Global Stem Cell Media Market Competitive Dynamics and Industry Outlook 2025 – 3rd Watch News

Report Summary:,The global Stem Cell Media market report is a comprehensive study that encompasses top manufacturers, prospective market share, revenue, purchaser volume with respect to dealing volume and global segmentation for the Stem Cell Media industry. The report further includes market classification and definitions, product and industry overview, manufacturing specifications and cost structure, included raw materials and so on.

In addition to the vast definitive data, the report also sheds light on the past behavior of the market and an upcoming growth graph that is expected to venture in an upwards trajectory despite market fluctuations and trends.

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Market Segmentation:,The Stem Cell Media report follows an accumulated research methodology that is based on years of experience combined with structured data points acquired from proprietary sources. These methods function with thorough research and analysis split between primary and secondary research combined with an in-house data wrangling process. In general, the data points are gathered from a variety of sources such as vendor projections, product list, research papers and a detailed list of manufacturers. The analysis is than derived into quantitative market values such as qualitative and quantitative qualities, market forecast models, market segmentations and business models that revolve around the Stem Cell Media industry.

Moreover, the Stem Cell Media market report clarifies the market segmentation based on various parameters and attributes that can be classified on geographical region, product types and market applications.

The report provides a comprehensive analysis of the Stem Cell Media industry market by types, applications, players and regions. This report also displays the production, Consumption, revenue, Gross margin, Cost, Gross, market share, CAGR, and Market influencing factors of the Stem Cell Media industry in USA, EU, China,India, Japan and other regions, and forecast to 2025, from 2019.

Market Analysis by Players,Thermo Fisher,STEMCELL Technologies,Merck Millipore,Lonza,GE Healthcare,Miltenyi Biotec,Corning,CellGenix,Takara,PromoCell

Market Analysis by Regions:,USA,Europe,Japan,China,India,Southeast Asia,South America,South Africa,Others

Market Analysis by Types:,Pluripotent Stem Cell Culture,Hematopoietic Stem Cell Culture,Mesenchymal Stem Cell Culture,Others

Market Analysis by Applications:,Scientific Research,Industrial Production

The report also focuses on developing market trends, preferred market channels and market drivers & restraints to name a few.

Major Point of TOC:

Chapter One: Stem Cell Media Market Overview

Chapter Two: Global Stem Cell Media Competitions by Players

Chapter Three: Global Stem Cell Media Competitions by Types

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Chapter Four: Global Stem Cell Media Competitions by Application

Chapter Five: Global Stem Cell Media Production Market Analysis by Region

Chapter Six: Global Stem Cell Media Sales Market Analysis by Region

Chapter Seven: Imports and Exports Market Analysis

Chapter Eight: Global Stem Cell Media Players Profiles and Sales Data

Chapter Nine: Stem Cell Media Upstream and Downstream Analysis

Chapter Ten: Global Stem Cell Media Market Forecast (2017-2022)

Chapter Eleven: Research Findings and Conclusion, Continue

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NOTE: Our report does take into account the impact of coronavirus pandemic and dedicates qualitative as well as quantitative sections of information within the report that emphasizes the impact of COVID-19.

As this pandemic is ongoing and leading to dynamic shifts in stocks and businesses worldwide, we take into account the current condition and forecast the market data taking into consideration the micro and macroeconomic factors that will be affected by the pandemic.

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Global Stem Cell Media Market Competitive Dynamics and Industry Outlook 2025 - 3rd Watch News

The Impact of the Coronavirus on the Nerve Repair and Regeneration Market Growth, Trends and Competitive Landscape | P&S Intelligence – Cole of Duty

The prevalence of neurological disorders and chronic pain is increasing rapidly at the present time across the globe. Depression, fecal incontinence, epilepsy, Parkinsons, and Alzheimers are the different kinds of neurological disorders. As per the Alzheimers Association, about 5.35 million people aged 65 years and above were suffering from Alzheimers diseases in the U.S. in 2015. Apart from this, as per the Parkinsons Diseases Foundation, nearly 60,000 new cases of Parkinsons disease are reported each year in the U.S. Attributed to these reasons, the demand for efficient medical technologies, such as neuromodulation and neurostimulation devices, is increasing rapidly.

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The different applications of the nerve repair and regeneration devices are stem cell therapy, neurostimulation and neuromodulation surgeries, nerve grafting, and direct nerve repair/neurorrhaphy. Out of these, the largest demand for different nerve repair and regeneration devices was created for neurostimulation and neuromodulation surgeries in the past. Ambulatory surgery centers and hospitals & clinics are the major end users of the nerve repair and regeneration devices. Between these two, the hospitals & clinics category is predicted to witness the fastest growth in the coming years because of the surging patient pool, increasing geriatric population, and improving healthcare infrastructure.

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The potential of stem cell therapy in the field is predicted to create wide opportunities for players operating in the nerve repair and regeneration market. Stem cell therapy is an emerging branch of medicine which has the potential of restoring tissue and /or organ function in patients suffering from critical injuries or chronic diseases. According to clinical research findings, stem cell therapy provides better quality as compared to nerve graft surgeries. Moreover, research is going on in the field of stem cell therapy for its application in the treatment of Alzheimers disease and Parkinsons disease. This is further expected to drive the market in the near future.

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P&S Intelligence is a provider of market research and consulting services catering to the market information needs of burgeoning industries across the world. Providing the plinth of market intelligence, P&S as an enterprising research and consulting company, believes in providing thorough landscape analyses on the ever-changing market scenario, to empower companies to make informed decisions and base their business strategies with astuteness.

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Platelet Rich Plasma and Stem Cell Alopecia Treatment Market Development, Trends, Key Driven Factors, Segmentation And Forecast to 2020-2026 – Cole of…

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The report is a compilation of different studies, including regional analysis where leading regional Platelet Rich Plasma and Stem Cell Alopecia Treatment markets are comprehensive studied by market experts. Both developed and developing regions and countries are covered in the report for a 360-degree geographic analysis of the Platelet Rich Plasma and Stem Cell Alopecia Treatment market. The regional analysis section helps readers to become familiar with the growth patterns of important regional Platelet Rich Plasma and Stem Cell Alopecia Treatment markets. It also provides information on lucrative opportunities available in key regional Platelet Rich Plasma and Stem Cell Alopecia Treatment markets.

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Table of Content

1 Introduction of Platelet Rich Plasma and Stem Cell Alopecia Treatment Market

1.1 Overview of the Market1.2 Scope of Report1.3 Assumptions

2 Executive Summary

3 Research Methodology

3.1 Data Mining3.2 Validation3.3 Primary Interviews3.4 List of Data Sources

4 Platelet Rich Plasma and Stem Cell Alopecia Treatment Market Outlook

4.1 Overview4.2 Market Dynamics4.2.1 Drivers4.2.2 Restraints4.2.3 Opportunities4.3 Porters Five Force Model4.4 Value Chain Analysis

5 Platelet Rich Plasma and Stem Cell Alopecia Treatment Market, By Deployment Model

5.1 Overview

6 Platelet Rich Plasma and Stem Cell Alopecia Treatment Market, By Solution

6.1 Overview

7 Platelet Rich Plasma and Stem Cell Alopecia Treatment Market, By Vertical

7.1 Overview

8 Platelet Rich Plasma and Stem Cell Alopecia Treatment Market, By Geography

8.1 Overview8.2 North America8.2.1 U.S.8.2.2 Canada8.2.3 Mexico8.3 Europe8.3.1 Germany8.3.2 U.K.8.3.3 France8.3.4 Rest of Europe8.4 Asia Pacific8.4.1 China8.4.2 Japan8.4.3 India8.4.4 Rest of Asia Pacific8.5 Rest of the World8.5.1 Latin America8.5.2 Middle East

9 Platelet Rich Plasma and Stem Cell Alopecia Treatment Market Competitive Landscape

9.1 Overview9.2 Company Market Ranking9.3 Key Development Strategies

10 Company Profiles

10.1.1 Overview10.1.2 Financial Performance10.1.3 Product Outlook10.1.4 Key Developments

11 Appendix

11.1 Related Research

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Platelet Rich Plasma and Stem Cell Alopecia Treatment Market Development, Trends, Key Driven Factors, Segmentation And Forecast to 2020-2026 - Cole of...

The impact of the coronavirus on the Stem Cell and Platelet Rich Plasma (PRP) Alopecia Therapies Size, Analysis, and Forecast Report 2019-2023 Cole…

Companies in the Stem Cell and Platelet Rich Plasma (PRP) Alopecia Therapies market are vying suggestive steps to tackle the challenges resulting from the COVID-19 (Coronavirus) pandemic. Exhaustive research about COVID-19 is providing present-day techniques and alternative methods to mitigate the impact on Coronavirus on the revenue of the Stem Cell and Platelet Rich Plasma (PRP) Alopecia Therapies market.

The report on the Stem Cell and Platelet Rich Plasma (PRP) Alopecia Therapies market provides a birds eye view of the current proceedings and advancements within the Stem Cell and Platelet Rich Plasma (PRP) Alopecia Therapies landscape. Further, the report ponders over the various factors that are likely to impact the overall dynamics of the Stem Cell and Platelet Rich Plasma (PRP) Alopecia Therapies market over the forecast period (20XX-20XX) including the current trends, business expansion opportunities and restraining factors amongst others.

As per the market report suggested by ResearchMoz.us, the global Stem Cell and Platelet Rich Plasma (PRP) Alopecia Therapies market is expected to register a CAGR growth of ~XX% during the forecast period and attain a value of ~US$XX by the end of 20XX. Further, the report suggests that the growth of the Stem Cell and Platelet Rich Plasma (PRP) Alopecia Therapies market is largely influenced by a range of factors including, emphasis on R&D innovations by market players, surging investments to increase product portfolio, and favorable regulatory policies among others.

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Questions Related to the Stem Cell and Platelet Rich Plasma (PRP) Alopecia Therapies Market Explained:

Competitive Landscape

The report provides critical insights related to the leading players operating in the Stem Cell and Platelet Rich Plasma (PRP) Alopecia Therapies market. The revenue generated, market presence, product range, and financials of each company are enclosed in the report.

The key players covered in this studyOrange County Hair Restoration CenterHair Sciences Center of ColoradoAnderson Center for HairEvolution Hair Loss InstituteSavola Aesthetic Dermatology CenterVirginia Surgical CenterHair Transplant Institute of MiamiColorado Surgical Center & Hair Institute

Market segment by Type, the product can be split intoPlatelet Rich Plasma InjectionsStem Cell TherapyMarket segment by Application, split intoDermatology ClinicsHospitals

Market segment by Regions/Countries, this report coversNorth AmericaEuropeChinaJapanSoutheast AsiaIndiaCentral & South America

The study objectives of this report are:To analyze global Stem Cell and Platelet Rich Plasma (PRP) Alopecia Therapies status, future forecast, growth opportunity, key market and key players.To present the Stem Cell and Platelet Rich Plasma (PRP) Alopecia Therapies development in North America, Europe, China, Japan, Southeast Asia, India and Central & South America.To strategically profile the key players and comprehensively analyze their development plan and strategies.To define, describe and forecast the market by type, market and key regions.

In this study, the years considered to estimate the market size of Stem Cell and Platelet Rich Plasma (PRP) Alopecia Therapies are as follows:History Year: 2015-2019Base Year: 2019Estimated Year: 2020Forecast Year 2020 to 2026For the data information by region, company, type and application, 2019 is considered as the base year. Whenever data information was unavailable for the base year, the prior year has been considered.

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Regional Landscape

The regional landscape of the report provides resourceful insights related to the revenue share analysis of the Stem Cell and Platelet Rich Plasma (PRP) Alopecia Therapies market in different regions. Further, the market attractiveness of each region provides players a clear understanding of the overall growth potential in each regional market.

End-User Analysis

The report provides an in-depth understanding of the various end-users of the Stem Cell and Platelet Rich Plasma (PRP) Alopecia Therapies along with the market share, size, and revenue generated by each end-user.

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The impact of the coronavirus on the Stem Cell and Platelet Rich Plasma (PRP) Alopecia Therapies Size, Analysis, and Forecast Report 2019-2023 Cole...

Stem Cell Therapy Market by Treatment,Application,End Users and Geography Forecast To… – Azizsalon News

Stem Cell Therapy Marketis expected to reach 202.77 billion by 2026 from XX billion in 2018 at CAGR of XX %.

Stands for use of stem cells to treat or prevent disease or condition.Bone marrow transplant and some therapies derived from umbilical cord blood are mainly used in stem cell therapy. Advancement, in order to establish new sources for stem cells, and to apply stem-cell treatments for neurodegenerative diseases and conditions such as diabetes, heart disease, and other conditions, are increased in recent years.

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The report study has analyzed revenue impact of covid-19 pandemic on the sales revenue of market leaders, market followers and disrupters in the report and same is reflected in our analysis.

Stem Cell Therapy Market Researchers are making efforts to discover novel methods to create human stem cells. This will increase the demand as well as supply for stem cell production and potential investigation in disease management. Increasing investment & research grants for developing safe and effective stem cell therapy products, the growing patient base for target diseases, concentrated product pipelines, increasing approval of the new clinical trials, rapid technological advancement in genomics, and the rising awareness about the stem cell are expected to drive the growth of the Stem Cell Therapy solutions market during the forecast period.

However, improper infrastructure, insufficient storage systems, nascent technology in underdeveloped economies, Ethical issues related to an embryonic stem cell, low patient acceptance rate, Difficulty in the preservation of stem cell are expected to restrain the market growth. North America is expected to be the largest growing region by 2026; the reason behind that is extensive funding by Government. However, Emerging countries like India, china, Korea have low growth rate as compared to Developed regions in 2017 but increase in awareness about stem cell therapy will lead the Asia Pacific to generate a significant level of revenue by 2026.

Key Highlights of Stem Cell Therapy Market report

Detailed quantitative analysis of the current and future trends from 2017 to 2026, which helps to identify the prevailing market opportunities.Comprehensive analysis of factors instrumental in changing the market scenario, rising prospective opportunities, market shares, core competencies in terms of market development, growth strategies and identification of key companies that can influence this market on a global and regional scale.Assessment of Market definition along with the identification of key drivers, restraints opportunities and challenges for this market during the forecast period.Complete analysis of micro-markets with respect to individual growth trends, prospects, and contributions to the overall Stem Cell Therapy Solutions market.Stem Cell Therapy market analysis and comprehensive segmentation with respect to the Application, End users, Treatment, and geography to assist in strategic business planning.Stem Cell Therapy market analysis and forecast for five major geographies-North America, Europe, Asia Pacific, Middle East & Africa, Latin America, and their key regions.For company profiles, 2017 has been considered as the base year. In cases, wherein information was unavailable for the base year, the years prior to it have been considered.

Research Methodology:

The market is estimated by triangulation of data points obtained from various sources and feeding them into a simulation model created individually for each market. The data points are obtained from paid and unpaid sources along with paid primary interviews with key opinion leaders (KOLs) in the market. KOLs from both, demand and supply side were considered while conducting interviews to get an unbiased idea of the market. This exercise was done at a country level to get a fair idea of the market in countries considered for this study. Later this country-specific data was accumulated to come up with regional numbers and then arrive at a global market value for the stem cell therapy market.Key Players in the Stem Cell Therapy Market are:

Chiesi Farmaceutici S.P.A Are:Gamida CellReNeuron Group, plcOsiris Therapeutics, Inc.Stem Cells, Inc.Vericel Corporation.Mesoblast, Ltd.

Key Target Audience:

Stem Cell Associations and OrganizationsGovernment Research Boards and OrganizationsResearch and consulting firmsStem Cell Therapy Market InvestorsHealthcare Service Providers (including Hospitals and Diagnostic Centers)Stem Cell Therapeutic Product Manufacturing OrganizationsResearch LabsClinical research organizations (CROs)Stem Cell Therapy Marketing PlayersPharmaceutical Product Manufacturing Companies

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Scope of the Stem Cell Therapy Market Report:

Stem Cell Therapy market research report categorizes the Stem Cell Therapy market based on Application, End users, Treatment, and geography (region wise). Market size by value is estimated and forecasted with the revenues of leading companies operating in the Stem Cell Therapy market with key developments in companies and market trends.Stem Cell Therapy Market, By Treatments:

Allogeneic Stem Cell TherapyAutologous Stem Cell Therapy

Stem Cell Therapy Market, By End Users:

HospitalsAmbulatory Surgical Centers

Stem Cell Therapy Market, By Application:

OncologyCentral Nervous System DiseasesEye DiseasesMusculoskeletal DiseasesWound & InjuriesMetabolic DisordersCardiovascular DisordersImmune System DisordersStem Cell Therapy Market, By Geography:

North AmericaEuropeAsia PacificMiddle East & AfricaLatin America

MAJOR TOC OF THE REPORT

Chapter One: Stem Cell Therapy Market Overview

Chapter Two: Manufacturers Profiles

Chapter Three: Global Stem Cell Therapy Market Competition, by Players

Chapter Four: Global Stem Cell Therapy Market Size by Regions

Chapter Five: North America Stem Cell Therapy Revenue by Countries

Chapter Six: Europe Stem Cell Therapy Revenue by Countries

Chapter Seven: Asia-Pacific Stem Cell Therapy Revenue by Countries

Chapter Eight: South America Stem Cell Therapy Revenue by Countries

Chapter Nine: Middle East and Africa Revenue Stem Cell Therapy by Countries

Chapter Ten: Global Stem Cell Therapy Market Segment by Type

Chapter Eleven: Global Stem Cell Therapy Market Segment by Application

Chapter Twelve: Global Stem Cell Therapy Market Size Forecast (2019-2026)

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Stem Cell Therapy Market by Treatment,Application,End Users and Geography Forecast To... - Azizsalon News

Georgetown student takes Islamic bioethics research at QF to Washington and wins – Gulf Times

An academic paper analysing the Muslim perspective on the controversial use of stem cell research has won Amna al-Essa, a Georgetown University in Qatar (GU-Q) student, second place in the Bioethics Research Showcase sponsored by the Kennedy Institute of Ethics in Washington, DC, one of the oldest academic ethics centres in the world.Amnas winning entry was judged by an interdisciplinary panel of judges and announced during a virtual awards ceremony.In the paper, she explores the background behind the Islamic rulings guiding the use and limitation of embryonic stem cells in the medical sciences, a field of research that holds great promise for the treatment of degenerative conditions and the understanding of human development.The medical technology uses cells from human embryos which has raised a host of ethical concerns and debates across cultures and countries.Muslim countries also face these debates, explained Amna, but often lack the needed guidance of a religious authority ruling.There is a pressing need to address continuing ethical concerns and questions that arise from societal, cultural and religious perspectives on issues that transgress into matters of prohibitions and permissibility in Islam.She was encouraged to submit her paper for competition by the instructor of her Islam, Culture and Bioethics course, associate research professor Dr Ayman Shabana.He is also the director of the Islamic Bioethics Project at GU-Q, which has been supported by three consecutive grants from Qatar National Research Funds National Priorities Research Programme.Being at GU-Q has definitely deepened my interest in the connections between Islam and bioethics. We are offered this great opportunity to be exposed to multiple fields and wider disciplines, like theology, philosophy and politics. This opportunity has allowed us to cultivate our own selves and knowledge based on our personal interests across different fields.An International Politics major student at GU-Q, a Qatar Foundation (QF) partner institution, Amna said it was during her pursuit of the Theology minor that she became interested in bioethics.I have always had a passion for science and medicine, which is why I decided to pursue them within the realm of liberal arts. Studying theology at Georgetown has widened my horizons to think about issues in the medical field and to consider how contemporary religious beliefs and practices deal with those issues.The Showcase is a jurieddigital exhibition of under-graduate research in a varietyof categories and disciplineson the ethics of health,the environment and thebioethics of emerging technologies.The virtual award ceremony as well as Amnas winning paper are available for viewing on the Kennedy Institute of Ethics website.

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Georgetown student takes Islamic bioethics research at QF to Washington and wins - Gulf Times

Dose-dependent functions of SWI/SNF BAF in permitting and inhibiting cell proliferation in vivo – Science Advances

INTRODUCTION

During development and tissue homeostasis, proliferating stem and progenitor cells ultimately give rise to daughter cells that acquire specialized functions. The terminal differentiation of such cells coincides with a permanent withdrawal from the cell division cycle. This cell cycle arrest is achieved by a combination of cell cycle regulators that include the retinoblastoma tumor suppressor (Rb) protein family of transcriptional corepressors, cyclin-dependent kinase (CDK)inhibitory proteins (CKIs) that bind and block CDKs, and E3 ubiquitin ligases such as the anaphase-promoting complex in association with the coactivator Cdh1/FZR1 (APC/C-FZR1) that promote protein degradation (1). In addition to these general regulators of the cell cycle, lineage-specific transcription factors and chromatin regulators coordinate the arrest of cell division with terminal differentiation. In particular, SWI/SNF (switch/sucrose nonfermenting) chromatin remodeling complexes have been found to play an important role in this process (24).

The multisubunit SWI/SNF chromatin remodeling complexes were initially identified as positive regulators of gene expression in yeast [for review, see (5)]. Independent studies in Drosophila identified SWI/SNF components as antagonists of Polycomb-mediated transcriptional repression, with homology searches revealing evolutionary conservation in mammals. Extensive biochemical characterizations support that multiple SWI/SNF subcomplexes are modularly assembled from a variety of different subunits. These SWI/SNF complexes contain an adenosine triphosphatase (ATPase) core subunit and use the energy generated by ATP hydrolysis to alter nucleosome occupancy at gene regulatory regions, to evict Polycomb-repressor complexes, and to participate in additional cellular processes such as DNA repair (68). SWI/SNF complexes can be divided into BRG1/BRM-associated factor (BAF) and Polybromo-associated BAF (PBAF) variants. These complexes consist of one of two mutually exclusive ATPase subunits (BRM/SMARCA2 or BRG1/SMARCA4), additional highly conserved core subunits (SNF5/SMARCB1, BAF155/SMARCC1, and BAF170/SMARCC2), an array of variable accessory subunits, and BAF- or PBAF-specific variant subunits (ARID1A/B, or ARID2, PBRM1, and BRD7, respectively) (9) (Fig. 1, A and B). While sophisticated in vitro studies have described the nature and function of SWI/SNF complexes at a biochemical level, in vivo characterizations of SWI/SNF complex functions and interactions with Polycomb group (PcG) proteins have been limited.

(A) Schematic representation of the two conserved SWI/SNF subcomplexes (using C. elegans nomenclature). (B) Table of C. elegans and mammalian homolog names for SWI/SNF subunits. The SWI/SNF complex consists of core subunits (green), accessory (blue), and BAF- (purple) and PBAF-specific (orange) signature subunits. (C) Lineage of the C. elegans mesoblast (M). The M cell is born during early embryogenesis and initiates proliferation halfway through the first larval stage (L1), forming 14 striated muscle cells (BWM), two scavenger cells [coelomocytes (CC)], and two ventral muscle precursor cells [sex myoblasts (SM)]. The SMs remain quiescent and migrate anteriorly to the vulva, resuming proliferation late in the third larval stage (L3), and differentiate to form 16 muscle cells required for egg laying. (D) Design of the lineage-tracing reporter, single-copy integrated into the C. elegans genome. A universal promoter (Peft-3) drives expression of tagBFP2 flanked by two LoxP sites and followed by the let-858 untranslated region (UTR). Excision of tagBFP2 leads to mCherry expression, providing a visible switch from blue-to-red fluorescence in cells where CRE is expressed and all daughter cells. (E) Representative image of mesoblast lineage descendants marked by the lineage tracing construct in an L4 larva (lateral view, ventral down; arrowheads point to BWM, brackets indicate egg-laying muscle precursors). (F) Representative images of the vulva region of RNAi-treated larvae. Anterior to the left, ventral down; scale bars, 10 m in all images. (G) Quantification of mesoblast lineage descendants per animal at the L4 stage following RNAi by feeding of synchronized L1 larvae for the indicated genes, in wild-type or fzr-1 mutant backgrounds. Twenty to 30 animals were scored for each condition.

Understanding in vivo function is particularly important because mammalian SWI/SNF complexes act as tumor suppressors and are altered in a wide variety of cancers. Mutations in the collective set of SWI/SNF subunitencoding genes have been found in 20% of examined human cancers (7, 10, 11). The broad spectrum of the identified genetic alterations makes it difficult to understand their exact oncogenic effects. While the BAF-specific subunit ARID1A is most frequently mutated, alteration of specific SWI/SNF subunits is associated with specific cancer types (7, 10, 11). Moreover, cancer-associated SWI/SNF missense mutations or deletions are often heterozygous or affect subunits for which paralogs exist [(6, 12), http://www.cbioportal.org]. Heterozygous mutations in genes encoding SWI/SNF subunits are also associated with intellectual disability disorders such as the Coffin-Siris syndrome (12). While haploinsuffiency likely explains the prevalence of genetically dominant loss-of-function SWI/SNF mutations in neurologic diseases, the unusual mutation spectrum of SWI/SNF genes in human cancer remains puzzling.

In this study, we characterize how partial versus complete loss of function of various SWI/SNF subunits affects the in vivo proliferation and differentiation of muscle precursor cells. We take advantage of the invariant cell lineage and advanced possibilities for controlled manipulation of the nematode Caenorhabditis elegans (13). Using lineage-specific gene knockout and protein degradation technologies, we demonstrate that various subunits of the SWI/SNF BAF complex contribute strong dosage-dependent functions in cell proliferation. As such, partial loss of function of BAF subunits leads to hyperplasia, which is enhanced by loss of negative cell cycle regulators. This indicates a tumor-suppressive function of SWI/SNF BAF, which resides, in part, on PcG protein opposition. Notably, we found that in the same cells, low levels of the SWI/SNF complex are required for cell proliferation, independently of the presence of PcG proteins or negative cell cycle regulators. Our single-molecule fluorescence in situ hybridization (smFISH) and RNA-sequencing (RNA-seq) studies show that acute inactivation of SWI/SNF BAF in muscle precursor cells rapidly alters the transcript levels of several hundred genes, including cyd-1 cyclin D, demonstrating that the complex is continuously required for the regulation of gene expression. Thus, in the same cell type and developmental decisions, a high dosage of SWI/SNF BAF subunits is needed for temporal arrest of cell division and PcG opposition, while a low level is required to sustain proliferation. We propose that similar dosage-dependent effects contribute to the selection of SWI/SNF partial loss-of-function mutations during carcinogenesis.

To investigate how the SWI/SNF complex regulates cell proliferation, we exploited the fact that cell divisions in the nematode C. elegans follow a well-characterized invariant pattern throughout development. Abnormalities resulting from aberrant regulation of proliferation-differentiation processes can therefore be readily recognized, monitored, and quantified on the basis of in vivo observations. Previously, we observed that a lineage-specific temperature-sensitive mutation in the SWI/SNF core subunit gene swsn-1 (SMARCC1/2) gives rise to hyperplasia during C. elegans postembryonic mesoderm development. When combined with loss of negative cell cycle regulators, this mutation induces a unique tumorous overproliferation phenotype (2).

To examine the role of specific SWI/SNF subunits in the regulation of proliferation, we performed RNA interference (RNAi) experiments for C. elegans genes predicted to encode components of the BAF and PBAF subcomplexes. These complexes share core subunits and several additional proteins, while differing in a few specific factors (Fig. 1, A and B). We focused on the mesoblast (M) lineage, which includes two sequential periods of cell cycle quiescence, proliferation, and muscle differentiation (Fig. 1C) (13). An integrated tagBFP2-to-mCherry lineage-tracing reporter and hlh-8 Twist promoter-CRE recombinase transgene (Phlh-8::CRE) facilitated the quantification of mCherry-positive mesoblast daughter cells (Fig. 1, D and E). Using this background, we observed that knockdown of the core ATPase subunit swsn-4 BRM/BRG1, the core subunit snfc-5 SNF5, and the BAF-specific subunit swsn-8 ARID1 increased the number of M descendants. Knockdown of either one of three PBAF-specific SWI/SNF subunits had limited effects (Fig. 1, F and G, and fig. S1, C and D). Simultaneous inhibition of negative regulators of the cell cycle further emphasized the different contributions of BAF versus PBAF subunits. Single knockout of the APC/C activator fzr-1 Cdh1, an inhibitor of cell cycle entry, did not alter the M lineage division pattern. However, fzr-1 loss enhanced the hyperplasia of M descendants when combined with knockdown of SWI/SNF core subunits and swsn-8 ARID1, but not when combined with PBAF-specific subunits (Fig. 1, F and G, and fig. S1, C and D). These data indicate that the SWI/SNF BAF complex contributes critically to the cell division arrest of muscle precursor cells.

RNAi of one of the core subunits, swsn-1 (SMARCC1/2), led to an unexpectedly variable number of mesoblast descendants, with animals showing a range from fewer to more than the normal number of cells (Fig. 1, F and G, and fig. S1, C and D). To test whether this reflects variability in RNAi-induced loss of function, we created conditional knockout alleles, as SWI/SNF null mutations are lethal. Using CRISPR-Cas9mediated genome editing, we introduced Lox sites in endogenous genes encoding the SWSN-1 and SWSN-4 core components, the BAF-specific SWSN-8 subunit, and the accessory subunit SWSN-2.1 BAF60 (Fig. 2A). We combined these loxed SWI/SNF alleles with the Phlh-8::CRE and tagBFP2-to-mCherry integrated transgenes to induce M lineagespecific gene deletion and reporter expression.

(A) Schematic of Lox sites (yellow diamonds) integrated into the endogenous SWI/SNF genes indicated. The swsn-4 ATPase-dead lysine-to-alanine mutation (K to A) is shown as a red block. Transcriptional start sites are indicated with arrows, introns are shown as black lines, and exons as colored blocks. (B) Representative images of mesoblast lineage descendants in wild-type and indicated SWI/SNF gene knockout animals. Arrowheads point at body-wall muscle (BWM), and brackets indicate egg-laying muscle precursors. Scale bar, 10 m. (C) Quantifications of mesoblast lineage descendants for the indicated genotypes, in the tail area (early dividing body wall muscles), and around the vulva (late-dividing egg-laying muscles). Note that, in contrast to RNAi, SWI/SNF gene knockouts lead to overproliferation of the early dividing BWM precursors and cell division arrest of the late-dividing egg-laying muscle precursor cells. Twenty-six to 35 animals were scored per condition.

The swsn-1, swsn-4, and swsn-8 knockout phenotypes differed greatly from those resulting from RNAi knockdown of the same genes and from the temperature-sensitive swsn-1 phenotype (Fig. 2, B and C, and fig. S2) (2). Specifically, instead of the RNAi-induced extra M descendants in the vulva region, the gene knockouts resulted in fewer late muscle precursors. Moreover, early-formed M cell descendants, which showed normal cell cycle arrest after RNAi treatment, overproliferated in the knockout strains (Fig. 2, B and C). Simultaneous inactivation of the fzr-1 cell cycle inhibitor synergistically increased the number of extra M lineage divisions in early development but did not suppress the reduced number of late M lineage divisions (fig. S2). On the basis of these knockout data, the SWI/SNF BAF complex appears to exert a critical function in cell number expansion, in addition to promoting cell cycle arrest and differentiation.

In contrast to the other conditional SWI/SNF mutants, swsn-2.1 knockout larvae remained normal. Two paralogous C. elegans genes, swsn-2.1 and swsn-2.2, encode BAF60-related SWI/SNF subunits, compared to three paralogs in mammals (14). When combined with swsn-2.2 RNAi, the swsn-2.1 knockout closely resembled the other conditional SWI/SNF gene knockouts (Fig. 2C). This indicates that swsn-2.1 and swsn-2.2 BAF60 act redundantly, and likely in combination with core subunits as well as SWSN-8 ARID1, in M-lineage control (Fig. 2C).

To assess whether the knockout phenotypes result from loss of the ATPase-dependent functions of the complex, we created an ATPase-dead swsn-4 allele by introducing a lysine-to-alanine (KA) mutation of a conserved residue that is essential for ATP hydrolysis (15) (Fig. 2A and fig. S2A). Because this mutant dies soon after hatching, we maintained the swsn4KA mutation in a trans-heterozygous combination with a wild-type or swsn-4Lox allele. Following M lineagespecific CRE expression, the swsn-4KA/swsn-4Lox mutant showed similar or somewhat stronger cell division abnormalities, compared with homozygous swsn-4Lox knockout animals (Fig. 2C and fig. S2). These data support that ATPase activity of the SWI/SNF BAF complex is required to promote both the cell cycle arrest of early body wall muscle (BWM) precursors and the expansion of egg-laying muscle precursor cells in late development.

We used promoter-fusion reporters and single-molecule FISH (smFISH) experiments to examine the proliferation-differentiation status of the SWI/SNF knockout cells. This showed residual hlh-8 Twist expression, which is normally restricted to undifferentiated muscle precursors (fig. S3, A and B) (16). Moreover, expression of the differentiation-specific myo-3 myosin heavy chain reporter was reduced at the time of normal BWM differentiation (17) (fig. S3, C and D). Further, expression of the S-phase cyclin cye-1 cyclin E was increased, and expression of the CDK inhibitor cki-1 Kip1 decreased compared with wild type, based on quantification of the number of mRNA copies per cell in smFISH experiments (fig. S3E). These data support that the extra cells in the conditional SWI/SNF knockout strains result from a prolonged proliferation-competent, not fully differentiated state compared with wild-type mesoblast descendants.

We considered whether different levels of SWI/SNF BAF may explain the opposite overproliferation and proliferation-arrest phenotypes. Dosage sensitivity of SWI/SNF complex functions has been implied by the spectrum of mutations detected in human cancer and intellectual disability disorders (11, 12, 18). When examined as the only alteration, a heterozygous swsn-4KA/wt BRG1/BRM mutation did not alter the mesoblast proliferation-differentiation pattern in our C. elegans model, with both the early-formed BWM and late-formed egg-laying muscle cells being normal in number and appearance (Fig. 3A and fig. S2D). By contrast, loss of the G1 inhibitors lin-23 -TrCP or cki-1 Kip1 leads to hyperplasia (2), which was enhanced by inactivation of a single swsn-4 allele. Specifically, we combined lin-23 RNAi and lineage-specific cki-1Lox knockout with a single inactive swsn-4 allele (swsn-4KA/wt) and observed significant increases in the number of M cell descendants (Fig. 3A). This haploinsufficiency indicates that the cell cycle arrest function of SWI/SNF BAF is highly sensitive to the expression level of the complex.

(A) Quantification of total number of mesoblast descendants for the indicated genotypes. *P 0.05, ****P 0.0001. (B) Quantification of mesoblast descendants for the indicated genotypes in the tail (early divisions) and around the vulva (late divisions). (C) Expression of SWSN-1::GFP in the M cell at 4 and 7 hours of larval development following gene knockout or gene knockout combined with protein degradation (+Prot. Deg.). Scale bars, 10 m. Arrows indicate mesoblast cells, outlined in zoom images (scale bars, 1 m). (D) Quantification of SWSN-1::GFP by fluorescence intensity in M for indicated times and genotypes (normalized to wild-type levels). (E) Quantifications of total numbers of mesoblast descendants for the indicated genotypes. (F) Representative images of strong overproliferation following SWSN-1 protein degradation and lin-23 RNAi (top), and of the one-cell arrest (arrow) after swsn-1 gene knockout together with protein degradation in lin-23 RNAi (bottom). Scale bars, 10 m. (G) Quantifications of mesoblast descendants for indicated genotypes, in the tail (early) and around the vulva (late). (H) Quantification of SWSN-1::GFP by fluorescence intensity in M descendants for indicated times and genotypes (normalized to wild-type levels). (I) Quantifications of total numbers of mesoblast descendants for the indicated genotypes and times. n numbers of worms scored for all panels in fig. S4D. A.U., arbitrary units.

More effectively than missing one allele of swsn-4, extra cell divisions result from RNAi of SWI/SNF BAF subunits, the swsn-1ts mutation (2), and, initially, SWI/SNF gene knockout. We hypothesized that in each of these situations, hyperplasia is associated with incomplete loss of SWI/SNF function. Following CRE-Loxmediated gene excision, residual mRNA and protein are initially present and will be depleted over time and with additional cell divisions. This means that a true null phenotype will follow gene excision after a certain delay and could be manifested as cell division arrest. To test this hypothesis, we sought to advance and increase SWI/SNF inactivation. First, we combined the swsn-1(os22ts) mutation with lineage-specific swsn-1 RNAi. Here, we expressed a swsn-1 double-stranded RNA (dsRNA) hairpin in the embryonic mesoblast, controlled by the hlh-8 Twist promoter. Compared with swsn-1(os22ts) and RNAi by feeding L1 larvae, the hairpin RNAi animals, with or without the swsn-1ts mutation, showed a phenotype more similar to the swsn-1 gene knockout, both in overproliferation of the early BWM precursors and in cell division arrest of the late-dividing egg-laying muscle precursors (Fig. 3B). Further, we also combined the lineage-specific hairpin RNAi with swsn-1 knockout to deplete swsn-1 mRNA earlier in development. This led to decreased numbers of both the early-dividing and late-dividing cells compared with the knockout alone. This illustrates that loss of SWI/SNF function may lead to either increased or reduced cell numbers, with stronger interference apparently resulting in fewer cells.

To further examine and control the degree of SWI/SNF gene inactivation, we made use of the combined insertion of a green fluorescent protein (GFP) tag and Lox sites into the endogenous swsn-1 gene (Fig. 2A). Following lineage-specific gene knockout, SWSN-1::GFP expression was still detectable in the mesoblast before (4 hours) and at the time (7 hours) of the first postembryonic cell division, although at progressively lower levels than observed in the wild type (Fig. 3, C and D). These observations support that despite SWI/SNF gene knockout, residual protein remains present during the early mesoblast divisions.

To create an acute null phenotype, we combined the conditional gene knockout with lineage-specific protein degradation. This was achieved by expressing an anti-GFP nanobody fusion protein (nanobody::ZIF-1) that targets GFP to a CUL-2based E3 ubiquitin ligase (19) and thereby triggers efficient SWSN-1::GFP proteolysis. To create a system for lineage-specific protein degradation, we integrated a transgene with a STOP-Lox cassette in between the ubiquitous eft-3 promoter and nanobody::ZIF-1 coding sequences (fig. S4, A and B). This way, CRE expression in the mesoblast can be used to induce protein degradation in parallel to swsn-1::gfp gene excision. This double inactivation approach reduced SWSN-1::GFP expression to undetectable levels before the first larval division (Fig. 3C). Nanobody-mediated degradation alone, without gene knockout, also led to strong SWSN-1::GFP depletion before the time of the first mesoblast cell division (Fig. 3D).

Notably, the effects of SWSN-1::GFP degradation alone versus degradation plus gene knockout were completely opposite. The combined SWSN-1::GFP protein degradation and gene knockout resulted in a complete block of cell division of the mesoblast in most animals (Fig. 3E). Even when combined with lin-23 knockdown, the single embryonic mesoblast did not enter cell division during larval development (Fig. 3, E and F, bottom). This result demonstrates that a certain level of the SWI/SNF complex is required for mesoblast proliferation. By contrast, lineage-specific SWSN-1::GFP protein degradation by itselfwithout gene knockoutresulted in strong overproliferation of early and late muscle precursor cells (Fig. 3G). The overproliferation of both early and late precursors was further enhanced by simultaneously interfering with negative cell cycle regulation (lin-23 RNAi; Fig. 3, E and F, top).

To further characterize the relationship between SWI/SNF levels and cell proliferation, we quantified SWSN-1::GFP levels over time during the course of the mesoblast divisions in the L1/L2 larval stages. We performed these experiments for three genetic backgrounds: the control reporter strain (wild type), the strains with the swsn-1::gfpLox conditional knockout alone, or the SWSN-1::GFP protein degradation alone (Fig. 3H and fig. S4C; note: combined knockout with protein degradation was excluded because of the complete arrest of M division). In parallel, we counted the numbers of mesoblast descendants over the same time period (Fig. 3I). We found that SWSN-1::GFP was initially invisible in the protein degradation alone strain (7 to 10 hours; Fig. 3, D and H), which corresponded to a temporary delay in cell division (Fig. 3I). At 14 hours of larval development, SWSN-1::GFP was reexpressed at low levels, and cell proliferation had resumed. Low levels of SWSN-1::GFP were maintained over the subsequent time points. Thus, SWSN-1 was present at a low level when protein degradation interfered with division arrest and induced overproliferation of M descendants (Fig. 3, H and I).

Upon swsn-1 knockout alone, SWSN-1::GFP levels declined only gradually and remained detectable throughout the initial rounds of cell division, which occurred at times similar to wild-type cell divisions (Fig. 3, H and I). At the time that wild-type cells normally exit the cell cycle, swsn-1 knockout cells briefly continued proliferation to reach cell quantities that resemble those scored in later stages (L4), and proliferation arrested during the time window in which SWSN-1::GFP reached undetectable levels (Fig. 3, B, H, and I). Together, these data demonstrate that the SWI/SNF complex exerts dosage-sensitive functions: A low amount is essential to allow proliferation, while a higher level is needed for temporal cell division arrest (fig. S4E).

To expand our analysis to a different cell type, we tested how different levels of SWI/SNF function affect the proliferation of epithelial cells. We chose to examine vulva formation, which is formed by descendants of the ventral cord precursor cells (Fig. 4A). The first postembryonic division of these cells generates a neuroblast and epithelial precursor. The central epithelial precursor cells acquire the potential to contribute cells to the vulva [vulval precursor cells (VPCs)]. Dependent on multiple integrated signal transduction pathways, these VPCs invariably generate 22 vulval cells during late larval development, which form a functional connection between the uterus and the outside by the adult stage (Fig. 4A) (20).

(A) The lineage of vulval development. The y axis indicates the time (hours) of larval development after hatching; vertical lines represent vulval precursor cells (VPCs), horizontal lines are cell divisions, and hyp7 denotes hypodermal fusion fate. (B) Maximum projection of the vulva after 40 hours of development, at the time when quantifications are carried out. Vulval nuclei express mCherry from the lineage-tracing reporter after Plin-31::CRE activity. Individual nuclei are easily identifiable. Scale bar, 10 m. See movie S1 for Z-stack. (C) Quantification of the number of vulval nuclei for the indicated genotypes. The lin-35(n745) mutation did not affect the VPC division pattern but was included to increase the efficiency of RNAi, as the neuroblast derived precursor (P) cells are relatively resistant to RNAi. Eleven to 90 animals were scored per condition. **P 0.01, ****P 0.0001. ns, not significant.

We combined our lineage-tracing reporter (Fig. 1D) with CRE expression from the lin-31 FOXB1 promoter, which is active in the VPCs. As expected, this resulted in mCherry-positive VPCs from the L2 stage onward (Fig. 4B). The most anterior of the six VPCs fuses with the surrounding epidermis (hypodermis) in 50% of the animals. We observed an equal distribution of animals with 5 or 6 VPCs, which always expanded to 22 cells by the end of the vulval cell divisions (Fig. 4, B and C, wild type). These cells expressed SWSN-1::GFP, as did all other cells throughout development (fig. S5A, top). Notably, weak inactivation of swsn-1, using the os22ts allele at a semipermissive temperature (20 or 21C) or RNAi, occasionally resulted in extra vulva cells, which was never observed in the wild type (Fig. 4C). In contrast, following swsn-1 RNAi or lineage-specific knockout, VPC daughter cell numbers were variably reduced. Complete inactivation through combined SWSN-1::GFP gene knockout and protein degradation resulted in a complete cell proliferation arrest of the VPCs (Fig. 4C; note: only five or six cells, corresponding to the undivided VPC number). We conclude that the SWI/SNF complex probably contributes to proliferation inhibition during vulva cell differentiation and that the essential SWI/SNF function in sustaining proliferation is conserved across multiple tissues in C. elegans.

SWI/SNF complexes oppose gene silencing by Polycomb repressor complexes PRC1 and PRC2 (11, 21, 22). Therefore, unrestrained PcG-mediated gene silencing might underlie the overproliferation and cell division arrest phenotypes of SWI/SNF knockout cells. To address this, we examined the contribution of MES-2, a H3K27 methyltransferase similar to EZH2, which is the critical catalytic component of the PRC2 complex (11, 21, 22). We generated GFP-tagged and mCherry-tagged endogenous alleles to visualize in vivo expression of MES-2 EZH2 and SWI/SNF BAF subunits. This revealed coexpression of PcG and SWI/SNF components throughout C. elegans development, and in all cell types, including the M lineage (fig. S5, A and B). Thus, removal of the antagonistic SWI/SNF complexes could, in principle, lead to prolonged or abnormal PcG-mediated gene silencing.

To be able to test whether unopposed PcG activity contributes to the SWI/SNF knockout phenotypes, we created conditional alleles of mes-2, again using CRE-Loxbased recombination of the endogenous gene, with or without a GFP tag (Fig. 5A). Nanobody::ZIF-induced protein degradation alone reduced MES-2::GFP below the detectable level (fig. S6A). As expected for PcG-mediated epigenetic repression, gene knockout of mes-2Lox, or even mes-2::gfpLox knockout combined with nanobody::ZIF-1 expression, did not immediately alter the M lineage. However, after four to seven rounds of cell division, mes-2 PRC2 inactivation resulted in a variable and partially penetrant premature arrest of cell divisionand possibly premature initiation of differentiation (fig. S6B).

(A) Schematic of Lox site integrations into the endogenous EZH2-related Polycomb gene mes-2, with Lox sites indicated by yellow diamonds. The transcriptional start site is indicated with an arrow, introns are shown as black lines, and exons as colored blocks. (B) Quantifications of mesoblast lineage descendants in the indicated genotypes, in the tail area (early-dividing BWM), and around the vulva (late-dividing egg-laying muscles). Thirteen to 27 animals were scored per condition. (C) Quantifications of total numbers of mesoblast lineage descendants in the indicated genotypes. Sixteen to 35 animals were scored per condition. *P 0.05, **P 0.01, ****P 0.0001.

When combined with knockout of mes-2, the overproliferation of early muscle precursor cells in SWI/SNF gene knockout animals was substantially reduced. The double knockout animals often showed close to wild-type BWM numbers (Fig. 5B). In agreement with previous RNAi experiments (2), these data support that SWI/SNF BAF promotes cell cycle arrest and differentiation of early muscle precursors, in part, by antagonizing Polycomb-mediated transcriptional repression.

Contrary to this early effect, the mes-2Lox knockout did not suppress the arrest of late mesoblast descendants in SWI/SNF mutants (Fig. 5B). The removal of mes-2 exacerbated the cell division arrest of SWI/SNF mutant late egg-laying muscle precursor cells (Fig. 5B). Because mes-2 and swsn-1 knockout both lead to reduced proliferation of late muscle precursors, we also examined the one-cell mesoblast arrest in L1. Acute double knockout of mes-2::gfp and swsn-1::gfp in the mesoblast gave rise to the single-cell arrest phenotype (Fig. 5C). Thus, PcG PRC2 loss, supported by complete absence of MES-2::GFP, did not alleviate the SWI/SNF complex requirement in cell proliferation. These data imply that the essential SWI/SNF complex function is separate from its antagonism of PcG-mediated gene repression.

The immediate arrest of swsn-1 null mesoblasts indicates that a SWI/SNF complex activity is continuously required. The arrested cells did not undergo cell death and remained present even in old adults. These observations appear consistent with SWI/SNF BAF requirement in inducing or sustaining cell proliferation. A previous study reported that SWI/SNF BAF promotes chromosome decatenation by promoting chromatin binding of topoisomerase IIA (23). While this function would be critical in mitosis, our quantitative measurements of DNA content showed that the arrested SWI/SNF null mesoblasts stopped the cell cycle before, or very early in, the S phase (Fig. 6A). We considered the possibility of a DNA damage or intraS phase checkpointinduced arrest, as SWI/SNF complexes have also been implicated in DNA damage repair and replication (6, 24). To test whether such checkpoints are responsible for the one-cell arrest, we added high concentrations of exogenous deoxynucleotide triphosphates (dNTPs), which has been reported to bypass DNA damagemediated arrests (25). Further, we also performed RNAi of chk-1 Chk1 and double RNAi of lin-35 Rb and cep-1 p53, conditions that also should prevent DNA damagemediated checkpoint arrest (26). As none of these conditions affected the single-cell arrest phenotype, evidence for checkpoint arrest was not obtained (Fig. 6B).

(A) Quantification of M cell DNA content in synchronized L1 larvae after 7 hours of development for the indicated genotypes. Wild-type M cells have undergone the S phase but not yet divided, leading to a 4C DNA content, whereas M cells in swsn-1::gfpLox + Prot. Deg. animals show an approximately 2C DNA content, indicative of cells arresting in the G1/early S phase. DNA was stained with propidium iodide, and DNA content normalized to that of differentiated embryonic BWM cells (2C). (B) Quantifications of mesoblast descendants for the indicated genotypes and treatments in L1 larvae. Fourteen to 28 animals were quantified per condition. (C) Principal components analysis (PCA) indicating clustering of replicate RNA-seq libraries, prepared from fluorescence-activated cell sorting (FACS)sorted 2000-cell samples from wild-type and swsn-1::gfpLox + Prot. Deg. L1 larvae at 5.5 hours of development. Samples A and B are true biological replicates, with RNA-seq libraries prepared from different starting populations of synchronized worms. Within A and B, duplicate/triplicate RNA-seq libraries were prepared from different 2000-cell populations, isolated from the same starting worm population, and can thus be considered semibiological replicates. (D) Volcano plot indicating differentially expressed genes between swsn-1::gfpLox + Prot. Deg. and wild-type isolated mesoblast cells at 5.5 hours of development. (E) Quantifications of the number of mRNA molecules per cell in smFISH experiments for the indicated genes, in synchronized L1 larvae at 6.5 hours of larval development (just before the usual first M division), and in wild-type compared with swsn-1::gfpLox + Prot. Deg. Twenty to 27 animals were scored per condition. **P 0.05.

We performed whole transcriptome RNA-seq to further characterize the arrested cells. We used pools of 2000 wild-type or acute swsn-1 knockout mesoblasts, isolated from synchronous cultures of L1 larvae at 5.5 hours of development (1 to 1.5 hours before the normal time of the first mitosis). Principal components analysis (PCA) showed a clear separation of the wild-type and mutant sequence data sets (Fig. 6C). Nevertheless, only a limited number of genes showed significantly different expression, of which the large majority were reduced in the SWSN-1depleted mesoblasts (213 genes; table S2). Among those, cell cycle genes were well represented, in particular presumed E2F targets (e.g., cdc-25.2, cdk-1, cyb-1 cyclin B1, and cyb-3 cyclin B3) (Fig. 6D, red boxes). These genes encode regulators of the G2/M transition and are expected to be expressed in wild-type cells, which at this stage are preparing for mitosis, but not in G1-arrested acute swsn-1 knockout cells. Therefore, the reduced transcript levels of these cell cycle genes may result indirectly from the early cell cycle arrest of swsn-1 mutant mesoblasts.

Regulators of the G1/S transition, such as cdk-4 CDK4/6, cye-1 cyclin E, cki-1 p21, and lin-35 Rb, showed similar expression in wild-type and arrested mesoblasts (Fig. 6D, gray boxes). As a possible exception, cyd-1 cyclin D transcripts were significantly reduced in one of the two biological replicates of swsn-1 mutant mesoblasts. As cyclin D transcription is an important regulator of cell cycle entry, we followed up on this finding by examining transcript numbers with single-cell resolution. Using smFISH, we observed that the number of cyd-1 mRNA molecules was much lower in swsn-1 mutant mesoblasts, compared with normal mesoblasts before the first cell division (Fig. 6E). These observations point to cyd-1 as a candidate for being a direct SWI/SNF target. RNAi of critical cyd-1 downstream targets, lin-35 Rb, and fzr-1 FZR1/Cdh1 (27), did not suppress the one-cell arrest, which indicates that cyd-1 is not the only critical gene to depend on the SWI/SNF complex. Together, our data demonstrate a continuous requirement for SWI/SNF BAF complexes in normal transcription and proliferation control.

In this study, we examined SWI/SNF and PcG complex functions in an in vivo system that provides a well-defined cellular context and reproducible developmental decisions. Our gene knockdown and knockout experiments demonstrate that in the same cell type and developmental stage, reducing the level of SWI/SNF core subunits or C. elegans ARID1 interferes with cell cycle exit, while complete inactivation of the identical subunits is incompatible with cell proliferation. Our quantifications of residual SWSN-1 protein amounts and cell numbers over time, following different treatments, indicate that hyperplasia is consistently associated with a reduced but detectable level of SWSN-1. The timing of overproliferation and gene expression studies support that the reduced SWI/SNF levels result in suspended cell cycle withdrawal associated with precursor cell differentiation. By contrast, a complete SWI/SNF inactivation appeared capable of arresting cell division at any point in the mesoblast and VPC lineages. Therefore, we conclude that a low level of SWI/SNF activity is continuously needed, independently of cellular context, to support cellular proliferation (fig. S4E). Together with EZH2 knockout studies, our data imply that the SWI/SNF BAF ATPase exerts a tumor suppressor function in the mesoblast lineage that requires a relatively high functional level and involves PcG opposition, while a low level is essential and sufficient to sustain cell proliferation. Our data are consistent with the model that partial loss-of-function SWI/SNF gene mutations are selected during carcinogenesis because they reduce a differentiation-promoting tumor suppressor activity without inactivating the critical requirement for the SWI/SNF complex.

That the function of SWI/SNF complexes is dosage sensitive is also indicated by the heterozygous and sometimes subtle mutations in SWI/SNF subunits identified in human cancer and neurologic disease (6, 12). Several mechanisms have been proposed to explain the remarkable mutation spectrum. Mutation or deletion of specific SWI/SNF subunits could lead to the formation of complexes with alternative or aberrant composition and activities (28, 29). In certain cases, mutations appear to lead to neomorphic gain of function or dominant-negative inhibition and thereby promote cancer formation or neurologic disease (12, 30). Moreover, mutations could affect the fidelity of DNA repair or chromosome segregation and indirectly contribute to tumorigenesis. Alternatively and more in line with our observations, various subunits of the SWI/SNF complex may be haploinsufficient if a single wild-type allele is not sufficient to maintain normal tumor suppression or development (68).

In our system, incomplete inactivation of multiple different BAF components, including the single ATPase and BAF-specific ARID1 subunit, results in very similar hyperplasia phenotypes. This indicates that the reduced SWI/SNF function, rather than the activity of complexes with an abnormal subunit composition, leads to overproliferation. Hyperplasia was observed early and reproducibly after SWI/SNF BAF gene knockout or protein degradation. This implies that the hyperplastic response in our system does not depend on a dominant-negative mechanism or on the generation of secondary mutations. In addition to dominant loss-of-function mutations, cancer typespecific gain of function and dominant-negative mutations affect specific SWI/SNF subunits. As such, common heterozygous mutations in the BRG1 ATPase selected in human cancer are likely to act in a dominant-negative way (30). Nevertheless, such mutations do not fully inactivate the wild-type allele, and residual BRG1 function is thus retained in the heterozygotes. The importance of residual SWI/SNF function seen in our system was previously revealed in synthetic lethal screens. Such screens and follow-up experiments demonstrated that ARID1B is essential in ARID1A mutant cancers, while tumors with mutations in the BRG1 (SMARCA4) ATPase depend on BRM (SMARCA2) (28, 31, 32).

Some cancer cells, however, appear to survive without SWI/SNF function. Malignant rhabdoid tumors are well known for their homozygous loss of SNF5 (SMARCB1), one of the core subunits of SWI/SNF complexes. Although initially expected to fully disable SWI/SNF complexes, SNF5-deficient cancer formation was found to depend on the presence of BRG1 (29). Recent studies revealed the existence of ncBAF complexes that do not contain SNF5, while removal of non-canonical BAF (ncBAF)specific subunits induces synthetic lethality in cancer cells lacking SNF5 (9, 33). Thus, in the best-described examples of homozygous SWI/SNF core subunit loss, cell proliferation still depends on the presence of residual SWI/SNF complex activity, in this case provided by the atypical SWI/SNF ATPase ncBAF (9, 33). In a specific small cell carcinoma of the ovary and a subset of cancer-derived cell lines, biallelic mutation of BRG1 coincides with transcriptional silencing of the BRM locus (6, 10, 34). Although it is difficult to exclude that a trace amount of residual BRM permits the proliferation of these cells, activation of compensatory mechanisms may allow complete loss of SWI/SNF ATPase activity in some cell types.

In our study, interfering with any one of the BAF complex subunits induced hyperplasia or cell proliferation arrest, depending on partial or complete removal. We characterized this thoroughly for SWNF-1, the sole homolog of the scaffold subunits BAF155/170. This subunit is shared between all SWI/SNF complexes, and without it, no version of the complex can assemble (9). Therefore, rather than changing the SWI/SNF subunit composition and allowing the formation of aberrant residual complexes, we affected the global levels of SWI/SNF activity. As such, our data support that the complete loss of all SWI/SNF ATPase activity is incompatible with cell proliferation and that there are perhaps overlapping core functions for all of the different SWI/SNF variants in promoting a proliferation-competent state.

Several mechanisms could underlie the dosage sensitivity of SWI/SNF functions. In our system, a high dosage is needed when cells transition to a differentiated state, at which time many loci are transcriptionally activated or silenced. Compared with altering the chromatin state during gene activation or silencing, the maintenance of gene expression may require lower levels of the SWI/SNF complex. If true, then partial SWI/SNF inactivation will interfere with differentiation but not continued proliferation, which would provide a mechanism promoting tumorigenesis. Possibly in support of such a mechanism, SMARCB1 or SMARCA4 gene knockout in mouse embryonic fibroblasts (MEFs) most significantly reduced the transcript numbers from genes with gene ontology (GO) terms associated with development and differentiation (35).

In our experiments, the essential SWI/SNF function appeared independent from PRC2-mediated gene silencing. Other activities of the complex, such as chromatin remodeling, could be critical for mesoblast and VPC proliferation. Both knockout MEF cells and embryonic stem cells with heterozygous dominant-negative alleles of BRG1 showed a broad reduction in chromatin accessibility at active enhancers, which was remarkably associated with loss of H3K27Ac rather than increased PcG protein binding (30, 35). These studies did not reveal whether widespread transcriptional deregulation, reduced expression of some critical genes, or other defects are incompatible with cellular proliferation when the SWI/SNF activity falls below a critical level. Our RNA-seq analysis showed that the acute arrest of mesoblast proliferation occurred when the expression of a limited number of genes was significantly altered. We identified C. elegans cyclin D as one of the genes whose transcription is acutely sensitive to SWI/SNF inactivation. In contrast to cyd-1 mutants, the proliferation arrest associated with strong SWI/SNF loss was insensitive to knockdown of cell cycle inhibitors (27, 36). Therefore, we expect that the down-regulation of cyd-1 and other critical genes is responsible for the tight cell cycle arrest. Two recent human cancer studies also concluded that SWI/SNF ATPases promote cyclin D1 expression (37, 38).

That loss of function of SWI/SNF subunits can lead to opposite phenotypes (hyperplasia versus division arrest), depending on residual complex levels, provides support for the clinical exploration of cancer cell vulnerabilities that result from SWI/SNF gene mutations (39). At the same time, the delicate balance between dosage-dependent SWI/SNF and PcG regulators observed in our system illustrates that the outcome of targeted therapies will be difficult to predict and highly context dependent. The many parallels between observations in our system and human cancer cells support that efficient genetic screens in C. elegans may help identify synthetic lethal interactions that are broadly associated with SWI/SNF loss and cause little toxicity in normal cells.

Genotypes of all strains used in this study are listed in table S1. C. elegans was cultured on nematode growth media (NGM) plates seeded with OP50 bacteria and generally maintained at 20C. Strains containing the pha-1(e2123) mutation were maintained at 15C and shifted to 25C for mutant phenotype analysis.

Bacterial cultures of Escherichia coli HT115 containing L4440 empty vector or vector with genomic or open reading frame (ORF) gene inserts were grown overnight, induced with 1 mM isopropyl--d-thiogalactopyranoside (IPTG) for 1 hour, concentrated 2.5 times, and seeded onto NGM plates containing tetracycline (12.5 g/ml), ampicillin (100 g/ml), and 2 mM IPTG. Early L1 larvae were exposed to feeding RNAi for knockdown of SWI/SNF components, and the number of mesoblast descendants was analyzed in late L3/early L4 animals of the same generation. swsn-1, swsn-4, swsn-8, swsn-7, swsn-9, swsn-2.2, swsn-3, swsn-6, and phf-10 RNAi vectors were cloned by ligating a ~1000-bp complementary DNA (cDNA) fragment into the L4440 vector. When examining contributions of lin-23, chk-1, lin-35, or cep-1, L4 animals were placed on RNAi plates and the F1 was analyzed.

Single-copy integration of the recombination reporter (readoutlox; Peft-3::LoxP::egl-13NLS::tagBFP2::tbb-2UTR::LoxP::egl-13NLS::mCherry::tbb-2UTR) into chromosomes III and V standard MosSCI sites was performed as described in (2). The Phlh-8::swsn-1::unc-54 untranslated region (UTR) hairpin construct was generated by inserting a ~1100-bp swsn-1 cDNA fragment, followed by the antisense sequence of the same ~1100-bp swsn-1 cDNA fragment including a stop codon, after the Phlh-8 promoter. See fig. S5 for details on the anti-GFP nanobodyZIF-1 construct.

All Lox insertions, as well as the ATPase dead swsn-4 mutant, were generated by temperature-sensitive pha-1 coconversion (40) using single-stranded DNA oligonucleotides with 40-bp homology arms as repair templates. For pha-1 coconversion, seven times outcrossed pha-1(e2123) young adults, grown at the permissive temperature of 15C, were injected into the gonads with the following injection mix: U6::gRNA target construct (50 ng/l), pJW1285 (60 ng/l; U6::gRNA pha-1 and Cas9 construct), and single-stranded DNA repair templates (50 ng/l) for pha-1 as well as the appropriate target. Injected worms were immediately placed at 25C. F1 rescued pha-1 animals were analyzed by polymerase chain reaction (PCR) amplification, using primers flanking the Lox insertion site, for the presence of a reduced-mobility DNA band indicative of Lox site insertion. The swsn-4 K-to-A mutation was generated in a strain with a GFP-expression cassette, eft-3::GFP::2NLS::tbb-2 3UTR, integrated on chromosome IV close to the swsn-4 locus. By selecting GFP-positive animals, the homozygous lethal swsn-4 ATPase-dead mutation can be easily maintained. All mutations were sequence verified. The swsn-1::egfpLoxP strain was generated by inserting enhanced GFP (eGFP) using the self-excising cassette (SEC) method (41) into wild-type N2 worms, which leaves a LoxP scar. The injection mix contained the following: U6::gRNA target construct (100 ng/l), pDD268 eGFP SEC vector (20 ng/l) with 150-bp swsn-1 left homology arm and swsn-1 600-bp right homology arm, Peft-3::Cas9 (50 ng/l; Addgene 46168), and Pmyo-2::tdTomato (2.5 ng/l). The second LoxP site was introduced by crossing the strain with pha-1(e2123) and by temperature-sensitive pha-1 coconversion as described above. The mes-2::egfpLoxN strain was made by inserting eGFP with a LoxN site in one of the GFP introns into a strain that already contained a LoxN site in the first intron of mes-2.

For analysis and quantification, animals were mounted on 3% agarose slides, using tetramisole (10 mM) in M9 plus 0.05% Tween (36). Combining Phlh-8::CRE with the lineage-tracing reporter allowed rapid identification of cells in the mesoblast lineage (mCherry positive), whereas Plin-31::CRE was used to visualize VPC daughter cells. The numbers of M descendants and VPC descendants were quantified by counting the number of mCherry-positive cells at specific developmental times. Images of the proliferation phenotypes were obtained using a Zeiss LSM700 confocal microscope. SWSN-1::GFP fluorescence intensities were quantified by using the ImageJ measurement tool, selecting the region of interest (ROI; M cell nucleus), and subtracting the background signal (same ROI, not including GFP-positive cells in the same larva). At least 16 larvae per condition were measured.

To quantify vulval nuclei, animals were synchronized using hypochlorite treatment and grown for 40 (tracing-reporter controls, swsn-1ts, or knockout) or 50 hours [strains containing lin-35(n745) mutation and protein degradation strains) at 20C unless indicated otherwise. Still images and Z-stacks were taken using a 63/1.4 numerical aperture lens on a Zeiss Axioplan microscope or a Zeiss confocal microscope, with a slice interval of 0.32 m for Z-stacks. Vulval cell quantifications were performed on the basis of Z-stacks.

smFISH was performed essentially as described in (2). Cy5-coupled probes against mRNAs of interest were ordered from Stellaris (http://singlemoleculefish.com/), with 23 to 48 probes per gene of interest ranging from 18 to 22 bp in length. L1 or L4 animals were fixed for 30 min at room temperature (RT) in 400 l of Bouins fixative + 400 l of methanol and 10 l of -mercaptoethanol, three times freeze thawed and again tumbled for 30 min in fixative at RT. For permeabilization, the fixative was removed and exchanged for borateTriton-mercaptoethanol (BTB; 1 borate buffer, 0.5% Triton, and 2% -mercaptoethanol) solution. Animals were tumbled three times for 1 hour in BTB solution at RT. BTB solution was then replaced with wash buffer A (Stellaris) containing 20% formamide, and then with 100 l of hybridization solution containing smFISH probes to a final concentration of 0.25 to 0.5 M, and incubated overnight at 32C. Samples were washed in wash buffer A without formamide and incubated with 0.05 ng of 4,6-diamidino-2-phenylindole (DAPI) in wash buffer A for 30 min at 32C. After a final wash in wash buffer B (Stellaris), animals were mounted on slides with Vectashield mounting medium and imaged within 4 hours. Images were acquired using a Nikon Eclipse Ti Spinning Disk confocal microscope, using a 100 objective. The tetramethylrhodamine (TMR) (mCherry) spots were used to draw an ROI around (mCherry-positive) M lineage descendants in ImageJ, in which the number of Cy5 fluorescent mRNA spots was quantified using the ComDet plugin in ImageJ [https://imagej.net/Spots_colocalization_(ComDet)].

Sample sizes were not predetermined; instead, all available animals of the right stage and genotype were counted. smFISH data are included from at least 8 independent animals, and reporter expression and cell numbers from at least 10 independent animals. Graphs and data analysis were produced using GraphPad Prism 6.05. Plots indicate all data points and the mean (average) SEM. As the data essentially fit normal distributions, unpaired two-tailed Students t tests were used to examine statistical significance of the difference between means.

Propidium iodide staining was carried out after Carnoys fixation as previously described (42). For DNA quantification, Z-stacks were acquired using a Zeiss LSM700 confocal microscope. Maximum projections (SUM) were made in ImageJ from all the stacks in which the M cell DNA was visible, and pixels were quantified using ImageJ. Postmitotic, differentiated BWM cells (2C) were quantified in the same manner and used as a reference.

The C. elegans L1 larval cell isolation protocol was adapted from (36). To generate large amounts of synchronized L1 larvae, worms were grown in S medium in liquid culture for two generations (to enrich for gravid adults) and bleached. Eggs were hatched overnight (for 18 to 22 hours) in S medium without food, and starved L1 larvae were split into three aliquots and put back into S medium with OP50 for 5.5 hours. Cultures were put on ice for 15 min, spun down at 1300g, and washed two times in M9 and once in H20. L1 larvae were then transferred to 1.5-ml Eppendorf tubes (20 to 40 l of L1 pellet per Eppendorf) and spun down at 16,000g. Larvae were treated with SDSdithiothreitol (DTT) solution (20 mM Hepes, pH 8.0, 0.25% SDS, 200 mM DTT, and 3% sucrose) for 2 min, washed six times in egg buffer (25 mM Hepes, pH 7.3, 118 mM NaCl, 48 mM KCl, 2 mM CaCl2, and 2 mM MgCl2, adjusted to 340 5 mOsm with H2O), and then treated with pronase E (20 mg/ml) in L15/fetal bovine serum (FBS) buffer [10% FBS and 1% penicillin-streptomycin (Sigma, P4458) in L15 insect medium, adjusted to 340 5 mOsm with 60% sucrose] for 30 to 40 min. After 10- and 20-min incubation in pronase E, a pellet pestle motor with a pellet pestle adapted to 1.5-ml microtubes (Sigma, Z359971 and Z359947) was used for 1 min on each sample. Last, cell preparations were washed three times in L15/FBS, spun down at 9600g for 5 min between each wash, and resuspended in 1 ml of L15/FBS.

Cell preparations were allowed to settle on ice for 30 min, and the top 850 l of the supernatant was removed and transferred to a new Eppendorf tube for fluorescence-activated cell sorting (FACS). Cells were sorted according to mCherry-positive signal using a BD FACSAria III (BD Biosciences). For each sample, 2000 cells were sorted into L15/FBS buffer. In one session, three wild-type and three mutant samples were sorted. Immediately after sorting, cells were spun down at 12,000g for 5 min, resuspended in TRIzol, and frozen at 80C.

cDNA libraries were prepared according to a combination of the CEL-Seq and CEL-Seq2 protocols with some modifications (43, 44). RNA was precipitated using chloroform/isopropanol precipitation at 20C for 48 to 72 hours and washed once in 75% ethanol. CEL-Seq2 primers were used (one unique primer per sample), with each primer containing an anchored polyT, a 6-bp unique barcode, 6-bp Unique molecular identifier (UMI), a 5 Illumina adaptor, and a T7 promoter. The CEL-Seq1 protocol was followed for a first round of reverse transcription and cDNA cleanup followed by in vitro transcription, as well as for fragmentation of amplified RNA (aRNA), as described (43). aRNA was run on an Agilent bioanalyzer [RNA picochromatin immunoprecipitation (ChIP)] for quality control and quantification. The CEL-Seq2 protocol was followed for a second round of reverse transcription and PCR amplification, as described (44). cDNA was amplified for 11 to 15 cycles depending on aRNA amounts, run on an Agilent bioanalyzer (DNA pico-ChIP), quantified using a Qubit, and 1 to 2 ng was sequenced with 5% coverage on an Illumina NextSeq500.

Data analysis was carried out in R version 3.4.4. PCA was performed with the plotPCA function after carrying out variance-stabilized transformation on the data. Differential gene expression was analyzed using DESeq2 (default settings) using a padj cutoff of 0.1 (45).

Acknowledgments: We are grateful to members of the Korswagen and Van Oudenaarden groups at the Hubrecht Institute for help with RNA-seq experiments, and to P. Verrijzer and members of the Van den Heuvel and Boxem groups for input, discussion, and comments on the manuscript. Several strains were provided by the CGC, which is funded by the NIH National Center for Research Resources (NCRR). Funding: This work was supported by Worldwide Cancer Research (WCR) grant 14-1294, and M.G. was supported by the EMBO Long-Term Fellowship ALTF 991-2016. Author contributions: A.v.d.V. performed most of the SWI/SNF knockdown and knockout experiments, analyzed the results, and cowrote the paper. M.G. generated cki-1Lox and mes-2::gfpLox strains; performed the smFISH, DNA and protein quantifications, and RNA-seq experiments; analyzed the results; and cowrote the paper. V.P. generated the anti-GFP nanobody::ZIF-1 construct and strains, performed the VPC experiments, and contributed to the experimental design. S.v.d.H. conceived the study, acquired funding, provided guidance with experimental design, and cowrote the manuscript. 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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Ultrasound-Guided Lumbar Intradiscal Injection for Discogenic Pain: Te | JPR – Dove Medical Press

Tsung-Ju Wu,1,2 Chen-Yu Hung,3 Chih-Wei Lee,4 Stanley Lam,5 Thomas B Clark,6 Ke-Vin Chang3

1Graduate Institute of Basic Medical Science, China Medical University, Taichung, Taiwan; 2Department of Physical Medicine and Rehabilitation, Yuanlin Christian Hospital, Changhua, Taiwan; 3Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Bei-Hu Branch, Taipei, Taiwan; 4Department of Medical Imaging, Changhua Christian Hospital, Changhua, Taiwan; 5Department of Family Medicine, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong; 6Private Practice Ultrasonographic Training, Vista, CA, USA

Correspondence: Chen-Yu HungDepartment of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Bei-Hu Branch, Taipei, TaiwanEmail chenyu810@gmail.com

Abstract: We described two cases and the techniques for using the ultrasound (US) to guide lumbar intradiscal injection with platelet-rich plasma (PRP). The two cases suffered from chronic low back pain. Magnetic resonance imaging revealed posterior annular tear of the L5/S1 intervertebral disc (IVD) in the first case and L4/5 and L5/S1 IVDs in the second case. For the US-guided lumbar intradiscal injection, the patient was placed in a prone position. By placing the transducer in the axial plane at the interlaminar space, the needle was directed toward the center of the aimed IVD. The needle tip was ensured inside the IVD by using the end-feel of sudden reduction of resistance and the poking technique with the transducer oriented in the paramedian sagittal oblique plane. At the follow-up, both patients had significant improvement after the intradiscal PRP injections (visual analogue scale from 7.5 to 1.5 on average). The report indicated US-guided lumbar intradiscal PRP injection to be a feasible approach for treatments of low back pain. Familiarization of the anatomy and sonoanatomy of the lumbar spine is fundamental to achieve the success of intradiscal injection.

Keywords: low back pain, lumbar spine, ultrasound, platelet-rich plasma, intervertebral disc

This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution - Non Commercial (unported, v3.0) License.By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms.

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COVID-19: Recommendations for Treating MS and Related… : Neurology Today – LWW Journals

Article In Brief

Most therapies for multiple sclerosis and neuromyelitis optica spectrum disorder should be continued and not stopped during the COVID-19 pandemic, MS experts agree. But there are also pros and cons of starting certain B-cell depleting and other therapies.

For most patients with multiple sclerosis (MS), the benefits of staying on therapy will outweigh the risks of stopping due to concerns over COVID-19, according to new guidelines for treating MS during the pandemic.

Even in those with a documented mild case of COVID-19, continued treatment with most MS medications may be reasonable, the guidelines recommend. However, they emphasize: Neurologists should have a lower threshold for stopping treatment in people taking therapies with greater immunosuppressive effects and those with risk factors for a more severe disease (older age, comorbidities), or if COVID-19 symptoms are deteriorating.

Published online in Neurology on April 2 by a team of MS neurologists from the United States, Australia, The Netherlands, and the United Kingdom, the new guidelines cover both MS and neuromyelitis optica (NMO) spectrum disorder. The guidelines differ only slightly from guidelines previously released by the National Multiple Sclerosis Society, the Italian Society of Neurology, and other groups.

Even so, MS neurologists not involved in preparing the recommendations welcomed their publication.

Kudos to the authors for taking the time to do this when we're all under so much pressure, said Annette Langer-Gould, MD, PhD, the regional lead for clinical and translational neuroscience for the Southern California Permanente Medical Group/Kaiser Permanente.

Based on prior experience with other viral infections in people with MS, the recommendations will likely need to be updated as data emerges from actual cases of patients who develop COVID-19.

New data are emerging quickly from clinical experience and from registries that have been established for MS patients with COVID-19, said the first author of the paper, Wallace Brownlee, MD, PhD, a neurologist with the Queen Square MS Centre and the National Hospital for Neurology and Neurosurgery in London.

Indeed, one recommendation in the paper is already out of date. Face masks are only recommended for people who are coughing or sneezing, or for those caring for a patient with suspected COVID-19 infection, the guidelines stated. By now, of course, most public health recommendations call for wearing face masks whenever people are in public and are unable to stay at least six feet away from others.

Otherwise, MS neurologists told Neurology Today that they had few if any disagreements with the guidelines as published. In particular, they all agreed that IV treatments with drugs known to cause significant declines in immune function should be avoided or delayed as long as possible.

Dr. Brownlee and other MS neurologists urged any neurologist treating a patient with MS who develops a COVID-19 infection to submit data to one of the patient registries that have been established. In North America, the National MS Society and the Consortium of MS Centers have established the Coronavirus and MS Reporting Database at http://www.covims.org.

For MS patients who are just beginning treatment, Dr. Brownlee said, We recommend that neurologists take a cautious approach to initiating patients on treatments that can be associated with periods of significant immune suppression, including autologous hematopoietic stem cell transplantation, alemtuzumab and cladribine.

Although acute MS relapses are often treated with a short course of high-dose IV methylprednisolone, such treatments should be avoided during the pandemic, the guidelines stated. High-dose steroids hasten the recovery from MS relapses, but do not influence the final degree of recovery, the paper noted. Because steroids can increase the risk of infection, neurologists should have a higher threshold for offering them during the COVID-19 pandemic, according to the guidelines.

A few disease-modifying therapies (DMTs), including interferon-beta and glatiramer acetate, do not increase the risk of systemic infections. Other DMTs, however, do have immunosuppressive effects with alterations in lymphocyte number, trafficking, proliferation and function, with an increased risk of infections, including viral infections and respiratory infections, the guidelines stated.

People with MS who are profoundly lymphopenic, for example, after treatment with alemtuzumab or less commonly during treatment with cladribine, fingolimod or dimethyl fumarate, may be at higher risk.

As reasonable as such concerns appear to be at this time, the paper noted that no data specific to MS patients with COVID-19 has yet emerged supporting them.

For patients scheduled for routine treatment with alemtuzumab or cladribine, We recommend delaying treatment with these therapies, the paper stated. Likewise, standard every six-month dosing with ocrelizumab or rituximab can also be delayed in most cases.

B-cell depletion frequently lasts much longer than the scheduled dosing interval, the recommendations noted. Extended interval dosing should be considered, especially in patients who are B-cell depleted...or [in] those with low levels of immunoglobulin-G. Extended interval dosing is already widely used in patients treated with natalizumab because of observational data showing a reduced risk of progressive multifocal leukoencephalopathy. Whether this approach reduces the risk of other infections is unknown but should be considered during the COVID-19 pandemic to reduce hospital visits.

For MS patients who are hospitalized with a severe COVID-19 infection, consideration should be given to stopping treatment, the guidelines state. Treatment can be restarted after four weeks, or when symptoms have fully resolved, keeping in mind the risk of rebound MS activity with S1P modulators and natalizumab. Neurologists should alert intensive care physicians to the importance of fever management in people with MS.

Patients with neuromyelitis optica spectrum disorder who do not have a COVID-19 infection should be encouraged to continue attack-prevention therapies, because relapses of NMOSD can be devastating. If the need to stop or delay treatment in such patients arises, then moderate dose corticosteroids (e.g. prednisolone 20mg) can be used to prevent relapses in the short to medium term, the guidelines recommended.

Dr. Langer-Gould echoed the guidelines' concern about MS drugs associated with lymphopenia.

With COVID-19, we're seeing something very unusualthat in the people who do poorly, almost all of them have lymphopenia when they're admitted, she said. Any drug you're on that is causing T-cell lymphopenia is more likely to increase your risk of getting a severe case of COVID. So they have correctly identified the ones to stay away from, including alemtuzumab and cladribine, but I would add fingolimod, dimethyl fumarate and other S1P modulators to that list.

Starting in early March, she said, We actively reached out to patients on dimethyl fumarate and S1P inhibitors and are switching them, depending on their disease severity, either to interferon and glatiramer acetate, or if they had active disease, then we switched them to either rituximab or natalizumab.

But for all her patients other than those on interferon-beta or glatiramer acetate, she said, We're telling them to consider themselves immune-suppressed. They should immediately get themselves tested for COVID-19 if they develop fever or shortness of breath.

Her practice recently had an MS patient who had been stable on natalizumab until suddenly developing a high titer positive antibodies against JC Virus. The patient is now at increased risk of progressive multifocal leukoencephalopathy, Dr. Langer-Gould said.

Our plan had been to switch them to rituximab, but then they developed a COVID-19 infection and are mildly symptomatic. That's a big problem, because you need to pre-treat for rituximab with steroids, potentially increasing the risk of a more severe case of COVID-19, and the infusion is long, which raises the risk of infecting the nursing staff at the infusion center. We've decided to give her another dose of natalizumab eight weeks after her last dose. It's a short infusion, and we don't have to pre-treat with steroids. But what's the right decision?

Timothy L. Vollmer, MD, FAAN, professor of neurology at the University of Colorado Health Sciences Center and medical director of the Rocky Mountain MS Center, said that most of his group's patients are on ocrelizumab.

We probably didn't need to be dosing patients every six months, he said. As a result of COVID-19, we're reevaluating the dosing strategy. We're checking their B cells and antibody levels, and if they are still depleted, we wait another two months. It will take some patients a year or more before they begin to normalize their B cells. Dosing less frequently will also decrease costs substantially and make the drug more attractive for patients to use.

One clear effect of the COVID-19 pandemic is that many MS patients are reaching out to their neurologists about what it means for them.

My colleagues and I have been receiving many phone calls and messages about our recommendations, said Bardia Nourbakhsh, MD, assistant professor of neurology at Johns Hopkins. We try to extrapolate the information that we have from other viral infections.

Dr. Nourbakhsh said he had been contacted the week of April 13 by a community neurologist whose patient had developed a severe, disabling, demyelinating relapse that did not improve after IV steroids.

My recommendation was for the neurologist to set up a plasma exchange, he said. I would not delay the treatment of a serious relapse that could affect the mobility or vision of the patient. Treating an actual condition takes precedence over the possibility of coming into contact with coronavirus.

Bianca Weinstock-Guttman, MD, director of the Jacobs MC Center at the University of Buffalo and director of its Pediatric MS Center of Excellence, said she recommends that all MS patients should be reminded, now more than ever, to follow basic daily health recommendations.

Supportive recommendations for patients include keeping interactions with friends and relatives through video, exercising via YouTube, maintaining a healthy diet, and vitamin supplementation, especially vitamin D, she said.

Joseph Berger, MD, FAAN, professor and associate chief of the Multiple Sclerosis Division at the University of Pennsylvania School of Medicine, noted that the very same tendency of some MS drugs to suppress immune function could in fact benefit COVID-19 patients who develop acute respiratory distress syndrome (ARDS).

Individuals who end up developing ARDS are not dying because of unsuppressed viral replication, Dr. Berger said. Rather, it's an overly robust immune response, a cytokine storm, that appears to give rise to the ARDS. Many of the drugs we use may actually have a beneficial effect on the phase of the illness that results in high morbidity and mortality.

He pointed out that a non-randomized, open-label trial is underway in China to test the effect of giving fingolimod to 30 patients with COVID-19 in order to prevent ARDS.

Dr. Weinstock-Guttman said another drug that might block the cytokine storm is tocilizumab, approved to treat moderate to severe rheumatoid arthritis.

IL-6 blockade was shown beneficial recently also for NMO patients, so it will be interesting to see COVID-19 patients' outcome when treated with antiIL-6 products for a previous underlying disease, Dr. Weinstock-Guttman said.

Dr. Langer-Gould expressed caution about the approach. There's a big difference between using a drug like fingolimod for a few days to reduce a cytokine storm versus having someone on it as a long-term therapy, which results in chronic T-cell suppression and, in rare instances, fatal viral infections, she said.

If your T-cells are markedly diminished and you are infected with COVID-19, your body would have a hard time clearing that virus and you would potentially be at higher risk of developing pneumonia, ARDS, and, potentially, multisystem organ failure.

She added that none of the immunologists she works with are recommending a T-cell-depleting therapy for COVID-19. Most of the patients we're seeing already have low lymphocytes, she said. The virus is taking down the CD4 and CD8 cells. I don't think anyone would feel comfortable giving a drug that further suppresses CD4 and CD8.

Dr. Brownlee agreed that while the potential benefit of fingolimod as an acute treatment to prevent ARDS is interesting, we need to be careful about being too quick to translate hypotheses into treatment. It's not enough to inform patient care at the moment.

Ultimately, such questions can only be answered as more experience is gained in treating MS patients who develop a COVID-19 infection, Dr. Berger said. Time will tell, he said. It's going to be important to get real-world data from the registries to see whether or not what we think is correct. Is there a signal for any of these MS drugs? We'll know when the registries reveal their data. It's going to take the participation of neurologists around the world to distill out the treatments with one or another drug.

Dr. Brownlee has accepted speaker honoraria and/or participated in advisory boards for Biogen, Merck, Mylan, Novartis, Roche and Sanofi-Genzyme. Dr. Vollmer has received compensation for lectures and consultancy with Biogen IDEC, Genentech/Roche, Siranax, Celgene, EMD Serono, and Novartis. He has received research support from Rocky Mountain MS Center, Biogen,Actelion, Roche/Genentech;, F. Hoffman-La Roche, Ltd., and TG Therapeutics, Inc. Dr. Berger has received honoraria and an institutional grant from Biogen, and Genentech/Roche. He has received honoraria as a consultant for Celegene, Millennium/Takeda, Novartis, Inhibikase, Excision Biom Amgen, Shire, Dr. Reddy, Serono, Morphic, Encycle, Merck, and MAPI. Dr. Nourbarkhsh served on the advisory board for Jazz Pharmaceutical. Dr. Langer-Gould had no disclosures.

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COVID-19: Recommendations for Treating MS and Related... : Neurology Today - LWW Journals

COVID-19 Impact on Global Cell Therapy Market 2020: Industry Trends, Size, Share, Applications, SWOT Analysis by Top Key Players and Forecast Report…

The Global Cell Therapy Market was estimated to be valued at USD XX million in 2018 and is projected to reach USD XX million by 2026, at a CAGR of XX% during 2019 to 2026. Growing aging patient population, the rise in cell therapy transplantations globally, and rising disease awareness drive the growth of the market.

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Cell therapy involves the administration of somatic cell preparations for the treatment of diseases or traumatic damages. The objective of this study is to provide long term treatment through a single injection of therapeutic cells.

However, stringent regulatory policies may restrain growth of the market in the forecast period.

The global Cell Therapy Market is primarily segmented based on different type, technique, cell source, technology, end users and region.

On the basis of type, the market is split into:* Allogenic Therapies* Autologous Therapies

On the basis of technique, the market is split into:* Stem Cell Therapy* Cell Vaccine* Adoptive Cell Transfer (ACT)* Fibroblast Cell Therapy* Chondrocyte Cell Therapy* Other Technique

On the basis of cell source, the market is split into:* Bone Marrow* Adipose Tissue* Umbilical Cord Blood-Derived Cells

On the basis of technology, the market is split into:* Viral Vector Technology* Cell Immortalization Technology* Genome Editing Technology

On the basis of end user, the market is split into:* Hospitals & Clinics* Regenerative Medicine Centers* Other End Users

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Moreover, the market is classified based on regions and countries as follows:* North America- U.S., Canada* Europe- U.K., France, Germany, Italy and Rest of Europe* Asia-Pacific- China, Japan, India and Rest of Asia Pacific* South America- Brazil, Mexico and Rest of South America* Middle East & Africa- South Africa, Saudi Arabia and Rest of Middle East & Africa

Key Market Players: The key players profiled in the market include:* Kolon TissueGene, Inc.* JCR Pharmaceuticals Co. Ltd.* Osiris Therapeutics, Inc.* Stemedica Cell Technologies, Inc.* Fibrocell Science, Inc.* Vericel Corporation* Pharmicell Co., Ltd* Anterogen.CO.,LTD.* Baxter Healthcare Corporation.* Arteriocyte Medical Systems

These enterprises are focusing on growth strategies, such as new product launches, expansions, acquisitions, and agreements & partnerships to expand their operations across the globe.

Key Benefits of the Report:* Global, regional, country, type, technique, cell source, technology, end users market size and their forecast from 2018-2026* Identification and detailed analysis on key market dynamics, such as, drivers, restraints, opportunities, and challenges influencing growth of the market* Detailed analysis on industry outlook with market specific PESTLE, and supply chain to better understand the market and build expansion strategies* Identification of key market players and comprehensively analyze their market share and core competencies, detailed financial positions, key product, and unique selling points* Analysis on key players strategic initiatives and competitive developments, such as joint ventures, mergers, and new product launches in the market* Expert interviews and their insights on market shift, current and future outlook, and factors impacting vendors short term and long term strategies* Detailed insights on emerging regions, type, technique, cell source, technology and end users with qualitative and quantitative information and facts

Target Audience:* Cell Therapy Manufactures* Traders, Importers, and Exporters* Raw Material Suppliers and Distributors* Research and Consulting Firms* Government and Research Organizations* Associations and Industry Bodies

Research Methodology:The market is derived through extensive use of secondary, primary, in-house research follows by expert validation and third party perspective, such as, analyst reports of investment banks. The secondary research is the primary base of our study wherein we conducted extensive data mining, referring to verified data products, such as, white papers, government and regulatory published articles, technical journals, trade magazines, and paid data products.

For forecasting, regional demand & supply factors, recent investments, market dynamics including technical growth scenario, consumer behavior, and end use trends and dynamics, and production capacity were taken into consideration. Different weightages have been assigned to these parameters and quantified their market impacts using the weighted average analysis to derive the market growth rate.

The market estimates and forecasts have been verified through exhaustive primary research with the Key Industry Participants (KIPs), which typically include:* Manufacturers* Suppliers* Distributors* Government Body & Associations* Research Institutes

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Table of Content1. Introduction2. Research Methodology3. Executive Summary4. Global Cell Therapy Market Overview4.1. Market Segmentation & Scope4.2. Market Trends4.2.1. Drivers4.2.2. Restraints4.2.3. Opportunities4.2.4. Supply Chain Analysis4.3. Global Cell Therapy Market Porters Five Forces Analysis4.4. Global Cell Therapy Market PESTEL Analysis5. Global Cell Therapy Market, by Type5.1. Global Cell Therapy Market, Size and Forecast, 2015-20265.2. Global Cell Therapy Market, by Allogenic Therapies, 2015-20265.2.1. Key driving factors, trends and opportunities5.2.2. Market size and forecast, 2015-20265.3. Global Cell Therapy Market, by Autologous Therapies, 2015-20265.3.1. Key driving factors, trends and opportunities5.3.2. Market size and forecast, 2015-20266. Global Cell Therapy Market, by Technique6.1. Global Cell Therapy Market, Size and Forecast, 2015-20266.2. Global Cell Therapy Market, by Stem Cell Therapy, 2015-20266.2.1. Key driving factors, trends and opportunities6.2.2. Market size and forecast, 2015-20266.3. Global Cell Therapy Market, by Cell Vaccine, 2015-20266.3.1. Key driving factors, trends and opportunities6.3.2. Market size and forecast, 2015-2026

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