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In this narrative medicine essay, a second-year pediatric resident bears the scars from the terror that descended the moment of her son’s birth at 31 weeks’ gestation, terror relived even after he has come home healthy.

This Viewpoint discusses the controversy over mail-order mifepristone prescribed by primary care clinicians for first-trimester abortion as it relates to the history of initial approval, the Supreme Court case Alliance for Hippocratic Medicine v US Food and Drug Administration, and available clinical research.

This cohort study of US patients who are pregnant examines factors associated with health care use and costs during pregnancy in those with vs without congenital heart disease.

This cohort study estimates the effectiveness, acceptability, and feasibility of dispensing mifepristone for medication abortion using a mail-order pharmacy.

Permanent Procedures to Prevent Pregnancy in US Jumped After Dobbs JAMA News May 10, 2024 Reproductive Health Women's Health Pregnancy Obstetrics Full Text | pdf link PDF free

This cohort study evaluated the hazards of incident diabetes among women in Canada with gestational diabetes in their first, second, and in both the first and second pregnancies.

This cohort study assesses population-level associations of COVID-19 with birth parent and infant health, distinguishing the COVID-19 pandemic period from individual SARS-CoV-2 infection.

This systematic review investigates the prevalence of harassment, including sexual harassment, bullying, and abuse, among obstetrics and gynecology medical students and clinicians.

This cohort study assesses the perinatal outcomes associated with combined prenatal cannabis and nicotine product use compared with the use of either substance alone among pregnant individuals in the US.

Closing the Cervical Cancer Screening Gap—Reaching Sexual and Gender Diverse Populations JAMA Network Open Opinion May 6, 2024 Oncology Gynecologic Cancer Gynecology Women's Health Health Policy Full Text | pdf link PDF open access

This systematic review and meta-analysis investigates the association between provision of a relaxation intervention and lactation outcomes.

This cross-sectional study examines data across 17 birthing hospitals before and after a policy change at Boston Medical Center in how reporting decisions are made in cases of prenatal substance exposure.

This cross-sectional study describes the prevalence of up-to-date cervical cancer screening among lesbian, gay, and bisexual cisgender women vs heterosexual cisgender women in Chicago, Illinois.

This cross-sectional study evaluates the association of polycystic ovary syndrome, timing to regular menstrual cycles, and irregular cycles with cardiometabolic conditions.

This Viewpoint shares the experience of a single Otolaryngology−Head & Neck Surgery residency program that faced the scheduling challenges of having nearly a quarter of its residents expecting a child and on parental leave.

This randomized clinical trial examines the comparability of dequalinium chloride with metronidazole in the treatment of bacterial vaginosis among premenopausal women.

This cohort study estimates the prevalence of vaccination receipt among pregnant people with HIV and identifies demographic and clinical characteristics associated with vaccination.

Dequalinium Chloride—An Emerging Option in the Sparse Landscape of Bacterial Vaginosis Therapies JAMA Network Open Opinion May 2, 2024 Infectious Diseases Antibiotic Use, Overuse, Resistance, Stewardship Gynecology Women's Health Full Text | pdf link PDF open access

This cohort study examines the potential associations of adverse pregnancy outcomes with first-time use of psychiatric treatment among first-time fathers in Denmark.

This study compares the race and ethnicity of reproductive-age females between states that implemented restrictive abortion policies after the Dobbs v Jackson Women’s Health Organization decision and states that did not.

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J Gynecol Oncol
v.33(2); 2022 Mar

Major clinical research advances in gynecologic cancer in 2021

Jeong-yeol park.

1 Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.

Jung-Yun Lee

2 Department of Obstetrics and Gynecology, Yonsei University College of Medicine, Seoul, Korea.

Yoo-Young Lee

3 Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.

Seung-Hyuk Shim

4 Department of Obstetrics and Gynecology, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Korea.

Dong Hoon Suh

5 Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Korea.

Jae-Weon Kim

6 Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea.

Associated Data

In the 2021 series, we not only summarized the major clinical research advances in gynecologic oncology but also added discussions to every part, based on communications at the conference. A review of cervical cancer included adjuvant treatments such as radiation and chemoradiation (concurrent or sequential) after radical hysterectomy in early cervical cancer, and immune checkpoint inhibitors in advanced, recurrent, and metastatic disease. Ovarian cancer research included studies of secondary cytoreductive surgery in platinum-sensitive recurrent ovarian cancer, and various trials of immune checkpoint inhibitors with or without vascular endothelial growth factor inhibitors and conventional chemotherapy. The rechallenge of poly (ADP-ribose) polymerase inhibitor maintenance in heavily pretreated ovarian cancer were also addressed. For uterine corpus cancer, dostarlimab (anti-programmed cell death protein 1 antibody) alone, or a tyrosine kinase inhibitor in combination with pembrolizumab for advanced, metastatic, or recurrent endometrial cancer were reviewed. The survival differences between the intensive and minimalist follow-up protocols were also described. In this review, we compared salpingectomy with delayed oophorectomy and salpingo-oophorectomy in terms of quality of life in BRCA 1 and 2 pathogenic variant carriers.

INTRODUCTION

The Journal of Gynecologic Oncology review group has held a conference and compiled a list of major clinical studies on gynecologic cancer since 2020. With support from the Asian Society of Gynecologic Oncology (ASGO), a review course titled, “Major Clinical Advances in Gynecologic Cancer” was held at Daeyang AI Center at Sejong University on December 11, 2021 ( Table S1 ).

In this review, we summarized and discussed the major clinical research on gynecologic cancer in 2021 ( Table 1 ).

ATR, ataxia-telangiectasia and Rad3-related; DESKTOP, Descriptive Evaluation of preoperative Selection KriTeria for Operability; MMRd, mismatch repair-deficient; MMRp, mismatch repair-proficient; MSI-H, microsatellite instability-high; OS, overall survival; PARPi, poly (ADP-ribose) polymerase inhibitor.

CERVICAL CANCER

The major cervical cancer research findings reported in 2021 can be summarized in the following five categories:

1) The STARS trial investigated the role of adjuvant therapy after radical hysterectomy [ 1 ].
2) The OUTBACK trial examined outback chemotherapy after concurrent chemoradiation therapy (CCRT) in locally advanced cervical cancer [ 2 ].
3) The KN826 [ 3 ] & EMPOWER trials [ 4 ] explored the role of immunotherapy in first- and second-line chemotherapy.
4) The innovaTV 204 [ 5 ] study aimed to find a new target agent with a higher response rate in advanced, metastatic, and recurrent cervical cancer.
5) The CONCERV trial prospectively evaluated the feasibility of conservative surgery in early-stage, low-risk cervical cancer [ 6 ].

1. STARS trial

The STARS trial was a phase III randomized controlled trial that compared the effects of adjuvant radiation therapy (RT), CCRT, and sequential chemoradiation therapy (SCRT) in the International Federation of Gynaecology and Obstetrics (FIGO) stage IB–IIB patients with one or more risk factors for recurrence after radical hysterectomy [ 1 ]. The histological types included squamous cell carcinoma, adenocarcinoma, and adenosquamous carcinoma. The risk factors included lymph node metastasis, positive parametrium, positive margins, lymphovascular space involvement, and deep stromal invasion. It was possible to participate in the study if the patient had one or more risk factors. In this study. a total of 1,048 patients were enrolled and randomized into the RT, CCRT, and SCRT groups, in a ratio of 1:1:1. The primary endpoint was disease-free survival (DFS). In the intention-to-treat and per-protocol populations, the SCRT group had significantly better DFS than the RT group. Moreover, the overall survival (OS) of the SCRT group was significantly better than that of the RT group. However, there were no significant differences in DFS and OS between the CCRT and RT groups. There were also no significant differences in DFS and OS between the SCRT and CCRT groups. Therefore, the authors concluded that SCRT had a greater survival benefit than RT for post-radical hysterectomy and high-risk cervical cancer.

Efforts to find appropriate adjuvant therapy in intermediate- and high-risk groups after radical hysterectomy for early-stage cervical cancer have been ongoing for a long time. Regarding adjuvant therapy in the high-risk group, CCRT with 5-fluorouracil+cisplatin showed a significant improvement in survival compared to RT in the Intergroup trial 0107/GOG 109/SWOG-8797 study in the early 2000s [ 7 ]. The survival benefit of CCRT was reconfirmed in a population-based cohort study using the National Cancer Database [ 8 ]. In recent years, CCRT has become the standard adjuvant therapy for high-risk patients undergoing radical hysterectomy. The NOGGO-AGO intergroup study compared CCRT with cisplatin and SCRT composed of 4 cycles of paclitaxel + carboplatin followed by RT [ 9 ]. In that study, there was no difference in the survival rate between the CCRT and SCRT groups. However, CCRT and SCRT show different toxicity profiles. To date, SCRT has not yet been able to replace CCRT. In the STARS trial, SCRT reduced the risk of recurrence by 48% and 35% compared with RT and CCRT, respectively. Adverse events in the SCRT group were not different from those in the CCRT group, and gastrointestinal adverse events were fewer in the SCRT group than in the CCRT group [ 1 ]. One of the possible mechanisms for better survival in SCRT compared with RT or CCRT is the short interval between surgery and adjuvant treatment. Another mechanism suggested that paclitaxel + cisplatin is a better regimen for decreasing distant failure because weekly cisplatin is a radiosensitizer and has no advantage for distant control. Of note, the STARS trial had several limitations. First, the study design was problematic. The primary endpoint was not that CCRT and SCRT were compared, but that CCRT or SCRT would have a survival benefit compared to RT. Second, stratification according to risks was not performed when patients were randomized to three groups (RT, CCRT, and SCRT). Third, approximately 20% of patients received neoadjuvant chemotherapy. Fourth, the completion rate of treatment was 62% in the CCRT group, which was much lower than the 73% in the SCRT group. Owing to these problems, the authors also commented that SCRT may be a good treatment strategy and suggested that chemotherapy should be performed first, followed by RT, especially in a resource-limited country where the waiting time for RT is long because of a lack of RT resources. Further studies comparing the roles of CCRT and SCRT are necessary because the intermediate- and high-risk groups are mixed in the STARS trial. The NRG 0724 study comparing CCRT with cisplatin and CCRT with cisplatin followed by four cycles of paclitaxel + carboplatin, as adjuvant therapy for high-risk groups, and the GOG 263/KGOG 1008 study comparing adjuvant RT and CCRT with cisplatin in the intermediate-risk group are both still ongoing. Appropriate adjuvant therapy after radical hysterectomy will have to wait for the results of these studies.

2. OUTBACK trial

The OUTBACK trial was a phase III randomized controlled trial evaluating the role of outback chemotherapy after CCRT in locally advanced cervical cancer patients with FIGO stage IB1 with lymph node metastasis, IB2, II, IIIB, and IVA, by randomizing them into a group receiving CCRT only and additional adjuvant therapy after CCRT [ 2 ]. Patients with nodal metastasis in the L3-L4 para-aortic area were excluded from the study. The histological types included squamous cell carcinoma, adenocarcinoma, and adenosquamous carcinoma. Additional chemotherapy (ACT) was 4 cycles of paclitaxel (155 mg/m 2 ) and carboplatin (AUC 5) every 3 weeks. A total of 926 patients were randomized 1:1 to receive CCRT and ACT. The primary endpoint was OS, and there were no significant intergroup differences between the two groups.

The primary concern with CCRT, the standard treatment for locally advanced cervical cancer, is the possibility of distant failure. Therefore, adjuvant systemic chemotherapy (outback chemotherapy) has been considered a solution to reduce distant failure after CCRT. In a randomized controlled trial published in 2011, CCRT with gemcitabine + cisplatin followed by gemcitabine + cisplatin showed a significantly improved survival rate compared to CCRT with gemcitabine + cisplatin [ 10 ]. Grade 3 and 4 toxicities were significantly higher in the ACT group. In contrast, outback chemotherapy did not improve patient survival in the OUTBACK trial. OUTBACK trials have several limitations. First, the rate of failure to implement adjuvant chemotherapy is high. For example, 22% of the patients did not start adjuvant chemotherapy, and 38% did not complete adjuvant chemotherapy. Moreover, since only four cycles of adjuvant chemotherapy are used, low-dose intensity is also a potential concern. One strategy to reduce distant failure after CCRT in the future is the use of immunotherapy during and after CCRT. A study comparing CCRT and CCRT + durvalumab (CALLA trial) has completed patient registration, and a study comparing CCRT and CCRT + pembrolizumab (KEYNOTE-A18/ENGO-cx11) is currently ongoing.

3. KeyNote-826 trial

Following the positive results of the GOG-240 trial, showing a significant improvement in survival by adding bevacizumab to first-line chemotherapy for persistent, recurrent, and metastatic cervical cancer, platinum-based chemotherapy plus bevacizumab has become standard care. Although the response rate of immune checkpoint inhibitors in persistent, recurrent, and metastatic cervical cancer has been reported in several studies, there have been no phase III studies showing improved survival following treatment. The KeyNote-826 study is the first phase III study to show that when immune checkpoint inhibitors are added to standard care for persistent, recurrent, and metastatic cervical cancer, a significant improvement in survival is found. The results of this study will likely lead to a significant change in the treatment of cervical cancer. The KeyNote-826 trial was a phase III randomized controlled trial showing an additional improvement in survival rate by adding immunotherapy to standard care [ 3 ]. A total of 617 patients with persistent, recurrent, and metastatic cervical cancer were randomized to receive paclitaxel + cisplatin/carboplatin ± bevacizumab, or paclitaxel + cisplatin/carboplatin ± bevacizumab + pembrolizumab (up to 35 cycles). DFS and OS were significantly improved in the pembrolizumab group in the all-comers population. The safety profile was manageable by adding pembrolizumab.

4. EMPOWER trial

In the treatment of cervical cancer, the activity of immune checkpoint inhibitors as a second-line, or higher, chemotherapy has been introduced through several studies, but there has not been a phase III study showing the superiority of immune checkpoint inhibitors compared to cytotoxic chemotherapy corresponding to the current standard of care. The EMPOWER trial is the first phase III study to show the superiority of immune checkpoint inhibitors over second-line treatment in the treatment of recurrent, metastatic cervical cancer. The results of this study will likely lead to a paradigm shift in the treatment of cervical cancer. The EMPOWER trial is a phase III randomized controlled trial that showed the efficacy of immunotherapy in recurrent, metastatic cervical cancer resistant to platinum-based chemotherapy previously performed for persistent, metastatic, and recurrent cervical cancer [ 4 ]. The histological types included squamous cell carcinoma, adenocarcinoma, and adenosquamous carcinoma. A total of 608 patients were randomized 1:1 to either cemiplimab or physician-choice chemotherapy. Chemotherapy included pemetrexed, gemcitabine, topotecan, and irinotecan. The primary endpoint was OS. Compared to chemotherapy, cemiplimab demonstrated significant improvement in OS in all populations, including squamous cell and adenocarcinoma populations.

5. InnovaTV 204 trial

Tisotumab vedotin (TV) is another drug that has recently shown promising activities in the treatment of cervical cancer. TV is an antibody-drug conjugate that targets tissue factors. This was evaluated in the Innova TV 204 phase II trial [ 5 ]. Patients included in the study had recurrent or extrapelvic metastatic cervical cancer and had received two or fewer at least two prior systemic chemotherapy regimens for recurrent or metastatic disease. Patients had progressive disease during or after doublet chemotherapy (paclitaxel plus either platinum or topotecan) with bevacizumab, if eligible. The histological types included squamous cell carcinoma, adenocarcinoma, and adenosquamous carcinoma. A total of 101 patients were evaluated, with an objective response rate (ORR) of 24%. The complete response, partial response, and stable disease rates were 7%, 17%, and 49%, respectively. Most tumor responses were rapid, with a median response of 1.4 months. The median duration of response (DOR) was 8.3 months (95% confidence interval [CI]=4.2-not reached) and the median progression-free survival (PFS) was 4.2 months (95% CI=3.0–4.4 months). Furthermore, TV had a manageable safety profile.

6. ConCerv trial

The ConCerv trial evaluated the feasibility of conservative surgery in women with early- stage, low-risk cervical cancer [ 6 ]. This study included women with FIGO 2009 stage IA2-IB1 cervical cancer ≤2 cm, without lymphovascular space invasion, a depth of invasion ≤10 mm, and a negative conization margin. Conservative surgery was conization followed by lymph node assessment for women wishing to preserve fertility, and simple hysterectomy with lymph node assessment for women who did not want to preserve fertility. A total of 100 patients were included in this study. The surgery types were conization followed by lymph node dissection in 44 women, simple hysterectomy with lymph node evaluation in 40 women, and inadvertent simple hysterectomy followed by lymph node dissection in 16 women. Three patients experienced recurrence within 2 years following surgery, and the cumulative incidence of recurrence was 3.5%.

OVARIAN CANCER

1. secondary cytoreductive surgery (scs) in recurrent ovarian cancer.

The role of SCS in patients with platinum-sensitive recurrent ovarian cancer is controversial. The findings of three multicenter, randomized, phase III trials (DESKTOP III [ {"type":"clinical-trial","attrs":{"text":"NCT01611766","term_id":"NCT01611766"}} NCT01611766 ], GOG-213 [ {"type":"clinical-trial","attrs":{"text":"NCT00565851","term_id":"NCT00565851"}} NCT00565851 ], and SOC-1 [ {"type":"clinical-trial","attrs":{"text":"NCT01611766","term_id":"NCT01611766"}} NCT01611766 ]) have been published [ 11 , 12 , 13 ]. All three trials were distinct in terms of the patient cohort, eligibility criteria for surgery, and center selection ( Table 2 ).

PARP, poly (ADP-ribose) polymerase; DESKTOP, Descriptive Evaluation of preoperative Selection KriTeria for Operability; GOG, Gynecologic Oncology Group; SOC, Surgery or chemotherapy in recurrent Ovarian Cancer.

We noted inconsistent results from the three studies (DESKTOP III and SOC-1 trials vs. GOG-213 trial). One explanation may be related to the difference in bevacizumab usage. In the GOG 213 trial, 84% of patients received bevacizumab. In contrast, in the DESKTOP III and SOC-1 trials, only 23% and 1% of patients received bevacizumab, respectively. Another explanation may be the different processes used in each trial for selecting patients and centers.

The final analysis from DESKTOP III was published in the New England Journal of Medicine in 2021 [ 12 ]. The primary endpoint analysis of the DESKTOP III trial reported a median OS of 53.7 months with surgery and 46.0 months without surgery (p=0.02).

DESKTOP III is the first surgical study to demonstrate a meaningful survival benefit among patients with ovarian cancer, with an acceptable incidence of complications and without a detrimental effect on the quality of life, based on the Arbeitsgemeinschaft Gynaekologische Onkologie (AGO) score.

The authors emphasized that all patients with a first relapse after a platinum-free interval of at least 6 months should be assessed to determine if surgery is an option, and that the AGO score should be incorporated into the evaluation.

2. Unsatisfactory results from front-line chemo-immunotherapy

Two randomized phase III studies failed to show the benefit of adding immune checkpoint inhibitors to chemotherapy as first-line therapy and for maintenance in patients with newly diagnosed ovarian cancer [ 14 , 15 ].

In IMagyn 050, adding atezolizumab to a chemotherapy plus bevacizumab backbone did not improve PFS compared with chemotherapy plus bevacizumab alone in either the intention-to-treat or programmed death-ligand 1 (PD-L1) positive (immune cells [IC>1%) populations. Exploratory PFS analyses in the PD-L1 IC ≥5% subgroup showed a trend toward atezolizumab (PFS: hazard ratio [HR]=0.64, 95% CI=0.43–0.96).

The JAVELIN Ovarian 100 study did not meet either of its two primary objectives of improving PFS with two avelumab regimens with chemotherapy versus chemotherapy alone. PD-L1 status did not predict the benefit of avelumab treatment, either as maintenance therapy or in combination with chemotherapy. These findings did not concur with results from the JAVELIN Ovarian 200 study. In these two studies, the addition of PD-L1 inhibitors was unsatisfactory. Current attention is focused on doublet or triplet combination trials, including the DUO-O [ 16 ], FIRST/ENGOT-ov44 [ 17 ], KEYLINK-001/ENGOT-ov43 [ 18 ], and ATHENA [ 19 ] studies, which investigated immune checkpoint inhibitors with PARP inhibitors and/or bevacizumab in the first-line setting.

3. Overcoming PARP inhibitor resistance

As more patients receive PARP inhibitors as maintenance therapy as part of first- or second-line treatment, resistance to platinum agents and PARP inhibitors is inevitable. The EFFORT [ 20 ] and CAPRI [ 21 , 22 ] studies use targeting agents involved in DNA damage responses (DDR). OReO ( {"type":"clinical-trial","attrs":{"text":"NCT03106987","term_id":"NCT03106987"}} NCT03106987 ) evaluated PARP inhibitor retreatment in PARP inhibitor responders [ 23 ]. Various DDR inhibitors have been developed for anticancer therapy. PARP, ataxia-telangiectasia, Rad3-related (ATR), and WEE1 are the key components of different DDR pathways. PARP inhibitors are the best-studied class of DDR inhibitors. ATR inhibitors and WEE1 inhibitors are currently being investigated in clinical trials, especially in PARPi-resistant settings. In this review, the results of two phase II studies (EFFORT: WEE1 inhibitor, CAPRI: ATR inhibitor) and one phase III study (olaparib rechallenge with maintenance Olaparib [OReO]) were reviewed.

EFFORT showed that adavosertib (WEE1 inhibitor) alone and in combination with olaparib demonstrated efficacy in patients with PARP inhibitor-resistant ovarian cancer irrespective of BRCA status (ORR 29% from adavosertib+olaparib, ORR 23% from adavosertib alone) [ 20 ]. CAPRI evaluated the combination of a PARP inhibitor (olaparib) and ATR inhibitor (ceralasertib) in patients who were on a PARP inhibitor and experienced disease progression [ 22 ]. They showed that olaparib and ceralasertib were well-tolerated (no grade 4/5 toxicities) and showed clinical activity (ORR 46%) in platinum-sensitive patients who had progression with prior PARP inhibitors. However, there was no objective response in 12 platinum-resistant patients [ 21 ].

OReO/ENGOT Ov-38 is a randomized, double-blind trial, and the first phase III study to evaluate PARPi maintenance rechallenge. Patients enrolled in the BRCA1/2 mutated (BRCAm) (≥18 months [m] first-line [1 L] or ≥12 m 2 L + prior PARPi exposure [PPE]) and non-BRCAm (≥12 m 1 L or 6 m 2 L + PPE) cohorts were randomized (2:1; stratified by prior bevacizumab [yes vs. no] and prior lines of PBC [≤3 vs. ≥4]) to olaparib (O) tablets (300 mg bid [or 250 if 300 not previously tolerated]) or placebo (P) until progression. The primary endpoint was investigator-assessed PFS using Response Evaluation Criteria in Solid Tumours (RECIST) v1.1. OReO showed that, in a heavily pretreated ovarian cancer population, rechallenge with maintenance olaparib following response to platinum-based chemotherapy provided a statistically significant improvement in PFS compared with placebo, regardless of the BRCAm cohort (HR=0.57, 95% CI=0.37–0.87; nonBRCAm cohort: HR=0.43, 95% CI=0.26–0.71).

Future studies must investigate the following questions: 1) Who will benefit from PARP inhibitor retreatment? 2) Is the current “cut-off” of the previous PARP inhibitor duration the most appropriate? 3) Can we expect the same responses between women with progression prior to PARP inhibitors and those who progress after completion of the PARP inhibitor? 4) Are there several different effects if the PARP inhibitor is changed, for example, olaparib to olaparib/niraparib to olaparib?

UTERINE CORPUS CANCER

The incidence and mortality of endometrial cancer have been increasing [ 24 , 25 , 26 ]. The mortality rate is projected to rise by 19% between 2014 and 2035, and to 9 deaths per 100,000 females by 2035 [ 27 ]. The majority of endometrial cancers are diagnosed in the early stages and have a favorable prognosis. Survivorship has been highlighted and many gynecologic oncologists have enquired about the optimal follow-up protocol for patients with endometrial cancer. Routine cytology is not conducted as part of pelvic examination during follow-up [ 28 ] and the role of ultrasound, tumor markers, or computed tomography (CT) scans has also been questioned. To date, evidence for the ideal follow-up intervals is lacking. The TOTEM study compared the OS of an intensive (INT) vs. minimalist (MIN) 5-year follow-up regimen for endometrial cancer [ 29 ].

Endometrial cancer with unfavorable biomarkers, such as p53 abnormality [ 30 ], HER2 overexpression [ 31 ] or recurrent endometrial cancer, are the main reasons for the increased mortality among patients with endometrial cancer. Additionally, the search for effective new treatment has been met with limited success [ 32 , 33 ]. Significant improvement in recurrence-free survival among patients with high-risk endometrial tumors with p53 abnormality is achieved by adding chemotherapy during and after adjuvant radiation [ 34 ], regardless of the histologic type. The NRG Oncology GY-026 study investigated the treatment of HER2 positive endometrial cancer by adding trastuzumab to paclitaxel and carboplatin and found that it increased OS [ 32 ]. The GY-026 study is an international three-arm, phase III study of women with primary stage I–IV, HER2-positive endometrial cancer. The study examined the role of mono (trastuzumab) or dual inhibition of HER2 (trastuzumab/pertuzumab) in addition to cytotoxic chemotherapy.

In addition to p53 abnormality and HER2 overexpression, patients with mismatch repair deficiency (dMMR) or microsatellite instability-high (MSI-H), DNA polymerase epsilon (POLE) mutation, and nonspecific molecular profile (NSMP) are also considered distinct subgroups of endometrial cancer [ 35 ]. In contrast to other solid tumors, endometrial cancer is believed to be an ideal target for immunotherapy because of the unique immune landscape of the tumors, including a higher tumor mutation burden. Moreover, dMMR or MSI-H are surrogate markers for high tumor mutations, and are considered a predictive marker for immunotherapy. Consequently, several clinical trials have focused on dMMR or MSI-H tumors treated with immune checkpoint inhibitors in solid tumors, including endometrial cancer [ 36 ]. Recently, the GARNET and KEYNOTE 775 [ 37 ] trials have shown promising results in patients with recurrent endometrial cancer and also dMMR or MSI-H.

In endometrial cancer, only a few randomized controlled trials have been conducted to assess the role of a reduced number of scheduled visits. The contribution of routine serum, cytological, or imaging follow-up in improving OS or quality of life has not been observed. The TOTEM study is a multicenter randomized controlled clinical trial involving two follow-up regimens with different test intensities for endometrial cancer [ 29 ]. Patients with surgically treated endometrial cancer and who were in complete clinical remission as confirmed by imaging and FIGO stages I-IV were included. The patients were stratified by centers and low- or high-risk of recurrence, and then randomized to INT or MIN hospital-based follow-up regimens. In total, 1847 patients were included in the final analysis between 2008 and 2018.

Regarding follow-up protocols for the low-risk group defined as FIGO stage 1A and low-grade, one of the biggest differences between the MIN and INT arms was the lack of routine Pap smear and CT scans in the MIN arm. Routine CT scans were obtained in the 12 th and 24 th months after randomization during the 5-year follow-up in INT arm. The MIN arm was followed up every 6 months for 5 years. The INT arm was followed up every 4 months for the first 2 years, and every 6 months for the latter 3 years. For the high-risk group defined as FIGO stage IA with grade 3 or IB or above, no routine Pap smear, ultrasound, or tumor markers were planned in the MIN arm. However, routine CT scans in the 12 th and 24 th month after randomization were identical between the two arms. In all patients, unscheduled examinations were arranged if there were abnormal test results or clinical suspicion.

Overall compliance with the scheduled follow-up visits was 75.3% (INT 74.7% vs. MIN 75.9%). On the contrary, the mean number of recorded exams (laboratory or imaging) was significantly higher in the INT than in the MIN arms (9.7% vs. 2.9%, p<0.0001). After a median follow-up of 66 months, the 5-year OS rate was 91.3%, 90.6% in the INT arm and 91.9% in the MIN arm, respectively (HR=1.12, 95% CI=0.85–1.48, p=0.429). According to recurrence risk, the 5-year OS rate was 94.1% (INT) and 96.8% (MIN) (HR=1.48, 95% CI=0.92–2.37, p=0.104) in the low-risk group, and 85.3% (INT) and 84.7% (MIN) (HR=0.96, 95% CI=0.68–1.36, p=0.814) in the high-risk group. Health-related quality of life (HRQoL) data were available only for a subgroup of patients (50% at baseline) and did not differ between the arms. As a result, the INT follow-up protocol did not improve OS, even in high-risk patients, nor did it influence HRQoL. Based on these results, the authors suggested that the frequent routine use of imaging and laboratory examinations in these patients should be discouraged.

These findings may be applicable in patients with a low risk of recurrence. However, concerns remain for the high-risk patients. In the TOTEM study, patients with aggressive histology and/or advanced disease accounted for approximately 10% of the entire cohort, which appears to be too underpowered to draw any conclusions. Other limitations include the lack of molecular classification and incomplete data on lymphovascular space invasion and HRQoL. Of note, 80.4% of relapses in the low-risk group were diagnosed with clinical examination combined with other examinations, and 53.2% of relapses were identified with clinical examination and CT scan. This means that imaging and laboratory examinations still play a role in detecting recurrence, but should not be used for routine testing. There are three ongoing clinical trials (ENDCAT [ 38 ], ENSURE [ 39 , 40 ], and OPAL [ 41 ]) that are determining the optimal follow-up protocol for endometrial cancer. However, only patients with stage I or low/intermediate risk are eligible, which means that uncertainty for optimal follow-up in high-risk endometrial cancer may continue unless a new clinical trial for high-risk patients is developed.

Dostarlimab is an anti-programmed cell death protein 1 (PD-1) antibody, and GARNET is a phase I single-arm study of dostarlimab monotherapy in expanded cohorts of multiple tumor types [ 42 ]. The endometrial cancer cohort (A1, A2) included patients with recurrent/advanced dMMR/MSI-H (A1) or MMR-proficient (pMMR)/microsatellite instability-stable (MSS) (A2) endometrial cancer who had ≤2 prior lines of treatment for recurrent or advanced disease, and progression after platinum doublet therapy. Patients received 500 mg Q3W of dostarlimab for the first four cycles, followed by 1,000 mg Q6W, until disease progression or discontinuation. The primary endpoints were ORR and DOR using RECIST. irRECIST was the secondary endpoint.

In the interim analysis [ 43 ], 129 and 161 patients were enrolled in A1 and A2, respectively. pMMR/MSS patients had more aggressive histology (type II, 77.6% vs. 34.3%) and were more heavily pretreated (2 or above prior lines of chemotherapy, 53.8% vs. 36.1%) than dMMR/MSI-H patients. Radiation history was similar between the two groups. Based on RECIST, the ORRs in the dMMR/MSI-H and pMMR/MSS cohorts were 43.5% and 14.1%, respectively. Disease control rates in the dMMR/MSI-H and pMMR/MSS groups were 55.6% and 34.6%, respectively. The median DOR was not reached in either arm at the time of the analysis. The irORR was 44.8% in patients with dMMR/MSI-H and 14.4% in patients with pMMR/MSS. Overall, the efficacy results based on irRECIST were similar to those of RECIST. Most treatment-emergent adverse events were grade 1–2 (75.5%), with 5.5% discontinuation. The manageable toxicity profiles have been reported previously. In August 2021, the FDA approved dostarlimab for adult patients with dMMR recurrent or advanced solid tumors, including endometrial cancer.

Currently, dostarlimab is being evaluated in a phase III clinical trial (RUBY) in combination with standard chemotherapy in patients with recurrent or primary advanced endometrial cancer [ 44 ]. Another PD-1 inhibitor, pembrolizumab, is also being studied in a different phase III clinical trial (NRG GY-018) [ 45 ]. The NRG GY-018 study aimed to determine the efficacy of pembrolizumab in combination with paclitaxel and carboplatin in patients with advanced disease stages (measurable stage III or IVA, stage IVB, and recurrent endometrial cancer stratified by MMR status). A clinical trial with a PD-L1 inhibitor is also ongoing. The AtTEnd/ENGOT-en7 is a multicenter phase III double-blind randomized controlled trial of atezolizumab in combination with paclitaxel and carboplatin in women with advanced/recurrent endometrial cancer [ 46 , 47 ].

3. Keynote 775

The Keynote 775 study is a multicenter, open-label, randomized, phase III trial that compared the efficacy and safety of lenvatinib plus pembrolizumab versus treatment of physician’s choice in patients with advanced, metastatic, or recurrent endometrial cancer after one prior platinum-based chemotherapy [ 37 ]. Patients were randomized to receive lenvatinib 20 mg orally QD plus pembrolizumab 200 mg IV Q3W or treatment of the physician’s choice (doxorubicin, 60 mg/m 2 IV Q3W or paclitaxel, 80 mg/m 2 IV Q 3wk on/1wk off). Randomization was stratified by MMR status, and patients with pMMR tumors were further stratified by ECOG performance status, geographic region, and history of pelvic radiation. The primary endpoints were PFS and OS.

In total, 827 patients (697 with pMMR and 130 with dMMR) were randomly assigned to receive either lenvatinib plus pembrolizumab (411 patients) or chemotherapy (416 patients). The median PFS was longer in patients with lenvatinib plus pembrolizumab than with chemotherapy (pMMR population: 6.6 vs. 3.8 months, HR=0.60, 95% CI=0.50–0.72, p<0.001; dMMR population: 10.7 vs. 3.7 months, HR=0.36, 95% CI=0.23–0.57, p<0.001; overall: 7.2 vs. 3.8 months, HR=0.56, 95% CI=0.47–0.66, p<0.001). The median OS was better with lenvatinib plus pembrolizumab than with chemotherapy (pMMR population: 17.4 vs. 12.0 months, HR=0.68, 95% CI=0.56–0.84, p<0.001; dMMR population: not reached vs. 8.6 months, HR=0.37, 95% CI=0.11–0.62, p<0.001; overall: 18.3 vs. 11.4 months, HR=0.62, 95% CI=0.51–0.75, p<0.001). Adverse events of grade 3 or higher occurred in 88.9% of the patients who received lenvatinib plus pembrolizumab, and 72.7% of those who received chemotherapy.

This is the first clinical trial showing that a combination of immune checkpoint inhibitors and tyrosine kinase inhibitors led to superior survival rate compared to chemotherapy among patients with recurrent endometrial cancer with prior platinum-based chemotherapy, regardless of MMR status. The benefit appeared to be more prominent in patients with dMMR. In the dMMR subgroup in the Keynote 775 study, 40% of ORR with lenvatinib plus pembrolizumab was observed, which was significantly higher than the 12.3% observed in the chemotherapy group. KEYNOTE 146 [ 48 ] is a baseline study for KEYNOTE 775. It is a multinational, open-label, single-arm study of lenvatinib plus pembrolizumab in patients with selected solid tumors, including endometrial cancer. Among 118 patients with endometrial cancer in this study, 11 showed dMMR with a 63.6% ORR at the 24 th week. Although this was a very promising result, further verification is warranted because of the study’s small sample size. The clinically meaningful activity of lenvatinib plus pembrolizumab was confirmed in the KEYNOTE 775 study. The safety profile of dMMR patients was generally consistent with that of the full study population. Treatment-related adverse events of grade 3 or above were relatively high at 95.3%. Dose reduction, interruption, and discontinuation were observed in 64.1%, 71.9%, and 43.8% of dMMR patients, respectively. Hypothyroidism and hypertension were the most common symptoms observed. The combination of lenvatinib plus pembrolizumab was approved by the FDA only for patients with pMMR or MSS in July 2021. Currently, the combination of lenvatinib and pembrolizumab is being evaluated as a frontline treatment in patients with endometrial cancer. ENGOT-en9/LEAP-001 is a phase III study investigating first-line lenvatinib plus pembrolizumab versus chemotherapy in newly diagnosed patients with stage III, IV, or recurrent endometrial cancer [ 49 , 50 ].

In summary, the strong activity of dostarlimab, an anti PD-1 antibody, was observed in the GARNET study regardless of previous lines of therapy for patients with dMMR endometrial cancer. In the KEYNOTE 775 study, superior OS and PFS with lenvatinib plus pembrolizumab over chemotherapy were observed across all patient subgroups, including MMR status. Multiple studies on immune checkpoint inhibitors in the presence or absence of multiple kinases are ongoing, which may change the standard of treatment for endometrial cancer in the future.

PREVENTION OF GYNECOLOGIC CANCER

The major research results related to the prevention of gynecological cancer reported in 2021 can be summarized into two categories as follows:

1) Long-term follow-up results of the UKCTOCS study that evaluated the effectiveness of early ovarian cancer detection [ 51 ].
2) A TUBA trial compared salpingectomy with delayed oophorectomy and salpingo-oophorectomy in terms of quality of life in BRCA 1 and 2 pathogenic variant carriers [ 52 ].

1. UKCTOCS trial

The UKCTOCS trial was a randomized controlled trial to determine whether ovarian cancer population screening can reduce deaths due to ovarian cancer [ 51 ]. In this trial, 202,638 women from the general population were randomly assigned to two annual screening groups and a no screening group. One of the annual screening modalities was multimodal screening which consisted of longitudinal CA 125 and second-line transvaginal ultrasonography. The other was ultrasound screening. In the initial report of this trial in 2015, multimodal screening was associated with an increased number of patients diagnosed with stage I-II ovarian cancer, but neither of the two screening methods reduced the risk of ovarian cancer. In 2021, the long-term mortality effects of ovarian cancer screening in the UKCTOCS showed a reduction in stage III or IV disease incidence in the multimodal screening group. However, this reduction did not translate into a reduction in ovarian cancer mortality. Based on this study, general population screening for ovarian cancer is not recommended.

2. TUBA trial

Prophylactic bilateral salpingo-oophorectomy in BRCA 1 and 2 pathogenic mutation carriers has been shown to reduce the risk of ovarian cancer by 96%. Risk-reducing bilateral salpingo-oophorectomy (RRSO) is recommended for patients in their late 30s who are BRCA 1 pathogenic carriers, and patients in their early 40s who are BRCA 2 pathogenic carriers. However, in this case, early menopause is problematic and may lead to a decrease in the quality of life. Recently, based on the theory that high-grade serous carcinoma, the most common type of epithelial ovarian cancer, is of tubal origin, a preventive strategy of first performing only salpingectomy and later performing oophorectomy in BRCA 1 and 2 pathogenic carriers was proposed. Whether this strategy sufficiently reduces the risk of ovarian cancer has not yet been investigated in prospective trials. The TUBA trial was a prospective non-randomized trial that compared the menopause-related quality of life of risk-reducing salpingectomy with delayed oophorectomy and RRSO in BRCA 1 and 2 pathogenic carriers [ 52 ]. This study included 577 BRCA 1 and 2 pathogenic carriers. Of these, 394 underwent risk-reducing salpingectomy, and 154 had RRSO. The menopause-related quality of life was improved in patients who underwent risk-reducing salpingectomy compared to those who underwent RRSO regardless of hormone replacement therapy. Additional follow-up studies are required to determine the oncologic safety of risk-reducing salpingectomies.

ACKNOWLEDGEMENTS

We would like to express our sincere gratitude to the ‘2021 Team for Major Clinical Research Review’ as follows.

Soon-Beom Kang (Seoul National University, Seoul), Young Tae Kim (Yonsei University, Seoul), Joo-Hyun Nam (University of Ulsan, Seoul), Myong Cheol Lim (National Cancer Center, Goyang), Hee-Sug Ryu (Ajou University, Suwon), Byoung-Gie Kim (Sungkyunkwan University, Seoul) for organizing the review course. Sokbom Kang (National Cancer Center, Goyang), Hee Seung Kim (Seoul National University, Seoul), Maria Lee (Seoul National University, Seoul), Joseph J Noh (Sungkyunkwan University, Seoul), Soo Jin Park (Seoul National University, Seoul), So-Hyun Nam (University of Ulsan, Seoul) for reviewing cervical cancer. Jae Kwan Lee (Korea University, Seoul), Ju Won Roh (CHA University, Goyang), Sung Jong Lee (The Catholic University of Korea, Seoul), Tae Hun Kim (Seoul National University, Seoul), Sang Il Kim (The Catholic University of Korea, Suwon), Hyun-Woong Cho (Korea University, Korea) for prevention. Dae-Yeon Kim (University of Ulsan, Seoul), Seob Jeon (Soonchunhyang University, Cheoan), Kyung Jin Eoh (Yonsei University, Yongin), Woo Yeon Hwang (Seoul National University, Seongnam), Se Ik Kim (Seoul National University, Seoul), Kyeong-A So (Konkuk University, Seoul) for reviewing uterine corpus cancer. Suk-Joon Chang (Ajou University, Suwon), Sook Hee Hong (The Catholic University, Seoul), Tae-Wook Kong (Ajou University, Suwon), Hyun-Jin Choi (Chung-Ang University, Seoul), In Hee Lee (Daegu Catholic University, Daegu), Junsik Park (Yonsei University, Seoul) for reviewing ovarian cancer.

Conflict of Interest: No potential conflict of interest relevant to this article was reported.

Author Contributions:

Conceptualization: S.D.H., K.J.W.
Methodology: P.J.Y., L.J.Y., L.Y.Y., S.S.H., S.D.H.
Project administration: S.D.H., K.J.W.
Supervision: K.J.W.
Visualization: S.D.H.
Writing - original draft: P.J.Y., L.J.Y., L.Y.Y., S.D.H.
Writing - review & editing: P.J.Y., L.J.Y., L.Y.Y., S.S.H., S.D.H. K.J.W.

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Published: 09 May 2024

Abnormal uterine bleeding and its associated factors among reproductive-age women who visit the gynecology ward in Dilla University General Hospital, Southern Ethiopia, 2022

Mesfin Abebe 1 ,
Getnet Melaku 1 ,
Habtamu Endashaw Hareru 2 &
Tsion Mulat Tebeje 2

BMC Women's Health volume 24 , Article number: 281 ( 2024 ) Cite this article

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Metrics details

Abnormal uterine bleeding, a frequent gynecological problem among women of reproductive age, significantly affects their health and quality of life. Despite its problem, research on its extent and contributing factors in Ethiopia is scarce. Hence, this study is designed to determine the magnitude and factors associated with abnormal uterine bleeding among women visiting Dilla University General Hospital, Dilla, Ethiopia.

A cross-sectional study design was conducted with 380 women of reproductive age at Dilla University General Hospital. A systematic sampling method was employed to select the participants for the study. A structured interview administered questionnaire and checklist were used to collect the data. Stata V.14 software was used for cleaning, coding, ensuring completeness and accuracy, and further analysis. Bivariate and multivariable logistic regression analyses were used. Finally, the variables that have a p -value of < 0.05 were considered statistically significant.

In this study, the magnitude of abnormal uterine bleeding was 24.21% (95% CI, 20.14–28.79). History of sexually transmitted disease [AOR = 1.44, 95% CI: (1.33, 4.75)], history of anemia [AOR = 3.92, 95% CI: (1.20, 12.74)]., history of alcohol consumption [AOR = 2.49, 95% CI: (1.22, 5.06)], and perceived stress level [AOR = 1.30, 95% CI: (1.15, 1.69)] were found to be significantly associated with abnormal uterine bleeding.

Conclusions

The magnitude of abnormal uterine bleeding was 24.2% in the study setting. Factors such as a history of sexually transmitted disease, anemia, alcohol consumption, and perceived stress level were identified as significant risk factors for abnormal uterine bleeding. Addressing these factors is crucial for management. Further research and interventions targeting these risks are needed to enhance health outcomes. The study provides valuable insights for future interventions.

Peer Review reports

Introduction

Abnormal uterine bleeding (AUB) is defined as any menstrual bleeding from the uterus that is either abnormal in volume, regularity, or timing, or that is non-menstrual [ 1 ]. It is a common gynecologic concern in women of reproductive age [ 2 , 3 ]. The magnitude of AUB varies across populations, ranging from 10–30% [ 4 ]. It reduces quality of life and is linked to financial setbacks, decreased efficiency, worsening health, and greater healthcare costs [ 5 ]. In the United States, menorrhagia accounts for more than 18% of all gynecology outpatient visits [ 6 ]. Every year, over 800,000 women seek treatment for AUB in the United Kingdom. Along with the direct impact on the woman and her family, there are significant economic and healthcare costs [ 7 ]. AUB is a major cause of gynecological morbidity, affecting one out of every five women at some point during their reproductive period [ 8 ]. It is a medically and socially debilitating disorder. Furthermore, it is the most common cause of iron deficiency in the developed world, as well as chronic illness in the developing world [ 9 ].

From puberty to menopause, abnormal uterine bleeding is a common complaint among women. It hurts women’s health by causing anemia and lowering their quality of life. One of the most common reasons reproductive-aged women seek medical help is for AUB [ 6 , 10 ]. The pattern and factors that cause AUB differ depending on the woman’s age and reproductive health [ 8 ]. AUB accounts for roughly one-third of all visits to gynecologists among premenopausal women and more than 70% of office visits among perimenopausal and postmenopausal [ 11 ]. The estimated annual direct and indirect costs of abnormal bleeding are $1 billion and $12 billion, respectively [ 1 ]. Abnormal bleeding is also a common reason for women being referred to gynecologists, and it is a reason for up to 25% of all gynecologic surgeries [ 6 ].

According to studies conducted in Iran, India, Ethiopia, and Korea, the prevalence of abnormal uterine bleeding was 35.8%, 20.48%, 34.1%, and 14.3% respectively [ 8 , 12 , 13 , 14 ]. Pieces of evidence revealed that age, multiparty, body mass index, perceived stress, history of abortion, history of uterine fibroid, history of sexually transmitted infection, and history of IUCD were all contributing factors to abnormal uterine bleeding [ 3 , 8 , 12 , 13 , 14 ].

Abnormal uterine bleeding is a common condition that can result in significant morbidity, and women with abnormal uterine bleeding have a significantly lower quality of life than the general population [ 15 ]. Due to the scarcity of information on abnormal uterine bleeding and associated factors among women of reproductive age in Ethiopia and the study area, this current study is very important. By addressing this important public health issue, we aim to improve women’s health outcomes and enhance healthcare services in the region. This study aims to investigate the magnitude and factors associated with abnormal uterine bleeding among women attending Dilla University General Hospital, Southern Ethiopia.

Methods and materials

Study area, design, and period.

A facility-based cross-sectional study was conducted at Dilla University General Hospital, Dilla Town. Dilla University General Hospital is the only public hospital in town. Dilla University General Hospital serves as a referral hospital for all districts in the Gedeo zone, as well as some districts in Oromia and Sidama regions. The hospital in various wards provides preventive, curative, and rehabilitative services to a catchment population of 2 million people. The study was conducted from June 20 -August 20, 2022.

All reproductive-age women (15–49 years) who visited the gynecology outpatient department at Dilla University General Hospital were the source population. Selected reproductive-age women (15–49 years) who visited the gynecology outpatient department at Dilla University General Hospital during the study period in 2022 were the study population.

Eligibility criteria

Women in the reproductive age group of 15–49 years were included in the study. Those who were seriously ill, pregnant at the time of the study, who had undergone a hysterectomy or other surgical procedures that could affect their menstrual bleeding patterns, with a known history of bleeding disorders or coagulopathies, and unable to communicate during the data collection period were excluded.

Sample size determination

The sample size was calculated by using a single proportion formula by considering the assumptions: P = 34.1% the magnitude of AUB done in Jimma town [ 13 ], Oromia Region, Southwest Ethiopia. D = 5% the margin of error, Zα/2 = 1.96 at 95% confidence of certainty. Thus, n= ((Zα/2)2 * p (1 − p))/d2 = 345, considering 10% non-response rate = 35 and the final sample size was 380.

Sampling techniques and procedure

Dilla University General Hospital was selected. The total number of reproductive-age women visiting the Gynecology outpatient department in the previous year was obtained from the hospital’s registration log book. Then K th value was calculated by taking the previous year’s three-month period reports of the total number of reproductive-age women who visited the Gynecology outpatient department which was 750/380 ≈ 2. A systematic random sampling technique was used to choose our study participants. The first participant was selected randomly through a lottery method, and then every K th interval was chosen to identify subsequent participants for the study.

Study variables

Dependent variable.

Abnormal uterine bleeding (Yes or No).

Independent variables

Sociodemographic factors (age, marital status, residence, educational status, monthly income, occupational status) Reproductive health and clinically diagnosed related factors (parity, history of abortion, history of STI, history of IUCD, history of hormonal contraceptive, uterine cancer, bleeding disorder, thyroid disorder, anemia) Lifestyle behavior (drinking alcohol, smoking, BMI, stress).

Operational definition

Abnormal Uterine Bleeding (AUB) can be characterized by any of the following conditions: heavy menstrual bleeding, metrorrhagia, polymenorrhea, Oligomenorrhea, amenorrhea, or bleeding between menstrual cycles.

The Perceived Stress Scale was used to assess stress levels (PSS). PSS is a 10-item multiple-choice self-report psychological instrument for measuring stress perception. Each response was assigned a score ranging from 0 to 4. PSS is calculated by adding the totals of all scale items [ 16 , 17 ].

Data collection tools and procedures

The data were collected using a questionnaire that was developed after reviewing various pieces of literature. A structured interview administered questionnaire and checklist were used to collect the data. The questionnaire includes socio-demographic information, menstrual-related questions, lifestyle and behavioral questions, medical history questions, and anthropometric measurements (height and weight). Data collectors and supervisors were trained on data collection tools, interview techniques, information confidentiality, and the study’s objective and relevance. The Kobo Collect version 3.1 application was installed on the data collector’s Android phone, and the blank form was downloaded from the Kobo toolbox server.

Data quality control

To maintain data quality, the questionnaire was translated into the local language by a language expert. Data collectors and supervisors received two days of training to become familiarized with all types of data, tools, data collection methods, and study objectives. The questionnaires were pre-tested three weeks before the actual data collection. To ensure data quality, supervisors checked completed questionnaires for key content before uploading them from the Android mobile phone to the Kobo toolbox server. All data were collected on-site using Android mobile devices and uploaded to the Kobo server weekly using Kobo collect version 3.1. Regularly, the principal investigator checked the sent files from each data collector for consistency and completeness. Finally, to ensure data quality, proper data coding and categorization were performed.

Data processing and analysis

The data from the Kobo server was downloaded as an Excel file and exported to the Stata V.14 software for cleaning, coding, ensuring completeness and accuracy, and further analysis. Both bivariate and multivariable logistic regression analyses were used to assess the association between each independent variable and the outcome variable. Variables with a 95% confidence interval and a P -value of less than 0.25 in the bivariate analysis were included in the multivariable logistic regression analysis to control for all potential confounding variables. The Hosmer-Lemeshow goodness fitness test was performed to assess model fitness. The variance inflation factor (VIF) was used to assess multicollinearity amongst independent variables. Finally, adjusted odds ratios with 95% confidence intervals were calculated, and P -values less than 0.05 were considered statistically significant. Finally, data was presented in the form of tables, graphs, and text.

Sociodemographic and economic characteristics of study participants

In this study, 380 study participants were interviewed, with a 100% response rate. The mean and standard deviation of the study participants’ age was (28 ± 6.5) years. In terms of religion, about 236 (62.11%) of the women were Protestant, while 116(30.53%) women were Orthodox. Three hundred nine women (81.32%) of those respondents lived in urban areas. In terms of marital status, 250 (65.78%) of respondents were married.

In terms of the educational and occupational status of study participants, 92 (24.21%) had no formal education, and 200 (52.63%) were housewives. The median and interquartile range of monthly income was 100 Ethiopia Birr (IQR: 500, 2000). 193 (50.79%) of study participants earned less than 1000 (ETB) per month (Table 1 ).

Reproductive health and clinically diagnosed related characteristics of study participants

About 275 (72.37%) of the study’s participants were multiparous. Three hundred forty-two (90%) of women had no history of abortion. Out of the participants, 318(83.68%) women had a history of hormonal contraceptive usage. Seventeen (4.47%) of the respondents had a history of STI and anemia. 13(3.42%) of respondents had a previous history of uterine cancer and 27(7.11%) of participants had a history of bleeding disorder (Table 2 ).

Lifestyle behaviour-related characteristics of study participants

In terms of smoking and drinking alcohol, about 35(9.21%) and 39(10.26%) of women smoked and drank alcohol at least once a month, respectively. Around 281 (73.95%) of the participants had a body mass index between 18.5 and 24.9 kg/m 2 . Out of the study participants, 136(35.79%) women had high levels of stress level (Table 3 ).

Magnitude of abnormal uterine bleeding

In this study, the magnitude of abnormal uterine bleeding among study participants was 24.21% (95% CI, 20.14–28.79) (Fig. 1 ). Among the participants with AUB, the magnitude of heavy periods, metrorrhagia, polymenorrhea, oligomenorrhea, amenorrhea, and inter-menstrual bleeding in women of reproductive age was 27 (29.35%), 22 (23.92%), 15 (16.30%), 12 (13.04%), 7 (7.61%), and 9 (9.78%), respectively( Table 4 ).

Magnitude of abnormal uterine bleeding among study participants in Dilla University General Hospital, Southern Ethiopia, 2022( N = 380)

Factors associated with abnormal uterine bleeding

To identify the associated factors of abnormal uterine bleeding, variables with a p -value of less than 0.25 in bivariate analysis, significant associations in previous studies, and biological plausibility were considered for the multivariable model. In binary logistics regression analysis, residence, history of hormonal contraceptive used, history of abortion, history of STI, history of anemia, number of parity, history of cigarette smoking, history of alcohol consumption, and perceived stress level were found to be candidate variable for final multivariable logistics regression analysis model.

In the multivariable analysis history of STI, history of anemia, history of alcohol consumption, and perceived stress level were found to be significantly associated with abnormal uterine bleeding. The odds of abnormal uterine bleeding were 1.44 times higher in women who had a history of sexual transmission infection compared to women who hadn’t STI [AOR = 1.44, 95% CI: (1.33, 4.75)]. Women who had a history of anemia were 3.92 times more likely to have abnormal uterine bleeding than those who had no history of anemia [AOR = 3.92, 95% CI: (1.20, 12.74)].

Women who had a history of alcohol consumption were 2.49 times more likely to have abnormal uterine bleeding than women who had no history of alcohol consumption [AOR = 2.49, 95% CI: (1.22, 5.06)]. In comparison to women who had low perceived stress levels, those who have high perceived stress levels have a 1.30 times higher risk of having abnormal uterine bleeding [AOR = 1.30, 95% CI: (1.15, 1.69)] (Table 5 ).

Abnormal uterine bleeding (AUB) is one of the most common gynecologic complaints among reproductive-age women. It is the commonest presenting symptom and major gynecological problem responsible for as many as one-third of all outpatient gynecologic visits [ 18 ]. This study has the potential to significantly contribute to improving women’s health in Southern Ethiopia and beyond. The identification of factors associated with AUB can guide healthcare planning and policy-making.

Therefore, this study aimed to assess the magnitude of AUB and its associated factors among reproductive-age women in Dilla University General Hospital. According to this study, the magnitude of abnormal uterine bleeding was 24.21% (95% CI, 20.14–28.79). This study coincided with previous studies from developing countries (8–30%) [ 4 , 18 ] and Iran (27.2%) [ 12 ]. This finding was lower than studies done in Jimma (34.1%) [ 13 ], Debre Berhan (33.4%) [ 19 ], India (36%) [ 20 ], Iran (35.8%) [ 12 ], and Brazil (31.4%) [ 21 ]. This finding was also higher than that of a Chinese study (18.2%) [ 22 ]. The variations observed in the data could potentially be a result of the distinct methodologies implemented in the studies. However, other factors such as disparities in social, demographic, definitions of AUB, and cultural attributes, along with the level of access to health services, could also contribute to these differences.

A history of STIs was significantly associated with abnormal uterine bleeding. This finding is consistent with the study conducted in India [ 20 ] and Jimma [ 13 ]. This association might be explained by the fact that ascending infection causes uterine and Fallopian tube irritation, which leads to tubal dysfunction. It’s also possible that sexually transmitted infections (STIs) could lead to inflammation and infection in the reproductive system, disrupting the regular menstrual cycle and resulting in abnormal uterine bleeding (AUB).

The findings of this study revealed a significant association between anemia and menstrual irregularity. This is in line with studies conducted in Debre Berhan [ 17 ], and India [ 23 ]. In terms of stress, this finding revealed that a high level of perceived stress was associated with menstrual irregularity. A study conducted in China [ 24 ] and Debre Berhan [ 17 , 19 ] supported this finding. This could be due to psychological stress, which could impair HPO-Axis coordination. Another possible reason may be stress affects the menstrual cycle. When stress levels are high, the HPA axis activity is disrupted. As a result, women who are under a lot of stress may have more irregular periods than those who have low-stress levels.

The association between excessive alcohol consumption and menstrual irregularity was found to be significant in this study. According to a study conducted in China [ 22 ], Serbia [ 25 ], and Debre Berhan [ 17 ], those who drink regularly are more likely to report heavy periods than never drinkers. The possible explanation may be women who drink alcohol have higher levels of testosterone, estrogen, and luteinizing hormone [ 26 ]. In turn, such hormonal imbalance may result in menstrual irregularity, implying biological plausibility for the association between alcohol consumption and abnormal uterine bleeding. However, more research is needed to fully understand this relationship.

This study’s limitation was the presence of self-reported symptoms of abnormal menstrual bleeding patterns in the questionnaire, which may not indicate a problem. Additionally, because the study was cross-sectional in nature, cause and effect were not determined. The study was conducted in a single hospital, which may limit the generalizability of the findings to the wider population of reproductive-age women in Southern Ethiopia or other regions.

Conclusions and recommendations

The study revealed that the magnitude of AUB was 24.2% in the study setting and history of STI, history of anemia, history of alcohol consumption, and perceived stress level were found to be significantly associated with abnormal uterine bleeding. So local health planners, health institutions, health bureaus, and policymakers for routine screening and diagnosis of AUB for implementing appropriate strategies to decrease maternal morbidity and mortality due to abnormal uterine bleeding. Additional studies and interventions focusing on these risk factors are needed to enhance the overall health outcomes of those who experience abnormal uterine bleeding.

Data availability

All relevant data included in the manuscript are available from the corresponding author upon reasonable request.

Abbreviations

Abnormal Uterine Bleeding

Adjusted Odd Ratio

Body Mass Index

Confidence Interval

Hypothalamus Pituitary Adrenal

Intra Uterine Contraceptive Device

Sexual Transmitted Infections

Perceived Stress Scale

Melville C. Sexual and reproductive health at a glance. Wiley; 2015.

Kaunitz AM, Levine D. Abnormal uterine bleeding in nonpregnant reproductive-age patients: evaluation and approach to diagnosis. UpToDateToDate; 2021.

Sarala V, Gopalan U. Clinical pattern and presentation of abnormal uterine bleeding. Int J Reprod Contracept Obstet Gynecol. 2020;9(1):126–9.

Google Scholar

Sun Y, Wang Y, Mao L, Wen J, Bai W. Prevalence of abnormal uterine bleeding according to new International Federation of Gynecology and Obstetrics classification in Chinese women of reproductive age: a cross-sectional study. Medicine. 2018;97(31).

Wouk N, Helton M. Abnormal uterine bleeding in premenopausal women. Am Family Phys. 2019;99(7):435–43.

Rindfleisch K, Falleroni J, Schrager S. Abnormal uterine bleeding in reproductive-aged women. J Clin Outcomes Manag. 2015;22(2):83–94.

Whitaker L, Critchley HO. Abnormal uterine bleeding. Best Pract Res Clin Obstet Gynecol. 2016;34:54–65.

Article Google Scholar

Choudhury SA, Nath P. Abnormal uterine bleeding; its prevalence, causes and management in a tertiary care hospital. N Indian J OBGYN. 2020;7(1):52–7.

Saheta A, Hariharan C, Sharma U. Abnormal uterine bleeding. J Dent Med Sci. 2014;13:63–7.

ÖZKARA A, ABNORMAL UTERINE BLEEDING:. A REVIEW. CURRENT APPROACHES IN GYNECOLOGY AND GYNECO-ONCOLOGY. 2022:133.

Matthews ML. Abnormal uterine bleeding in reproductive-aged women. Obstet Gynecol Clin. 2015;42(1):103–15.

Kazemijaliseh H, Tehrani FR, Behboudi-Gandevani S, Khalili D, Hosseinpanah F, Azizi F. A Population-based study of the prevalence of abnormal uterine bleeding and its related factors among Iranian Reproductive-Age women: an updated data. Archives Iran Med (AIM). 2017;20(9).

Gerema U, Kene K, Abera D, Adugna T, Nigussie M, Dereje D, et al. Abnormal uterine bleeding and associated factors among reproductive age women in Jimma town, Oromia Region, Southwest Ethiopia. Women’s Health. 2022;18:17455057221077577.

CAS PubMed PubMed Central Google Scholar

Jung E-K, Kim S-W, Ock S-M, Jung K-I, Song C-H. Prevalence and related factors of irregular menstrual cycles in Korean women: the 5th Korean National Health and Nutrition Examination Survey (KNHANES-V, 2010–2012). J Psychosom Obstet Gynecol. 2018;39(3):196–202.

Fraser IS, Langham S, Uhl-Hochgraeber K. Health-related quality of life and economic burden of abnormal uterine bleeding. Expert Rev Obstet Gynecol. 2009;4(2):179–89.

Cohen S. Perceived stress in a probability sample of the United States. 1988.

Zeru AB, Gebeyaw ED, Ayele ET. Magnitude and associated factors of menstrual irregularity among undergraduate students of Debre Berhan University, Ethiopia. Reproductive Health. 2021;18(1):101.

Article PubMed PubMed Central Google Scholar

Saheta A, Hariharan C, Sharma U. Abnormal uterine bleeding. IOSR J Dent Med Sci. 2014;13(11):63–7.

Mittiku YM, Mekonen H, Wogie G, Tizazu MA, Wake GE. Menstrual irregularity and its associated factors among college students in Ethiopia, 2021. Front Global Women’s Health. 2022;3.

Rathi BA, Chaudhari SC. A clinical profile and factors associated with dysfunctional uterine bleeding at tertiary health care center. MedPulse Int J Gynaecol. 2017;4:25–7.

Rezende GP, Yela Gomes DA, Benetti-Pinto CL. Prevalence of abnormal uterine bleeding in Brazilian women: Association between self-perception and objective parameters. PLoS ONE. 2023;18(3):e0282605.

Article CAS PubMed PubMed Central Google Scholar

Ding C, Wang J, Cao Y, Pan Y, Lu X, Wang W, et al. Heavy menstrual bleeding among women aged 18–50 years living in Beijing, China: prevalence, risk factors, and impact on daily life. BMC Womens Health. 2019;19(1):1–9.

Mohite R, Mohite V, Kumbhar S, Ganganahalli P. Common menstrual problems among Slum adolescent girls of Western Maharashtra, India. J Krishna Inst Med Sci (JKIMSU). 2013;2(1).

Ansong E, Arhin SK, Cai Y, Xu X, Wu X. Menstrual characteristics, disorders and associated risk factors among female international students in Zhejiang Province, China: a cross-sectional survey. BMC Womens Health. 2019;19(1):1–10.

Ivanović R, Joksimović B, Čančar V, Marić H, Matović D, Lalović N, et al. Factors Associated with abnormal uterine bleeding in Perimenopausal Women. Clin Exp Obstet Gynecol. 2024;51(2):37.

Erol A, Ho AMC, Winham SJ, Karpyak VM. Sex hormones in alcohol consumption: a systematic review of evidence. Addict Biol. 2019;24(2):157–69.

Article CAS PubMed Google Scholar

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Acknowledgements

The authors would like to thank Dilla University General Hospital and the study participants who contributed their time and effort to this study.

No specific funding was received for this study and during the preparation of this manuscript.

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Department of Midwifery, College of Medicine & Health Sciences, Dilla University, Dilla, Ethiopia

Mesfin Abebe & Getnet Melaku

School of Public Health, College of Medicine & Health Sciences, Dilla University, Dilla, Ethiopia

Habtamu Endashaw Hareru & Tsion Mulat Tebeje

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Ethical approval and clearance were obtained from the Dilla University, College of Medicine and Health Science, Department of Midwifery ethical committee. Individual informed, voluntary, and signed consent was obtained from participating individuals. If our participants were under 16 years of age or uneducated, they obtained informed consent obtained from their legal guardian(s) of all subjects. To ensure the confidentiality of respondents their names were not written on the questionnaire. All interviews were made individually to keep privacy. The participants were informed that their responses would not result in any harm to them and would be offered full rights and freedom to participate or not to participate. Participant’s name and other personal identifiers were not collected and confidentiality was maintained. All necessary methods were conducted under the guidelines of the institution and declaration of Helsinki.

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Abebe, M., Melaku, G., Hareru, H.E. et al. Abnormal uterine bleeding and its associated factors among reproductive-age women who visit the gynecology ward in Dilla University General Hospital, Southern Ethiopia, 2022. BMC Women's Health 24 , 281 (2024). https://doi.org/10.1186/s12905-024-03128-6

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Medical residents are starting to avoid states with abortion bans, data shows

Julie Rovner

Rachana Pradhan

The Match Day ceremony at the University of California, Irvine, on March 15. Match Day is the day when medical students seeking residency and fellowship training positions find out their options. Increasingly, medical students are choosing to go to states that don't restrict abortion. Jeff Gritchen/MediaNews Group via Getty Images hide caption

Isabella Rosario Blum was wrapping up medical school and considering residency programs to become a family practice physician when she got some frank advice: If she wanted to be trained to provide abortions, she shouldn't stay in Arizona.

Blum turned to programs mostly in states where abortion access — and, by extension, abortion training — is likely to remain protected, like California, Colorado and New Mexico. Arizona has enacted a law banning most abortions after 15 weeks.

"I would really like to have all the training possible," she said, "so of course that would have still been a limitation."

In June, she will start her residency at Swedish Cherry Hill hospital in Seattle.

According to new statistics from the Association of American Medical Colleges (AAMC), for the second year in a row, students graduating from U.S. medical schools this year were less likely to apply for residency positions in states with abortion bans and other significant abortion restrictions.

Since the Supreme Court in 2022 overturned the constitutional right to an abortion, state fights over abortion access have created plenty of uncertainty for pregnant patients and their doctors. But that uncertainty has also bled into the world of medical education, forcing some new doctors to factor state abortion laws into their decisions about where to begin their careers.

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How florida and arizona supreme court rulings change the abortion access map.

Fourteen states, primarily in the Midwest and South, have banned nearly all abortions. The new analysis by the AAMC — exclusively reviewed by KFF Health News before its public release — found that the number of applicants to residency programs in states with near-total abortion bans declined by 4.2% between 2024 and 2023, compared with a 0.6% drop in states where abortion remains legal.

Notably, the AAMC's findings illuminate the broader problems that abortion bans can create for a state's medical community, particularly in an era of provider shortages: The organization tracked a larger decrease in interest in residencies in states with abortion restrictions not only among those in specialties most likely to treat pregnant patients, like OB-GYNs and emergency room doctors, but also among aspiring doctors in other specialties.

"It should be concerning for states with severe restrictions on reproductive rights that so many new physicians — across specialties — are choosing to apply to other states for training instead," wrote Atul Grover, executive director of the AAMC's Research and Action Institute.

The AAMC analysis found that the number of applicants to OB-GYN residency programs in abortion-ban states dropped by 6.7%, compared with a 0.4% increase in states where abortion remains legal. For internal medicine, the drop observed in abortion-ban states was over five times as much as in states where abortion is legal.

'Geographic misalignment'

In its analysis, the AAMC said that an ongoing decline in interest in abortion-ban states among new doctors ultimately "may negatively affect access to care in those states."

Dr. Jack Resneck Jr., immediate past president of the American Medical Association, said the data demonstrates yet another consequence of the post- Roe v. Wade era.

The AAMC analysis notes that even in states with abortion bans, residency programs are filling their positions — mostly because there are more graduating medical students in the U.S. and abroad than there are residency slots.

Still, Resneck said, "we're extraordinarily worried." For example, physicians without adequate abortion training may not be able to manage miscarriages, ectopic pregnancies or potential complications, such as infection or hemorrhaging, that could stem from pregnancy loss.

Those who work with students and residents say their observations support the AAMC's findings. "People don't want to go to a place where evidence-based practice and human rights in general are curtailed," said Beverly Gray, an associate professor of obstetrics and gynecology at Duke University School of Medicine.

Abortion in North Carolina is banned in nearly all cases after 12 weeks. Women who experience unexpected complications or discover their baby has potentially fatal birth anomalies later in pregnancy may not be able to receive care there.

Gray said she worries that even though Duke is a highly sought training destination for medical residents, the abortion ban "impacts whether we have the best and brightest coming to North Carolina."

Rohini Kousalya Siva will start her obstetrics and gynecology residency at MedStar Washington Hospital Center in Washington, D.C., this year. She said she did not consider programs in states that have banned or severely restricted abortion, applying instead to programs in Maryland, New Hampshire, New York and Washington, D.C.

"We're physicians," said Kousalya Siva, who attended medical school in Virginia and was previously president of the American Medical Student Association. "We're supposed to be giving the best evidence-based care to our patients, and we can't do that if we haven't been given abortion training."

Another consideration: Most graduating medical students are in their 20s, "the age when people are starting to think about putting down roots and starting families," said Gray, who added that she is noticing many more students ask about politics during their residency interviews.

And because most young doctors make their careers in the state where they do their residencies, "people don't feel safe potentially having their own pregnancies [while] living in those states" with severe restrictions, said Debra Stulberg, chair of the Department of Family Medicine at the University of Chicago.

Stulberg and others worry that this self-selection away from states with abortion restrictions will exacerbate the shortages of physicians in rural and underserved areas.

"The geographic misalignment between where the needs are and where people are choosing to go is really problematic," she said. "We don't need people further concentrating in urban areas where there's already good access."

From Tennessee to California

After attending medical school in Tennessee, which has adopted one of the most sweeping abortion bans in the U.S., Hannah Light-Olson will start her OB-GYN residency at the University of California San Francisco this summer.

It was not an easy decision, she said. "I feel some guilt and sadness leaving a situation where I feel like I could be of some help," she said. "I feel deeply indebted to the program that trained me and to the patients of Tennessee."

Light-Olson said some of her fellow students applied to programs in abortion-ban states "because they think we need pro-choice providers in restrictive states now more than ever." In fact, she said, she also applied to programs in abortion-ban states when she was confident the program had a way to provide abortion training.

"I felt like there was no perfect 100% guarantee. We've seen how fast things can change," she said. "I don't feel particularly confident that California and New York aren't going to be under threat too."

As a condition of a scholarship she received for medical school, Blum said, she will have to return to Arizona to practice, and it is unclear what abortion access will look like then. But she is worried about long-term impacts.

"Residents, if they can't get the training in the state, then they're probably less likely to settle down and work in the state as well," she said.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling and journalism.

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Cultural Relativity and Acceptance of Embryonic Stem Cell Research

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There is a debate about the ethical implications of using human embryos in stem cell research, which can be influenced by cultural, moral, and social values. This paper argues for an adaptable framework to accommodate diverse cultural and religious perspectives. By using an adaptive ethics model, research protections can reflect various populations and foster growth in stem cell research possibilities.

INTRODUCTION

Stem cell research combines biology, medicine, and technology, promising to alter health care and the understanding of human development. Yet, ethical contention exists because of individuals’ perceptions of using human embryos based on their various cultural, moral, and social values. While these disagreements concerning policy, use, and general acceptance have prompted the development of an international ethics policy, such a uniform approach can overlook the nuanced ethical landscapes between cultures. With diverse viewpoints in public health, a single global policy, especially one reflecting Western ethics or the ethics prevalent in high-income countries, is impractical. This paper argues for a culturally sensitive, adaptable framework for the use of embryonic stem cells. Stem cell policy should accommodate varying ethical viewpoints and promote an effective global dialogue. With an extension of an ethics model that can adapt to various cultures, we recommend localized guidelines that reflect the moral views of the people those guidelines serve.

Stem cells, characterized by their unique ability to differentiate into various cell types, enable the repair or replacement of damaged tissues. Two primary types of stem cells are somatic stem cells (adult stem cells) and embryonic stem cells. Adult stem cells exist in developed tissues and maintain the body’s repair processes. [1] Embryonic stem cells (ESC) are remarkably pluripotent or versatile, making them valuable in research. [2] However, the use of ESCs has sparked ethics debates. Considering the potential of embryonic stem cells, research guidelines are essential. The International Society for Stem Cell Research (ISSCR) provides international stem cell research guidelines. They call for “public conversations touching on the scientific significance as well as the societal and ethical issues raised by ESC research.” [3] The ISSCR also publishes updates about culturing human embryos 14 days post fertilization, suggesting local policies and regulations should continue to evolve as ESC research develops. [4] Like the ISSCR, which calls for local law and policy to adapt to developing stem cell research given cultural acceptance, this paper highlights the importance of local social factors such as religion and culture.

I. Global Cultural Perspective of Embryonic Stem Cells

Views on ESCs vary throughout the world. Some countries readily embrace stem cell research and therapies, while others have stricter regulations due to ethical concerns surrounding embryonic stem cells and when an embryo becomes entitled to moral consideration. The philosophical issue of when the “someone” begins to be a human after fertilization, in the morally relevant sense, [5] impacts when an embryo becomes not just worthy of protection but morally entitled to it. The process of creating embryonic stem cell lines involves the destruction of the embryos for research. [6] Consequently, global engagement in ESC research depends on social-cultural acceptability.

a. US and Rights-Based Cultures

In the United States, attitudes toward stem cell therapies are diverse. The ethics and social approaches, which value individualism, [7] trigger debates regarding the destruction of human embryos, creating a complex regulatory environment. For example, the 1996 Dickey-Wicker Amendment prohibited federal funding for the creation of embryos for research and the destruction of embryos for “more than allowed for research on fetuses in utero.” [8] Following suit, in 2001, the Bush Administration heavily restricted stem cell lines for research. However, the Stem Cell Research Enhancement Act of 2005 was proposed to help develop ESC research but was ultimately vetoed. [9] Under the Obama administration, in 2009, an executive order lifted restrictions allowing for more development in this field. [10] The flux of research capacity and funding parallels the different cultural perceptions of human dignity of the embryo and how it is socially presented within the country’s research culture. [11]

b. Ubuntu and Collective Cultures

African bioethics differs from Western individualism because of the different traditions and values. African traditions, as described by individuals from South Africa and supported by some studies in other African countries, including Ghana and Kenya, follow the African moral philosophies of Ubuntu or Botho and Ukama , which “advocates for a form of wholeness that comes through one’s relationship and connectedness with other people in the society,” [12] making autonomy a socially collective concept. In this context, for the community to act autonomously, individuals would come together to decide what is best for the collective. Thus, stem cell research would require examining the value of the research to society as a whole and the use of the embryos as a collective societal resource. If society views the source as part of the collective whole, and opposes using stem cells, compromising the cultural values to pursue research may cause social detachment and stunt research growth. [13] Based on local culture and moral philosophy, the permissibility of stem cell research depends on how embryo, stem cell, and cell line therapies relate to the community as a whole. Ubuntu is the expression of humanness, with the person’s identity drawn from the “’I am because we are’” value. [14] The decision in a collectivistic culture becomes one born of cultural context, and individual decisions give deference to others in the society.

Consent differs in cultures where thought and moral philosophy are based on a collective paradigm. So, applying Western bioethical concepts is unrealistic. For one, Africa is a diverse continent with many countries with different belief systems, access to health care, and reliance on traditional or Western medicines. Where traditional medicine is the primary treatment, the “’restrictive focus on biomedically-related bioethics’” [is] problematic in African contexts because it neglects bioethical issues raised by traditional systems.” [15] No single approach applies in all areas or contexts. Rather than evaluating the permissibility of ESC research according to Western concepts such as the four principles approach, different ethics approaches should prevail.

Another consideration is the socio-economic standing of countries. In parts of South Africa, researchers have not focused heavily on contributing to the stem cell discourse, either because it is not considered health care or a health science priority or because resources are unavailable. [16] Each country’s priorities differ given different social, political, and economic factors. In South Africa, for instance, areas such as maternal mortality, non-communicable diseases, telemedicine, and the strength of health systems need improvement and require more focus [17] Stem cell research could benefit the population, but it also could divert resources from basic medical care. Researchers in South Africa adhere to the National Health Act and Medicines Control Act in South Africa and international guidelines; however, the Act is not strictly enforced, and there is no clear legislation for research conduct or ethical guidelines. [18]

Some parts of Africa condemn stem cell research. For example, 98.2 percent of the Tunisian population is Muslim. [19] Tunisia does not permit stem cell research because of moral conflict with a Fatwa. Religion heavily saturates the regulation and direction of research. [20] Stem cell use became permissible for reproductive purposes only recently, with tight restrictions preventing cells from being used in any research other than procedures concerning ART/IVF. Their use is conditioned on consent, and available only to married couples. [21] The community's receptiveness to stem cell research depends on including communitarian African ethics.

c. Asia

Some Asian countries also have a collective model of ethics and decision making. [22] In China, the ethics model promotes a sincere respect for life or human dignity, [23] based on protective medicine. This model, influenced by Traditional Chinese Medicine (TCM), [24] recognizes Qi as the vital energy delivered via the meridians of the body; it connects illness to body systems, the body’s entire constitution, and the universe for a holistic bond of nature, health, and quality of life. [25] Following a protective ethics model, and traditional customs of wholeness, investment in stem cell research is heavily desired for its applications in regenerative therapies, disease modeling, and protective medicines. In a survey of medical students and healthcare practitioners, 30.8 percent considered stem cell research morally unacceptable while 63.5 percent accepted medical research using human embryonic stem cells. Of these individuals, 89.9 percent supported increased funding for stem cell research. [26] The scientific community might not reflect the overall population. From 1997 to 2019, China spent a total of $576 million (USD) on stem cell research at 8,050 stem cell programs, increased published presence from 0.6 percent to 14.01 percent of total global stem cell publications as of 2014, and made significant strides in cell-based therapies for various medical conditions. [27] However, while China has made substantial investments in stem cell research and achieved notable progress in clinical applications, concerns linger regarding ethical oversight and transparency. [28] For example, the China Biosecurity Law, promoted by the National Health Commission and China Hospital Association, attempted to mitigate risks by introducing an institutional review board (IRB) in the regulatory bodies. 5800 IRBs registered with the Chinese Clinical Trial Registry since 2021. [29] However, issues still need to be addressed in implementing effective IRB review and approval procedures.

The substantial government funding and focus on scientific advancement have sometimes overshadowed considerations of regional cultures, ethnic minorities, and individual perspectives, particularly evident during the one-child policy era. As government policy adapts to promote public stability, such as the change from the one-child to the two-child policy, [30] research ethics should also adapt to ensure respect for the values of its represented peoples.

Japan is also relatively supportive of stem cell research and therapies. Japan has a more transparent regulatory framework, allowing for faster approval of regenerative medicine products, which has led to several advanced clinical trials and therapies. [31] South Korea is also actively engaged in stem cell research and has a history of breakthroughs in cloning and embryonic stem cells. [32] However, the field is controversial, and there are issues of scientific integrity. For example, the Korean FDA fast-tracked products for approval, [33] and in another instance, the oocyte source was unclear and possibly violated ethical standards. [34] Trust is important in research, as it builds collaborative foundations between colleagues, trial participant comfort, open-mindedness for complicated and sensitive discussions, and supports regulatory procedures for stakeholders. There is a need to respect the culture’s interest, engagement, and for research and clinical trials to be transparent and have ethical oversight to promote global research discourse and trust.

d. Middle East

Countries in the Middle East have varying degrees of acceptance of or restrictions to policies related to using embryonic stem cells due to cultural and religious influences. Saudi Arabia has made significant contributions to stem cell research, and conducts research based on international guidelines for ethical conduct and under strict adherence to guidelines in accordance with Islamic principles. Specifically, the Saudi government and people require ESC research to adhere to Sharia law. In addition to umbilical and placental stem cells, [35] Saudi Arabia permits the use of embryonic stem cells as long as they come from miscarriages, therapeutic abortions permissible by Sharia law, or are left over from in vitro fertilization and donated to research. [36] Laws and ethical guidelines for stem cell research allow the development of research institutions such as the King Abdullah International Medical Research Center, which has a cord blood bank and a stem cell registry with nearly 10,000 donors. [37] Such volume and acceptance are due to the ethical ‘permissibility’ of the donor sources, which do not conflict with religious pillars. However, some researchers err on the side of caution, choosing not to use embryos or fetal tissue as they feel it is unethical to do so. [38]

Jordan has a positive research ethics culture. [39] However, there is a significant issue of lack of trust in researchers, with 45.23 percent (38.66 percent agreeing and 6.57 percent strongly agreeing) of Jordanians holding a low level of trust in researchers, compared to 81.34 percent of Jordanians agreeing that they feel safe to participate in a research trial. [40] Safety testifies to the feeling of confidence that adequate measures are in place to protect participants from harm, whereas trust in researchers could represent the confidence in researchers to act in the participants’ best interests, adhere to ethical guidelines, provide accurate information, and respect participants’ rights and dignity. One method to improve trust would be to address communication issues relevant to ESC. Legislation surrounding stem cell research has adopted specific language, especially concerning clarification “between ‘stem cells’ and ‘embryonic stem cells’” in translation. [41] Furthermore, legislation “mandates the creation of a national committee… laying out specific regulations for stem-cell banking in accordance with international standards.” [42] This broad regulation opens the door for future global engagement and maintains transparency. However, these regulations may also constrain the influence of research direction, pace, and accessibility of research outcomes.

e. Europe

In the European Union (EU), ethics is also principle-based, but the principles of autonomy, dignity, integrity, and vulnerability are interconnected. [43] As such, the opportunity for cohesion and concessions between individuals’ thoughts and ideals allows for a more adaptable ethics model due to the flexible principles that relate to the human experience The EU has put forth a framework in its Convention for the Protection of Human Rights and Dignity of the Human Being allowing member states to take different approaches. Each European state applies these principles to its specific conventions, leading to or reflecting different acceptance levels of stem cell research. [44]

For example, in Germany, Lebenzusammenhang , or the coherence of life, references integrity in the unity of human culture. Namely, the personal sphere “should not be subject to external intervention.” [45] Stem cell interventions could affect this concept of bodily completeness, leading to heavy restrictions. Under the Grundgesetz, human dignity and the right to life with physical integrity are paramount. [46] The Embryo Protection Act of 1991 made producing cell lines illegal. Cell lines can be imported if approved by the Central Ethics Commission for Stem Cell Research only if they were derived before May 2007. [47] Stem cell research respects the integrity of life for the embryo with heavy specifications and intense oversight. This is vastly different in Finland, where the regulatory bodies find research more permissible in IVF excess, but only up to 14 days after fertilization. [48] Spain’s approach differs still, with a comprehensive regulatory framework. [49] Thus, research regulation can be culture-specific due to variations in applied principles. Diverse cultures call for various approaches to ethical permissibility. [50] Only an adaptive-deliberative model can address the cultural constructions of self and achieve positive, culturally sensitive stem cell research practices. [51]

II. Religious Perspectives on ESC

Embryonic stem cell sources are the main consideration within religious contexts. While individuals may not regard their own religious texts as authoritative or factual, religion can shape their foundations or perspectives.

The Qur'an states:

“And indeed We created man from a quintessence of clay. Then We placed within him a small quantity of nutfa (sperm to fertilize) in a safe place. Then We have fashioned the nutfa into an ‘alaqa (clinging clot or cell cluster), then We developed the ‘alaqa into mudgha (a lump of flesh), and We made mudgha into bones, and clothed the bones with flesh, then We brought it into being as a new creation. So Blessed is Allah, the Best of Creators.” [52]

Many scholars of Islam estimate the time of soul installment, marked by the angel breathing in the soul to bring the individual into creation, as 120 days from conception. [53] Personhood begins at this point, and the value of life would prohibit research or experimentation that could harm the individual. If the fetus is more than 120 days old, the time ensoulment is interpreted to occur according to Islamic law, abortion is no longer permissible. [54] There are a few opposing opinions about early embryos in Islamic traditions. According to some Islamic theologians, there is no ensoulment of the early embryo, which is the source of stem cells for ESC research. [55]

In Buddhism, the stance on stem cell research is not settled. The main tenets, the prohibition against harming or destroying others (ahimsa) and the pursuit of knowledge (prajña) and compassion (karuna), leave Buddhist scholars and communities divided. [56] Some scholars argue stem cell research is in accordance with the Buddhist tenet of seeking knowledge and ending human suffering. Others feel it violates the principle of not harming others. Finding the balance between these two points relies on the karmic burden of Buddhist morality. In trying to prevent ahimsa towards the embryo, Buddhist scholars suggest that to comply with Buddhist tenets, research cannot be done as the embryo has personhood at the moment of conception and would reincarnate immediately, harming the individual's ability to build their karmic burden. [57] On the other hand, the Bodhisattvas, those considered to be on the path to enlightenment or Nirvana, have given organs and flesh to others to help alleviate grieving and to benefit all. [58] Acceptance varies on applied beliefs and interpretations.

Catholicism does not support embryonic stem cell research, as it entails creation or destruction of human embryos. This destruction conflicts with the belief in the sanctity of life. For example, in the Old Testament, Genesis describes humanity as being created in God’s image and multiplying on the Earth, referencing the sacred rights to human conception and the purpose of development and life. In the Ten Commandments, the tenet that one should not kill has numerous interpretations where killing could mean murder or shedding of the sanctity of life, demonstrating the high value of human personhood. In other books, the theological conception of when life begins is interpreted as in utero, [59] highlighting the inviolability of life and its formation in vivo to make a religious point for accepting such research as relatively limited, if at all. [60] The Vatican has released ethical directives to help apply a theological basis to modern-day conflicts. The Magisterium of the Church states that “unless there is a moral certainty of not causing harm,” experimentation on fetuses, fertilized cells, stem cells, or embryos constitutes a crime. [61] Such procedures would not respect the human person who exists at these stages, according to Catholicism. Damages to the embryo are considered gravely immoral and illicit. [62] Although the Catholic Church officially opposes abortion, surveys demonstrate that many Catholic people hold pro-choice views, whether due to the context of conception, stage of pregnancy, threat to the mother’s life, or for other reasons, demonstrating that practicing members can also accept some but not all tenets. [63]

Some major Jewish denominations, such as the Reform, Conservative, and Reconstructionist movements, are open to supporting ESC use or research as long as it is for saving a life. [64] Within Judaism, the Talmud, or study, gives personhood to the child at birth and emphasizes that life does not begin at conception: [65]

“If she is found pregnant, until the fortieth day it is mere fluid,” [66]

Whereas most religions prioritize the status of human embryos, the Halakah (Jewish religious law) states that to save one life, most other religious laws can be ignored because it is in pursuit of preservation. [67] Stem cell research is accepted due to application of these religious laws.

We recognize that all religions contain subsets and sects. The variety of environmental and cultural differences within religious groups requires further analysis to respect the flexibility of religious thoughts and practices. We make no presumptions that all cultures require notions of autonomy or morality as under the common morality theory , which asserts a set of universal moral norms that all individuals share provides moral reasoning and guides ethical decisions. [68] We only wish to show that the interaction with morality varies between cultures and countries.

III. A Flexible Ethical Approach

The plurality of different moral approaches described above demonstrates that there can be no universally acceptable uniform law for ESC on a global scale. Instead of developing one standard, flexible ethical applications must be continued. We recommend local guidelines that incorporate important cultural and ethical priorities.

While the Declaration of Helsinki is more relevant to people in clinical trials receiving ESC products, in keeping with the tradition of protections for research subjects, consent of the donor is an ethical requirement for ESC donation in many jurisdictions including the US, Canada, and Europe. [69] The Declaration of Helsinki provides a reference point for regulatory standards and could potentially be used as a universal baseline for obtaining consent prior to gamete or embryo donation.

For instance, in Columbia University’s egg donor program for stem cell research, donors followed standard screening protocols and “underwent counseling sessions that included information as to the purpose of oocyte donation for research, what the oocytes would be used for, the risks and benefits of donation, and process of oocyte stimulation” to ensure transparency for consent. [70] The program helped advance stem cell research and provided clear and safe research methods with paid participants. Though paid participation or covering costs of incidental expenses may not be socially acceptable in every culture or context, [71] and creating embryos for ESC research is illegal in many jurisdictions, Columbia’s program was effective because of the clear and honest communications with donors, IRBs, and related stakeholders. This example demonstrates that cultural acceptance of scientific research and of the idea that an egg or embryo does not have personhood is likely behind societal acceptance of donating eggs for ESC research. As noted, many countries do not permit the creation of embryos for research.

Proper communication and education regarding the process and purpose of stem cell research may bolster comprehension and garner more acceptance. “Given the sensitive subject material, a complete consent process can support voluntary participation through trust, understanding, and ethical norms from the cultures and morals participants value. This can be hard for researchers entering countries of different socioeconomic stability, with different languages and different societal values. [72]

An adequate moral foundation in medical ethics is derived from the cultural and religious basis that informs knowledge and actions. [73] Understanding local cultural and religious values and their impact on research could help researchers develop humility and promote inclusion.

IV. Concerns

Some may argue that if researchers all adhere to one ethics standard, protection will be satisfied across all borders, and the global public will trust researchers. However, defining what needs to be protected and how to define such research standards is very specific to the people to which standards are applied. We suggest that applying one uniform guide cannot accurately protect each individual because we all possess our own perceptions and interpretations of social values. [74] Therefore, the issue of not adjusting to the moral pluralism between peoples in applying one standard of ethics can be resolved by building out ethics models that can be adapted to different cultures and religions.

Other concerns include medical tourism, which may promote health inequities. [75] Some countries may develop and approve products derived from ESC research before others, compromising research ethics or drug approval processes. There are also concerns about the sale of unauthorized stem cell treatments, for example, those without FDA approval in the United States. Countries with robust research infrastructures may be tempted to attract medical tourists, and some customers will have false hopes based on aggressive publicity of unproven treatments. [76]

For example, in China, stem cell clinics can market to foreign clients who are not protected under the regulatory regimes. Companies employ a marketing strategy of “ethically friendly” therapies. Specifically, in the case of Beike, China’s leading stem cell tourism company and sprouting network, ethical oversight of administrators or health bureaus at one site has “the unintended consequence of shifting questionable activities to another node in Beike's diffuse network.” [77] In contrast, Jordan is aware of stem cell research’s potential abuse and its own status as a “health-care hub.” Jordan’s expanded regulations include preserving the interests of individuals in clinical trials and banning private companies from ESC research to preserve transparency and the integrity of research practices. [78]

The social priorities of the community are also a concern. The ISSCR explicitly states that guidelines “should be periodically revised to accommodate scientific advances, new challenges, and evolving social priorities.” [79] The adaptable ethics model extends this consideration further by addressing whether research is warranted given the varying degrees of socioeconomic conditions, political stability, and healthcare accessibilities and limitations. An ethical approach would require discussion about resource allocation and appropriate distribution of funds. [80]

While some religions emphasize the sanctity of life from conception, which may lead to public opposition to ESC research, others encourage ESC research due to its potential for healing and alleviating human pain. Many countries have special regulations that balance local views on embryonic personhood, the benefits of research as individual or societal goods, and the protection of human research subjects. To foster understanding and constructive dialogue, global policy frameworks should prioritize the protection of universal human rights, transparency, and informed consent. In addition to these foundational global policies, we recommend tailoring local guidelines to reflect the diverse cultural and religious perspectives of the populations they govern. Ethics models should be adapted to local populations to effectively establish research protections, growth, and possibilities of stem cell research.

For example, in countries with strong beliefs in the moral sanctity of embryos or heavy religious restrictions, an adaptive model can allow for discussion instead of immediate rejection. In countries with limited individual rights and voice in science policy, an adaptive model ensures cultural, moral, and religious views are taken into consideration, thereby building social inclusion. While this ethical consideration by the government may not give a complete voice to every individual, it will help balance policies and maintain the diverse perspectives of those it affects. Embracing an adaptive ethics model of ESC research promotes open-minded dialogue and respect for the importance of human belief and tradition. By actively engaging with cultural and religious values, researchers can better handle disagreements and promote ethical research practices that benefit each society.

This brief exploration of the religious and cultural differences that impact ESC research reveals the nuances of relative ethics and highlights a need for local policymakers to apply a more intense adaptive model.

[1] Poliwoda, S., Noor, N., Downs, E., Schaaf, A., Cantwell, A., Ganti, L., Kaye, A. D., Mosel, L. I., Carroll, C. B., Viswanath, O., & Urits, I. (2022). Stem cells: a comprehensive review of origins and emerging clinical roles in medical practice. Orthopedic reviews , 14 (3), 37498. https://doi.org/10.52965/001c.37498

[2] Poliwoda, S., Noor, N., Downs, E., Schaaf, A., Cantwell, A., Ganti, L., Kaye, A. D., Mosel, L. I., Carroll, C. B., Viswanath, O., & Urits, I. (2022). Stem cells: a comprehensive review of origins and emerging clinical roles in medical practice. Orthopedic reviews , 14 (3), 37498. https://doi.org/10.52965/001c.37498

[3] International Society for Stem Cell Research. (2023). Laboratory-based human embryonic stem cell research, embryo research, and related research activities . International Society for Stem Cell Research. https://www.isscr.org/guidelines/blog-post-title-one-ed2td-6fcdk ; Kimmelman, J., Hyun, I., Benvenisty, N. et al. Policy: Global standards for stem-cell research. Nature 533 , 311–313 (2016). https://doi.org/10.1038/533311a

[4] International Society for Stem Cell Research. (2023). Laboratory-based human embryonic stem cell research, embryo research, and related research activities . International Society for Stem Cell Research. https://www.isscr.org/guidelines/blog-post-title-one-ed2td-6fcdk

[5] Concerning the moral philosophies of stem cell research, our paper does not posit a personal moral stance nor delve into the “when” of human life begins. To read further about the philosophical debate, consider the following sources:

Sandel M. J. (2004). Embryo ethics--the moral logic of stem-cell research. The New England journal of medicine , 351 (3), 207–209. https://doi.org/10.1056/NEJMp048145 ; George, R. P., & Lee, P. (2020, September 26). Acorns and Embryos . The New Atlantis. https://www.thenewatlantis.com/publications/acorns-and-embryos ; Sagan, A., & Singer, P. (2007). The moral status of stem cells. Metaphilosophy , 38 (2/3), 264–284. http://www.jstor.org/stable/24439776 ; McHugh P. R. (2004). Zygote and "clonote"--the ethical use of embryonic stem cells. The New England journal of medicine , 351 (3), 209–211. https://doi.org/10.1056/NEJMp048147 ; Kurjak, A., & Tripalo, A. (2004). The facts and doubts about beginning of the human life and personality. Bosnian journal of basic medical sciences , 4 (1), 5–14. https://doi.org/10.17305/bjbms.2004.3453

[6] Vazin, T., & Freed, W. J. (2010). Human embryonic stem cells: derivation, culture, and differentiation: a review. Restorative neurology and neuroscience , 28 (4), 589–603. https://doi.org/10.3233/RNN-2010-0543

[7] Socially, at its core, the Western approach to ethics is widely principle-based, autonomy being one of the key factors to ensure a fundamental respect for persons within research. For information regarding autonomy in research, see: Department of Health, Education, and Welfare, & National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research (1978). The Belmont Report. Ethical principles and guidelines for the protection of human subjects of research.; For a more in-depth review of autonomy within the US, see: Beauchamp, T. L., & Childress, J. F. (1994). Principles of Biomedical Ethics . Oxford University Press.

[8] Sherley v. Sebelius , 644 F.3d 388 (D.C. Cir. 2011), citing 45 C.F.R. 46.204(b) and [42 U.S.C. § 289g(b)]. https://www.cadc.uscourts.gov/internet/opinions.nsf/6c690438a9b43dd685257a64004ebf99/$file/11-5241-1391178.pdf

[9] Stem Cell Research Enhancement Act of 2005, H. R. 810, 109 th Cong. (2001). https://www.govtrack.us/congress/bills/109/hr810/text ; Bush, G. W. (2006, July 19). Message to the House of Representatives . National Archives and Records Administration. https://georgewbush-whitehouse.archives.gov/news/releases/2006/07/20060719-5.html

[10] National Archives and Records Administration. (2009, March 9). Executive order 13505 -- removing barriers to responsible scientific research involving human stem cells . National Archives and Records Administration. https://obamawhitehouse.archives.gov/the-press-office/removing-barriers-responsible-scientific-research-involving-human-stem-cells

[11] Hurlbut, W. B. (2006). Science, Religion, and the Politics of Stem Cells. Social Research , 73 (3), 819–834. http://www.jstor.org/stable/40971854

[12] Akpa-Inyang, Francis & Chima, Sylvester. (2021). South African traditional values and beliefs regarding informed consent and limitations of the principle of respect for autonomy in African communities: a cross-cultural qualitative study. BMC Medical Ethics . 22. 10.1186/s12910-021-00678-4.

[13] Source for further reading: Tangwa G. B. (2007). Moral status of embryonic stem cells: perspective of an African villager. Bioethics , 21(8), 449–457. https://doi.org/10.1111/j.1467-8519.2007.00582.x , see also Mnisi, F. M. (2020). An African analysis based on ethics of Ubuntu - are human embryonic stem cell patents morally justifiable? African Insight , 49 (4).

[14] Jecker, N. S., & Atuire, C. (2021). Bioethics in Africa: A contextually enlightened analysis of three cases. Developing World Bioethics , 22 (2), 112–122. https://doi.org/10.1111/dewb.12324

[15] Jecker, N. S., & Atuire, C. (2021). Bioethics in Africa: A contextually enlightened analysis of three cases. Developing World Bioethics, 22(2), 112–122. https://doi.org/10.1111/dewb.12324

[16] Jackson, C.S., Pepper, M.S. Opportunities and barriers to establishing a cell therapy programme in South Africa. Stem Cell Res Ther 4 , 54 (2013). https://doi.org/10.1186/scrt204 ; Pew Research Center. (2014, May 1). Public health a major priority in African nations . Pew Research Center’s Global Attitudes Project. https://www.pewresearch.org/global/2014/05/01/public-health-a-major-priority-in-african-nations/

[17] Department of Health Republic of South Africa. (2021). Health Research Priorities (revised) for South Africa 2021-2024 . National Health Research Strategy. https://www.health.gov.za/wp-content/uploads/2022/05/National-Health-Research-Priorities-2021-2024.pdf

[18] Oosthuizen, H. (2013). Legal and Ethical Issues in Stem Cell Research in South Africa. In: Beran, R. (eds) Legal and Forensic Medicine. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-32338-6_80 , see also: Gaobotse G (2018) Stem Cell Research in Africa: Legislation and Challenges. J Regen Med 7:1. doi: 10.4172/2325-9620.1000142

[19] United States Bureau of Citizenship and Immigration Services. (1998). Tunisia: Information on the status of Christian conversions in Tunisia . UNHCR Web Archive. https://webarchive.archive.unhcr.org/20230522142618/https://www.refworld.org/docid/3df0be9a2.html

[20] Gaobotse, G. (2018) Stem Cell Research in Africa: Legislation and Challenges. J Regen Med 7:1. doi: 10.4172/2325-9620.1000142

[21] Kooli, C. Review of assisted reproduction techniques, laws, and regulations in Muslim countries. Middle East Fertil Soc J 24 , 8 (2020). https://doi.org/10.1186/s43043-019-0011-0 ; Gaobotse, G. (2018) Stem Cell Research in Africa: Legislation and Challenges. J Regen Med 7:1. doi: 10.4172/2325-9620.1000142

[22] Pang M. C. (1999). Protective truthfulness: the Chinese way of safeguarding patients in informed treatment decisions. Journal of medical ethics , 25(3), 247–253. https://doi.org/10.1136/jme.25.3.247

[23] Wang, L., Wang, F., & Zhang, W. (2021). Bioethics in China’s biosecurity law: Forms, effects, and unsettled issues. Journal of law and the biosciences , 8(1). https://doi.org/10.1093/jlb/lsab019 https://academic.oup.com/jlb/article/8/1/lsab019/6299199

[24] Wang, Y., Xue, Y., & Guo, H. D. (2022). Intervention effects of traditional Chinese medicine on stem cell therapy of myocardial infarction. Frontiers in pharmacology , 13 , 1013740. https://doi.org/10.3389/fphar.2022.1013740

[25] Li, X.-T., & Zhao, J. (2012). Chapter 4: An Approach to the Nature of Qi in TCM- Qi and Bioenergy. In Recent Advances in Theories and Practice of Chinese Medicine (p. 79). InTech.

[26] Luo, D., Xu, Z., Wang, Z., & Ran, W. (2021). China's Stem Cell Research and Knowledge Levels of Medical Practitioners and Students. Stem cells international , 2021 , 6667743. https://doi.org/10.1155/2021/6667743

[27] Luo, D., Xu, Z., Wang, Z., & Ran, W. (2021). China's Stem Cell Research and Knowledge Levels of Medical Practitioners and Students. Stem cells international , 2021 , 6667743. https://doi.org/10.1155/2021/6667743

[28] Zhang, J. Y. (2017). Lost in translation? accountability and governance of Clinical Stem Cell Research in China. Regenerative Medicine , 12 (6), 647–656. https://doi.org/10.2217/rme-2017-0035

[29] Wang, L., Wang, F., & Zhang, W. (2021). Bioethics in China’s biosecurity law: Forms, effects, and unsettled issues. Journal of law and the biosciences , 8(1). https://doi.org/10.1093/jlb/lsab019 https://academic.oup.com/jlb/article/8/1/lsab019/6299199

[30] Chen, H., Wei, T., Wang, H. et al. Association of China’s two-child policy with changes in number of births and birth defects rate, 2008–2017. BMC Public Health 22 , 434 (2022). https://doi.org/10.1186/s12889-022-12839-0

[31] Azuma, K. Regulatory Landscape of Regenerative Medicine in Japan. Curr Stem Cell Rep 1 , 118–128 (2015). https://doi.org/10.1007/s40778-015-0012-6

[32] Harris, R. (2005, May 19). Researchers Report Advance in Stem Cell Production . NPR. https://www.npr.org/2005/05/19/4658967/researchers-report-advance-in-stem-cell-production

[33] Park, S. (2012). South Korea steps up stem-cell work. Nature . https://doi.org/10.1038/nature.2012.10565

[34] Resnik, D. B., Shamoo, A. E., & Krimsky, S. (2006). Fraudulent human embryonic stem cell research in South Korea: lessons learned. Accountability in research , 13 (1), 101–109. https://doi.org/10.1080/08989620600634193 .

[35] Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: interviews with researchers from Saudi Arabia. BMC medical ethics, 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6

[36] Association for the Advancement of Blood and Biotherapies. https://www.aabb.org/regulatory-and-advocacy/regulatory-affairs/regulatory-for-cellular-therapies/international-competent-authorities/saudi-arabia

[37] Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: Interviews with researchers from Saudi Arabia. BMC medical ethics , 21 (1), 35. https://doi.org/10.1186/s12910-020-00482-6

[38] Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: Interviews with researchers from Saudi Arabia. BMC medical ethics , 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6

Culturally, autonomy practices follow a relational autonomy approach based on a paternalistic deontological health care model. The adherence to strict international research policies and religious pillars within the regulatory environment is a great foundation for research ethics. However, there is a need to develop locally targeted ethics approaches for research (as called for in Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: interviews with researchers from Saudi Arabia. BMC medical ethics, 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6), this decision-making approach may help advise a research decision model. For more on the clinical cultural autonomy approaches, see: Alabdullah, Y. Y., Alzaid, E., Alsaad, S., Alamri, T., Alolayan, S. W., Bah, S., & Aljoudi, A. S. (2022). Autonomy and paternalism in Shared decision‐making in a Saudi Arabian tertiary hospital: A cross‐sectional study. Developing World Bioethics , 23 (3), 260–268. https://doi.org/10.1111/dewb.12355 ; Bukhari, A. A. (2017). Universal Principles of Bioethics and Patient Rights in Saudi Arabia (Doctoral dissertation, Duquesne University). https://dsc.duq.edu/etd/124; Ladha, S., Nakshawani, S. A., Alzaidy, A., & Tarab, B. (2023, October 26). Islam and Bioethics: What We All Need to Know . Columbia University School of Professional Studies. https://sps.columbia.edu/events/islam-and-bioethics-what-we-all-need-know

[39] Ababneh, M. A., Al-Azzam, S. I., Alzoubi, K., Rababa’h, A., & Al Demour, S. (2021). Understanding and attitudes of the Jordanian public about clinical research ethics. Research Ethics , 17 (2), 228-241. https://doi.org/10.1177/1747016120966779

[40] Ababneh, M. A., Al-Azzam, S. I., Alzoubi, K., Rababa’h, A., & Al Demour, S. (2021). Understanding and attitudes of the Jordanian public about clinical research ethics. Research Ethics , 17 (2), 228-241. https://doi.org/10.1177/1747016120966779

[41] Dajani, R. (2014). Jordan’s stem-cell law can guide the Middle East. Nature 510, 189. https://doi.org/10.1038/510189a

[42] Dajani, R. (2014). Jordan’s stem-cell law can guide the Middle East. Nature 510, 189. https://doi.org/10.1038/510189a

[43] The EU’s definition of autonomy relates to the capacity for creating ideas, moral insight, decisions, and actions without constraint, personal responsibility, and informed consent. However, the EU views autonomy as not completely able to protect individuals and depends on other principles, such as dignity, which “expresses the intrinsic worth and fundamental equality of all human beings.” Rendtorff, J.D., Kemp, P. (2019). Four Ethical Principles in European Bioethics and Biolaw: Autonomy, Dignity, Integrity and Vulnerability. In: Valdés, E., Lecaros, J. (eds) Biolaw and Policy in the Twenty-First Century. International Library of Ethics, Law, and the New Medicine, vol 78. Springer, Cham. https://doi.org/10.1007/978-3-030-05903-3_3

[44] Council of Europe. Convention for the protection of Human Rights and Dignity of the Human Being with regard to the Application of Biology and Medicine: Convention on Human Rights and Biomedicine (ETS No. 164) https://www.coe.int/en/web/conventions/full-list?module=treaty-detail&treatynum=164 (forbidding the creation of embryos for research purposes only, and suggests embryos in vitro have protections.); Also see Drabiak-Syed B. K. (2013). New President, New Human Embryonic Stem Cell Research Policy: Comparative International Perspectives and Embryonic Stem Cell Research Laws in France. Biotechnology Law Report , 32 (6), 349–356. https://doi.org/10.1089/blr.2013.9865

[45] Rendtorff, J.D., Kemp, P. (2019). Four Ethical Principles in European Bioethics and Biolaw: Autonomy, Dignity, Integrity and Vulnerability. In: Valdés, E., Lecaros, J. (eds) Biolaw and Policy in the Twenty-First Century. International Library of Ethics, Law, and the New Medicine, vol 78. Springer, Cham. https://doi.org/10.1007/978-3-030-05903-3_3

[46] Tomuschat, C., Currie, D. P., Kommers, D. P., & Kerr, R. (Trans.). (1949, May 23). Basic law for the Federal Republic of Germany. https://www.btg-bestellservice.de/pdf/80201000.pdf

[47] Regulation of Stem Cell Research in Germany . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-germany

[48] Regulation of Stem Cell Research in Finland . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-finland

[49] Regulation of Stem Cell Research in Spain . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-spain

[50] Some sources to consider regarding ethics models or regulatory oversights of other cultures not covered:

Kara MA. Applicability of the principle of respect for autonomy: the perspective of Turkey. J Med Ethics. 2007 Nov;33(11):627-30. doi: 10.1136/jme.2006.017400. PMID: 17971462; PMCID: PMC2598110.

Ugarte, O. N., & Acioly, M. A. (2014). The principle of autonomy in Brazil: one needs to discuss it ... Revista do Colegio Brasileiro de Cirurgioes , 41 (5), 374–377. https://doi.org/10.1590/0100-69912014005013

Bharadwaj, A., & Glasner, P. E. (2012). Local cells, global science: The rise of embryonic stem cell research in India . Routledge.

For further research on specific European countries regarding ethical and regulatory framework, we recommend this database: Regulation of Stem Cell Research in Europe . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-europe

[51] Klitzman, R. (2006). Complications of culture in obtaining informed consent. The American Journal of Bioethics, 6(1), 20–21. https://doi.org/10.1080/15265160500394671 see also: Ekmekci, P. E., & Arda, B. (2017). Interculturalism and Informed Consent: Respecting Cultural Differences without Breaching Human Rights. Cultura (Iasi, Romania) , 14 (2), 159–172.; For why trust is important in research, see also: Gray, B., Hilder, J., Macdonald, L., Tester, R., Dowell, A., & Stubbe, M. (2017). Are research ethics guidelines culturally competent? Research Ethics , 13 (1), 23-41. https://doi.org/10.1177/1747016116650235

[52] The Qur'an (M. Khattab, Trans.). (1965). Al-Mu’minun, 23: 12-14. https://quran.com/23

[53] Lenfest, Y. (2017, December 8). Islam and the beginning of human life . Bill of Health. https://blog.petrieflom.law.harvard.edu/2017/12/08/islam-and-the-beginning-of-human-life/

[54] Aksoy, S. (2005). Making regulations and drawing up legislation in Islamic countries under conditions of uncertainty, with special reference to embryonic stem cell research. Journal of Medical Ethics , 31: 399-403.; see also: Mahmoud, Azza. "Islamic Bioethics: National Regulations and Guidelines of Human Stem Cell Research in the Muslim World." Master's thesis, Chapman University, 2022. https://doi.org/10.36837/ chapman.000386

[55] Rashid, R. (2022). When does Ensoulment occur in the Human Foetus. Journal of the British Islamic Medical Association , 12 (4). ISSN 2634 8071. https://www.jbima.com/wp-content/uploads/2023/01/2-Ethics-3_-Ensoulment_Rafaqat.pdf.

[56] Sivaraman, M. & Noor, S. (2017). Ethics of embryonic stem cell research according to Buddhist, Hindu, Catholic, and Islamic religions: perspective from Malaysia. Asian Biomedicine,8(1) 43-52. https://doi.org/10.5372/1905-7415.0801.260

[57] Jafari, M., Elahi, F., Ozyurt, S. & Wrigley, T. (2007). 4. Religious Perspectives on Embryonic Stem Cell Research. In K. Monroe, R. Miller & J. Tobis (Ed.), Fundamentals of the Stem Cell Debate: The Scientific, Religious, Ethical, and Political Issues (pp. 79-94). Berkeley: University of California Press. https://escholarship.org/content/qt9rj0k7s3/qt9rj0k7s3_noSplash_f9aca2e02c3777c7fb76ea768ba458f0.pdf https://doi.org/10.1525/9780520940994-005

[58] Lecso, P. A. (1991). The Bodhisattva Ideal and Organ Transplantation. Journal of Religion and Health , 30 (1), 35–41. http://www.jstor.org/stable/27510629 ; Bodhisattva, S. (n.d.). The Key of Becoming a Bodhisattva . A Guide to the Bodhisattva Way of Life. http://www.buddhism.org/Sutras/2/BodhisattvaWay.htm

[59] There is no explicit religious reference to when life begins or how to conduct research that interacts with the concept of life. However, these are relevant verses pertaining to how the fetus is viewed. (( King James Bible . (1999). Oxford University Press. (original work published 1769))

Jerimiah 1: 5 “Before I formed thee in the belly I knew thee; and before thou camest forth out of the womb I sanctified thee…”

In prophet Jerimiah’s insight, God set him apart as a person known before childbirth, a theme carried within the Psalm of David.

Psalm 139: 13-14 “…Thou hast covered me in my mother's womb. I will praise thee; for I am fearfully and wonderfully made…”

These verses demonstrate David’s respect for God as an entity that would know of all man’s thoughts and doings even before birth.

[60] It should be noted that abortion is not supported as well.

[61] The Vatican. (1987, February 22). Instruction on Respect for Human Life in Its Origin and on the Dignity of Procreation Replies to Certain Questions of the Day . Congregation For the Doctrine of the Faith. https://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_19870222_respect-for-human-life_en.html

[62] The Vatican. (2000, August 25). Declaration On the Production and the Scientific and Therapeutic Use of Human Embryonic Stem Cells . Pontifical Academy for Life. https://www.vatican.va/roman_curia/pontifical_academies/acdlife/documents/rc_pa_acdlife_doc_20000824_cellule-staminali_en.html ; Ohara, N. (2003). Ethical Consideration of Experimentation Using Living Human Embryos: The Catholic Church’s Position on Human Embryonic Stem Cell Research and Human Cloning. Department of Obstetrics and Gynecology . Retrieved from https://article.imrpress.com/journal/CEOG/30/2-3/pii/2003018/77-81.pdf.

[63] Smith, G. A. (2022, May 23). Like Americans overall, Catholics vary in their abortion views, with regular mass attenders most opposed . Pew Research Center. https://www.pewresearch.org/short-reads/2022/05/23/like-americans-overall-catholics-vary-in-their-abortion-views-with-regular-mass-attenders-most-opposed/

[64] Rosner, F., & Reichman, E. (2002). Embryonic stem cell research in Jewish law. Journal of halacha and contemporary society , (43), 49–68.; Jafari, M., Elahi, F., Ozyurt, S. & Wrigley, T. (2007). 4. Religious Perspectives on Embryonic Stem Cell Research. In K. Monroe, R. Miller & J. Tobis (Ed.), Fundamentals of the Stem Cell Debate: The Scientific, Religious, Ethical, and Political Issues (pp. 79-94). Berkeley: University of California Press. https://escholarship.org/content/qt9rj0k7s3/qt9rj0k7s3_noSplash_f9aca2e02c3777c7fb76ea768ba458f0.pdf https://doi.org/10.1525/9780520940994-005

[65] Schenker J. G. (2008). The beginning of human life: status of embryo. Perspectives in Halakha (Jewish Religious Law). Journal of assisted reproduction and genetics , 25 (6), 271–276. https://doi.org/10.1007/s10815-008-9221-6

[66] Ruttenberg, D. (2020, May 5). The Torah of Abortion Justice (annotated source sheet) . Sefaria. https://www.sefaria.org/sheets/234926.7?lang=bi&with=all&lang2=en

[67] Jafari, M., Elahi, F., Ozyurt, S. & Wrigley, T. (2007). 4. Religious Perspectives on Embryonic Stem Cell Research. In K. Monroe, R. Miller & J. Tobis (Ed.), Fundamentals of the Stem Cell Debate: The Scientific, Religious, Ethical, and Political Issues (pp. 79-94). Berkeley: University of California Press. https://escholarship.org/content/qt9rj0k7s3/qt9rj0k7s3_noSplash_f9aca2e02c3777c7fb76ea768ba458f0.pdf https://doi.org/10.1525/9780520940994-005

[68] Gert, B. (2007). Common morality: Deciding what to do . Oxford Univ. Press.

[69] World Medical Association (2013). World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA , 310(20), 2191–2194. https://doi.org/10.1001/jama.2013.281053 Declaration of Helsinki – WMA – The World Medical Association .; see also: National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. (1979). The Belmont report: Ethical principles and guidelines for the protection of human subjects of research . U.S. Department of Health and Human Services. https://www.hhs.gov/ohrp/regulations-and-policy/belmont-report/read-the-belmont-report/index.html

[70] Zakarin Safier, L., Gumer, A., Kline, M., Egli, D., & Sauer, M. V. (2018). Compensating human subjects providing oocytes for stem cell research: 9-year experience and outcomes. Journal of assisted reproduction and genetics , 35 (7), 1219–1225. https://doi.org/10.1007/s10815-018-1171-z https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6063839/ see also: Riordan, N. H., & Paz Rodríguez, J. (2021). Addressing concerns regarding associated costs, transparency, and integrity of research in recent stem cell trial. Stem Cells Translational Medicine , 10 (12), 1715–1716. https://doi.org/10.1002/sctm.21-0234

[71] Klitzman, R., & Sauer, M. V. (2009). Payment of egg donors in stem cell research in the USA. Reproductive biomedicine online , 18 (5), 603–608. https://doi.org/10.1016/s1472-6483(10)60002-8

[72] Krosin, M. T., Klitzman, R., Levin, B., Cheng, J., & Ranney, M. L. (2006). Problems in comprehension of informed consent in rural and peri-urban Mali, West Africa. Clinical trials (London, England) , 3 (3), 306–313. https://doi.org/10.1191/1740774506cn150oa

[73] Veatch, Robert M. Hippocratic, Religious, and Secular Medical Ethics: The Points of Conflict . Georgetown University Press, 2012.

[74] Msoroka, M. S., & Amundsen, D. (2018). One size fits not quite all: Universal research ethics with diversity. Research Ethics , 14 (3), 1-17. https://doi.org/10.1177/1747016117739939

[75] Pirzada, N. (2022). The Expansion of Turkey’s Medical Tourism Industry. Voices in Bioethics , 8 . https://doi.org/10.52214/vib.v8i.9894

[76] Stem Cell Tourism: False Hope for Real Money . Harvard Stem Cell Institute (HSCI). (2023). https://hsci.harvard.edu/stem-cell-tourism , See also: Bissassar, M. (2017). Transnational Stem Cell Tourism: An ethical analysis. Voices in Bioethics , 3 . https://doi.org/10.7916/vib.v3i.6027

[77] Song, P. (2011) The proliferation of stem cell therapies in post-Mao China: problematizing ethical regulation, New Genetics and Society , 30:2, 141-153, DOI: 10.1080/14636778.2011.574375

[78] Dajani, R. (2014). Jordan’s stem-cell law can guide the Middle East. Nature 510, 189. https://doi.org/10.1038/510189a

[79] International Society for Stem Cell Research. (2024). Standards in stem cell research . International Society for Stem Cell Research. https://www.isscr.org/guidelines/5-standards-in-stem-cell-research

[80] Benjamin, R. (2013). People’s science bodies and rights on the Stem Cell Frontier . Stanford University Press.

Mifrah Hayath

SM Candidate Harvard Medical School, MS Biotechnology Johns Hopkins University

Olivia Bowers

MS Bioethics Columbia University (Disclosure: affiliated with Voices in Bioethics)

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Published: 14 May 2024

2023 summer warmth unparalleled over the past 2,000 years

Jan Esper ORCID: orcid.org/0000-0003-3919-014X 1 , 2 ,
Max Torbenson ORCID: orcid.org/0000-0003-2720-2238 1 &
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Including an exceptionally warm Northern Hemisphere (NH) summer 1 ,2 , 2023 has been reported as the hottest year on record 3-5 . Contextualizing recent anthropogenic warming against past natural variability is nontrivial, however, because the sparse 19 th century meteorological records tend to be too warm 6 . Here, we combine observed and reconstructed June-August (JJA) surface air temperatures to show that 2023 was the warmest NH extra-tropical summer over the past 2000 years exceeding the 95% confidence range of natural climate variability by more than half a degree Celsius. Comparison of the 2023 JJA warming against the coldest reconstructed summer in 536 CE reveals a maximum range of pre-Anthropocene-to-2023 temperatures of 3.93°C. Although 2023 is consistent with a greenhouse gases-induced warming trend 7 that is amplified by an unfolding El Niño event 8 , this extreme emphasizes the urgency to implement international agreements for carbon emission reduction.

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Major clinical research advances in gynecologic cancer in 2021

Jung-Yun Lee

Yoo-Young Lee

Seung-Hyuk Shim

Dong Hoon Suh

Jae-Weon Kim

Associated Data

INTRODUCTION

CERVICAL CANCER

1. STARS trial

2. OUTBACK trial

3. KeyNote-826 trial

4. EMPOWER trial

5. InnovaTV 204 trial

6. ConCerv trial

OVARIAN CANCER

2. Unsatisfactory results from front-line chemo-immunotherapy

3. Overcoming PARP inhibitor resistance

UTERINE CORPUS CANCER

3. Keynote 775

PREVENTION OF GYNECOLOGIC CANCER

1. UKCTOCS trial

2. TUBA trial

ACKNOWLEDGEMENTS

SUPPLEMENTARY MATERIAL

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