Intrathecal delivery of adipose-derived mesenchymal stem cells in traumatic spinal cord injury: Phase I trial.

Intrathecal delivery of autologous culture-expanded adipose tissue-derived mesenchymal stem cells (AD-MSC) could be utilized to treat traumatic spinal cord injury (SCI). This Phase I trial (ClinicalTrials.gov: NCT03308565) included 10 patients with American Spinal Injury Association Impairment Scale (AIS) grade A or B at the time of injury. The study's primary outcome was the safety profile, as captured by the nature and frequency of adverse events. Secondary outcomes included changes in sensory and motor scores, imaging, cerebrospinal fluid markers, and somatosensory evoked potentials. The manufacturing and delivery of the regimen were successful for all patients. The most commonly reported adverse events were headache and musculoskeletal pain, observed in 8 patients. No serious AEs were observed. At final follow-up, seven patients demonstrated improvement in AIS grade from the time of injection. In conclusion, the study met the primary endpoint, demonstrating that AD-MSC harvesting and administration were well-tolerated in patients with traumatic SCI.

SPECT-CT as a Predictor of Pain Generators in Patients Undergoing Intra-Articular Injections for Chronic Neck and Back Pain.

BACKGROUND: The ability to accurately predict pain generators for chronic neck and back pain remains elusive. OBJECTIVE: We evaluated whether injections targeted at foci with uptake on single-photon emission computerized tomography-computed tomography (SPECT-CT) were associated with improved outcomes in patients with chronic neck and back pain. METHODS: A retrospective review was completed on patients undergoing SPECT-CT for chronic neck and back pain between 2016 and 2020 at a tertiary academic center. Patients' records were reviewed for demographic, clinical, imaging, and outcomes data. Only those patients who had facet injections after SPECT-CT were included in this evaluation. Patients undergoing injections targeted at foci of abnormal radiotracer uptake were compared with patients without uptake concerning immediate positive response, visual analog scale, and the need for additional injection or surgery at the target level. RESULTS: A total of 2849 patients were evaluated with a SPECT-CT for chronic neck and back pain. Of those, 340 (11.9%) patients received facet joint injections after SPECT-CT. A propensity score regression analysis adjusted for age, gender, body mass index, hypertension, multiple target injections, and injection location showed uptake targeted injections not being associated with an improved immediate positive response (odds ratio: 0.64; 95% confidence interval: 0.34-1.21; P = 0.172). In patients with a failed facet injection preceding SPECT-CT, adding SPECT-CT to guide facet injections was associated with a decrease in visual analog scale pain scores 2 weeks after injection (P = 0.018), particularly when changes were made to the facets being targeted (P = 0.010). CONCLUSION: This study suggests that there is benefit with SPECT-CT specially to guide facet injections after failed prior facet injections.

The effectiveness of intradiscal biologic treatments for discogenic low back pain: a systematic review.

BACKGROUND CONTEXT: There are limited treatments for discogenic low back pain. Intradiscal injections of biologic agents such as platelet-rich plasma (PRP) or stem cells (SC) are theorized to have regenerative properties and have gained increasing interest as a possible treatment, but the evidence supporting their use in clinical practice is not yet well-defined. PURPOSE: Determine the effectiveness of intradiscal biologics for treating discogenic low back pain. STUDY DESIGN: PRISMA-compliant systematic review. PATIENT SAMPLE: Patients with discogenic low back pain confirmed by provocation discography or clinical and imaging findings consistent with discogenic pain. OUTCOME MEASURES: The primary outcome was the proportion of individuals with ≥50% pain relief after intradiscal biologic injection at 6 months. Secondary outcomes included ≥2-point pain score reduction on NRS; patient satisfaction; functional improvement; decreased use of other health care, including analgesics and surgery; and structural disc changes on MRI. METHODS: Comprehensive literature search performed in 2018 and updated in 2020. Interventions included were biologic therapies including mesenchymal stem cells, platelet rich plasma, microfragmented fat, amniotic membrane-based injectates, and autologous conditioned serum. Any other treatment (sham or active) was considered for comparative studies. Studies were independently reviewed. RESULTS: The literature search yielded 3,063 results, 37 studies were identified for full-text review, and 12 met established inclusion criteria for review. The quality of evidence on effectiveness of intradiscal biologics was very low. A single randomized controlled trial evaluating platelet-rich plasma reported positive outcomes but had significant methodological flaws. A single trial that evaluated mesenchymal stem cells was negative. Success rates for platelet-rich plasma injectate in aggregate were 54.8% (95% Confidence Interval: 40%-70%). For mesenchymal stem cells, the aggregate success rate at six months was 53.5% (95% Confidence Interval: 38.6%-68.4%), though using worst-case analysis this decreased to 40.7% (95% Confidence Interval: 28.1%-53.2%). Similarly, ≥30% functional improvement was achieved in 74.3% (95% Confidence Interval: 59.8%-88.7%) at six months but using worst-case analysis, this decreased to 44.1% (95% Confidence Interval: 28.1%-53.2%). CONCLUSION: Limited observational data support the use of intradiscal biologic agents for the treatment of discogenic low back pain. According to the Grades of Recommendation, Assessment, Development and Evaluation System, the evidence supporting use of intradiscal mesenchymal stem cells and platelet-rich plasma is very low quality.

Outcomes of a Comprehensive Pain Rehabilitation Program for Patients With Fibromyalgia.

OBJECTIVE: To analyze opioid intake interference with psychological, well-being, and functional outcomes and medication tapering in patients with fibromyalgia admitted to the Mayo Clinic Pain Rehabilitation Program (MCPRP) in Florida. PATIENTS AND METHODS: A retrospective study on MCPRP outcomes was conducted. We reviewed the health records of 150 patients with fibromyalgia who participated in the program from May 1, 2014, to May 1, 2015. All patients were asked to fill out a survey at admission to and dismissal from the program. Surveys contained questions from the numeric pain score, Multidimensional Pain Inventory (perceived life control and interference of pain subscales), Center for Epidemiological Studies-Depression Scale, Pain Catastrophizing Scale, 36-Item Short-Form Health Status Survey (general health perceptions subscale), and Pain Self-Efficacy Questionnaire. A medical record review identified categories and number of medications at program admission and dismissal. Patients were divided in 2 groups: those whose concomitant medication did not include opioids at admission (no opioids group) and those whose concomitant medication included opioids at admission (opioids group). RESULTS: By dismissal from the MCPRP, patients with fibromyalgia in the no opioids group had a significant (P<.05) improvement in all the self-reported scores. Medication, including opioids, were effectively tapered at a substantially higher percentage in the opioids group. CONCLUSION: Benefit of the comprehensive pain rehabilitation program in patients with fibromyalgia was indicated by clinical improvements in pain severity, physical and emotional health, and functional capacity while successfully tapering medication. Opioid intake at admission may modify the program outcomes.

A three-dimensional computed tomography study to determine the ideal method for fluoroscopically-guided bone marrow aspiration from the iliac crest.

Bone marrow aspiration (BMA) through the iliac crest is potentially unsafe due to the vicinity of neurovascular structures in the greater sciatic notch. Our objective was to investigate the safety of a recently described BMA technique, specifically a trajectory from the posterior superior iliac spine (PSIS) to the anterior inferior iliac spine (AIIS). We conducted a chart review of 260 patients, analyzing three-dimensional reconstructed computed tomography images of the pelvis and sacrum to validate that this new approach offers a wide safety margin from the greater sciatic notch. Analysis of three-dimensional computed tomography scans demonstrated that the PSIS to AIIS trajectory never crossed the greater sciatic notch. The trajectory was noted to be at least one cm away from the greater sciatic notch in all measurements. The new trajectory entered the PSIS at 25.29 ± 4.34° (left side) and 24.93 ± 4.15° (right side) cephalad from the transverse plane, and 24.58 ± 4.99° (left side) and 24.56 ± 4.67° (right side) lateral from the mid-sagittal plane. The area of bone marrow encountered with the new approach was approximately 22.5 cm2. Utilizing the same CT scans, the trajectory from the traditional approach crossed the greater sciatic notch in all scans, highlighting the potential for violating the greater sciatic notch boundary and damaging important neurovascular structures. Statistically significant sex-related differences were identified in needle trajectory angles for both approaches. We conclude that based on this three-dimensional computed tomography study, a trajectory from the PSIS to the AIIS for BMA may offer a wide safety margin from the greater sciatic notch.

Promising role for mesenchymal stromal cells in coronavirus infectious disease-19 (COVID-19)-related severe acute respiratory syndrome?

Mesenchymal stromal cells (MSC) have immune regulatory and tissue regenerative properties. MSCs are being studied as a therapy option for many inflammatory and immune disorders and are approved to treat acute graft-versus-host disease (GvHD). The severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic and associated coronavirus infectious disease-19 (COVID-19) has claimed many lives. Innovative therapies are needed. Preliminary data using MSCs in the setting of acute respiratory distress syndrome (ARDS) in COVID-19 are emerging. We review mechanisms of action of MSCs in inflammatory and immune conditions and discuss a potential role in persons with COVID-19.

Differences in Cytotoxicity of Lidocaine, Ropivacaine, and Bupivacaine on the Viability and Metabolic Activity of Human Adipose-Derived Mesenchymal Stem Cells.

PURPOSE: We evaluated biological effects of distinct local anesthetics on human adipose-derived mesenchymal stem cells when applied to reduce periprocedural pain during mesenchymal stem cell injections. METHODS AND MATERIALS: Metabolic activity (MTS assay), viability (Live/Dead stain), and gene expression (quantitative real-time reverse-transcriptase polymerase chain reaction) were measured in mesenchymal stem cells incubated with various concentrations of lidocaine, ropivacaine, or bupivacaine during a 12-hr time course. RESULTS: Cell viability and metabolic activity decreased in a dose, time, and substance-specific manner after exposure to lidocaine, ropivacaine, and bupivacaine, with ropivacaine being the least cytotoxic. Cell viability decreases after brief exposure (<1.5 hrs) at clinically relevant concentrations (eg, 8 mg/ml of lidocaine, 2.5 mg/ml of ropivacaine or bupivacaine). Mesenchymal stem cells exposed to local anesthetics change their expression of mRNA biomarkers for stress response (EGR1, EGR2), proliferation (MKI67, HIST2H4A), ECM (COL1A1, COL3A1), and cell surface marker (CD105). CONCLUSIONS: Local anesthetics are cytotoxic to clinical-grade human mesenchymal stem cells in a dose-, time-, and agent-dependent manner and change expression of ECM, proliferation, and cell surface markers. Lidocaine and bupivacaine are more cytotoxic than ropivacaine. Single-dose injections of local anesthetics may affect the biological properties of mesenchymal stem cells in vitro but may not affect the effective dose of MSCs in a clinical setting.

Sex-Related Differences in Symptoms and Psychosocial Outcomes in Patients With Fibromyalgia: A Prospective Questionnaire Study.

OBJECTIVE: To investigate sex-related differences in patients with fibromyalgia (FM) in terms of demographic characteristics and clinical features, including tender point count (TPC), mood disorders, sleep problems, FM symptom severity, fatigue, cognitive dysfunction, and quality of life (QOL). PATIENTS AND METHODS: We studied 668 consecutive patients with FM (606 women) from May 1, 2012, to November 30, 2013. Validated questionnaires assessed outcomes of depression (Patient Health Questionnaire-9), anxiety (Generalized Anxiety Disorder-7), sleep problems (Medical Outcomes Study Sleep Scale), FM symptom severity (Revised Fibromyalgia Impact Questionnaire), fatigue (Multidimensional Fatigue Inventory), cognitive dysfunction (Multiple Ability Self-report Questionnaire), and QOL (36-Item Short Form Health Survey). Nonparametric Mann-Whitney U and Pearson χ2 tests were used to compare continuous and categorical outcome measures, respectively, between men and women. Linear regression models were performed for all continuous dependent variables, adjusting for age, body mass index, ethnicity, marital status, and highest education level completed. P<.05 was considered statistically significant. The Benjamini-Hochberg procedure was used to adjust for multiple comparisons. RESULTS: Multiple linear regression analysis revealed a significant association of female sex and greater TPC (P<.001), lower overall FM symptom severity (lower overall Revised Fibromyalgia Impact Questionnaire score; P=.03), and higher QOL subscale score for vitality (36-Item Short Form Health Survey vitality subscale score; P=.02). After adjustment for multiple comparisons, only the association between female sex and greater TPC remained significant. There were no sex-related differences in demographic characteristics, depression, anxiety, sleep problems, FM symptom severity, cognitive dysfunction, and QOL. CONCLUSION: A higher TPC may be associated with female sex in patients with FM. The assumption of other sex-based differences in the clinical presentation of FM was not supported in our study.

A Systematic Review of Intra-Articular Ketamine for Postoperative Analgesia.

BACKGROUND: This systematic review appraises the evidence from human clinical trials comparing postoperative pain scores and opioid consumption in patients receiving intra-articular ketamine versus other modalities of analgesia after orthopedic joint procedures. METHODS: Studies were identified from Embase, Scopus, and OVID Medline databases. Included studies compared patients receiving intra-articular ketamine versus other modalities of analgesia. The primary outcome of interest was postprocedural pain score and total opioid consumption, whereas secondary outcomes included time to rescue analgesic medication request, active range of motion, time to mobilization, and adverse effects. RESULTS: Seventeen studies were included. Dosage of ketamine varied widely from 0.25 to 2 mg/kg. Fifteen of 17 demonstrated decreased overall pain scores and decreased total postoperative opioid consumption in patients receiving intra-articular ketamine versus control groups. Included studies generally demonstrated reduced time to mobilization and increased latency until rescue analgesic medication in the intra-articular ketamine group. CONCLUSIONS: Patients who received intra-articular ketamine generally reported lower pain scores and had lower postoperative opioid consumption after orthopedic joint procedures. This suggests that the intra-articular route of ketamine delivery may be a useful analgesic modality, although future larger-scale trials should explore its pharmacokinetics, optimal dosing, safety, and cost-effectiveness.

Use of regenerative treatments in treatment of lumbar Degenerative Disc Disease: A systematic review.

Low back pain due to lumbar Degenerative Disc Disease (DDD) is one of the most common causes of disability and morbidity, particularly among older adults. Current research efforts in lumbar DDD management are shifting towards identifying and correcting the pathology in intervertebral discs without any external manipulation. Herein, we present a systematic review of current literature regarding regenerative treatments for lumbar DDD. An electronic search of databases including PubMed, Ovid/MEDLINE, Cochrane and Scopus was conducted for articles in all available years. Studies that investigated treatment for discogenic pain in lumbar DDD, including any type of stem cell or bone marrow concentrate as the treatment agent and studies that report both baseline and follow-up pain and Oswestry Disability Index (ODI) scores were included in the review. Changes in pain and ODI scores were calculated for 3-month, 6-month and 12-month periods. Six studies with a total of 93 patients were evaluated. Mean (SD) age of the pooled sample was 40.0(8.1) and 39.5% (32/81) of patients were female. Pain improvement was reported in 38.8% of patients at 3-month, 40.8% at 6-month and 44.1% at 12-month follow-up. Average improvement in ODI score for 3-month, 6-month and 12-month follow-ups was calculated to be 24.0, 26.5 and 25.7, respectively. Regenerative treatments are being increasingly employed across all spectrums of medicine. Review of six single arm studies revealed a potential positive impact in the preliminary results. However, these promising 'preliminary' results should not be interpreted as the definite treatment and should be validated with further prospective studies.

Cell-based therapy to reduce mortality from COVID-19: Systematic review and meta-analysis of human studies on acute respiratory distress syndrome.

Severe cases of COVID-19 infection, often leading to death, have been associated with variants of acute respiratory distress syndrome (ARDS). Cell therapy with mesenchymal stromal cells (MSCs) is a potential treatment for COVID-19 ARDS based on preclinical and clinical studies supporting the concept that MSCs modulate the inflammatory and remodeling processes and restore alveolo-capillary barriers. The authors performed a systematic literature review and random-effects meta-analysis to determine the potential value of MSC therapy for treating COVID-19-infected patients with ARDS. Publications in all languages from 1990 to March 31, 2020 were reviewed, yielding 2691 studies, of which nine were included. MSCs were intravenously or intratracheally administered in 117 participants, who were followed for 14 days to 5 years. All MSCs were allogeneic from bone marrow, umbilical cord, menstrual blood, adipose tissue, or unreported sources. Combined mortality showed a favorable trend but did not reach statistical significance. No related serious adverse events were reported and mild adverse events resolved spontaneously. A trend was found of improved radiographic findings, pulmonary function (lung compliance, tidal volumes, PaO2 /FiO2 ratio, alveolo-capillary injury), and inflammatory biomarker levels. No comparisons were made between MSCs of different sources.

Fibromyalgia Symptom Severity and Psychosocial Outcomes in Fibromyalgia Patients with Hypovitaminosis D: A Prospective Questionnaire Study.

OBJECTIVE: To evaluate the association between hypovitaminosis D and outcomes of symptom severity, mood disorders, fatigue, and quality of life in fibromyalgia (FM) patients. METHODS: Five hundred ninety-three FM patients were surveyed from May 2012 to November 2013. Patients with serum vitamin D <25 ng/mL were considered to have hypovitaminosis D. The primary outcome was FM symptom severity (FIQ-R questionnaire). Secondary outcomes included quality of life (SF-36), fatigue (MFI-20), anxiety (GAD-7), and depression (PHQ-9). Independent t tests and chi-square tests were performed for continuous and categorical variables, respectively. Regression analysis was performed adjusting for age, gender, body mass index, ethnicity, and season. A post hoc analysis examined for correlation between outcomes and serum vitamin D (ng/mL) as a continuous variable. RESULTS: One hundred twenty-two patients (20.6%) had hypovitaminosis D. In our adjusted regression analysis, the total FIQ-R score in patients with hypovitaminosis D was higher compared with control patients with adequate serum vitamin D (57.85 ± 18.09 vs 62.79 ± 18.10, P = 0.04). Adjusted regression analysis revealed higher total GAD-7 (P = 0.01) and higher total PHQ-9 scores (P = 0.04) in patients with hypovitaminosis D compared with control patients. There were no differences based on severity of depression or anxiety. No differences in fatigue or quality of life were identified. Unadjusted post hoc analysis revealed that as serum vitamin D increased, there was an association with lower total FIQ-R (ß coefficient = -0.11, P = 0.02) and lower SF-36 subscale scores of role-physical (ß coefficient = -0.10, P = 0.03). Adjusted post hoc analysis revealed no significant associations. CONCLUSIONS: Hypovitaminosis D may be a risk factor for worse symptom severity, anxiety, and depression in FM patients.

Hypothermia and nutrient deprivation alter viability of human adipose-derived mesenchymal stem cells.

PURPOSE: Adipose-derived mesenchymal stem cells (MSCs) are attractive biological agents in regenerative medicine. To optimize cell therapies, it is necessary to determine the most effective delivery method for MSCs. Therefore, we evaluated the biological properties of MSCs after exposure to various temperatures to define optimal storage conditions prior to therapeutic delivery of MSCs. DESIGN: Prospective observational study. METHODS AND MATERIALS: Adherent and non-adherent MSCs were incubated at multiple temperatures (i.e., 4, 23 and 37 °C) in Lactated Ringers (LR) solution lacking essential cell growth ingredients, or in culture media which is optimized for cell growth. Cells were assessed either after the temperature changes (4 h) or after recovery (24 h). Metabolic activity of MSCs, cell number and expression of representative mRNA biomarkers were evaluated to assess the biological effects of temperature. We monitored changes in mRNAs expression related to cytoprotective- or stress-related responses (e.g., FOS, JUN, ATF1, ATF4, EGR1, EGR2, MYC), proliferation (e.g., HIST2H4, CCNB2), and extracellular matrix production (ECM; e.g., COL3A1, COL1A1) by quantitative real time reverse-transcriptase polymerase chain reaction (RT-qPCR) analysis. RESULTS: Our study demonstrates that storing MSCs in Lactated Ringers (LR) solution for 4 h decreases cell number and metabolic activity. The number of viable MSCs decreased significantly when cultured at physiological temperature (37 °C) and severe hypothermia (4 °C), while cells grown at ambient temperature (23 °C) exhibited the least detrimental effects. There were no appreciable biological differences in mRNA markers for proliferation or ECM deposition at any of the temperatures. However, biomarkers related to cytoprotective- or stress-responses were selectively elevated depending on temperature or media type (i.e., LR versus standard media). CONCLUSION: The biological impact of nutrient-free media and temperature changes after 4 h exposure persists after a 24 h recovery period. Hence, storage temperature and media conditions should be optimized to improve effective dosing of MSCs.

CELLTOP Clinical Trial: First Report From a Phase 1 Trial of Autologous Adipose Tissue-Derived Mesenchymal Stem Cells in the Treatment of Paralysis Due to Traumatic Spinal Cord Injury.

Spinal cord injury (SCI) is a devastating condition with limited pharmacological treatment options to restore function. Regenerative approaches have recently attracted interest as an adjuvant to current standard of care. Adipose tissue-derived (AD) mesenchymal stem cells (MSCs) represent a readily accessible cell source with high proliferative capacity. The CELLTOP study, an ongoing multidisciplinary phase 1 clinical trial conducted at Mayo Clinic (ClinicalTrials.gov Identifier: NCT03308565), is investigating the safety and efficacy of intrathecal autologous AD-MSCs in patients with blunt, traumatic SCI. In this initial report, we describe the outcome of the first treated patient, a 53-year-old survivor of a surfing accident who sustained a high cervical American Spinal Injury Association Impairment Scale grade A SCI with subsequent neurologic improvement that plateaued within 6 months following injury. Although he improved to an American Spinal Injury Association grade C impairement classification, the individual continued to be wheelchair bound and severely debilitated. After study enrollment, an adipose tissue biopsy was performed and MSCs were isolated, expanded, and cryopreserved. Per protocol, the patient received an intrathecal injection of 100 million autologous AD-MSCs infused after a standard lumbar puncture at the L3-4 level 11 months after the injury. The patient tolerated the procedure well and did not experience any severe adverse events. Clinical signs of efficacy were observed at 3, 6, 12, and 18 months following the injection in both motor and sensory scores based on International Standards for Neurological Classification of Spinal Cord Injury. Thus, in this treated individual with SCI, intrathecal administration of AD-MSCs was feasible and safe and suggested meaningful signs of improved, rather than stabilized, neurologic status warranting further clinical evaluation.

Tobacco Use in Fibromyalgia Is Associated With Cognitive Dysfunction: A Prospective Questionnaire Study.

OBJECTIVE: To evaluate the association between smoking and cognitive function in patients with fibromyalgia. PATIENTS AND METHODS: We surveyed 668 patients with fibromyalgia from May 1, 2012 through November 30, 2013 at a major tertiary referral center. Patients were categorized by smoking status. Primary outcome of interest was cognitive function (MASQ questionnaire), and secondary outcomes included fibromyalgia symptom severity (FIQ-R questionnaire), quality of life (SF-36 questionnaire), fatigue (MFI-20 questionnaire), sleep (MOS-sleep scale), anxiety (GAD-7 questionnaire), and depression (PHQ-9 questionnaire). Independent Students' t-tests and χ2 tests were performed for continuous and categorical variables, respectively. Univariate regression analysis identified variables predictive of outcomes, adjusting for age, gender, body mass index, marital status, and educational level. RESULTS: Ninety-four (14.07%) patients self-identified as smokers. There was an association of lower education level, unmarried status, and younger age in smokers compared with nonsmokers. In the adjusted univariate regression analysis, fibromyalgia smokers reported greater perceived total cognitive dysfunction (P=.009) and greater subscale scores of perceived difficulty in language (P=.03), verbal memory (P=.003), visual-spatial memory (P=.02), and attention (P=.04) compared with nonsmokers with fibromyalgia. For secondary outcomes, smokers with fibromyalgia reported greater severity of fibromyalgia-related symptoms (P=.006), worse quality-of-life index in the mental component scale (P=.02), greater sleep problems (P=.01), and increased anxiety (P=.001) compared with nonsmokers who had fibromyalgia. CONCLUSION: In patients with fibromyalgia, smoking is a risk factor for cognitive dysfunction. Moreover, smokers with fibromyalgia were more likely to report increased severity of fibromyalgia symptoms, worse quality of life, more sleep problems, and increased anxiety compared with nonsmokers with fibromyalgia.

Effect of Lidocaine on Viability and Gene Expression of Human Adipose-derived Mesenchymal Stem Cells: An in vitro Study.

OBJECTIVE: To assess the biologic effects of lidocaine on the viability, proliferation, and function of human adipose tissue-derived mesenchymal stromal/stem cells (MSCs) in vitro. METHODS: Adipose-derived MSCs from three donors were exposed to lidocaine at various dilutions (2 mg/mL to 8 mg/mL) and exposure times (0.5 to 4 hours). Cell number and viability, mitochondrial activity, and real-time reverse-transcriptase quantitative polymerase chain reaction (RT-qPCR) were analyzed at 0 (immediate effects) or 24 and 48 hours (recovery effects) after treatment with lidocaine. RESULTS: Trypan blue staining showed that increasing concentrations of lidocaine decreased the number of observable viable cells. 3-[4,5,dimethylthiazol-2-yl]-5-[3-carboxymethoxy-phenyl]-2-[4-sulfophenyl]-2H-tetrazolium (MTS) assays revealed a concentration- and time- dependent decline of mitochondrial activity and proliferative ability. Gene expression analysis by RT-qPCR revealed that adipose-derived MSCs exposed to lidocaine express robust levels of stress response/cytoprotective genes. However, higher concentrations of lidocaine caused a significant downregulation of these genes. No significant differences were observed in expression of extracellular matrix (ECM) markers COL1A1 and DCN except for COL3A1 (P < .05). Levels of messenger RNA (mRNA) for proliferation markers (CCNB2, HIST2H4A, P < .001) and MKI67 (P < .001) increased at 24 and 48 hours. Expression levels of several transcription factors- including SP1, PRRX1, and ATF1-were modulated in the same manner. MSC surface markers CD44 and CD105 demonstrated decreased expression immediately after treatment, but at 24 and 48 hours postexposure, the MSC markers showed no significant difference among groups. CONCLUSION: Lidocaine is toxic to MSCs in a dose- and time- dependent manner. MSC exposure to high (4-8 mg/mL) concentrations of lidocaine for prolonged periods can affect their biologic functions. Although the exposure time in vivo is short, it is essential to choose safe concentrations when applying lidocaine along with MSCs to avoid compromising the viability and potency of the stem cell therapy.

Office-Based Mesenchymal Stem Cell Therapy for the Treatment of Musculoskeletal Disease: A Systematic Review of Recent Human Studies.

BACKGROUND: The use of mesenchymal stem cells (MSCs) in clinical applications for the treatment of musculoskeletal disease is steadily increasing in office-based practice. The so-called "first generation" of MSCs is defined as autologous stem cells that have undergone minimal manipulation and are used for a homologous purpose. Systematic reviews of the clinical trials completed to date of such MSCs enable practitioners to better understand what is currently known about the outcomes and side effects of such treatments. STUDY DESIGN: A systematic review of human clinical studies of office-based MSC therapy for the treatment of painful degenerative musculoskeletal conditions. METHODS: A search of the Ovid MEDLINE, EMBASE, and Scopus databases was conducted from 2006 through September 2016. Seven hundred sixty-one records were identified from database searching, and two records from reference review of included papers. Studies with human subjects that evaluated treatment of musculoskeletal disease with minimally manipulated MSCs were included. RESULTS: Eight studies were included in this review based on selection criteria. A total of 941 patients were included, 841 of whom received cellular products, and no significant adverse events were reported. Symptomatology generally improved, though no differences were seen over controls where present. CONCLUSION: Support in the literature is strongest for the use of bone marrow aspirate concentrate (BMAC) injections for the treatment of knee pain, but applications of the use of BMAC and peripheral blood-derived MSCs for the treatment of hip pain, tendon pain, and disc pain have all been reported. Further research is required, with large randomized controlled trials.

MicroRNA Quantitation During Dendritic Cell Endocytosis Using Imaging Flow Cytometry: Key Factors and Requirements.

BACKGROUND/AIMS: MicroRNA (miRNA)-induced suppression of dendritic cells (DCs) has been implicated in many diseases. Therefore, accurate monitoring of miRNA endocytosis by DCs is important for understanding the role of miRNAs in many diseases. Recently, a method for measuring the co-localization of Argonaute 2 (AGO2)-associated miRNAs on laser-scanning confocal microscopy method was proposed to localize the miRNAs. But its definition was limited by the number of observed cells through its accuracy. METHODS: In this study, a method based on imaging flow cytometry was developed to localize miR-590-5p with fluorescent probes in DCs. miR-590-5p proven to play an important role in tumor immunity. This method enabled the quantification, visualization and localization of the fluorescence intensity in 30,000 individual cells. RESULTS: Using this method, the DCs with different endocytotic ability were distinguished. The behaviour of miR-590-5p during endocytosis under the stimulation of tumor antigen in DCs was observed, binding to its cognate target mRNA and degradation in DCs. CONCLUSION: This method based on imaging flow cytometry provide an additional method to study miRNA processing in DCs, which makes it a valuable addition to existing miRNA research techniques.

Cytotoxic Effects of Nonionic Iodinated Contrast Agent on Human Adipose-Derived Mesenchymal Stem Cells.

BACKGROUND: Transplantation of mesenchymal stem cells (MSCs) is a promising therapy for degenerative spine conditions. However, cell therapy for painful spine degeneration presently requires use of contrast agents during fluoroscopy-guided injections, and the effects of these agents on MSCs represents a gap in knowledge. OBJECTIVE: To investigate the biological effects of contrast media (CM) that are coinjected with MSCs. DESIGN: Prospective observational study. SETTING: Academic medical center. PARTICIPANTS: Patient-derived clinical-grade culture expanded MSCs. INTERVENTIONS: Iohexol (Omnipaque300) was reduced to 12.5%, 25%, 50%, and 100% of the stock solution and incubated with MSCs for 30 minutes, 4 hours, and 48 hours. We also used complete media and 12.5%, 25%, 50%, 100% of phosphate-buffered saline as a control group. MAIN OUTCOME MEASURES: We examined cytotoxicity of iohexol at different concentrations and exposure duration, as well as the potential for recovery over time. Cell counts, mitochondrial activity, and quantitative real time reverse-transcriptase polymerase chain reaction of related genes were analyzed immediately after exposure (day 0) and after 2 days of exposure (day 2). RESULTS: Human MSCs exhibit a time- and concentration-dependent cytotoxic response to iodinated CM. A brief, 30-minute exposure did not affect MSCs function and viability. However, extended treatment with iohexol for 4 hours at 50% or higher concentration had a significant impact on both viability and gene expression in MSCs. CONCLUSIONS: CM (Omnipaque300) is cytotoxic to MSCs in a time-and concentration-dependent manner. Hence, the concentration of CM that accompanies MSC injections should be carefully considered during MSC therapy for disk-degenerative diseases. LEVEL OF EVIDENCE: To be determined.

The effectiveness and safety of nonsurgical integrative interventions for symptomatic lumbar spinal spondylolisthesis: A randomized controlled multinational, multicenter trial protocol.

BACKGROUND: Surgery is generally accepted as the main therapeutic option for symptomatic lumbar spondylolisthesis. However, new nonsurgical therapeutic options need to be explored for this population. OBJECTIVES: The objective of this study is to assess the effectiveness and safety of a 5-week Mokhuri treatment program compared with conventional nonsurgical treatments for symptomatic lumbar spondylolisthesis. METHODS: This is a study protocol for a multinational, multicenter clinical randomized controlled trial comparing the effectiveness and safety of 5 weeks of nonsurgical integrative treatments (a Mokhuri treatment program consisting of Chuna, acupuncture, and patient education) with nonsurgical conventional treatments (drugs for pain relief, epidural steroid injections, and physical therapy). Clinical outcomes including visual analogue scale (VAS) scores ranging from 0 to 100 for low back pain and leg pain, EQ-5D scores, Oswestry disability index (ODI) scores, Roland-Morris Disability Questionnaire (RMDQ) scores, Zurich Claudication Questionnaire (ZCQ) scores, walking duration and distance without leg pain, and a 5-minute treadmill test, and the ratio between the actual duration of participation and the originally scheduled duration in each group, the presence of any additional spondylolisthesis treatments, the types of concomitant treatments during the follow-up period, and adverse events (AEs) will be assessed at 7 weeks, 18 weeks, 30 weeks, 54 weeks, and 102 weeks after the end of the treatments. CONCLUSION AND DISCUSSION: The results of this study will provide clinical evidence on nonsurgical integrative interventions for patients with symptomatic lumbar spondylolisthesis. CLINICAL TRIAL REGISTRY:: clinicaltrials.gov (NCT03107468).