Interpeduncular cistern intrathecal targeted drug delivery for intractable postherpetic neuralgia: A case report.

BACKGROUND: Intractable postherpetic neuralgia (PHN) can be difficult to manage even with aggressive multimodal therapies. Patients who experience uncontrolled refractory cranial PHN despite conservative treatment may benefit from an intrathecal drug delivery system (IDDS). For craniofacial neuropathic pain, the traditional approach has been to place the intrathecal catheter tip below the level of the cranial nerve root entry zones, which may lead to insufficient analgesia. CASE SUMMARY: We describe a 69-year-old man with a 1-year history of PHN after developing a vesicular rash in the ophthalmic division of cranial nerve V (trigeminal nerve) distribution. The pain was rated 7-8 at rest and 9-10 at breakthrough pain (BTP) on a numeric rating scale. Despite receiving aggressive multimodal therapies including large doses of oral analgesics (gabapentin 150 mg q12 h, oxycodone 5 mg/acetaminophen 325 mg q6 h, and lidocaine 5% patch 700 mg q12 h) and sphenopalatine ganglion block, there was no relief of pain. Subsequently, the patient elected to have an implantable IDDS with the catheter tip placed at the interpeduncular cistern. The frequency of BTP episodes decreased. The patient's continuous daily dose was adjusted to 0.032 mg/d after 3 mo of follow-up and stopped 5 mo later. He did not report pain or other discomfort at outpatient follow-up 6 mo and 1 year after stopping intracisternal hydromorphone. CONCLUSION: The use of interpeduncular cistern intrathecal infusion with low-dose hydromorphone by IDDS may be effective for severe craniofacial PHN.

Long-term clinical observation of patients with acute and chronic complete spinal cord injury after transplantation of NeuroRegen scaffold.

Spinal cord injury (SCI) often results in an inhibitory environment at the injury site. In our previous studies, transplantation of a scaffold combined with stem cells was proven to induce neural regeneration in animal models of complete SCI. Based on these preclinical studies, collagen scaffolds loaded with the patients' own bone marrow mononuclear cells or human umbilical cord mesenchymal stem cells were transplanted into SCI patients. Fifteen patients with acute complete SCI and 51 patients with chronic complete SCI were enrolled and followed up for 2 to 5 years. No serious adverse events related to functional scaffold transplantation were observed. Among the patients with acute SCI, five patients achieved expansion of their sensory positions and six patients recovered sensation in the bowel or bladder. Additionally, four patients regained voluntary walking ability accompanied by reconnection of neural signal transduction. Among patients with chronic SCI, 16 patients achieved expansion of their sensation level and 30 patients experienced enhanced reflexive defecation sensation or increased skin sweating below the injury site. Nearly half of the patients with chronic cervical SCI developed enhanced finger activity. These long-term follow-up results suggest that functional scaffold transplantation may represent a feasible treatment for patients with complete SCI.

Clinical observations on the release of tethered spinal cord in children with intra-operative neurophysiological monitoring: A retrospective study.

To study the utility of neurophysiological monitoring in the micro-surgical treatments on children with Tethered Cord Syndrome (TCS). A total of 100 patients were included in this study. 51 children underwent micro-surgical treatments without neurophysiological monitoring (no monitoring group) from 2004 to 2009, whereas 49 children with neurophysiological monitoring (monitoring group) from 2010 to 2016. Postoperative evaluations demonstrated that more children in monitoring group (39, 80%) achieved total release than no monitoring group (36, 71%). Fewer new complications (9, 18%) were found in children of monitoring group than that of no monitoring group (19, 37%) (χ2 = 4.422, P < 0.05). Additionally, more children in monitoring group (34, 76%) achieved complete recovery or significant improvement than that of no monitoring group (24, 54%) (χ2 = 4.326, P < 0.05). This retrospective study provided the evidence supporting the hypothesis that intra-operative neurophysiological monitoring may better guide the surgical process, reduce the risk of post-operative complications, and improve the recovery of children with TCS.

Significant Improvement of Acute Complete Spinal Cord Injury Patients Diagnosed by a Combined Criteria Implanted with NeuroRegen Scaffolds and Mesenchymal Stem Cells.

Stem cells and biomaterials transplantation hold a promising treatment for functional recovery in spinal cord injury (SCI) animal models. However, the functional recovery of complete SCI patients was still a huge challenge in clinic. Additionally, there is no clinical standard procedure available to diagnose precisely an acute patient as complete SCI. Here, two acute SCI patients, with injury at thoracic 11 (T11) and cervical 4 (C4) level respectively, were judged as complete injury by a stricter method combined with American Spinal Injury Association (ASIA) Impairment Scale, magnetic resonance imaging (MRI) and nerve electrophysiology. Collagen scaffolds, named NeuroRegen scaffolds, with human umbilical cord mesenchymal stem cells (MSCs) were transplanted into the injury site. During 1 year follow up, no obvious adverse symptoms related to the functional scaffolds implantation were found after treatment. The recovery of the sensory and motor functions was observed in the two patients. The sensory level expanded below the injury level, and the patients regained the sense function in bowel and bladder. The thoracic SCI patient could walk voluntary with the hip under the help of brace. The cervical SCI patient could raise his lower legs against the gravity in the wheelchair and shake his toes under control. The injury status of the two patients was improved from ASIA A complete injury to ASIA C incomplete injury. Furthermore, the improvement of sensory and motor functions was accompanied with the recovery of the interrupted neural conduction. These results showed that the supraspinal control of movements below the injury was regained by functional scaffolds implantation in the two patients who were judged as the complete injury with combined criteria, it suggested that functional scaffolds transplantation could serve as an effective treatment for acute complete SCI patients.

Cetuximab modified collagen scaffold directs neurogenesis of injury-activated endogenous neural stem cells for acute spinal cord injury repair.

Studies have shown that endogenous neural stem cells (NSCs) activated by spinal cord injury (SCI) primarily generate astrocytes to form glial scar. The NSCs do not differentiate into neurons because of the adverse microenvironment. In this study, we defined the activation timeline of endogenous NSCs in rats with severe SCI. These injury-activated NSCs then migrated into the lesion site. Cetuximab, an EGFR signaling antagonist, significantly increased neurogenesis in the lesion site. Meanwhile, implanting cetuximab modified linear ordered collagen scaffolds (LOCS) into SCI lesion sites in dogs resulted in neuronal regeneration, including neuronal differentiation, maturation, myelination, and synapse formation. The neuronal regeneration eventually led to a significant locomotion recovery. Furthermore, LOCS implantation could also greatly decrease chondroitin sulfate proteoglycan (CSPG) deposition at the lesion site. These findings suggest that endogenous neurogenesis following acute complete SCI is achievable in species ranging from rodents to large animals via functional scaffold implantation. LOCS-based Cetuximab delivery system has a promising therapeutic effect on activating endogenous neurogenesis, reducing CSPGs deposition and improving motor function recovery.

Clinical Study of NeuroRegen Scaffold Combined With Human Mesenchymal Stem Cells for the Repair of Chronic Complete Spinal Cord Injury.

Regeneration of damaged neurons and recovery of sensation and motor function after complete spinal cord injury (SCI) are challenging. We previously developed a collagen scaffold, NeuroRegen, to promote axonal growth along collagen fibers and inhibit glial scar formation after SCI. When functionalized with multiple biomolecules, this scaffold promoted neurological regeneration and functional recovery in animals with SCI. In this study, eight patients with chronic complete SCI were enrolled to examine the safety and efficacy of implanting NeuroRegen scaffold with human umbilical cord mesenchymal stem cells (hUCB-MSCs). Using intraoperative neurophysiological monitoring, we identified and surgically resected scar tissues to eliminate the inhibitory effect of glial scarring on nerve regeneration. We then implanted NeuroRegen scaffold loaded with hUCB-MSCs into the resection sites. No adverse events (infection, fever, headache, allergic reaction, shock, perioperative complications, aggravation of neurological status, or cancer) were observed during 1 year of follow-up. Primary efficacy outcomes, including expansion of sensation level and motor-evoked potential (MEP)-responsive area, increased finger activity, enhanced trunk stability, defecation sensation, and autonomic neural function recovery, were observed in some patients. Our findings suggest that combined application of NeuroRegen scaffold and hUCB-MSCs is safe and feasible for clinical therapy in patients with chronic SCI. Our study suggests that construction of a regenerative microenvironment using a scaffold-based strategy may be a possible future approach to SCI repair.

One-year clinical study of NeuroRegen scaffold implantation following scar resection in complete chronic spinal cord injury patients.

The objective of this clinical study was to assess the safety and feasibility of the collagen scaffold, NeuroRegen scaffold, one year after scar tissue resection and implantation. Scar tissue is a physical and chemical barrier that prevents neural regeneration. However, identification of scar tissue is still a major challenge. In this study, the nerve electrophysiology method was used to distinguish scar tissue from normal neural tissue, and then different lengths of scars ranging from 0.5-4.5 cm were surgically resected in five complete chronic spinal cord injury (SCI) patients. The NeuroRegen scaffold along with autologous bone marrow mononuclear cells (BMMCs), which have been proven to promote neural regeneration and SCI recovery in animal models, were transplanted into the gap in the spinal cord following scar tissue resection. No obvious adverse effects related to scar resection or NeuroRegen scaffold transplantation were observed immediately after surgery or at the 12-month follow-up. In addition, patients showed partially autonomic nervous function improvement, and the recovery of somatosensory evoked potentials (SSEP) from the lower limbs was also detected. The results indicate that scar resection and NeuroRegen scaffold transplantation could be a promising clinical approach to treating SCI.

Human umbilical cord blood cells express neurotrophic factors.

Freshly isolated or culture-expanded human umbilical cord blood mononuclear cells (CBMNCs) have been known to express neural phenotypes in vitro and to differentiate into neural cells and improve neurological function recovery after being administrated into rodent models of neurological diseases. However, the mechanism of action remains unclear. The present study observed that CBMNCs expressed higher level mRNAs of several neurotrophic factors than adult peripheral blood mononuclear cells (PBMCs). In addition, a significantly increase in the levels of brain-derived neurotrophic factor (BDNF) and neurotrophin-4/5 (NT4/5) was found in culture supernatants of CBMNCs compared to that of PBMNCs. These findings indicate that CBMNCs express several neurotrophic factors and suggest that the neurotrophic factors secreted by CBMNCs may be responsible for amelioration of central nervous system deficits in animal models after CBMNC administration.

[In vitro vasculogenesis and angiogenesis of mouse embryonic stem cells].

OBJECTIVE: To explore an optional condition to induce mouse embryonic stem (ES) cells to differentiate into endothelial cells and to establish in vitro models of vasculogenesis and angiogenesis. METHODS: Mouse ES cells were cultured in differentiation medium containing a cocktail of vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), interleukin-6 (IL-6) and erythropoietin (EPO) in 1% methylcellulose to induce formation of embryoid bodies (EBs). At day 11, EBs were harvested and suspended in rat-tail collagen type I with the same cocktail of cytokines cultured for three additional days. The differentiation of ES cells into endothelial cells, processes of vasculogenesis and angiogenesis were examined using immunostaining of EBs slices and whole-mount immunocytochemistry of EBs with monoclonal antibodies (mAbs) against platelet endothelial cell adhesion molecule-1 (PECAM-1) and alpha-smooth muscle actin (SMA). RESULTS: Under appropriate culture conditions; ES cells spontaneously differentiated and formed EBs containing vascular structures and tubular channels, which were positive for PECAM-1 co-differentiated with smooth muscle. When not treated with angiogenic growth factors, PECAM-1-positive cells could not organize into vascular structures of 11-day-old EBs. In the presence of angiogenic factors 11-day old EBs embedded into type I collagen, and rapidly developed an endothelial networks. Whole-mount immunocytochemistry of collagen gel with anti-PECAM-1 antibody showed the formation of primary vascular structures sprouting from EBs. Quantitative analysis revealed that 100 microg/ml thalidomide significantly reduced the number and length of EBs endothelial sprouting. CONCLUSIONS: Mouse ES cells can differentiate into endothelial cells combined with smooth muscle differentiation during EBs formation and further develop endothelial outgrowths after EBs embedded into collagen, which respectively recapitulate vasculogenesis, angiogenesis, and arteriogenesis processes in vivo. The models provide a useful tool to investigate vasculogenesis, angiogenesis, and arteriogenesis mechanisms and evaluate the effects of angiogenic and angiostatic agents.

Early down-regulation of Bcl-xL expression during megakaryocytic differentiation of thrombopoietin-induced CD34+ bone marrow cells in essential thrombocythemia.

BACKGROUND AND OBJECTIVES: Essential thrombocythemia (ET) is a chronic myeloproliferative disorder with abnormal megakaryocyte/platelet production. Recent studies have found that Bcl-xL, as a member of the bcl-2 family of proteins that inhibit apoptosis, is essential in megakaryocytic differentiation. In this study the expression of Bcl-xL was evaluated during megakaryocytic differentiation in ET patients. DESIGN AND METHODS: To study the role of Bcl-xL in megakaryocyte differentiation, we evaluated the effect of small interfering RNA (siRNA) on the expression of Bcl-xL. CD34+ cells from patients with ET, chronic myeloid leukemia (CML), polycythemia vera (PV) and normal individuals were cultured in serum-free medium supplemented with thrombopoietin (TPO). Immunocytochemical staining and flow cytometric analysis were used to evaluate the Bcl-xL expression during megakaryocytic differentiation of CD34+ cells. RESULTS: When exposured to si-Bcl-xL, the percentage of K562 cells induced into megakaryocytes in 72 hours was lower than the corresponding percentage of control cells. CD41a+ cells from the three groups of patients and the control group were cultured. At day 10, the percentage of Bcl-xL- cells in CD41a+ cells from ET patients was 61.0+/-28.1%, which was significantly higher than that from patients with CML (2.5+/-20.9%), PV (33.6+/-10.0%) or control subjects (15.1+/-13.0%).] INTERPRETATION AND CONCLUSIONS: These results demonstrate that Bcl-xL is down-regulated early during in vitro differentiation of megakaryocytes from ET patients; this might reflect an early entry of megakaryocytes into a degenerating mature stage.

[Intra-bone marrow cavity transplantation of human umbilical cord blood mononuclear cells into NOD/SCID mice].

OBJECTIVE: To evaluate the hematopoietic reconstitution of implanted NOD/SCID mice, after intra-bone marrow cavity injection (iBM) of human umbilical cord blood (CB) mononuclear cells (MNCs). METHODS: 24 female NOD/SCID mice were divided into different MNCs dosage iBM groups (3 x 10(6), 1 x 10(7), 3 x 10(7) cells), tail vein intravenous injection (iTV) group (3 x 10(7) cells) and control group (iBM of medium only). CB MNCs sorted by Ficoll-Hypaque were transplanted into left tibia bone marrow cavity of 6- to 8-week-old NOD/SCID mice, which were anesthetized and sublethally irradiated (270 cGy (137)Cs-gamma irradiation). The distribution of injected CB MNCs in noninjected right tibia of the same implanted mice was observed 24 hours after iBM. The establishment of hematopoiesis and the survival of mice were observed. BM cell surface CD marker expressions, dye Dil-CM tracing and human beta-actin from implanted mice were assessed 8 weeks after iBM or iTV. RESULTS: Dil-CM marker could be detected on BM cells from noninjected right tibia 24 hours after iBM. Fourteen engrafted mice survived at the end of our study. Among them two, four and five were of iBM-1, iBM-2 and iBM-3 groups respectively, and one of control group and two of iTV group. White blood cell reconstitution was better in iBM mice than in iTV and control mice. There were human markers including CD45, Dil-CM and beta-actin DNA in the marrow cells from the human CB MNC engrafted mice. CONCLUSION: The preliminary results showed that hematopoiesis reconstitution by iBM was significantly better than iTV.