An 82-year-old female presented with longstanding history of both painful bladder syndrome and atrial fibrillation. She underwent hydrodistension remarkable for hematuria without temporary discontinuation of Dabigatran. Subsequently, patient was admitted to the hospital secondary to anemia and hemorrhagic cystitis.

Office Care of Women covers a wide range of topics which are pertinent to the provision of excellent healthcare. Common gynecologic topics are discussed in depth, as well as non-gynecologic medical conditions which are frequently faced by female patients. This book is designed as a single source reference which covers the majority of topics seen by clinicians as they care for women patients in the office setting. The fifty chapters include topics unique to female patients but also include other health conditions which are affected by the patient’s gender. The authors of this book span six specialties and three continents thereby giving the reader a comprehensive source of information to improve the healthcare of women. / https://dc.etsu.edu/etsu_books/1261/thumbnail.jpg

Gynecologic Care provides a succinct yet comprehensive discussion of critical knowledge required for gynecologists. Concise, easily accessible chapters allow the reader to quickly review essential material for patient care, or comprehensively study the modern management of gynecology. New residents can quickly cover the breadth of gynecology, while more experienced physicians will find the materials useful for review purposes. Each chapter covers key topics listed by the Committee for Resident Education in Obstetrics and Gynecology. Gynecologic Care is part of a three book series which covers the breadth of the Obstetrics and Gynecology specialty. The other books in the series are Obstetric Care and Office Care of Women. Presents comprehensive coverage for the breadth of gynecologic management. Along with the other books in the series, this covers the key topics listed by Committee for Resident Education in Obstetrics and Gynecology. Short chapters mean students can cover the entire breadth of obstetrics and gynecology in a short time with this series of books.

Objectives: The objectives of this study were to a) examine the distribution of chondrocalcinosis (CC), b) determine the risk factors of CC, and c) examine the radiographic phenotype of osteoarthritis (OA) associated with CC. Methods: Data from the Genetics of Osteoarthritis and Lifestyle (GOAL) study were used to describe the radiographic distribution of CC, and to conduct a case-control study in which cases with CC were compared with controls without CC. All participants had already completed a detailed questionnaire, been examined by a research metrologist, had radiographs of knees, hands, and pelvis, and had given urine and blood samples. All radiographs had been scored for structural radiographic changes of OA, and for the presence of CC. Frontal plane knee alignment was measured on all knee radiographs. The prevalence (95% confidence interval (CI)) of CC was calculated. The odds ratio (OR) and 95% CI were calculated for risk factors of CC, and for structural changes associated with CC in joints with OA. This was adjusted for age, gender, body mass index (BMI), and OA as appropriate, using logistic regression. Results: 3170 participants were included in this study. There were 431 cases with CC. The overall prevalence (95%CI) of CC in the GOAL population was 13.7% (12.5% - 14.9%). In the GOAL population, knee was the commonest site of CC. However, 42% of participants with CC did not have any knee involvement. There was evidence for a generalized predisposition to CC. For example, CC at one joint associated with CC at distant joints. Joints with CC clustered together more than would be expected by chance alone. At knees, wrists and hips, bilateral CC was more likely to associate with CC at distant joints than unilateral CC – also supporting the existence of a systemic predisposition to CC. After adjusting for confounding factors, there was an association between CC and increasing age, lower current BMI, and OA. The association between OA at one joint and CC at the same joint was present for all joints except for the hip. There was no association between CC and gender, diuretic intake, and selected single nucleotide polymorphisms in enzymes involved in pyrophosphate (PPi) metabolism. CC associated with peri-articular calcification, vascular calcification, low cortical bone mineral density (BMD) but not with low cancellous BMD. Self-reported arthroscopy, meniscectomy, knee injury, occupational knee joint loading and knee mal-alignment in the 3rd decade of life associated with knee CC. However, after adjusting for confounding factors including OA, there was no association between either self-reported or radiographically assessed current knee mal-alignment and knee CC. In joints with OA, the additional presence of CC at the same joint associated with a different radiographic phenotype of structural arthropathy. For example, in knees with OA, knee CC associated with attrition. In hips with OA, hip CC associated negatively with osteophytes, joint space narrowing, and sclerosis at the right hip but not at the left. Similarly, in wrists with OA, wrist CC associated with sclerosis in the right but not in the left wrist; in scapho-trapezioid joints (STJs) with OA wrist CC associated with sclerosis on both sides; in metacarpophalangeal joints with OA, wrist CC associated with cysts in the right but not in the left hand; and in 1st carpometacarpal joint with OA, wrist CC associated with cysts in the left but not in the right hand. In knees with OA, the additional presence of CC at distant joints associated with knee attrition. Those with knee CC + OA were excluded from this analysis to remove any local effects of CC. CC at distant joints did not associate with a distinct structural OA phenotype in other joints examined. Conclusion: These findings suggest that CC results form a systemic predisposition, and that it commonly occurs at other joints in the absence of knee involvement. Established risk factors of CC such as age, OA, and previous arthroscopy and/or meniscectomy were validated in this study. Several novel risk factors of CC e.g. low current BMI, low cortical BMD, and vascular calcification were identified. Several novel associations of knee CC i.e. early life knee malalignment, self-reported knee injury, and occupational knee loading were also recognised. There was convincing evidence to suggest that in joints with OA, the additional presence of CC modifies the OA phenotype, and that this varies from joint to joint.

PCOS is one of the leading causes of infertility worldwide affecting 1 in 10 women of a reproductive age. One of the fundamental abnormalities in women with PCOS can be seen within hormonal irregularities, which may include hyperandrogenemia hyperinsulinemia and hyper secretion of luteinising hormone (LH); and it is hypothesised that a defect in steroid secreting ovarian theca cells is involved due to their contribution in non-PCOS hormonal synthesis. Hyperinsulinemia has been associated with hyper-androgenemia through in vitro studies of cultured PCOS theca, where it has been suggested that insulin increases progesterone and androstenedione secretion when compared to normal theca cells. Furthermore the augmented effects of LH and insulin have been seen to increase ovarian androgen synthesis in non-PCOS theca cultures whilst also increasing the expression of steroidogenic enzymes specific to the PI3-K pathway. Many theories exist toward the etiology of hyper androgenemia within PCOS. Very few approaches however, consider dysfunction in multiple tissue types that may contribute to hormonal imbalances. It is well established that an association between obesity and PCOS exists and it is often the first therapeutic target for re-establishing reproductive function in obese PCOS patients. Furthermore PCOS patients tend to show distinct gynoid body fat distribution, which is reported to aggravate PCOS symptoms. It was therefore valid to examine the involvement in adipocyte function and its contribution to androgen levels within peos. This is further supported through the link between metabolic disorders such as insulin resistance and hyperinsulinemia, and their associations to obesity. Our study employed isolated preadipocyte and thecal cultures with close regulation of the influential factors LH and insulin. In doing so, we analysed androgen synthesis through activation and expression of steroidogenic enzymes CYP17 within both normal and polycystic ovaries. This allowed us to examine whether protein/hormonal concentrations vary across non-PCOS and peos cultures. This also allowed us to examine the possibility of a novel pathway leading to localised adipocyte synthesis as well as pinpointing whether dysfunction existed within the insulin-signalling pathway of thecal androgen steroidogenesis. The work in this thesis shows that adipocytes derived from non-PCOS and PCOS women, maintained in vitro differ on the basis of their morphology, rates of differentiation and proliferation. Furthermore, they reacted differently under conditions designed to mimic PCOS in vitro (increased insulin and LH), with reduced non-PCOS proliferation, and increased non-PCOS androgen secretion on insulin treatment. We also found increased steroidogenic CYP 17 expression in PCOS cultures under insulin stimulation. However PCOS adipocytes androstenedione secretion remained unaffected by insulin stimulation and secreted constant levels of androstenedione similar to that seen by insulin stimulated non-PCOS adipocytes. Our examination of non-PCOS and PCOS primary thecal cultures showed CYP17 expression is increased in pcas theca under basal conditions and that increases in insulin and LH leads to increases in in vitro theca proliferation. These conditions were also seen to lead to significant increases in androstenedione secretion over non-PCOS thecal cultures, and the results suggest it to be acting through the PI3-K pathway. These results therefore point to a specific area of dysfunction that should be further targeted for examination. Furthermore, they suggest that an adipocyte dysfunction exists within PCOS patients that may significantly contribute to hyperandrogenemia through localized synthesis of androgens.

The effect of metabolic and inflammatory parameters on pregnancy success in terms of implantation, metabolic adaptation to pregnancy and fetal programming is yet to be fully understood. This thesis explores the activity of metabolic and inflammatory pathways in pregnancy, highlighting their importance throughout gestation. In a cell culture study, a model of in vivo blastocyst-uterine adhesion to study the effect of insulin during uterine implantation was explored. JAR spheroid-RL95-2 monolayer adhesion reached 98% by 24 hours in the absence of insulin. A low dose (0.03nM) of added insulin concentrations resulted in 26% adhesion, or 74% inhibition; a high level (0.24nM) inhibited the JAR spheroid-RL95-2 monolayer adhesion by 9%. Therefore insulin did not have a dose-dependent on JAR spheroid-RL95-2 monolayer adhesion in the cell culture model of implantation. Polymerase chain reaction (PCR) studies revealed laminin α1 RNA detection on JAR cells only, CD44 on RL95-2 cells only, no trophinin on both cell types, FBLN-1 and -2 on JAR and FBLN-1 on RL95-2 cells only and an insulin receptor in both cell types. Western blot and immunohistochemistry (IHC) studies showed laminin α1 detection and stains on the JAR cell extracellular matrix. In a prospective human study, the metabolites of lipid and carbohydrate metabolism and inflammatory mediators very early (between day 0 and day 45) in gestation and their link to successful pregnancy in women undergoing natural cycle frozen embryo transfer (FET) in assisted conception, was investigated. Plasma triglyceride (TG), total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), glucose, c-reactive protein (CRP) and non-esterified fatty acid (NEFA) were measured on routine biochemistry; insulin, interleukin (IL)-6, plasminogen activated inhibitor (PAI)-1 and PAI-2 on ELISA; IL-8 (CXCL8), CCL2, CCL3, CCL4 and CCL11 on BioPlex; and human chronic gonadotrophin (hCG) on an Immulite system. For all 196 FET cycles, participants' demographics and plasma parameters of pregnant (n=36) and non-pregnant (n=106) women were explored. Neither obesity, the plasma parameters nor insulin resistance were predictive of successful pregnancy, but ICSI (predominately associated with male factor infertility) was. Overall, the hCG, insulin, rebound TG and HDL-C (except TC), homeostasis model assessment (HOMA), CRP and PAI-2 levels were higher, whereas CXCL8, CCL2, CCL11 and PAI-1 were significantly lower by day 45. Baseline obesity related to positive changes in plasma insulin, HDL-C and HOMA and negative changes in CXCL8, CCL3 and CCL4. In a cross-sectional study in late pregnancy, offspring's reflection of parameters in women with preeclampsia (PE) (n=29) and intrauterine growth restriction (IUGR) (n=14), compared to BMI-matched healthy groups (n=87) and (n=42), respectively, was explored. Fetal cord was found to be hyperlipidaemic, normoglycaemic and had reduced inflammatory response, while mothers who suffered PE had altered plasma TG, TC, NEFA, glucose, leptin and IL-10 compared to controls. IUGR babies were dyslipidaemic. The role of cholesterol transporters was assessed in PE (n=20) and IUGR (n=9) BMI-matched controls (n=20 and n=9) respectively. Among fifteen steroidogenic acute regulatory protein (STAR)-related lipid transfer domains, only STARD6 and STARD15 were not detected in the placenta via PCR. IHC studies were also explored on the placentae. The real-time PCR (RT-PCR) of messenger RNA of low-density lipoprotein receptor (LDLR), STARD3 and ATP-binding cassette A1 (ABCA1) without protein were higher in PE compared to controls. LDLR, STARD3 and ABCA1 localisation and detection were consistent to placental lipid (cholesterol) transport systems. In summary, all this led to the conclusion of the importance of metabolic and inflammatory pathways in all stages of pregnancy in leading to pregnancy success; these pathways may influence implantation, adaptation to pregnancy and, potentially, fetal programming of offspring.

Maternal obesity has been at the forefront of pregnancy-related research in recent times. The impact of this chronic health condition has been highlighted in reports on maternal mortality (CEMACH, 2007, CEMACH, 2011), where 30% of mothers who died from pregnancy related causes were obese (CEMACH, 2011). The importance of maternal obesity and how it affects maternal adaptation to pregnancy is well documented with obese women exhibiting low grade inflammation, greater coagulability and poorer improvement in vascular function during pregnancy compared to lean women (Stewart et al., 2007a). These findings suggest that obese women display similar characteristics to the non-pregnant adult metabolic syndrome and these attributes may be important in explaining why obese pregnancies have higher rates of obstetric complications including gestational diabetes (GDM) and pre-eclampsia (PET). In non-pregnant adult obesity it has been found that central or truncal adiposity is associated with increased NEFA (non-esterified fatty acids) turnover and ectopic fat (especially liver) deposition. It has been suggested that obese pregnant women may also preferentially gain fat in central depots and this may be the mechanism by which poor vascular improvement and inflammation are initiated. The aims of this thesis were to assess subcutaneous fat accumulation and distribution throughout pregnancy in both lean and OW/OB women. Furthermore this thesis aimed to acquire a better understanding of the impact of anatomical fat deposition on metabolic and vascular function during pregnancy. A final aim was to assess vascular function and evidence of lipotoxicity during pregnancy and test whether the site of fat accumulation and distribution was associated with gestational improvement of vascular function. A longitudinal study was performed and anthropometric data was collected from 26 lean and 16 OW/OB women at three antenatal time points (15, 25 and 35 weeks’ gestation) during pregnancy. Direct measurements of energy metabolism (basal metabolic rate, substrate utilisation, physical activity and diet) were also collected to assess the impact of energy metabolism on fat accumulation and distribution. A comprehensive panel of plasma markers of carbohydrate and lipid metabolism (fasting glucose, fasting insulin, total cholesterol [TC], total triglyceride [TG], high density lipoprotein [HDL] and NEFA) and inflammatory (C-reactive protein [CRP], interleukin-6 [IL6] and tumour necrosis factor alpha [TNF]) were quantitated at each study appointment. Endothelial function was measured using laser Doppler imaging (LDI). Measurement of plasma and urinary biomarkers of endothelial function and lipotoxicity including soluble intracellular adhesion molecule 1 (sICAM-1), soluble vascular adhesion molecule-1 (sVCAM-1), oxidised low density lipoprotein (oxLDL), plasma superoxide and urinary isoprostanes were undertaken. Lean and OW/OB women gained similar amounts of total body weight and fat mass during pregnancy. Only in lean women was there an anatomical preference for site of fat storage and this was in the upper peripheral subcutaneous depots. In healthy OW/OB pregnancy no such anatomical preference of fat deposition was found. The study of energy metabolism found that OW/OB women had higher basal metabolic rate and higher fat oxidation than lean women, whilst lean women had higher rates of carbohydrate oxidation and physical activity than OW/OB women. In the lean and OW/OB groups dietary macronutrient intakes were similar. Overall the parameters of energy metabolism were not associated with overall fat mass accumulation or distribution. During pregnancy, OW/OB women were more insulin resistant and pro-inflammatory (CRP and TNFα) than lean women and lean women had higher concentrations of plasma HDL. Interestingly the lean group had higher plasma concentrations of IL6 which may be a result of higher rates of vascular remodelling and may reflect a physiological rather than pathological process. In both lean and OW/OB pregnancies the gestational increase in subcutaneous adipose depots was not associated with the gestational changes in markers of carbohydrate, lipid or inflammatory profiles. Both lean and OW/OB women exhibited similar gestational improvement in endothelial microvascular function. During pregnancy both groups showed an increase in markers of lipotoxicity but levels were not associated with vascular function. Changes in anatomical subcutaneous fat distribution were also not associated with the changes in vascular function during pregnancy. In conclusion, in pregnancy, only lean women exhibit an anatomical site-specific fat accumulation. Although the OW/OB group displayed some aspects of the metabolic syndrome in general the OW/OB women studied here adapted to pregnancy in a similar way to lean women in terms of vascular function and levels of lipotoxicity. However, visceral adiposity was not assessed and OW/OB women with larger visceral adipose stores may exhibit a more lipotoxic phenotype and more pathological adaptation to pregnancy that may make them susceptible to metabolic complications of pregnancy. This study highlights the heterogeneity of maternal obesity and suggests that further studies into ‘metabolically healthy’ and ‘metabolically unhealthy’ lean and OW/OB women is warranted.

Genes that are imprinted are subject to a developmentally determined epigenetic marking, which restricts expression to a single allele, dependant on the parent of origin. Selection of imprinted genes for monoallelic expression indicates their function is highly dosage sensitive. Altered dosage of imprinted genes has been linked to a number of neurological conditions, including psychosis. Cdkn1c is an example of an imprinted gene whose expression is sensitive to the in utero environment. Considerable development of the nervous system takes place in utero and suboptimal pregnancies have been linked to the occurrence of psychiatric and other behavioural disorders in adults. One mechanism through which the maternal environment may impact foetal development is by altering the epigenetic regulation of vulnerable genes. A prenatal low protein or high fat diet resulted in alterations in a subset of imprinted gene in the brains of the offspring at E18.5. This was accompanied by sexually dimorphic changes in the dopaminergic system. Previously published findings reporting sensitivity of Cdkn1c to a prenatal low protein diet were replicated with a 1.8 fold increase in neural Cdkn1c expression observed. This was shown to be due to a change in the parental contribution to expression levels of this gene. Modelling the specific alteration of an increase in Cdkn1c genetically (Cdkn1cBACx1 line) revealed anhedonia, but with an increased motivational drive, towards a palatable solution, with corresponding changes in the reward system responsivity and chemistry in the adult brain. Additionally presence of a Cdkn1cBACx1 animal in a group destabilised the social hierarchy, negatively effecting fitness of all group members. An adverse inutero environment increases Cdkn1c levels to those reminiscent of the genetic ‘loss of imprinting’ model. Such alteration in expression of Cdkn1c has significant consequences for adult neurochemistry, reward processing and the social environment and fitness of the group. This work suggests a potentially crucial role, of at least Cdkn1c, and perhaps imprinted genes more generally, in mediating the negative consequences of an adverse in utero environment.

Diabetes is the most frequently encountered endocrine disorder in pregnancy and is associated with adverse outcomes. Despite the urgent need for interventions to improve the outcomes for pregnancies complicated with diabetes, and the consistent recognition of preconception care as an effective intervention, there has been lack of systematically produced evidence to support it. My first publication (Preconception Care for Diabetic Women for Improving Maternal and Fetal Outcomes: a Systematic Review and Meta-analysis) was the first systematically produced high level evidence addressing the effectiveness and the safety of all aspects of preconception care. This publication had high impact on practice and research evident by the incorporation of its findings in clinical guidelines and the number of times it was cited in the literature. My second publication (Pre-pregnancy care for women with pre-gestational diabetes mellitus: a systematic review and meta-analysis) was designed for deeper analysis of the safety of preconception care. The third and the fourth publications addressed the prevalence of pre-gestational and gestational diabetes and the rate of complications associated with diabetes in pregnancy in Saudi Arabia and contributed to the quantification of diabetes in pregnancy as a public health problem in the country. These two publications provided important information, considering that there was paucity of publications about diabetes in pregnancy in Saudi Arabia for more than a decade, and they gave the needed evidence to revise the hospital policy for screening and management of diabetes in pregnancy as well as the implementation of preconception care for women with pre-existing diabetes. My fifth publication investigated an important clinical intervention for pregnant women with diabetes which is induction of labour. Similar to the second and third publication there was paucity of information about the indications and the determinants of successful induction of labour in Saudi Arabia. This publication was the first to address this important intervention in the practice of obstetrics in general and in the specific management of women with diabetes. Thus my work in "diabetes in pregnancy as a clinical and public health problem" provided an important evaluation of interventions at the clinical and public health levels and important information for the management of diabetic pregnant women in Saudi Arabia and across the world.

Background: Current evidence indicates that DNA damage response (DDR) is a highly complex process that involves various pathways working in an orchestrated and interwoven manner in response to different types of damage to DNA. Although specific defects of DDR remain to be deciphered in cancer as a general, there is certainly an undeniable relationship between a particular dysfunction of DDR and the phenotype of tumour [1, 2]. It has been demonstrated that familial forms of breast and ovarian cancer are characterised by defects in one of the main mechanisms of DDR homologous recombination (HR) as a result of germline loss-of-function mutations in one of HR modifying genes, such as BRCA1 and BRCA2 [1, 3, 4]. Defects of genes involved in other DDR pathways are also associated with specific types of cancers; for instance hereditary non polyposis colorectal cancer (HNPCC) is strongly associated with specific mutations in the DNA mismatch repair pathway. Several previous studies have demonstrated that impaired DDR play a fundamental role in the pathogenesis and behaviour of breast cancer (BC). However, characterisation of this complex process, the expression and co-expression of the key proteins involved in the various DDR pathways and their prognostic significance in BC remain to be defined. In BC, it is reported that genes involved in DNA double strand breaks (DSB) repair are the most important. Two main pathways are involved in the repair of DNA-DSB; HR and Non Homologous End Joining (NHEJ) [3]. The common characteristics of global DDR are multiple genes induction directly associated with sensing and repair of DNA, arrest of cell cycle, and cell division inhibition. As a result DDR process does not only include genes activation involved in damage sensing as well as repair but additionally genes involved in control of cell-cycle [5]. Despite the fact that DDR may possibly involve activation of several pathways (such as SUMOylation (SUMO)) [6, 7] and many genes are engaged in different overlapping mechanisms, each pathway is characterised by activation and expression of a unique set of genes. This could allow discovering the active or aberrant pathway in a given tumour [1, 4, 5]. This study explores the hypothesis that investigation of alterations in the different pathways of DNA-DSB, may contribute to the characteristics of BC. Therefore, the aim was to perform a comprehensive profiling of key proteins involved in the different DNA-DSB repair pathways in the different molecular classes of BC. This approach aims to address the inherent problems arising from the complexity of DDR mechanism in BC with the potential of discovering a key pathway that is active or inactive in specific forms of BC that can be helpful to identify DNA repair status in individual BC patients. Method: The study cohort comprises three BC groups: A) Large series of unselected primary sporadic operable invasive tumours (n=1904) in addition to B) 386 cases of oestrogen receptor (ER) negative tumours and C) a well-characterised series of BC from patients with known BRCA1 germline mutations (n=24). The proteins investigated in this study are known to participate in different DNA-DSB repair pathways including, DNA damage sensors (ATM and ATR), HR repair (BRCA1, BARD1, Rad51, γH2AX and SMC6L1), DNA damage checkpoint signalling protein (CHK1 and CHK2), NHEJ repair (KU70/KU80, and DNA-PK), and SUMO (PIAS1, PIAS4, and UBC9). Because subcellular localisation of DDR proteins may affect their function, two markers that have role in nuclear transport in the cell were examined (NPM and KPNA2). The expression of these proteins was assessed using the well-established immunohistochemical technique utilising tissue microarray technology. The expression of proteins was further evaluated in various cell lines; BRCA1 deficient HeLaSilenciX® cells, and control BRCA1 proficient HeLaSilenciX®, MDA-MB-436 (BRCA1 deficient), and MCF-7 (BRCA1 proficient and ER+) using Reverse Phase Protein Microarray (RPPA). Results: Both cytoplasmic and nuclear expression was observed for expression of Rad51, SMC6L1, BRCA1, BARD1; (HR markers), PIAS1, UBC9 (SUMO markers), γH2AX (DNA-DSB marker) and CHK1 (checkpoint signalling protein). In contrast, both NHEJ markers and most of the DNA damage sensors (ATM and ATR), CHK2 and PIAS4 were mainly expressed in the nucleus. Generally, tumours that showed positive cytoplasmic/negative nuclear expression such as CHK1, PIAS1, Rad51, and BRCA1, and positive nuclear NHEJ markers showed an association with a poor outcome and adverse prognostic characteristics including high histologic grade, high mitotic frequency, high nuclear pleomorphism and larger tumour size in addition to ER negativity, and triple negative breast cancer (TNBC). Conversely, nuclear+/cytoplasmic- expression showed an association the better outcome. Interestingly, ATM protein expression showed no association with the expression of the two NHEJ markers, whereas ATR showed an association with cytoplasmic expression of BRCA1 and BARD1 and was positively associated with NHEJ markers. In non-TNBC, tumours showing BRCA1-/KU70/KU80- phenotype had worse breast cancer specific survival (BCSS) than positive expression (P<0.0001), whereas in the TN cohort,complex of KU70/KU80-&DNA-PK+ had the worst BCSS (P=0.001), and both are independent prognostic markers for BC. KPNA2, but not NPM was highly associated with poor BCSS (P<0.0001). At least one of nucleocytoplasmic transport markers (NPM or KPNA2) was significantly associated with the subcellular localisation of the most of the markers that showed cytoplasmic expression including SMC6L1, γH2AX, BRCA1, BARD1, UBC9, PIAS1 ,Rad51 and CHK1. RPPA was used to investigate the protein expression in different cell lines, although the correlation between RPPA and IHC was not significant, the results of RPPA were consistent with that demonstrated by IHC further supporting the finding of the current study. Conclusion: This study highlight the complexity of DDR related proteins and the overlap between different pathways involved in DDR. The finding of this study may help in the classification of BC and therefore, targeting active pathways in the development of drugs would enhance better patients’ outcomes. Major prognostic and predictive variables can be very important in choosing suitable treatment plans, identifying the risk of recurrence and classifying patients for clinical trials. Our results show that the HR- repair marker Rad51, complex of HR and NHEJ repair markers (BRCA1&KU70/KU80) in non-TNBC, and a complex of NHEJ markers (KU70/KU80&DNA-PK) are all independent prognostic markers for BC. In addition to expression, subcellular localisation of DDR proteins appeared to be a major factor in their role. Particularly, HR repair markers (but not NHEJ) showed worse features of cytoplasmic location of expression, whereas nuclear expression was associated with more favourable features. Finally, the results of this study provide further evidence to support combined use of IHC with the parallel analytic capability of protein microarray RPPA to investigate protein alterations in human tumours.