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Rademakers DJ, Saffari S, Saffari TM, Pulos N, Shin AY. The Effect of Local Purified Exosome Product, Stem Cells, and Tacrolimus on Neurite Extension. J Hand Surg Am 2024; 49:237-246. [PMID: 38165293 DOI: 10.1016/j.jhsa.2023.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 11/20/2023] [Accepted: 11/22/2023] [Indexed: 01/03/2024]
Abstract
PURPOSE The combination of cellular and noncellular treatments has been postulated to improve nerve regeneration through a processed nerve allograft. This study aimed to evaluate the isolated effect of treatment with purified exosome product (PEP), mesenchymal stem cells (MSCs), and tacrolimus (FK506) alone and in combination when applied in decellularized allografts. METHODS A three-dimensional in vitro-compartmented cell culture system was used to evaluate the length of regenerating neurites from the neonatal dorsal root ganglion into the adjacent peripheral nerve graft. Decellularized nerve allografts were treated with undifferentiated MSCs, 5% PEP, 100 ng/mL FK506, PEP and FK506 combined, or MSCs and FK506 combined (N = 9/group) and compared with untreated nerve autografts (positive control) and nerve allografts (negative control). Neurite extension was measured to quantify nerve regeneration after 48 hours, and stem cell viability was evaluated. RESULTS Stem cell viability was confirmed in all MSC-treated nerve grafts. Treatments with PEP, PEP + FK506, and MSCs + FK506 combined were found to be superior to untreated allografts and not significantly different from autografts. Combined PEP and FK506 treatment resulted in the greatest neurite extension. Treatment with FK506 and MSCs was significantly superior to MSC alone. The combined treatment groups were not found to be statistically different. CONCLUSIONS Although all treatments improved neurite outgrowth, treatments with PEP, PEP + FK506, and MSCs + FK506 combined had superior neurite growth compared with untreated allografts and were not found to be significantly different from autografts, the current gold standard. CLINICAL RELEVANCE Purified exosome product, a cell-free exosome product, is a promising adjunct to enhance nerve allograft regeneration, with possible future avenues for clinical translation.
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Affiliation(s)
- Daan J Rademakers
- Division of Hand and Microvascular Surgery, Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN; Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Plastic Surgery, Nijmegen, The Netherlands
| | - Sara Saffari
- Division of Hand and Microvascular Surgery, Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN; Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Plastic Surgery, Nijmegen, The Netherlands
| | - Tiam M Saffari
- Division of Hand and Microvascular Surgery, Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Nicholas Pulos
- Division of Hand and Microvascular Surgery, Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Alexander Y Shin
- Division of Hand and Microvascular Surgery, Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN.
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Panagopoulos GN, Megaloikonomos PD, Mitsiokapa EA, Bami M, Agrogiannis G, Johnson EO, Soucacos PN, Papagelopoulos PJ, Mavrogenis AF. Adipose-Derived Stem Cells and Tacrolimus Improve Nerve Regeneration in a Rat Sciatic Nerve Defect Model. Orthopedics 2023; 46:e353-e361. [PMID: 37052592 DOI: 10.3928/01477447-20230407-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
This study compared the effect of undifferentiated adipose-derived stem cells (ADSCs) vs tacrolimus (FK506) in peripheral nerve regeneration in a rat sciatic nerve complete transection model. Forty Wistar rats were equally distributed in four groups. In the SHAM surgery group, the sciatic nerve was exposed and no further intervention was done. In the conduit-alone group (the SLN group), a 10-mm nerve gap was created and bridged with a fibrin conduit filled in with normal saline. In the FK506 group, the fibrin conduit was injected with soluble FK506. In the ADSC group, the conduit was impregnated with undifferentiated ADSCs. Nerve regeneration was assessed by means of walking track analysis, electromyography, and neurohistomorphometry. Clinically and microscopically, nerve regeneration was achieved in all groups at 12 weeks. Walking track analysis confirmed functional recovery in the FK506 and ADSC groups, but there was no difference between them. Recovery in function was also achieved in the SLN group, but it was inferior (P<.05). Electromyography demonstrated superior nerve regeneration in the FK506 and ADSC groups compared with the SLN group (P<.05), with no difference between the FK506 and ADSC groups. Similarly, histology showed no difference between the FK506 and ADSC groups, although both outperformed the SLN group (P<.05). No complications were observed. Successful peripheral nerve regeneration can be accomplished after a 10-mm nerve defect treated with nerve conduits. Superior nerve regeneration may be expected when the conduits are loaded with undifferentiated ADSCs or FK506, with similar outcomes for ADSCs and FK506. [Orthopedics. 2023;46(6):e353-e361.].
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Liu Y, Zhang X, Xiao C, Liu B. Engineered hydrogels for peripheral nerve repair. Mater Today Bio 2023; 20:100668. [PMID: 37273791 PMCID: PMC10232914 DOI: 10.1016/j.mtbio.2023.100668] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/06/2023] [Accepted: 05/16/2023] [Indexed: 06/06/2023] Open
Abstract
Peripheral nerve injury (PNI) is a complex disease that often appears in young adults. It is characterized by a high incidence, limited treatment options, and poor clinical outcomes. This disease not only causes dysfunction and psychological disorders in patients but also brings a heavy burden to the society. Currently, autologous nerve grafting is the gold standard in clinical treatment, but complications, such as the limited source of donor tissue and scar tissue formation, often further limit the therapeutic effect. Recently, a growing number of studies have used tissue-engineered materials to create a natural microenvironment similar to the nervous system and thus promote the regeneration of neural tissue and the recovery of impaired neural function with promising results. Hydrogels are often used as materials for the culture and differentiation of neurogenic cells due to their unique physical and chemical properties. Hydrogels can provide three-dimensional hydration networks that can be integrated into a variety of sizes and shapes to suit the morphology of neural tissues. In this review, we discuss the recent advances of engineered hydrogels for peripheral nerve repair and analyze the role of several different therapeutic strategies of hydrogels in PNI through the application characteristics of hydrogels in nerve tissue engineering (NTE). Furthermore, the prospects and challenges of the application of hydrogels in the treatment of PNI are also discussed.
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Affiliation(s)
- Yao Liu
- Hand and Foot Surgery Department, First Hospital of Jilin University, Xinmin Street, Changchun, 130061, PR China
| | - Xiaonong Zhang
- Key Laboratory of Polymer Ecomaterials, Jilin Biomedical Polymers Engineering Laboratory, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, Changchun, 130022, PR China
| | - Chunsheng Xiao
- Key Laboratory of Polymer Ecomaterials, Jilin Biomedical Polymers Engineering Laboratory, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, Changchun, 130022, PR China
| | - Bin Liu
- Hand and Foot Surgery Department, First Hospital of Jilin University, Xinmin Street, Changchun, 130061, PR China
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Xue J, Liu Y. Mesenchymal Stromal/Stem Cell (MSC)-Based Vector Biomaterials for Clinical Tissue Engineering and Inflammation Research: A Narrative Mini Review. J Inflamm Res 2023; 16:257-267. [PMID: 36713049 PMCID: PMC9875582 DOI: 10.2147/jir.s396064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 01/18/2023] [Indexed: 01/21/2023] Open
Abstract
Mesenchymal stromal/stem cells (MSCs) have the ability of self-renewal, the potential of multipotent differentiation, and a strong paracrine capacity, which are mainly used in the field of clinical medicine including dentistry and orthopedics. Therefore, tissue engineering research using MSCs as seed cells is a current trending directions. However, the healing effect of direct cell transplantation is unstable, and the paracrine/autocrine effects of MSCs cannot be effectively elicited. Tumorigenicity and heterogeneity are also concerns. The combination of MSCs as seed cells and appropriate vector materials can form a stable cell growth environment, maximize the secretory features of stem cells, and improve the biocompatibility and mechanical properties of vector materials that facilitate the delivery of drugs and various secretory factors. There are numerous studies on tissue engineering and inflammation of various biomaterials, mainly involving bioceramics, alginate, chitosan, hydrogels, cell sheets, nanoparticles, and three-dimensional printing. The combination of bioceramics, hydrogels and cell sheets with stem cells has demonstrated good therapeutic effects in clinical applications. The application of alginate, chitosan, and nanoparticles in animal models has also shown good prospects for clinical applications. Three-dimensional printing technology can circumvent the shortage of biomaterials, greatly improve the properties of vector materials, and facilitate the transplantation of MSCs. The purpose of this narrative review is to briefly discuss the current use of MSC-based carrier biomaterials to provide a useful resource for future tissue engineering and inflammation research using stem cells as seed cells.
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Affiliation(s)
- Junshuai Xue
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, People’s Republic of China
| | - Yang Liu
- Department of General Surgery, Vascular Surgery, Qilu Hospital of Shandong University, Jinan City, People’s Republic of China,Correspondence: Yang Liu, Department of General surgery, Vascular Surgery, Qilu Hospital of Shandong University, Jinan, Shandong, 250012, People’s Republic of China, Tel +86 18560088317, Email
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Xiong Y, Mi BB, Lin Z, Hu YQ, Yu L, Zha KK, Panayi AC, Yu T, Chen L, Liu ZP, Patel A, Feng Q, Zhou SH, Liu GH. The role of the immune microenvironment in bone, cartilage, and soft tissue regeneration: from mechanism to therapeutic opportunity. Mil Med Res 2022; 9:65. [PMID: 36401295 PMCID: PMC9675067 DOI: 10.1186/s40779-022-00426-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 10/30/2022] [Indexed: 11/21/2022] Open
Abstract
Bone, cartilage, and soft tissue regeneration is a complex spatiotemporal process recruiting a variety of cell types, whose activity and interplay must be precisely mediated for effective healing post-injury. Although extensive strides have been made in the understanding of the immune microenvironment processes governing bone, cartilage, and soft tissue regeneration, effective clinical translation of these mechanisms remains a challenge. Regulation of the immune microenvironment is increasingly becoming a favorable target for bone, cartilage, and soft tissue regeneration; therefore, an in-depth understanding of the communication between immune cells and functional tissue cells would be valuable. Herein, we review the regulatory role of the immune microenvironment in the promotion and maintenance of stem cell states in the context of bone, cartilage, and soft tissue repair and regeneration. We discuss the roles of various immune cell subsets in bone, cartilage, and soft tissue repair and regeneration processes and introduce novel strategies, for example, biomaterial-targeting of immune cell activity, aimed at regulating healing. Understanding the mechanisms of the crosstalk between the immune microenvironment and regeneration pathways may shed light on new therapeutic opportunities for enhancing bone, cartilage, and soft tissue regeneration through regulation of the immune microenvironment.
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Affiliation(s)
- Yuan Xiong
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Hubei Province Key Laboratory of Oral and Maxillofacial Development and Regeneration, Wuhan, 430022, China
| | - Bo-Bin Mi
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Hubei Province Key Laboratory of Oral and Maxillofacial Development and Regeneration, Wuhan, 430022, China
| | - Ze Lin
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Hubei Province Key Laboratory of Oral and Maxillofacial Development and Regeneration, Wuhan, 430022, China
| | - Yi-Qiang Hu
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Hubei Province Key Laboratory of Oral and Maxillofacial Development and Regeneration, Wuhan, 430022, China
| | - Le Yu
- Department of Chemical and Biomolecular Engineering, Ohio University, Athens, OH, 45701, USA
| | - Kang-Kang Zha
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Hubei Province Key Laboratory of Oral and Maxillofacial Development and Regeneration, Wuhan, 430022, China.,Key Laboratory of Biorheological Science and Technology,Ministry of Education College of Bioengineering, Chongqing University, Shapingba, Chongqing, 400044, China
| | - Adriana C Panayi
- Department of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02152, USA
| | - Tao Yu
- Department of Orthopaedics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Lang Chen
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Hubei Province Key Laboratory of Oral and Maxillofacial Development and Regeneration, Wuhan, 430022, China.,Department of Physics, Center for Hybrid Nanostructure (CHyN), University of Hamburg, Hamburg, 22761, Germany
| | - Zhen-Ping Liu
- Department of Physics, Center for Hybrid Nanostructure (CHyN), University of Hamburg, Hamburg, 22761, Germany.,Joint Laboratory of Optofluidic Technology and System,National Center for International Research on Green Optoelectronics, South China Academy of Advanced Optoelectronics, South China Normal University, Guangzhou, 510006, China
| | - Anish Patel
- Skeletal Biology Laboratory, Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02120, USA
| | - Qian Feng
- Key Laboratory of Biorheological Science and Technology,Ministry of Education College of Bioengineering, Chongqing University, Shapingba, Chongqing, 400044, China.
| | - Shuan-Hu Zhou
- Skeletal Biology Laboratory, Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02120, USA. .,Harvard Stem Cell Institute, Harvard University, Cambridge, MA, 02138, USA.
| | - Guo-Hui Liu
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China. .,Hubei Province Key Laboratory of Oral and Maxillofacial Development and Regeneration, Wuhan, 430022, China.
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Leung KS, Shirazi S, Cooper LF, Ravindran S. Biomaterials and Extracellular Vesicle Delivery: Current Status, Applications and Challenges. Cells 2022; 11:cells11182851. [PMID: 36139426 PMCID: PMC9497093 DOI: 10.3390/cells11182851] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 09/05/2022] [Accepted: 09/07/2022] [Indexed: 12/14/2022] Open
Abstract
In this review, we will discuss the current status of extracellular vesicle (EV) delivery via biopolymeric scaffolds for therapeutic applications and the challenges associated with the development of these functionalized scaffolds. EVs are cell-derived membranous structures and are involved in many physiological processes. Naïve and engineered EVs have much therapeutic potential, but proper delivery systems are required to prevent non-specific and off-target effects. Targeted and site-specific delivery using polymeric scaffolds can address these limitations. EV delivery with scaffolds has shown improvements in tissue remodeling, wound healing, bone healing, immunomodulation, and vascular performance. Thus, EV delivery via biopolymeric scaffolds is becoming an increasingly popular approach to tissue engineering. Although there are many types of natural and synthetic biopolymers, the overarching goal for many tissue engineers is to utilize biopolymers to restore defects and function as well as support host regeneration. Functionalizing biopolymers by incorporating EVs works toward this goal. Throughout this review, we will characterize extracellular vesicles, examine various biopolymers as a vehicle for EV delivery for therapeutic purposes, potential mechanisms by which EVs exert their effects, EV delivery for tissue repair and immunomodulation, and the challenges associated with the use of EVs in scaffolds.
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Affiliation(s)
- Kasey S. Leung
- Department of Oral Biology, College of Dentistry, University of Illinois Chicago, Chicago, IL 60612, USA
| | - Sajjad Shirazi
- Department of Oral Biology, College of Dentistry, University of Illinois Chicago, Chicago, IL 60612, USA
| | - Lyndon F. Cooper
- School of Dentistry, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Sriram Ravindran
- Department of Oral Biology, College of Dentistry, University of Illinois Chicago, Chicago, IL 60612, USA
- Correspondence:
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Yang MG, Xu L, Ji S, Gao H, Zhang Q, Bu B. Tacrolimus Combined with Corticosteroids Improved the Outcome of CIDP Patients with Autoantibodies Against Paranodal Proteins. Neuropsychiatr Dis Treat 2022; 18:1207-1217. [PMID: 35734550 PMCID: PMC9208735 DOI: 10.2147/ndt.s361461] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 05/25/2022] [Indexed: 12/19/2022] Open
Abstract
PURPOSE To investigate the response of tacrolimus to chronic inflammatory demyelinating polyneuropathy (CIDP) with autoantibodies against paranodal proteins, including neurofascin-155 (NF155), contactin-1 (CNTN1) and contactin-associated protein 1 (Caspr1). METHODS We retrospectively reviewed all CIDP patients who carried anti-NF155, CNTN1 and Caspr1 antibodies and were treated with tacrolimus at Tongji hospital from Jan 2018 to Apr 2021. RESULTS There were 58 patients with CIDP and only 9 patients had autoantibodies against paranodal proteins (17.2%). Five of the 9 patients received tacrolimus treatment with an initial dose of 2-3 mg once daily. One patient with anti-CNTN1 antibody started tacrolimus and corticosteroid treatment, at the first episode and eventually achieved full clinical remission without relapse. Four patients with anti-NF155 or -Caspr1 antibodies experienced relapse during corticosteroids tapering. Then, they were given oral tacrolimus and presented with clinical improvement. During follow-up, only one patient developed worsening weakness due to unreasonable tacrolimus discontinuation. Moreover, 3 patients were successfully withdrawn from corticosteroids and 2 patients took corticosteroids at low maintenance dose (10mg/d) after tacrolimus treatment. No severe adverse events were observed in all the patients. CONCLUSION Patients with autoantibodies against paranodal proteins had a better long-term outcome after adding tacrolimus. Combination therapy with corticosteroids and tacrolimus may be an effective therapeutic regimen.
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Affiliation(s)
- Meng-Ge Yang
- Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Li Xu
- Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Suqiong Ji
- Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Huajie Gao
- Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Qing Zhang
- Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Bitao Bu
- Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
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Saffari S, Saffari TM, Chan K, Borschel GH, Shin AY. Mesenchymal stem cells and local tacrolimus delivery synergistically enhance neurite extension. Biotechnol Bioeng 2021; 118:4477-4487. [PMID: 34396506 DOI: 10.1002/bit.27916] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 08/04/2021] [Accepted: 08/12/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND The aim of this study was to investigate the combined effect of mesenchymal stem cells (MSC) and local delivery of tacrolimus (FK506) on nerve regeneration when applied to nerve autografts and decellularized allografts. METHODS A three-dimensional in vitro compartmented cell culture system consisting of a neonatal dorsal root ganglion adjacent to a nerve graft was used to evaluate the regenerating neurites into the peripheral nerve scaffold. Nerve autografts and allografts were treated with (i) undifferentiated MSCs, (ii) FK506 (100 ng/mL) or (iii) both (N = 9/group). After 48 hours, neurite extension was measured to quantify nerve regeneration and stem cell viability was evaluated. RESULTS Stem cell viability was confirmed in all MSC-treated grafts. Neurite extension was superior in autografts treated with FK506, and MSCs and FK506 combined (p < 0.001 and p = 0.0001, respectively), and autografts treated with MSCs (p = 0.12) were comparable to untreated autografts. In allografts, FK506 treatment and combined treatment were superior to controls (p < 0.001 and p = 0.0001, respectively), and treatment with MSCs (p = 0.09) was comparable to controls. All autograft groups were superior compared to their respective allograft treatment group (p < 0.05) in neurite extension. CONCLUSIONS Alone, either MSC or FK506 treatment improved neurite outgrowth, and combined they further enhanced neurite extension in both autografts and allografts.
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Affiliation(s)
- Sara Saffari
- Division of Hand and Microvascular Surgery, Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA.,Department of Plastic-, Reconstructive- and Hand Surgery, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Tiam M Saffari
- Division of Hand and Microvascular Surgery, Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA.,Department of Plastic-, Reconstructive- and Hand Surgery, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Katelyn Chan
- Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Engineering, Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Gregory H Borschel
- Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Engineering, Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada.,Division of Neurosciences and Mental Health, SickKids Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada.,Division of Plastic & Reconstructive Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of Plastic Surgery, Indiana University and Riley Hospital for Children, Indianapolis, Indiana, USA
| | - Alexander Y Shin
- Division of Hand and Microvascular Surgery, Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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