Real-World Evidence for Safety and Effectiveness of Repeated Courses of Hyaluronic Acid Injections on the Time to Knee Replacement Surgery.

Osteoarthritis (OA) of the knee is a top cause of disability among the elderly. Total knee replacement (TKR) has been available as an effective and definite surgical method to treat severe OA of the knee. However, TKR is a significant procedure with potential risk for serious complications and high costs. Alternative lower risk therapies that can delay or obviate TKR are valuable to those who are poor candidates for surgery or wish to avoid TKR as long as possible. Given the chondroprotective effects of hyaluronic acid (HA) injections, they are a safe and effective treatment to improve pain, function, and longevity of the knee. Thus, HA features the potential to delay or obviate TKR. We aim to study the safety and effectiveness of repeated courses of HA on the time to TKR over a 3-year period using data from a large US health plan administrative claims database. Retrospective analyses were conducted by identifying knee OA patients during the selection period (2007-2010). The follow-up period was 36 months, post-index date of initial HA injection. Procedural outcomes and adverse events of interest were tabulated and analyzed. A Cox proportional hazards model was used to model the risk of TKR. A total of 50,389 patients who received HA for treatment of knee OA and met the study inclusion criteria were analyzed. Successive courses of HA showed a good safety profile and led to high proportions of patients without TKR 3 years after treatment initiation. Multivariate statistical modeling showed that multiple courses of HA injections significantly decreased the rates of TKR (95.0% without TKR for ≥5 courses vs 71.6% without TKR for 1 course; hazard ratio, 0.138; P < .0001). Repeated courses of treatment with HA are safe and are associated with the delay of TKR for up to 3 years. Additional research is needed to evaluate the effect of repeated HA courses on delaying TKR beyond a 3-year time horizon.

Differentiation of in vitro-modified human peripheral blood monocytes into hepatocyte-like and pancreatic islet-like cells.

BACKGROUND & AIMS: Adult stem cells provide a promising alternative for the treatment of diabetes mellitus and end-stage liver diseases. We evaluated the differentiation potential of human peripheral blood monocytes into hepatocyte-like and pancreatic islet-like cells. METHODS: Monocytes were treated with macrophage colony-stimulating factor and interleukin 3 for 6 days, followed by incubation with hepatocyte and pancreatic islet-specific differentiation media. Cells were characterized by flow cytometry, gene-expression analysis, metabolic assays, and transplantation for their state of differentiation and tissue-specific functions. RESULTS: In response to macrophage colony-stimulating factor and interleukin 3, monocytes resumed cell division in a CD115-dependent fashion, which was associated with a down-regulation of the PRDM1 and ICSBP genes. These programmable cells of monocytic origin were capable of differentiating into neohepatocytes, which closely resemble primary human hepatocytes with respect to morphology, expression of hepatocyte markers, and specific metabolic functions. After transplantation into the liver of severe combined immunodeficiency disease/nonobese diabetic mice, neohepatocytes integrated well into the liver tissue and showed a morphology and albumin expression similar to that of primary human hepatocytes transplanted under identical conditions. Programmable cells of monocytic origin-derived pancreatic neoislets expressed beta cell-specific transcription factors, secreted insulin and C peptide in a glucose-dependent manner, and normalized blood glucose levels when xenotransplanted into immunocompetent, streptozotocin-treated diabetic mice. Programmable cells of monocytic origin retained monocytic characteristics, notably CD14 expression, a monocyte-specific methylation pattern of the CD115 gene, and expression of the transcription factor PU.1. CONCLUSIONS: The ability to reprogram, expand, and differentiate peripheral blood monocytes in large quantities opens the real possibility of the clinical application of programmable cells of monocytic origin in tissue repair and organ regeneration.

Human monocyte-derived neohepatocytes: a promising alternative to primary human hepatocytes for autologous cell therapy.

BACKGROUND: There is growing interest in new therapeutic options for the treatment of end-stage liver diseases. In addition to mechanical devices supporting liver function, such as bioreactors, the transplantation of hepatocyte-like cells derived from (adult) stem cells offer great perspectives. We have generated hepatocyte-like (NeoHep) cells from terminally differentiated peripheral blood monocytes and, in this study, have evaluated these cells as a possible tool for autologous cell therapy. METHODS: Peripheral blood monocytes were cultured under conditions that promote hepatocyte-like differentiation and were characterized for hepatocyte marker expression by reverse-transcriptase polymerase chain reaction, immunohistochemistry, and immunoblotting and for specific secretory and metabolic functions with the appropriate biochemical assays. RESULTS: NeoHep cells resembled primary human hepatocytes with respect to morphology, expression of hepatocyte markers (albumin, cytochrome P450 isoenzymes, asialoglycoprotein receptor, coagulation factor VII), various secretory and metabolic functions (albumin secretion, urea production, lactate formation, and lactate dehydrogenase and aspartate transaminase release), and drug detoxification activities (phase I metabolization of ethoxycoumarin into 7OH-coumarin after stimulation with 3-methylcholanthren, induction of CYP3A4 activity, and phase II metabolization through UDP-glucuronidation of 4-methyl-umbelliferone). CONCLUSIONS: These data convincingly show that NeoHep cells display a phenotype and specific in vitro metabolic functions that are quantitatively and qualitatively comparable in part with those of primary human hepatocytes. These cells could thus be clinically applied in an autologous setting for the treatment of end-stage liver diseases or for improving liver function in patients who have undergone critical liver-mass resection.

Induction, expression and maintenance of cytochrome P450 isoforms in long-term cultures of primary human hepatocytes.

Within the past decade, tremendous progress has been made in the isolation and culture of human hepatocytes for drug metabolism and toxicology, which could potentially reduce the number of animal experiments performed. However, human hepatocyte cultures are still not widely used for preclinical drug testing, partly due to inconsistent supply and quality of human tissue. Thus, the aim of this study was to evaluate primary cultured human hepatocytes from different patients over a study period of 14 days, by assays that characterise cell quality and function. We found urea production and albumin synthesis in all cell cultures over at least 7 days. Cytochrome P4501A2, CYP2D6, and CYP3A4 protein expression was demonstrated by Western Blot analysis and CYP1A1/2 and CYP3A4 induction by 3-methylcholantrene, phenobarbital or rifampicin over 14 days. In addition, we saw that UDP-glucoronyltransferase activity was preserved in human hepatocytes over 2 weeks. In conclusion, we could show that primary human hepatocytes isolated from discarded liver tissue can consistently be kept in culture over a long time period and are therefore well suited for preclinical drug testing.

Technique and first clinical results of robot-assisted total knee replacement.

Total knee replacement (TKR) is a common procedure for treatment of severe gonarthrosis, but the outcome may be unsatisfactory due to primary malalignment of the prosthetic components. In order to improve precision and accuracy of this surgical procedure, a commercial robotic surgical system (CASPAR) has been adapted to assist the surgeon in the preoperative planning and intraoperative execution of TKR. So far, 70 patients with idiopathic gonarthrosis were successfully treated with a robot-assisted technique in our institution. No major adverse events related to the use of the robotic system have been observed. The mean difference between preoperatively planned and postoperatively achieved tibiofemoral alignment was 0.8 degrees (0-4.1 degrees ) in the robotic group vs. 2.6 degrees (0-7 degrees ) in a manually operated historical control group of 50 patients. A clear advantage of robot-assisted TKR seems to be the ability to execute a highly precise preoperative plan based on computed tomography (CT) scans. Due to better alignment of the prosthetic components and improved bone-implant fit, implant loosening is anticipated to be diminished which may be most evident in non-cemented prostheses. Current disadvantages such as the need for placement of fiducial markers, increased operating times and higher overall costs have to be resolved in the future.

Molecular and functional observations on the donor intestinal muscularis during human small bowel transplantation.

BACKGROUND & AIMS: Ischemia-reperfusion injury or intestinal manipulation evokes an inflammatory response within the intestinal muscularis that is associated with intestinal dysmotility. We hypothesize that human small intestinal transplantation induces an analogous response. METHODS: Human intestinal graft specimens were obtained during transplantation and compared with specimens removed early during elective bowel resections. Inflammatory gene expression was quantified by real-time reverse-transcription polymerase chain reaction. Histochemistry and immunohistochemistry were used to characterize leukocyte infiltration and macrophage activation. In vitro circular muscle contractility and intracellular electric neuromuscular transmission in response to electric field stimulation (EFS) were measured. RESULTS: Messenger RNA (mRNA) values were significantly elevated before reperfusion and further increased during reperfusion (4 hour reperfusion: interleukin [IL]-6, 311-fold; monocyte chemoattractant protein [MCP-1, 122-fold; IL-8, 338-fold; epithelial neutrophil-activating peptide-78 [ENA-78], 56-fold; intercellular adhesion molecule-1 [ICAM-1], 9-fold; and cyclooxygenase-2 [COX2], 37-fold) over elective specimens. Neutrophils and monocytes extravasated in increased numbers in whole mounts before and after reperfusion over the elective specimens. Activated resident macrophages were identified as a major source of inflammatory mediators. Muscle contractions and neuromuscular transmission were markedly attenuated in the grafts. CONCLUSIONS: The data suggest that manipulation during organ harvesting initiates a functionally relevant molecular and cellular inflammatory response within the graft muscularis that is potentiated during the reperfusion period. Significant mechanical and neuromuscular functional alterations occurred during the transplant process.