact of Coronavirus on Platelet Rich Plasma and Stem Cell Alopecia Treatment Market : In-depth study on Industry Size and Analysis on…

Global Platelet Rich Plasma and Stem Cell Alopecia Treatment Market Growth Projection

The new report on the global Platelet Rich Plasma and Stem Cell Alopecia Treatment market is an extensive study on the overall prospects of the Platelet Rich Plasma and Stem Cell Alopecia Treatment market over the assessment period. Further, the report provides a thorough understanding of the key dynamics of the Platelet Rich Plasma and Stem Cell Alopecia Treatment market including the current trends, opportunities, drivers, and restraints. The report introspects the micro and macro-economic factors that are expected to nurture the growth of the Platelet Rich Plasma and Stem Cell Alopecia Treatment market in the upcoming years and the impact of the COVID-19 pandemic on the Platelet Rich Plasma and Stem Cell Alopecia Treatment . In addition, the report offers valuable insights pertaining to the supply chain challenges market players are likely to face in the upcoming months and solutions to tackle the same.

The report suggests that the global Platelet Rich Plasma and Stem Cell Alopecia Treatment market is projected to reach a value of ~US$XX by the end of 2029 and grow at a CAGR of ~XX% through the forecast period (2019-2029). The key indicators such as the year-on-year (Y-o-Y) growth and CAGR growth of the Platelet Rich Plasma and Stem Cell Alopecia Treatment market are discussed in detail in the presented report. This data is likely to provide readers an understanding of qualitative and quantitative growth prospects of the Platelet Rich Plasma and Stem Cell Alopecia Treatment market over the considered assessment period.

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Segmentation of the Platelet Rich Plasma and Stem Cell Alopecia Treatment Market

Market: Drivers and RestrainsThe research report has incorporated the analysis of different factors that augment the markets growth. It constitutes trends, restraints, and drivers that transform the market in either a positive or negative manner. This section also provides the scope of different segments and applications that can potentially influence the market in the future. The detailed information is based on current trends and historic milestones. This section also provides an analysis of the volume of sales about the global market and also about each type from 2015 to 2026. This section mentions the volume of sales by region from 2015 to 2026. Pricing analysis is included in the report according to each type from the year 2015 to 2026, manufacturer from 2015 to 2020, region from 2015 to 2020, and global price from 2015 to 2026.A thorough evaluation of the restrains included in the report portrays the contrast to drivers and gives room for strategic planning. Factors that overshadow the market growth are pivotal as they can be understood to devise different bends for getting hold of the lucrative opportunities that are present in the ever-growing market. Additionally, insights into market experts opinions have been taken to understand the market better.Global Platelet Rich Plasma and Stem Cell Alopecia Treatment Market: Segment Analysis The research report includes specific segments such as application and product type. Each type provides information about the sales during the forecast period of 2015 to 2026. The application segment also provides revenue by volume and sales during the forecast period of 2015 to 2026. Understanding the segments helps in identifying the importance of different factors that aid the market growth.Global Platelet Rich Plasma and Stem Cell Alopecia Treatment Market: Regional AnalysisThe research report includes a detailed study of regions of North America, Europe, Asia Pacific, Latin America, and Middle East and Africa. The report has been curated after observing and studying various factors that determine regional growth such as economic, environmental, social, technological, and political status of the particular region. Analysts have studied the data of revenue, sales, and manufacturers of each region. This section analyses region-wise revenue and volume for the forecast period of 2015 to 2026. These analyses will help the reader to understand the potential worth of investment in a particular region.Global Platelet Rich Plasma and Stem Cell Alopecia Treatment Market: Competitive LandscapeThis section of the report identifies various key manufacturers of the market. It helps the reader understand the strategies and collaborations that players are focusing on combat competition in the market. The comprehensive report provides a significant microscopic look at the market. The reader can identify the footprints of the manufacturers by knowing about the global revenue of manufacturers, the global price of manufacturers, and sales by manufacturers during the forecast period of 2015 to 2019.Following are the segments covered by the report are:Androgenic AlopeciaCongenital AlopeciaCicatricial Or Scarring AlopeciaBy Application:HospitalDermatology ClinicOtherKey Players:The Key manufacturers that are operating in the global Platelet Rich Plasma and Stem Cell Alopecia Treatment market are:KerastemEclipseRegen Lab SAStemcell TechnologiesRepliCel Life SciencesHistogenGlofinn Oy.Competitive LandscapeThe analysts have provided a comprehensive analysis of the competitive landscape of the global Platelet Rich Plasma and Stem Cell Alopecia Treatment market with the company market structure and market share analysis of the top players. The innovative trends and developments, mergers and acquisitions, product portfolio, and new product innovation to provide a dashboard view of the market, ultimately providing the readers accurate measure of the current market developments, business strategies, and key financials.

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The Economic Impact of Coronavirus on Platelet Rich Plasma and Stem Cell Alopecia Treatment Market : In-depth study on Industry Size and Analysis on...

World coronavirus Dispatch: Rheumatoid Arthritis Stem Cell Therapy market to witness robust revenue growth between 2018 to 2028 – Cole of Duty

The global Rheumatoid Arthritis Stem Cell Therapy market is experiencing a slowdown in trade practices amidst the growing COVID-19 (Coronavirus) pandemic. This is why, companies in the Rheumatoid Arthritis Stem Cell Therapy market are vying opportunities that serve as alternative solutions to positively capitalize on the ongoing lockdown period. This and more strategic implications enclosed in our comprehensive report on the Rheumatoid Arthritis Stem Cell Therapy market that will help you take market lead.

Assessment of the Global Rheumatoid Arthritis Stem Cell Therapy Market

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World coronavirus Dispatch: Rheumatoid Arthritis Stem Cell Therapy market to witness robust revenue growth between 2018 to 2028 - Cole of Duty

Blocking the deadly cytokine storm is a vital weapon for treating COVID-19 – TheStreet

Courtesy of Alexander (Sasha) Poltorak, Tufts University

The killer is not the virus but the immune response.

The current pandemic is unique not just because it is caused by a new virus that puts everyone at risk, but also because the range of innate immune responses is diverse and unpredictable. In some it is strong enough to kill. In others it is relatively mild.

My research relates to innate immunity. Innate immunity is a persons inborn defense against pathogens that instruct the bodys adaptive immune system to produce antibodies against viruses. Those antibody responses can be later used for developing vaccination approaches. Working in the lab of Nobel laureate Bruce Beutler, I co-authored the paper that explained how the cells that make up the bodys innate immune system recognize pathogens, and how overreacting to them in general could be detrimental to the host. This is especially true in the COVID-19 patients who are overreacting to the virus.

I study inflammatory response and cell death, which are two principal components of the innate response. White blood cells called macrophages use a set of sensors to recognize the pathogen and produce proteins called cytokines, which trigger inflammation and recruit other cells of the innate immune system for help. In addition, macrophages instruct the adaptive immune system to learn about the pathogen and ultimately produce antibodies.

To survive within the host, successful pathogens silence the inflammatory response. They do this by blocking the ability of macrophages to release cytokines and alert the rest of the immune system. To counteract the viruss silencing, infected cells commit suicide, or cell death. Although detrimental at the cellular level, cell death is beneficial at the level of the organism because it stops proliferation of the pathogen.

For example, the pathogen that caused the bubonic plague, which killed half of the human population in Europe between 1347 and 1351, was able to disable, or silence, peoples white blood cells and proliferate in them, ultimately causing the death of the individual. However, in rodents the infection played out differently. Just the infected macrophages of rodents died, thus limiting proliferation of the pathogen in the rodents bodies which enabled them to survive.

The silent response to plague is strikingly different from the violent response to SARS-CoV-2, the virus that causes COVID-19. This suggests that keeping the right balance of innate response is crucial for the survival of COVID-19 patients.

Heres how an overreaction from the immune system can endanger a person fighting off an infection.

Some of the proteins that trigger inflammation, named chemokines, alert other immune cells like neutrophils, which are professional microbe eaters to convene at the site of infections where they can arrive first and digest the pathogen.

Others cytokines such as interleukin 1b, interleukin 6 and tumor necrosis factor guide neutrophils from the blood vessels to the infected tissue. These cytokines can increase heartbeat, elevate body temperature, trigger blood clots that trap the pathogen and stimulate the neurons in the brain to modulate body temperature, fever, weight loss and other physiological responses that have evolved to kill the virus.

When the production of these same cytokines is uncontrolled, immunologists describe the situation as a cytokine storm. During a cytokine storm, the blood vessels widen further (vasolidation), leading to low blood pressure and widespread blood vessel injury. The storm triggers a flood of white blood cells to enter the lungs, which in turn summon more immune cells that target and kill virus-infected cells. The result of this battle is a stew of fluid and dead cells, and subsequent organ failure.

The cytokine storm is a centerpiece of the COVID-19 pathology with devastating consequences for the host.

When the cells fail to terminate the inflammatory response, production of the cytokines make macrophages hyperactive. The hyperactivated macrophages destroy the stem cells in the bone marrow, which leads to anemia. Heightened interleukin 1b results in fever and organ failure. The excessive tumor necrosis factor causes massive death of the cells lining the blood vessels, which become clotted. At some point, the storm becomes unstoppable and irreversible.

One strategy behind the treatments for COVID is, in part, based in part on breaking the vicious cycle of the cytokine storm. This can be done by using antibodies to block the primary mediators of the storm, like IL6, or its receptor, which is present on all cells of the body.

Inhibition of tumor necrosis factor can be achieved with FDA-approved antibody drugs like Remicade or Humira or with a soluble receptor such as Enbrel (originally developed by Bruce Beutler) which binds to tumor necrosis factor and prevents it from triggering inflammation. The global market for tumor necrosis factor inhibitors is US$22 billion.

Drugs that block various cytokines are now in clinical trials to test whether they are effective for stopping the deadly spiral in COVID-19.

[Get facts about coronavirus and the latest research. Sign up for The Conversations newsletter.]

Alexander (Sasha) Poltorak, Professor of Immunology, Tufts University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

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Blocking the deadly cytokine storm is a vital weapon for treating COVID-19 - TheStreet

Animal Stem Cell Therapy Market: Overview, Opportunities, Analysis of Features, Benefits, Manufacturing Cost and Forecast To 2025 – Cole of Duty

The Global Animal Stem Cell Therapy Market report provides information by Key Players, Geography, End users, Applications, Competitor analysis, Sales, Revenue, Price, Gross Margin, Market Share, Import-Export, Trends and Forecast.

Initially, the report provides a basic overview of the industry including definitions, classifications, applications and industry chain structure. The Animal Stem Cell Therapy market analysis is provided for the international markets including development trends, competitive landscape analysis, and key regions development status.

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Global Animal Stem Cell Therapy market competition by top manufacturers, with production, price, revenue (value) and market share for each manufacturer.

The Top players are MediVet Biologic, VETSTEM BIOPHARMA, J-ARM, Celavet, Magellan Stem Cells, U.S. Stem Cell, Cells Power Japan, ANIMAL CELL THERAPIES, Animal Care Stem, Cell Therapy Sciences, VetCell Therapeutics, Animacel, Aratana Therapeutics,.

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The report introduces Animal Stem Cell Therapy basic information including definition, classification, application, industry chain structure, industry overview, policy analysis, and news analysis. Insightful predictions for the Animal Stem Cell Therapy market for the coming few years have also been included in the report.

Development policies and plans are discussed as well as manufacturing processes and cost structures are also analyzed. This report also states import/export consumption, supply and demand Figures, cost, price, revenue and gross margins.

The report focuses on global major leading Animal Stem Cell Therapy Market players providing information such as company profiles, product picture and specification, capacity, production, price, cost, revenue and contact information. Upstream raw materials and equipment and downstream demand analysis is also carried out.

The Animal Stem Cell Therapy industry development trends and marketing channels are analyzed. Finally the feasibility of new investment projects are assessed and overall research conclusions offered.

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Table of Contents

1 Animal Stem Cell Therapy Market Overview

2 Global Animal Stem Cell Therapy Market Competition by Manufacturers

3 Global Animal Stem Cell Therapy Capacity, Production, Revenue (Value) by Region)

4 Global Animal Stem Cell Therapy Supply (Production), Consumption, Export, Import by Region

5 Global Animal Stem Cell Therapy Production, Revenue (Value), Price Trend by Type

6 Global Animal Stem Cell Therapy Market Analysis by Application

7 Global Animal Stem Cell Therapy Manufacturers Profiles/Analysis

8 Animal Stem Cell Therapy Manufacturing Cost Analysis

9 Industrial Chain, Sourcing Strategy and Downstream Buyers

10 Marketing Strategy Analysis, Distributors/Traders

11 Market Effect Factors Analysis

12 Global Animal Stem Cell Therapy Market Forecast

13 Research Findings and Conclusion

14 Appendix

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Animal Stem Cell Therapy Market: Overview, Opportunities, Analysis of Features, Benefits, Manufacturing Cost and Forecast To 2025 - Cole of Duty

In situ repair abilities of human umbilical cordderived mesenchymal stem cells and autocrosslinked hyaluronic acid gel complex in rhesus monkeys with…

Abstract

Increasing occurrence of moderate to severe intrauterine adhesion (IUA) is seriously affecting the quality of human life. The aim of the study was to establish IUA models in nonhuman primates and to explore the dual repair effects of human umbilical cordderived mesenchymal stem cells (huMSCs) loaded on autocrosslinked hyaluronic acid gel (HA-GEL) on endometrial damage and adhesion. Here, we recorded the menstrual cycle data in detail with uterine cavities observed and endometrial tissues detected after intervention, and the thicker endometria, decreased amount of fibrotic formation, increased number of endometrium glands, etc., suggested that both HA-GEL and huMSC/HA-GEL complexes could partially repair IUA caused by mechanical injury, but huMSC/HA-GEL complex transplantation had notable dual repair effects: a reliable antiadhesion property and the promotion of endometrial regeneration.

Intrauterine adhesion (IUA), known as Asherman syndrome, is described as the partial or complete binding of the uterine cavity due to the buildup of scar tissue formation in the upper functional layer, resulting from endometrial damage to the lower basal layer (1). Repeated intrauterine operations, such as dilatation and curettage (D&C) and hysteroscopy, are the main cause of the common prevalence of IUA, with approximately 45% of moderate-to-severe cases occurring in these circumstances (2). Severe endometrium dysfunction will cause women within reproductive age to have this reproductive disadvantage, which was once considered a terminal disease that caused infertility (3, 4).

Therefore, the vital aim for IUA treatment is to re-establish the uterine cavity and restore endometrial function. The current and standard operation method for IUA is hysteroscopic transcervical resection of adhesion (TCRA), while the preferred alternative involves the combined application of various adjuvant therapies, including physical barriers (contraceptive device, intrauterine balloon device, Foley balloon, etc.) for postoperative adhesion and estrogen therapy and amnion graft for endometrial regeneration (58). Although there is a certain therapeutic efficacy of these antiadhesion strategies, there are some disadvantages and shortcomings to the strategies that cannot be ignored, such as resistance to secondary surgery, limited area of isolation, induction of intrauterine inflammatory response, and difficulty in endometrial regeneration (9). Further, the high recurrence rate of postoperative adhesion and the low clinical pregnancy rate are still a focus and are universally recognized as a problem for patients with severe IUAs (4, 10).

Autocrosslinked hyaluronic acid gel (HA-GEL), another promising physical barrier with natural mix of extracellular matrix and synovial fluid, has been approved by China Food & Drug Administration (CFDA) as a medical device for clinical practice after hysteroscopic adhesiolysis to achieve improvement in histocompatibility and viscosity, and the American Association of Gynecologic Laparoscopists has reported the effectiveness of HA-GEL in the prevention of IUAs in 2017 (11). The application of HA-GEL in uterine cavity treatment has its own advantages of few degradations by product retention following the outflow of menstrual blood (11, 12). Compared to the previously used biomaterials, HA-GEL has a prolonged absorption time (as long as 7 to 14 days), the expansion characteristics of which can continuously isolate the postoperative uterine cavity to resist adhesion recurrence, and its other material properties can regulate the inflammatory response and repair endometrial injuries. Related experimental and clinical studies have suggested that HA-GEL is effective in the prevention of postoperative adhesion, and when combined application with a TCRA operation, it showed increases (~58.5%) in the effective rate of postoperative antiadhesion and decreases (~66.1%) in the postoperative recurrence rate (13). However, for severe IUA with a seriously injured basal layer and a loss of functional endometrium, endometrial regeneration remains an enormous challenge owing to the limited efficacy of current interventions.

Recently, stem cellbased therapy has emerged as a promising and exciting method of tissue regeneration (1416). Human umbilical cordderived mesenchymal stem cells (huMSCs) originate from the embryonic mesoderm and have the potential for multipotent differentiation; they have been regarded as a promising and extensive source for cell-based therapies due to their easy collection from discarded umbilical cords and their low immunogenicity. Some studies have shown the potential of huMSCs to repair damaged tissue (1720), and the feasibility of stem cells in restoring the endometrial structure and function has also been verified by additional clinical and experimental studies (2124). In this study, we used rhesus monkeys to construct a previously unidentified animal model of IUA and aimed to develop a complex of huMSCs loaded on HA-GEL to increase the local perseverance and activity of the stem cells and to improve the poor prognosis with the following dual functions: preventing postoperative adhesion with biomaterials and repairing the full layer of uterine wall. We also aimed to analyze the related repair or endometrial injuries, to study the motivation behind endometrial regeneration, and to explore the underlying mechanisms.

huMSCs [passage 3 (P3) to P9] had an appearance that was similar to typical spindle-shaped fibroblast-like cells, and they were arranged closely with vortex-like growth (fig. S1A1). The positive cells that were expanded in the enriching culture were successfully induced to become osteoblasts with bone matrix formation and adipocytes with lipid droplet formation (fig. S1A2 and A3). In addition, fluorescence-activated cell sorting (FACS) showed that the targeted cells expressed CD44 (99.40%), CD73 (99.56%), CD90 (99.92%), and CD105 (99.80%), but not CD34, CD45, and HLA-DR (<1%; fig. S1B).

To further evaluate the safety of huMSCs on HA-GEL, FACS results preliminarily verified that there was a low parentage of apoptotic cells in the coculture group (huMSCs/HA-GEL), and there was no notable difference between the coculture group and the culture-separated group (huMSCs) (fig. S2, A to C). In addition, the live-dead cell staining result we obtained before was added, and the result showed a small number of dead cells in both the huMSCs/HA-GEL and huMSCs groups, without significant difference compared with that in the culture-separated group (huMSCs) (fig. S2, D and E).

Two months after endometrial intervention by uterine D&C, all six monkeys stopped menstruating; smaller uterine cavities and pale and uneven endometrial surfaces were observed, which had an adhesive zone full of endometrial cavity fluid. Thinner endometrial tissue was detected and observed under Doppler ultrasound scanning with discontinuous endometria and strong echo (Fig. 1A), and the endometrial thickness (1.9833 0.4298 mm) after mechanical injury showed significant differences when compared with the thickness (4.0333 0.5185 mm) before intervention (P < 0.01, n = 6; Fig. 1B and table S1). Changes in the structure of the endometrial tissues were assessed by hematoxylin and eosin (H&E) staining. Two months after mechanical injury, the endometrium was disorganized and had few or no glands (Fig. 1C). Endometrial gland numbers decreased markedly compared with those of the premechanical injury (0.6839 0.8608 versus 6.8576 2.6901 per unit area, respectively) (P < 0.001, n = 6; Fig. 1D and table S1). Similarly, to further evaluate the degree of fibrosis, Masson staining was performed at 2 months after mechanical injury (Fig. 1E). Increased fibrotic area ratios were detected and were analyzed quantitatively; more collagen deposition was observed at 2 months after mechanical injury compared with that of the premechanical injury (0.6557 0.6359% versus 0.0716 0.0942%) (P < 0.05, n = 6; Fig. 1F and table S1).

(A) Detection of Doppler ultrasound. A1: Representative image of endometrial thickness for pre-D&C; A2: Representative image of endometrial thickness at 2 months post-D&C (red arrow, the endometrium echo; blue area, the largest cross section of endometrium). (B) Comparisons of endometrial thickness for pre- or post-D&C. (C) H&E staining of endometria for pre-D&C (C1, C3, and C5) and post-D&C (C2, C4, and C6); 10401, 10403, and 10406, respectively; see table S3 for details. Inserted overview pictures are of lower magnification; black squares are highly magnified regions. (D) Masson staining of endometria for pre-D&C (D1, D3, and D5) and post-D&C (D2, D4, and D6); 10401, 10403, and 10406, respectively; see table S3 for details. Inserted overview pictures are of lower magnification; black squares are highly magnified regions. (E) Comparisons of endometrial gland numbers per unit area for pre- or post-D&C. (F) Comparisons of fibrotic area ratios for pre- or post-D&C. *P < 0.05, **P < 0.01, and ***P < 0.001 versus the pre-D&C group, and the results shown are the mean SEM of three technical replicates from each animal.

Two months after the huMSCs/HA-GEL complex was transplanted into the uterine cavity, menstruation resumed cycling in all monkeys, and there were significantly more endometrial gland numbers (4.9662 1.4935, per unit area) than there were (3.6320 1.0060, per unit area) after HA-GEL transplantation alone (P < 0.01; Fig. 2, A and B, and table S2). Moreover, the huMSCs/HA-GEL transplantation group showed marked decreases in fibrotic areas (5.5955 3.6572%) compared with that of the HA-GEL transplantation group (14.2131 13.7193%) (P < 0.01; Fig. 2, C and D, and table S2).

(A) Endometrial H&E staining at 2 months after HA-GEL transplantation (A1, A3, and A4 correspond to 10401, 10403, and 10404, respectively) and huMSCs/HA-GEL transplantation (A2, A5, and A6 correspond to 10402, 10405, and 10406, respectively); 10401 to 10406, see table S3 for details. (B) Endometrial Masson staining at 2 months after HA-GEL transplantation (B1, B3, and B4 correspond to 10401, 10403, and 10404, respectively) and huMSCs/HA-GEL transplantation (B2, B5, and B6 correspond to 10402, 10405, and 10406, respectively); 10401 to 10406, see table S3 for details. (C) Comparisons of endometrial gland numbers per unit area between the HA-GEL transplantation group and the huMSC/HA-GEL transplantation group. (D) Comparisons of fibrotic area ratios between the HA-GEL transplantation group and the huMSCs/HA-GEL transplantation group. ##P < 0.01 versus HA-GEL transplantation group, and the results shown are the mean SEM of three technical replicates from each animal.

Abdominal surgeries were carried out, and three normal uterine cavities were exposed and revealed a thicker endometrium without an adhesive zone and endometrial cavity fluid in the huMSCs/HA-GEL transplantation group, whereas three uterine cavities in the HA-GEL transplantation group were still found to be abnormal with a mild to moderate amount of adhesion and a thinner rough endometrium (Fig. 3A). In addition, the smooth and thicker endometrial tissue with a third-line echo was also revealed and verified by ultrasound examination in the huMSCs/HA-GEL transplantation group (Fig. 3B), and the endometrial thickness (4.2667 0.5558 mm) was significantly different compared with that (1.0667 0.6650 mm) in the HA-GEL transplantation group (P < 0.01; Fig. 3C and table S2). Furthermore, the ultrastructure of the endometrium in the huMSCs/HA-GEL transplantation group showed short and sparse microvilli on the surface of epithelial cells, mucinous secretions in the glandular cavity with orderly arranged cells, tight intercellular junctions, and obvious edema of stroma, but the endometrial ends were uneven and the cellular edges had a frayed morphology. Further, loose connections between cells were observed in the HA-GEL transplantation group (Fig. 3D).

(A) Representative images of uterine cavities in the HA-GEL transplantation and huMSCs/HA-GEL transplantation groups (the dotted area and the red arrow mark the endometrial area). (B) Representative images of endometrial thickness for ultrasound detection in the HA-GEL transplantation and huMSCs/HA-GEL transplantation groups (the red arrow marks the endometrial echo; the blue area marks the largest cross section of the endometrium). (C) Comparisons of endometrial thickness between the HA-GEL transplantation group and the huMSCs/HA-GEL transplantation group. (D) Representative images of ultrastructural changes in the HA-GEL transplantation and huMSCs/HA-GEL transplantation groups (the left panel shows the surface of epithelial cells; the right panel shows the intercellular changes). ##P < 0.01 versus 2 months postHA-GEL, and the results shown are the mean SEM of three technical replicates from each animal. Photos provided by Lingjuan Wang and Chengliang Xiong (Institute of Reproductive Health, Center of Reproductive Medicine, Tongji Medical College, Huazhong University of Science and Technology).

By systematic and comprehensive comparison of endometrial tissues before surgery, increased gland numbers were found both in the HA-GEL transplantation group (3.63 1.01 versus 0.68 0.86, respectively, per unit area; P < 0.001) and in the huMSCs/HA-GEL transplantation group (4.97 1.49 versus 0.68 0.86, respectively, per unit area; P < 0.001). The gland numbers were approaching normal levels (6.86 2.69, per unit area; pre-D&C) 2 months after huMSCs/HA-GEL transplantation (Fig. 4A and table S3). Conversely, the Masson staining showed an increasing degree of fibrotic aggravation 2 months after HA-GEL transplantation (14.21 13.72% versus 0.66 0.64%; P < 0.05), but there was only a slight increase in fibrosis and some relief of aggravation after transplantation of the huMSCs/HA-GEL complex (5.60 3.66 versus 0.66 0.64; P < 0.01) (Fig. 4B and table S3). There was no significant difference in endometrial thickness or after mechanical injury (1.07 0.67 versus 1.98 0.41 mm) 2 months after HA-GEL transplantation compared with that of the HA-GEL transplantation, while the endometrial thickness was notably increased after transplantation of the huMSCs/HA-GEL complex (4.27 0.56 versus 1.98 0.41 mm; P < 0.01) that was similar to the normal levels observed before mechanical injury of the endometria (4.03 0.52 mm; pre-D&C) (Fig. 4C and table S3).

(A) Comparisons of endometrial gland numbers per unit area. (B) Comparisons of ratios of fibrotic area (%). (C) Comparisons of endometrial thickness (mm). *P < 0.05, **P < 0.01, and ***P < 0.001, all versus pre-D&C; ###P < 0.001 versus pre-D&C; #P < 0.05, ##P < 0.01, and ###P < 0.001, all versus 2 months post-D&C; ##P < 0.01 versus 2 months postHA-GEL, and the results shown are the mean SEM of three technical replicates from each animal.

The probe Vysis SRY Probe LSI SRY Spectrum Orange/Vysis CEP X Spectrum Green was used to mark huMSCs by a fluorescence in situ hybridization (FISH) technique. However, it was unclear if there was homology of probe sequences for the Yp11.3 region [sex-determining region Y (SRY), associated probe sequence] and DXZ1 (Xp11.1-Xq11.1) (CEP X, associated probe sequence) between human and rhesus monkeys. By directly extracting DNA from huMSCs (containing XY chromosome) and the spleens of rhesus monkeys, it was verified that the two probe sequences did not share homology between human and rhesus monkey (fig. S3). Then, human endometrial tissue was obtained as a positive control group (Fig. 5A), and one of the three endometria in the HA-GEL transplantation group was randomly selected as a negative control (Fig. 5B). FISH detection showed the absence of a positive signal (green/orange double signal or green signal) in the endometria 2 months after huMSCs/HA-GEL transplantation (Fig. 5, C to E), suggesting that huMSCs failed to locate to the endometrium after transplantation into the uterine cavity.

(A) Positive control, human endometrium (containing XX chromosomes); the red arrow indicates the green signal for Vysis CEP X (DXZ1). (B) Endometrial localization of huMSCs in the HA-GEL transplantation group (negative control). (C to E) Distribution of huMSCs in endometria 2 months after huMSCs/HA-GEL co-transplantation. Double/single-labeled staining (orange/green signal or just green signal) cells were defined as huMSCs. For details on 10402, 10405, and 10406, see table S3. Inserted overview pictures show a lower magnification.

Furthermore, potential cytokines secreted by huMSCs were further detected in the endometria by immunofluorescence staining, and as expected, increased positive expression was found in the endometria of the huMSCs/HA-GEL transplantation group; there were significant differences in insulin-like growth factor (IGF-1), epidermal growth factor (EGF), and brain-derived neurotrophic factor (BDNF) between the two transplanted groups (P < 0.05), but there were no significant differences in vascular endothelial growth factor (VEGF) and hepatocyte growth factor (HGF) (Fig. 6, A and B). In addition, when compared with the HA-GEL transplantation group, the expression levels of proinflammatory cytokines [interferon- (IFN-)] were significantly decreased in the huMSCs/HA-GEL transplantation group (P < 0.01, Fig. 6C1), and significantly up-regulated expression was found for the anti-inflammatory cytokine [interleukin 4 (IL-4)] (P < 0.01, Fig. 6C2), as well as related cytokines that promote cell proliferation and tissue repair (IGF-1 and EGF) (P < 0.001, P < 0.05, respectively; Fig. 6, C3 and C4).

(A) The expression and localization of the potential cytokines secreted by huMSCs in the HA-GEL transplantation group and the huMSCs/HA-GEL transplantation group; inserted overview pictures show a lower magnification. (B) The optical density (OD) value of IGF-1, EGF, BDNF, VEGF, and HGF 2 months after HA-GEL transplantation or huMSCs/HA-GEL co-transplantation. (C1) Comparison of IFN- mRNA expression between the HA-GEL transplantation group and the huMSC/HA-GEL transplantation group. (C2) Comparison of IL-4 mRNA expression between the HA-GEL transplantation group and the huMSC/HA-GEL transplantation group. (C3) Comparison of IGF-1 mRNA expression between the HA-GEL transplantation group and the huMSC/HA-GEL transplantation group. (C4) Comparison of EGF mRNA expression between the HA-GEL transplantation group and the huMSC/HA-GEL transplantation group. *P < 0.05, **P < 0.01, and ***P < 0.001 versus 2 months postHA-GEL; the results shown are the mean SEM of three technical replicates from each animal.

At present, according to relevant reports, approximately 2.8 to 45.5% of women with impaired fertility suffer from IUA, and more than 90% of cases occur after pregnancy-related D&C (25). In this study, an IUA model was successfully established with an invasive surgery in nonhuman primates (rhesus monkeys), which have a genetic background, endocrine system, menstrual cycle, and anatomical structure that are similar to humans (26). This model allowed us to further explore new approaches for the intervention and treatment of adhesion, especially the thin endometrium caused by endometrial injury.

In the primate experiments, 6- to 7-year-old rhesus monkeys (reproductive age) were identified as the ideal subjects for establishing IUA models; they had regular menstrual cycles of approximately 21 to 30 days, which was observed and recorded in succession for the 2 months before mechanical injury. We developed the first model of endometrial injury in rhesus monkeys by open abdominal surgery; we verified the successful establishment by visualizing the hard and narrow cervix and confirmed that D&C could ultimately lead to severe IUA, which was characterized by severe endometrial fibrosis, loss of normal endometrial glands, paper-thin and discontinuous endometria, full of adhesive zone and endometrial cavity fluid, as well as amenorrhea, as noted by the American Fertility Society scoring method (27).

This study explored the effect of transplantation huMSCs combined with HA-GEL on intrauterine reconstruction and endometrial regeneration in an IUA model. In our study, when compared with the control group (transplantation of only HA-GEL), the effects of the group with huMSCs were confirmed by Doppler ultrasonic scanning, histological inspection, and ultrastructure detection 2 months after transplantation. In the experimental group, the injured endometrial tissue presented with a thicker endometrium, an increased number of endometrial glands, a decreased fibrotic area, and typical changes in the secretory phase, showing how the positive huMSCs acted upon endometrial repair and regeneration through secreting cytokines and growth factors (16); further, the HA-GEL acted as a physical barrier to severe adhesion and provided an ideal physical support for the attachment of huMSCs to prevent their rapid outflow from uterine cavity.

Specifically, in the control group (HA-GEL transplanted alone), subjects did not recover menstruation and normal uterine cavity. However, recovery of menstruation, the appearance of a normal uterine cavity, and normal cycling were observed in the other three rhesus monkeys 2 months after huMSCs/HA-GEL co-transplantation, suggesting the great effect of the huMSCs/HA-GEL complex on the reconstruction of the uterine cavity and on the blocking of adhesion. Meanwhile, we also found that HA-GEL transplantation could increase the number of endometrial glands, but it played no effective role in endometrial thickness, which was important because it was less effective than the huMSCs/HA-GEL complex. This amelioration of the damage to the endometria resulted in nearly normal levels and suggested the re-emergence of endometrial repair and regeneration after huMSCs/HA-GEL co-transplantation. In addition, the degree of fibrosis in the damaged endometria was found to be increasingly worse 2 months after transplantation despite HA-GEL or huMSCs/HA-GEL intervention, and it remained unclear whether HA-GEL had an effect on resisting fibrogenesis because of the small sample size of rhesus monkeys. Obviously, huMSCs/HA-GEL intervention relieved the worse aspects of fibrogenesis, suggesting a better outcome and potential effect on the reconstruction of abnormal tissue.

Then, it was unclear what the underlying mechanism of endometrial reconstruction was. Transplanted huMSCs were tracked in endometria, and the result showed no obvious labeled signal in endometrial tissue at 2 months after huMSCs/HA-GEL complex transplantation, which was contrary to a previous report (28, 29). To explain these conflicting results, three possibilities were proposed: (i) missed target area due to random sampling, (ii) completely eliminated following the outflow of menstrual blood, and (iii) huMSC apoptosis and depletion. However, the last two assumptions were preferred for the reason of multipoint sampling and continuous paraffin section, and if the endometrial tissues were obtained at 1 week or 2 weeks after huMSCs/HA transplantation, we might get different results owing to the similar menstrual cycles to human and different physiological function from animal models such as mice and rabbits. Alternatively, some cytokines and growth factors related to huMSCs were detected, and the results showed that huMSCs/HA-GEL complex transplantation could obviously increase the expression of IGF-1, EGF, BDNF, and so on compared to that of the control group (HA-GEL transplanted alone). Growth factors and their related peptides were deemed to mediate and regulate hormones working on target tissues through autocrine or paracrine function, and some growth factors, the endocrine basis of endometrium recycling including transforming growth factor, EGF, IGF, fibroblast growth factor, etc., were reported to regulate the differentiation and proliferation of endometrial cells (30). EGF, present in stromal and epithelial cells of the endometrium, could regulate endometrial proliferation, gland secretion, and decidual transformation (31). IGF played important roles in endometrial physiology and could regulate the cell cycle and promoted the proliferation of endometrial epithelial cells after the activation of estrogen (32, 33). Moreover, some reports showed the key role of BDNF in the regulation of endometrial cell proliferation by the downstream signal transducer and activator of transcription 3 signaling pathway and participating in the damage repair of endometrium (34, 35). Furthermore, considering the effect of huMSCs on uncontrolled fibrogenesis resulting from inflammatory activity and endometrial cell proliferation, anti-inflammatory cytokines (IL-4) were observed to be up-regulated, and proinflammatory cytokines (IFN-) were down-regulated; further, related cytokines that promote cell proliferation and tissue repair were up-regulated, such as IGF-1 and EGF, suggesting that excessive fiber formation could be inhibited by anti-inflammatory effects due to the advantageous microenvironment constructed by abundant huMSCs in the uterine cavity. VEGF, as the most important vascular growth factor, could be stimulated by ischemia and hypoxia in the endometrial layer after endometrial injury and played an important role in the early stage of endometrial repair and proliferation; during the time, angiogenesis could be promoted rapidly, but no effects were shown once the neovascularization was over (3639). We speculated that no difference found in VEGF expression might be related to the samples extracted from the endometrium during the secretory phase, a plateau stage of vascular repair and VEGF secretion in the endometrial basal layer. Overall, all of these results further verified the important role of huMSCs in damage repair by secreting a series of paracrine factors, such as anti-inflammatory factors, growth factors, and cytokines, related to constructing the microenvironment with properties such as anti-inflammatory, promoting repair, maintaining cell function, angiogenesis, etc., which was consistent with the previous report (40).

In conclusion, this study showed that both HA-GEL and huMSC/HA-GEL complexes could partially repair severe IUA caused by mechanical injury, but huMSC/HA-GEL complex transplantation indicated significant advantages in the dual repair effects of antiadhesive property and promotion of endometrial regeneration. By constructing a complex of huMSCs/HA-GEL with a biomaterial to prevent adhesion and allow stem cells to act at the appropriate site of repair of the endometrium, we have provided a method for solving a problem for patients with moderate to severe IUA and thin endometria caused by IUA. We hope that this novel strategy using the huMSCs/HA-GEL complex will be offered as a basic clinical research strategy in the future, and it might be a potential valuable treatment for gel loaded with cytokines to repair moderate to severe IUA.

The basic information for the six rhesus monkeys used in this study is shown in table S4. They were bred and supplied by Fujian Experiment Center of Nonhuman Primate for Family Planning, where they were maintained the clean-class animal feeding standards. We used these rhesus monkeys in the study following the outlined steps of the flowchart (fig. S4) from 17 September 2018 to 16 March 2019 with regular menstrual cycle observed (26). All experiments were conducted in accordance with the National Research Councils Guideline for the Care and Use of Laboratory Animals and approved by the Ethics Committee of the Center of Reproductive Medicine of Tongji Medical College of Huazhong University of Science and Technology in China.

The six rhesus monkeys were chosen for IUA models following mechanical injury, and intraperitoneal surgery was the proper choice for curettage in view of the special structure of the vagina and the cervix, which are characterized by hardness, toughness, a small aperture, and a long cervix. All monkeys were provided general anesthesia with an appropriate dose of ketamine by intramuscular injection, and then a mid-abdominal longitudinal incision was made to expose the uterus. A vertical incision (~0.5 cm) was made in the lower uterine segment. A small curettage spoon was used to deeply scrape the uterine walls until they became rough and pale, and the collected endometrial tissues were stored at 80C. Subsequently, the uterine and abdominal incisions were closed by continuous stitching with 6-0 Vicryl sutures and 3-0 silk absorbable sutures, respectively. After the operation, antibiotics were used to prevent infection, and observation on the first day after the operation showed that these rhesus monkeys were in good condition.

huMSCs were kindly provided by the Stem Cell Laboratory of the Center of Reproductive Medicine (Tongji Medical College, Huazhong University of Science and Technology, China). Frozen huMSCs between P3 and P9 were freshly seeded in 10-cm culture dishes (1 106 cells per dish) in Iscoves modified Dulbeccos medium (IMDM, Genom, China) supplemented with 10% (v/v) fetal bovine serum (FBS, Gibco, USA), penicillin (100 U/ml), and streptomycin (100 mg/ml; Gibco, USA). Briefly, the phenotypes of huMSCs were specifically identified by FACS, and the osteogenic and adipogenic capacities of the mesenchymal stem cells were assessed with a MesenCult Osteogenic Stimulatory Kit (STEMCELL Technologies Inc., Canada) and a MesenCult Adipogenic Differentiation Kit (STEMCELL Technologies Inc., Canada). P3 to P9 were used for the experiments.

To further evaluate the safety of huMSCs on HA-GEL, we mixed huMSCs (1 105 to 2 105 per well) and 300 l of HA-GEL [Con., 5 mg/ml; Bioregen, Co., Ltd., China, approved by CFDA as a medical device (no. 20153641542)] evenly with sterile syringes in 24-well plates and then added IMDM (Genom, China), including 10% (v/v) FBS (Gibco, USA), penicillin (100 U/ml), and streptomycin (100 mg/ml) (Gibco, USA). After co-culture for 48 hours, 0.8% collagenase type I supplemented with appropriate hyaluronidase was used to digest HA-GEL and release huMSCs, and FACS was chosen for the detection of cell apoptosis index in the coculture group (huMSCs/HA-GEL) and the culture-separated group (huMSCs), as well as live-dead cell detection with Live-Dead Cytotoxicity Assay Kit (MesGen Biotechnology, Shanghai).

Briefly, 50 l of huMSCs (1 107 to 2 107 cells) were injected into 200 l of HA-GEL (Bioregen, Co., Ltd. China), and then they were immediately transplanted into the uterine cavity through the open abdominal cavity. At the same time, the uterine cavity in the negative control group was injected into 200 l of HA-GEL following the same procedure that was used for the huMSC/HA-GEL transplantation group. All operations were performed under sterile conditions.

The endometrial thickness (before mechanical injury or after surgery for 2 months) was measured by an abdominal two-dimensional ultrasound system (Medison SA-600 Ultrasound System, Korea) with 3.5-MHz pulse repetition frequency to evaluate the damage to the endometrium and the endometrial regeneration.

The scraped pieces of endometrium were fixed in 4% paraformaldehyde for 24 hours and then embedded in paraffin. Serial paraffin-embedded sections (4 m) were obtained, sequentially dewaxed in xylene I and xylene II for 20 min each, and rehydrated in a series of ethanol solutions with a decreasing concentration (100% for 10 min, 100% for 10 min, 95% for 5 min, 90% for 5 min, 80% for 5 min, and 70% for 5 min). Then, the sections were rinsed in distilled water (three times, 5 min each). The sections were stained with an H&E solution (Servicebio, China) according to the manufacturers instructions. After staining, endometrial morphologic features were observed, and the number of uterine glands per unit area was counted according to five randomly selected high-power fields of each slide.

The 4-m paraffin sections of endometrium were dewaxed and rehydrated as described above and then were immersed in Masson A solution (Servicebio, China) overnight, which was followed by a brief wash under running water. Then, the sections were stained in a mixed solution of Masson A and Masson B (1:1, Servicebio, China) for 1 min, washed under running water, and placed in 1% hydrochloric acid alcohol for 10 s before they were washed again. Subsequently, sections were immersed in Masson D solution (Servicebio, China) for 6 min and then were stained in Masson E solution (Servicebio, China) for 1 min. The solution was then slightly drained, and the sections were placed directly in Masson F solution (Servicebio, China) for 2 to 30 s, and then they were rinsed in 1% glacial acetic acid for differentiation of the signals. Last, the sections were dehydrated in absolute ethyl alcohol, clarified in xylene for 5 min, and sealed in Permount Mounting Medium (Sinopharm Chemical Reagent Co., Ltd., China). Endometrial fibrosis was assessed according to five random fields on each slide, and the fibrotic area ratios were calculated using Image-Pro Plus software (version 6.0).

The total DNA samples were extracted from spleen tissue of rhesus monkeys and huMSCs carrying XY or XX chromosomes with a TIANamp Genomic DNA Kit (Tiangen Biotech Co., Ltd., Beijing). mRNA samples were extracted from endometrial tissue, and cDNA was synthesized with a RevertAid First Strand cDNA Synthesis Kit (Thermo, USA). Subsequently, quantitative real-time polymerase chain reaction (qRT-PCR) was performed to verify the specific expression of the DXZ1 gene on the X chromosome, SRY on the Y chromosome, and IFN-, IL-4, IGF-1, and EGF using StepOne and StepOnePlus Real-Time PCR Systems Version 2.3. The final reaction volume of 20 l contained 10 l of Bestar qPCR MasterMix (SYBR Green) (DBI Bioscience), 4 l of DNA samples, 0.4 l of forward/reverse primer (10 M), and 5.2 l of DNA/RNase-free double-distilled water (ddH2O). Last, agarose gel electrophoresis was performed to verify the expression of DXZ1 and SRY in the spleen and huMSC tissues. In addition, primer sequences used for DXZ1 (Xp11.1-Xq11.1), SRY (Yp11.3 Region), IFN-, IL-4, IGF-1, and EGF are summarized in table S5.

FISH analysis was performed to trace huMSCs for 2 months after the huMSCs/HA-GEL complexes were transplanted into the uterine cavity. Endometrial tissue was collected and immediately fixed in 10% paraformaldehyde before paraffin embedding. A Vysis SRY Probe LSI SRY Spectrum Orange/Vysis CEP X Spectrum Green Kit (Abbott Laboratories, USA) was used to mark huMSCs in the endometrium. All paraffin sections were dewaxed, rehydrated, hybridized with the probe, and so on according to the probes instructions; a final counterstaining of 4,6-diamidino-2-phenylindole (DAPI) was added, and visualization took place with fluorescence microscopy (Nikon Eclipse Ci, Nikon DS-U3). The orange (SRY/Y chromosome) and/or green (DXZ1/X chromosome) signals were used to verify the presence or absence of huMSCs in the endometrium.

The following factors were analyzed after transplantation of the huMSCs/HA-GEL complex: trophic factors (cytokines) that are secreted by huMSCs [according to relevant reports (17)], proinflammatory cytokines, anti-inflammatory cytokines, and related cytokines that promote cell proliferation and tissue repair. After fixation with 4% paraformaldehyde, paraffin embedding, and cutting 4-m paraffin sections, the slides were immersed in xylene and rehydrated through incubation in a series of alcohol gradients. The following specific antibodies were applied to sections at 4C overnight in humidified chambers: recombinant anti-BDNF antibody (EPR1292) (ab108319, Abcam), anti-VEGF antibody (C-1: sc-7269, Santa Cruz), antiIGF-1 antibody (W18: sc-74116, Santa Cruz), anti-HGFa antibody (H-10: sc-374422, Santa Cruz), and anti-EGF antibody (F-9: sc-166779, Santa Cruz). Then, these sections were incubated with a Cy3-tagged secondary antibody for 1 hour at room temperature and were then rinsed in ddH2O three times. Counterstaining was performed with DAPI for 5 min, and the fluorescence signal was detected under a fluorescence microscope (Nikon Eclipse Ci, Nikon DS-U3).

We collected three technical replicates from each animal and repeated the experiments at least three times. The data presented as the mean SEM were analyzed with Statistical Package for the Social Sciences Statistics 17.0. The normally distributed numerical variance was assessed by a t test with homogeneity of variance, and 2 tests were used to analyze the differences between two or more rates. The percentage of positive area after H&E staining and Masson staining was measured using ImageJ 1.43u (Wayne Rasband, National Institutes of Health, USA). Statistical significance was assumed for P < 0.05.

This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial license, which permits use, distribution, and reproduction in any medium, so long as the resultant use is not for commercial advantage and provided the original work is properly cited.

Acknowledgments: We acknowledge the breeding and technical assistance of Fujian Experiment Center of Nonhuman Primate for Family Planning. We thank C. Yu for the operation of uterine D&C and open abdominal surgery. We thank C. Xiong and P. Su for their invaluable contributions in critically revising the manuscript and providing guidance for important intellectual content. We thank M. Zhang, T. Chang, and S. Song for analyzing the data and collecting the samples. Funding: This work was supported by the National Natural Science Foundation of China (NSFC 81571434) and the National Key Research and Development Program of China (2017YFC1002002). The funders played no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. Author contributions: W.X. designed the study and published this manuscript; L.W. and C.Y. performed the experiments and wrote the manuscript; M.Z., T.C., and S.S. analyzed the data and collected the samples; C.X. and P.S. provided their invaluable contributions in critically revising the manuscript and providing guidance for important intellectual content. Competing interests: The authors declare that they have no competing interests. Data and materials availability: All data needed to evaluate the conclusions in the paper are present in the paper and/or the Supplementary Materials. Additional data related to this paper may be requested from the authors.

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In situ repair abilities of human umbilical cordderived mesenchymal stem cells and autocrosslinked hyaluronic acid gel complex in rhesus monkeys with...