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1.
Pain Physician ; 23(2): E85-E131, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32214287

RESUMO

BACKGROUND: The use of bone marrow concentrate (BMC) for treatment of musculoskeletal disorders has become increasingly popular over the last several years, as technology has improved along with the need for better solutions for these pathologies. The use of cellular tissue raises a number of issues regarding the US Food and Drug Administration's (FDA) regulation in classifying these treatments as a drug versus just autologous tissue transplantation. In the case of BMC in musculoskeletal and spine care, this determination will likely hinge on whether BMC is homologous to the musculoskeletal system and spine. OBJECTIVES: The aim of this review is to describe the current regulatory guidelines set in place by the FDA, specifically the terminology around "minimal manipulation" and "homologous use" within Regulation 21 CFR Part 1271, and specifically how this applies to the use of BMC in interventional musculoskeletal medicine. METHODS: The methodology utilized here is similar to the methodology utilized in preparation of multiple guidelines employing the experience of a panel of experts from various medical specialties and subspecialties from differing regions of the world. The collaborators who developed these position statements have submitted their appropriate disclosures of conflicts of interest. Trustworthy standards were employed in the creation of these position statements. The literature pertaining to BMC, its effectiveness, adverse consequences, FDA regulations, criteria for meeting the standards of minimal manipulation, and homologous use were comprehensively reviewed using a best evidence synthesis of the available and relevant literature. RESULTS/Summary of Evidence: In conjunction with evidence-based medicine principles, the following position statements were developed: Statement 1: Based on a review of the literature in discussing the preparation of BMC using accepted methodologies, there is strong evidence of minimal manipulation in its preparation, and moderate evidence for homologous utility for various musculoskeletal and spinal conditions qualifies for the same surgical exemption. Statement 2: Assessment of clinical effectiveness based on extensive literature shows emerging evidence for multiple musculoskeletal and spinal conditions. • The evidence is highest for knee osteoarthritis with level II evidence based on relevant systematic reviews, randomized controlled trials and nonrandomized studies. There is level III evidence for knee cartilage conditions. • Based on the relevant systematic reviews, randomized trials, and nonrandomized studies, the evidence for disc injections is level III. • Based on the available literature without appropriate systematic reviews or randomized controlled trials, the evidence for all other conditions is level IV or limited for BMC injections. Statement 3: Based on an extensive review of the literature, there is strong evidence for the safety of BMC when performed by trained physicians with the appropriate precautions under image guidance utilizing a sterile technique. Statement 4: Musculoskeletal disorders and spinal disorders with related disability for economic and human toll, despite advancements with a wide array of treatment modalities. Statement 5: The 21st Century Cures Act was enacted in December 2016 with provisions to accelerate the development and translation of promising new therapies into clinical evaluation and use. Statement 6: Development of cell-based therapies is rapidly proliferating in a number of disease areas, including musculoskeletal disorders and spine. With mixed results, these therapies are greatly outpacing the evidence. The reckless publicity with unsubstantiated claims of beneficial outcomes having putative potential, and has led the FDA Federal Trade Commission (FTC) to issue multiple warnings. Thus the US FDA is considering the appropriateness of using various therapies, including BMC, for homologous use. Statement 7: Since the 1980's and the description of mesenchymal stem cells by Caplan et al, (now called medicinal signaling cells), the use of BMC in musculoskeletal and spinal disorders has been increasing in the management of pain and promoting tissue healing. Statement 8: The Public Health Service Act (PHSA) of the FDA requires minimal manipulation under same surgical procedure exemption. Homologous use of BMC in musculoskeletal and spinal disorders is provided by preclinical and clinical evidence. Statement 9: If the FDA does not accept BMC as homologous, then it will require an Investigational New Drug (IND) classification with FDA (351) cellular drug approval for use. Statement 10: This literature review and these position statements establish compliance with the FDA's intent and corroborates its present description of BMC as homologous with same surgical exemption, and exempt from IND, for use of BMC for treatment of musculoskeletal tissues, such as cartilage, bones, ligaments, muscles, tendons, and spinal discs. CONCLUSIONS: Based on the review of all available and pertinent literature, multiple position statements have been developed showing that BMC in musculoskeletal disorders meets the criteria of minimal manipulation and homologous use. KEY WORDS: Cell-based therapies, bone marrow concentrate, mesenchymal stem cells, medicinal signaling cells, Food and Drug Administration, human cells, tissues, and cellular tissue-based products, Public Health Service Act (PHSA), minimal manipulation, homologous use, same surgical procedure exemption.


Assuntos
Transplante de Medula Óssea/normas , Medicina Baseada em Evidências/normas , Doenças Musculoesqueléticas/terapia , Manejo da Dor/normas , Médicos/normas , Sociedades Médicas/normas , Medula Óssea/fisiologia , Transplante de Medula Óssea/métodos , Medicina Baseada em Evidências/métodos , Humanos , Doenças Musculoesqueléticas/diagnóstico , Doenças Musculoesqueléticas/epidemiologia , Dor/diagnóstico , Dor/epidemiologia , Manejo da Dor/métodos , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos , Resultado do Tratamento , Estados Unidos , United States Food and Drug Administration/normas
2.
Int Orthop ; 41(10): 2097-2103, 2017 10.
Artigo em Inglês | MEDLINE | ID: mdl-28748380

RESUMO

PURPOSE: The purpose of this study is to assess safety and feasibility of intradiscal bone marrow concentrate (BMC) injections to treat low back discogenic pain as an alternative to surgery with three year minimum follow-up. METHODS: A total of 26 patients suffering from degenerative disc disease and candidates for spinal fusion or total disc replacement surgery were injected with 2 ml autologous BMC into the nucleus pulposus of treated lumbar discs. A sample aliquot of BMC was characterized by flow cytometry and CFU-F assay to determine progenitor cell content. Improvement in pain and disability scores and 12 month post-injection MRI were compared to patient demographics and BMC cellularity. RESULTS: After 36 months, only six patients progressed to surgery. The remaining 20 patients reported average ODI and VAS improvements from 56.7 ± 3.6 and 82.1 ± 2.6 at baseline to 17.5 ± 3.2 and 21.9 ± 4.4 after 36 months, respectively. One year MRI indicated 40% of patients improved one modified Pfirrmann grade and no patient worsened radiographically. Cellular analysis showed an average of 121 million total nucleated cells per ml, average CFU-F of 2713 per ml, and average CD34+ of 1.82 million per ml in the BMC. Patients with greater concentrations of CFU-F (>2000 per ml) and CD34+ cells (>2 million per ml) in BMC tended to have significantly better clinical improvement. CONCLUSIONS: There were no adverse events related to marrow aspiration or injection, and this study provides evidence of safety and feasibility of intradiscal BMC therapy. Patient improvement and satisfaction with this surgical alternative supports further study of the therapy.


Assuntos
Transplante de Medula Óssea/métodos , Degeneração do Disco Intervertebral/terapia , Dor Lombar/terapia , Adolescente , Adulto , Autoenxertos , Transplante de Medula Óssea/efeitos adversos , Estudos de Viabilidade , Feminino , Seguimentos , Humanos , Vértebras Lombares , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Medição da Dor , Estudos Prospectivos , Índice de Gravidade de Doença , Resultado do Tratamento , Adulto Jovem
3.
Int Orthop ; 40(1): 135-40, 2016 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-26156727

RESUMO

PURPOSE: The purpose of this study is to assess safety and feasibility of intradiscal bone marrow concentrate (BMC) injections to treat discogenic pain as an alternative to surgery. METHODS: A total of 26 patients (11 male, 15 female, aged 18-61 years, 13 single level, 13 two level) that met inclusion criteria of chronic (> 6 months) discogenic low back pain, degenerative disc pathology assessed by magnetic resonance imaging (MRI) with modified Pfirrmann grade of IV-VII at one or two levels, candidate for surgical intervention (failed conservative treatment and radiologic findings) and a visual analogue scale (VAS) pain score of 40 mm or more at initial visit. Initial Oswestry Disability Index (ODI) and VAS pain score average was 56.5 % and 80.1 mm (0-100), respectively. Adverse event reporting, ODI score, VAS pain score, MRI radiographic changes, progression to surgery and cellular analysis of BMC were noted. Retrospective cell analysis by flow cytometry and colony forming unit-fibroblast (CFU-F) assays were performed to characterise each patient's BMC and compare with clinical outcomes. The BMC was injected into the nucleus pulposus of the symptomatic disc(s) under fluoroscopic guidance. Patients were evaluated clinically prior to treatment and at three, six, 12 and 24 months and radiographically prior to treatment and at 12 months. RESULTS: There were no complications from the percutaneous bone marrow aspiration or disc injection. Of 26 patients, 24 (92 %) avoided surgery through 12 months, while 21 (81 %) avoided surgery through two years. Of the 21 surviving patients, the average ODI and VAS scores were reduced to 19.9 and 27.0 at three months and sustained to 18.3 and 22.9 at 24 months, respectively (p ≤ 0.001). Twenty patients had follow-up MRI at 12 months, of whom eight had improved by at least one Pfirrmann grade, while none of the discs worsened. Total and rate of pain reduction were linked to mesenchymal stem cell concentration through 12 months. Only five of the 26 patients elected to undergo surgical intervention (fusion or artificial disc replacement) by the two year milestone. CONCLUSIONS: This study provides evidence of safety and feasibility in the non-surgical treatment of discogenic pain with autologous BMC, with durable pain relief (71 % VAS reduction) and ODI improvements (> 64 %) through two years.


Assuntos
Transplante de Medula Óssea/métodos , Degeneração do Disco Intervertebral/terapia , Dor Lombar/terapia , Transplante Autólogo/métodos , Adolescente , Adulto , Idoso , Transplante de Medula Óssea/efeitos adversos , Feminino , Seguimentos , Humanos , Dor Lombar/etiologia , Vértebras Lombares/patologia , Vértebras Lombares/cirurgia , Imagem por Ressonância Magnética , Masculino , Células-Tronco Mesenquimais , Pessoa de Meia-Idade , Estudos Prospectivos , Estudos Retrospectivos , Substituição Total de Disco/efeitos adversos , Transplante Autólogo/efeitos adversos , Adulto Jovem
4.
Stem Cells ; 33(1): 146-56, 2015 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-25187512

RESUMO

Degenerative disc disease (DDD) induces chronic back pain with limited nonsurgical options. In this open label pilot study, 26 patients (median age 40 years; range 18-61) received autologous bone marrow concentrate (BMC) disc injections (13 one level, 13 two levels). Pretreatment Oswestry disability index (ODI) and visual analog scale (VAS) were performed to establish baseline pain scores (average 56.5 and 79.3, respectively), while magnetic resonance imaging was independently scored according to the modified Pfirrmann scale. Approximately 1 ml of BMC was analyzed for total nucleated cell (TNC) content, colony-forming unit-fibroblast (CFU-F) frequency, differentiation potential, and phenotype characterization. The average ODI and VAS scores were reduced to 22.8 and 29.2 at 3 months, 24.4 and 26.3 at 6 months, and 25.0 and 33.2 at 12 months, respectively (p ≤ .0001). Eight of twenty patients improved by one modified Pfirrmann grade at 1 year. The average BMC contained 121 × 10(6) TNC/ml with 2,713 CFU-F/ml (synonymous with mesenchymal stem cells). Although all subjects presented a substantial reduction in pain, patients receiving greater than 2,000 CFU-F/ml experienced a significantly faster and greater reduction in ODI and VAS. Subjects older than 40 years who received fewer than 2,000 CFU-F/ml experienced an average pain reduction of 33.7% (ODI) and 29.1% (VAS) at 12 months, while all other patients' average reduction was 69.5% (ODI, p = .03) and 70.6% (VAS, p = .01). This study provides evidence of safety and feasibility in the nonsurgical treatment of DDD with autologous BMC and indicates an effect of mesenchymal cell concentration on discogenic pain reduction.


Assuntos
Células da Medula Óssea/citologia , Transplante de Medula Óssea/métodos , Transplante de Células-Tronco Hematopoéticas/métodos , Degeneração do Disco Intervertebral/terapia , Células-Tronco Mesenquimais/citologia , Administração Cutânea , Adolescente , Adulto , Feminino , Humanos , Injeções , Masculino , Pessoa de Meia-Idade , Transplante Autólogo , Adulto Jovem
5.
J Clin Med ; 2(3): 49-66, 2013 Aug 19.
Artigo em Inglês | MEDLINE | ID: mdl-26237062

RESUMO

For spinal fusions and the treatment of non-union fractures, biological substrates, scaffolds, or carriers often are applied as a graft to support regeneration of bone. The selection of an appropriate material critically influences cellular function and, ultimately, patient outcomes. Human bone marrow mesenchymal stem cells (BMSCs) are regarded as a critical component of bone healing. However, the interactions of BMSCs and commercial bone matrices are poorly reported. BMSCs were cultured with several commercially available bone substrates (allograft, demineralized bone matrix (DBM), collagen, and various forms of calcium phosphates) for 48 h to understand their response to graft materials during surgical preparation and the first days following implantation (cell retention, gene expression, pH). At 30 and 60 min, bone chips and inorganic substrates supported significantly more cell retention than other materials, while collagen-containing materials became soluble and lost their structure. At 48 h, cells bound to ß-tricalcium phosphate-hydroxyapatite (ßTCP-HA) and porous hydroxyapatite (HA) granules exhibited osteogenic gene expression statistically similar to bone chips. Through 24 h, the DBM strip and ßTCP-collagen became mildly acidic (pH 7.1-7.3), while the DBM poloxamer-putties demonstrated acidity (pH < 5) and the bioglass-containing carrier became basic (pH > 10). The dissolution of DBM and collagen led to a loss of cells, while excessive pH changes potentially diminish cell viability and metabolism. Extracts from DBM-poloxamers induced osteogenic gene expression at 48 h. This study highlights the role that biochemical and structural properties of biomaterials play in cellular function, potentially enhancing or diminishing the efficacy of the overall therapy.

6.
Tissue Eng Part A ; 15(2): 221-9, 2009 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-18847356

RESUMO

Mesenchymal stem cells (MSCs) are multipotent cells that have the capacity to develop into different mature mesenchymal cell types. They were originally isolated from bone marrow, but MSC-like cells have also been isolated from other tissues. The common feature of all of these tissues is that they all house blood vessels. It is, thus, possible that MSCs are associated with perivascular locations. The objective of this work was to test the hypothesis that MSCs are associated with blood vessels by verifying if MSC frequency positively correlates with blood vessel density. To this end, samples from highly and poorly vascularized adipose tissue sites of two equine donors were collected and processed for histology and cell isolation. MSC frequency in these samples was estimated by means of CFU-F assays, which were performed under MSC conditions. Culture-adherent cells from equine adipose tissue and bone marrow were culture expanded, tested for differentiation into mesenchymal cell types in vitro, and implanted in vivo in porous ceramic vehicles to assess their osteogenic capacity, using human MSCs and brain pericytes as controls. The differentiation assays showed a difference between adipose tissue-derived cells as compared to equine bone marrow MSCs. While differences in CFU-F frequencies between both donors were evident, the CFU-F numbers correlated directly with blood vessel densities (r(2) = 0.86). We consider these preliminary data as further evidence linking MSCs to blood vessels.


Assuntos
Tecido Adiposo/citologia , Vasos Sanguíneos/citologia , Cavalos/fisiologia , Células-Tronco Mesenquimais/citologia , Adipogenia , Fosfatase Alcalina/metabolismo , Animais , Bioensaio , Células da Medula Óssea/citologia , Cálcio/metabolismo , Contagem de Células , Condrogênese , Ensaio de Unidades Formadoras de Colônias , Fibroblastos/citologia , Células-Tronco Mesenquimais/enzimologia , Osteogênese
7.
Biochem Biophys Res Commun ; 362(2): 347-53, 2007 Oct 19.
Artigo em Inglês | MEDLINE | ID: mdl-17719011

RESUMO

Stem cells are being evaluated in numerous human clinical trials and are commercially used in veterinary medicine to treat horses and dogs. Stem cell differentiation, homing to disease sites, growth and cytokine factor modulation, and low antigenicity contribute to their therapeutic success. Bone marrow and adipose tissue are the two most common sources of adult-derived stem cells in animals. We report on the existence of an alternative source of primitive, multipotent stem cells from the equine umbilical cord cellular matrix (Wharton's jelly). Equine umbilical cord matrix (EUCM) cells can be cultured, cryogenically preserved, and differentiated into osteo-, adipo-, chondrogenic, and neuronal cell lineages. These results identify a source of stem cells that can be non-invasively collected at birth and stored for future use in that horse or used as donor cells for treating unrelated horses.


Assuntos
Diferenciação Celular , Células-Tronco Multipotentes/citologia , Cordão Umbilical/citologia , Adipócitos/química , Adipócitos/citologia , Adipócitos/metabolismo , Adipogenia , Fosfatase Alcalina/metabolismo , Animais , Antraquinonas/química , Compostos Azo/química , Ciclo Celular , Proliferação de Células , Células Cultivadas , Condrócitos/química , Condrócitos/citologia , Condrócitos/metabolismo , Condrogênese , Feminino , Citometria de Fluxo , Cavalos , Imuno-Histoquímica , Células-Tronco Multipotentes/química , Células-Tronco Multipotentes/metabolismo , Neurônios/química , Neurônios/citologia , Neurônios/metabolismo , Osteócitos/química , Osteócitos/citologia , Osteócitos/metabolismo , Osteogênese , Cordão Umbilical/metabolismo
8.
Biosens Bioelectron ; 18(5-6): 797-804, 2003 May.
Artigo em Inglês | MEDLINE | ID: mdl-12706594

RESUMO

Traditional strategies for signal transduction in immunosensors are based on piezoelectric, thermometric, electrochemical, magnetic and optical methods. The use of pressure as a signal transduction method in immunosensors has not been reported previously. An immunosensor incorporating the detection of a change in pressure as the signal-transducing mechanism was investigated. A commercially available ultra-low pressure sensor was used in conjunction with a sealed chamber to assess the feasibility of this strategy. A key feature of the current approach is the use of a thin membrane (or film) in which to perform an immunoassay and subsequently to detect production of gas. The thinness contributes to efficient gas evolution and minimizes the effect of liquid acting as a "sink" for gas molecules. This feature also simplifies measurement of evolved gas, which traditionally was based on the use of bulk solutions, shaking and pH changes to "release" dissolved gas (especially carbon dioxide). Gas generation in the current approach is achieved by the coupling of catalase to haptens or antibodies for use in competitive or sandwich immunoassays, respectively. Hydrogen peroxide is used as the substrate. Performance characteristics of the sensor apparatus were assessed in several ways. Injection of various volumes of air from a gas-tight syringe produced an essentially linear relationship from 0.2 to 2.0 microl of injected volume, with a slope of approximately 5 V/microl. Depending on the duration of the sampling period, specific signals in excess of 2 V have been obtained for 0.01 units of catalase (approximately 0.4 ng of protein). Development and use of this sensing apparatus will be described for both competitive and sandwich immunoassays.


Assuntos
Aflatoxinas/análise , Técnicas Biossensoriais/instrumentação , Catalase/análise , Imunoensaio/instrumentação , Manometria/instrumentação , Oocistos/isolamento & purificação , Transdutores , Aflatoxinas/imunologia , Animais , Técnicas Biossensoriais/métodos , Catalase/química , Catalase/imunologia , Cryptosporidium parvum/imunologia , Cryptosporidium parvum/isolamento & purificação , Desenho de Equipamento , Análise de Falha de Equipamento , Estudos de Viabilidade , Imunoensaio/métodos , Manometria/métodos , Membranas Artificiais , Oocistos/imunologia , Pressão , Coelhos
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