Your name and credentials

Current Topics In Sports Medicine

Acting Head Team Physician University of New Hampshire

Wentworth Douglass Hospital Sports Medicine

David J Cormier DO DPT

Disclosures

bull No disclosures

Outline

bull Case 1

ndash Tendonopathy

ndash Orthobiologics

bull Case 2

ndash OA

ndash Orthobiologics

Goals Objectives

bull Participants will understand the theory and

interest in orthobiologics

bull Participants will be familiar with different

orthobiologic options

Case 1

bull 40 Year old woman presents with right lateral

hip pain for 2 months Her pain is worse with

walking especially hills She is unable to lay on

her right side at night She denies back pain

bull Exam

bull Limited hip ROM in flexion pain with ER

bull Full ROM Lumbar Spine

bull Intact Myotomes Dermatomes Reflexes

Case 2

bull Femoral internal rotation knee valgus foot

pronation with navicular drop during single leg

squat with contralateral hip drop

bull Weak hip abduction 45

bull Pain to palpation at the Greater trochanter

Diagnosis

Treatment

bull Palpation guided corticosteroid injection

ndash 6 weeks of relief

ndash Pain came back worse

ndash Repeat injection

ndash Pain came back

ndash Repeat for a total of 5 steroid injections

ndash Referred to Sports Medicine

Sports Medicine Clinic

bull Continued lateral hip pain

bull Pain to palpation over the GT

bull Trendelenberg gait ndash worsening

bull Hip Abduction 25

bull We obtained an MRI

MRI

MRI

MRI

GTPS

bull Schapira et al

ndash observational study

bull 72 patients followed for 2 years

bull 916 of patients diagnosed with symptomatic

trochanteric bursitis had other associated pathology

ndash osteoarthritis of the ipsilateral hip or lumbar spine

Schapira D Nahir M Scharf Y Trochanteric bursitis a common clinical problem Arch Phys Med Rehabil 1986 67815ndash817

GT MRI

bull Bird et al

ndash Retrospective review of MRI findings in 24 women

with greater trochanteric pain syndrome presenting

with lateral hip pain and point tenderness at the

greater trochanter reported

bull 625 had evidence of gluteus medius tendonitis

bull 458 had gluteus medius tears

bull only 2 patients (83) had objective evidence of

trochanteric bursitis

Bird PA Oakley SP Shnier R et al Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome Arthritis Rheum 2001442138ndash2145

GTPS

bull GTPS

ndash Gluteus medius dysfunction

ndash Gluteus medius or gluteus minimus tendinopathy

ndash Piriformis tendinopathy

ndash Iliotibial tract friction syndrome

ndash Trochanteric bursitis

Lateral Hip - GT

GTPS

bull Steroid ndash 75 success at 1 month

ndash The effect subsided with timebull 51 at 4 months

bull 48 at 15 months

bull Shockwave Therapyndash No benefit to early pain

ndash 68 at 4 months

ndash 74 at 15 months

bull Home PTndash Ineffective initially

ndash 41 at 4 months

ndash 81 at 15 months Am J Sports Med 2009 Oct37(10)1981-90 doi 1011770363546509334374 Epub 2009 May 13Home training local corticosteroid injection or radial shock wave therapy for greater trochanter pain syndromeRompe JD1 Segal NA Cacchio A Furia JP Morral A Maffulli N

Disclosures

bull No disclosures

Outline

bull Case 1

ndash Tendonopathy

ndash Orthobiologics

bull Case 2

ndash OA

ndash Orthobiologics

Goals Objectives

bull Participants will understand the theory and

interest in orthobiologics

bull Participants will be familiar with different

orthobiologic options

Case 1

bull 40 Year old woman presents with right lateral

hip pain for 2 months Her pain is worse with

walking especially hills She is unable to lay on

her right side at night She denies back pain

bull Exam

bull Limited hip ROM in flexion pain with ER

bull Full ROM Lumbar Spine

bull Intact Myotomes Dermatomes Reflexes

Case 2

bull Femoral internal rotation knee valgus foot

pronation with navicular drop during single leg

squat with contralateral hip drop

bull Weak hip abduction 45

bull Pain to palpation at the Greater trochanter

Diagnosis

Treatment

bull Palpation guided corticosteroid injection

ndash 6 weeks of relief

ndash Pain came back worse

ndash Repeat injection

ndash Pain came back

ndash Repeat for a total of 5 steroid injections

ndash Referred to Sports Medicine

Sports Medicine Clinic

bull Continued lateral hip pain

bull Pain to palpation over the GT

bull Trendelenberg gait ndash worsening

bull Hip Abduction 25

bull We obtained an MRI

MRI

MRI

MRI

GTPS

bull Schapira et al

ndash observational study

bull 72 patients followed for 2 years

bull 916 of patients diagnosed with symptomatic

trochanteric bursitis had other associated pathology

ndash osteoarthritis of the ipsilateral hip or lumbar spine

Schapira D Nahir M Scharf Y Trochanteric bursitis a common clinical problem Arch Phys Med Rehabil 1986 67815ndash817

GT MRI

bull Bird et al

ndash Retrospective review of MRI findings in 24 women

with greater trochanteric pain syndrome presenting

with lateral hip pain and point tenderness at the

greater trochanter reported

bull 625 had evidence of gluteus medius tendonitis

bull 458 had gluteus medius tears

bull only 2 patients (83) had objective evidence of

trochanteric bursitis

Bird PA Oakley SP Shnier R et al Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome Arthritis Rheum 2001442138ndash2145

GTPS

bull GTPS

ndash Gluteus medius dysfunction

ndash Gluteus medius or gluteus minimus tendinopathy

ndash Piriformis tendinopathy

ndash Iliotibial tract friction syndrome

ndash Trochanteric bursitis

Lateral Hip - GT

GTPS

bull Steroid ndash 75 success at 1 month

ndash The effect subsided with timebull 51 at 4 months

bull 48 at 15 months

bull Shockwave Therapyndash No benefit to early pain

ndash 68 at 4 months

ndash 74 at 15 months

bull Home PTndash Ineffective initially

ndash 41 at 4 months

ndash 81 at 15 months Am J Sports Med 2009 Oct37(10)1981-90 doi 1011770363546509334374 Epub 2009 May 13Home training local corticosteroid injection or radial shock wave therapy for greater trochanter pain syndromeRompe JD1 Segal NA Cacchio A Furia JP Morral A Maffulli N

Outline

bull Case 1

ndash Tendonopathy

ndash Orthobiologics

bull Case 2

ndash OA

ndash Orthobiologics

Goals Objectives

bull Participants will understand the theory and

interest in orthobiologics

bull Participants will be familiar with different

orthobiologic options

Case 1

bull 40 Year old woman presents with right lateral

hip pain for 2 months Her pain is worse with

walking especially hills She is unable to lay on

her right side at night She denies back pain

bull Exam

bull Limited hip ROM in flexion pain with ER

bull Full ROM Lumbar Spine

bull Intact Myotomes Dermatomes Reflexes

Case 2

bull Femoral internal rotation knee valgus foot

pronation with navicular drop during single leg

squat with contralateral hip drop

bull Weak hip abduction 45

bull Pain to palpation at the Greater trochanter

Diagnosis

Treatment

bull Palpation guided corticosteroid injection

ndash 6 weeks of relief

ndash Pain came back worse

ndash Repeat injection

ndash Pain came back

ndash Repeat for a total of 5 steroid injections

ndash Referred to Sports Medicine

Sports Medicine Clinic

bull Continued lateral hip pain

bull Pain to palpation over the GT

bull Trendelenberg gait ndash worsening

bull Hip Abduction 25

bull We obtained an MRI

MRI

MRI

MRI

GTPS

bull Schapira et al

ndash observational study

bull 72 patients followed for 2 years

bull 916 of patients diagnosed with symptomatic

trochanteric bursitis had other associated pathology

ndash osteoarthritis of the ipsilateral hip or lumbar spine

Schapira D Nahir M Scharf Y Trochanteric bursitis a common clinical problem Arch Phys Med Rehabil 1986 67815ndash817

GT MRI

bull Bird et al

ndash Retrospective review of MRI findings in 24 women

with greater trochanteric pain syndrome presenting

with lateral hip pain and point tenderness at the

greater trochanter reported

bull 625 had evidence of gluteus medius tendonitis

bull 458 had gluteus medius tears

bull only 2 patients (83) had objective evidence of

trochanteric bursitis

Bird PA Oakley SP Shnier R et al Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome Arthritis Rheum 2001442138ndash2145

GTPS

bull GTPS

ndash Gluteus medius dysfunction

ndash Gluteus medius or gluteus minimus tendinopathy

ndash Piriformis tendinopathy

ndash Iliotibial tract friction syndrome

ndash Trochanteric bursitis

Lateral Hip - GT

GTPS

bull Steroid ndash 75 success at 1 month

ndash The effect subsided with timebull 51 at 4 months

bull 48 at 15 months

bull Shockwave Therapyndash No benefit to early pain

ndash 68 at 4 months

ndash 74 at 15 months

bull Home PTndash Ineffective initially

ndash 41 at 4 months

ndash 81 at 15 months Am J Sports Med 2009 Oct37(10)1981-90 doi 1011770363546509334374 Epub 2009 May 13Home training local corticosteroid injection or radial shock wave therapy for greater trochanter pain syndromeRompe JD1 Segal NA Cacchio A Furia JP Morral A Maffulli N

Goals Objectives

bull Participants will understand the theory and

interest in orthobiologics

bull Participants will be familiar with different

orthobiologic options

Case 1

bull 40 Year old woman presents with right lateral

hip pain for 2 months Her pain is worse with

walking especially hills She is unable to lay on

her right side at night She denies back pain

bull Exam

bull Limited hip ROM in flexion pain with ER

bull Full ROM Lumbar Spine

bull Intact Myotomes Dermatomes Reflexes

Case 2

bull Femoral internal rotation knee valgus foot

pronation with navicular drop during single leg

squat with contralateral hip drop

bull Weak hip abduction 45

bull Pain to palpation at the Greater trochanter

Diagnosis

Treatment

bull Palpation guided corticosteroid injection

ndash 6 weeks of relief

ndash Pain came back worse

ndash Repeat injection

ndash Pain came back

ndash Repeat for a total of 5 steroid injections

ndash Referred to Sports Medicine

Sports Medicine Clinic

bull Continued lateral hip pain

bull Pain to palpation over the GT

bull Trendelenberg gait ndash worsening

bull Hip Abduction 25

bull We obtained an MRI

MRI

MRI

MRI

GTPS

bull Schapira et al

ndash observational study

bull 72 patients followed for 2 years

bull 916 of patients diagnosed with symptomatic

trochanteric bursitis had other associated pathology

ndash osteoarthritis of the ipsilateral hip or lumbar spine

Schapira D Nahir M Scharf Y Trochanteric bursitis a common clinical problem Arch Phys Med Rehabil 1986 67815ndash817

GT MRI

bull Bird et al

ndash Retrospective review of MRI findings in 24 women

with greater trochanteric pain syndrome presenting

with lateral hip pain and point tenderness at the

greater trochanter reported

bull 625 had evidence of gluteus medius tendonitis

bull 458 had gluteus medius tears

bull only 2 patients (83) had objective evidence of

trochanteric bursitis

Bird PA Oakley SP Shnier R et al Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome Arthritis Rheum 2001442138ndash2145

GTPS

bull GTPS

ndash Gluteus medius dysfunction

ndash Gluteus medius or gluteus minimus tendinopathy

ndash Piriformis tendinopathy

ndash Iliotibial tract friction syndrome

ndash Trochanteric bursitis

Lateral Hip - GT

GTPS

bull Steroid ndash 75 success at 1 month

ndash The effect subsided with timebull 51 at 4 months

bull 48 at 15 months

bull Shockwave Therapyndash No benefit to early pain

ndash 68 at 4 months

ndash 74 at 15 months

bull Home PTndash Ineffective initially

ndash 41 at 4 months

ndash 81 at 15 months Am J Sports Med 2009 Oct37(10)1981-90 doi 1011770363546509334374 Epub 2009 May 13Home training local corticosteroid injection or radial shock wave therapy for greater trochanter pain syndromeRompe JD1 Segal NA Cacchio A Furia JP Morral A Maffulli N

Case 1

bull 40 Year old woman presents with right lateral

hip pain for 2 months Her pain is worse with

walking especially hills She is unable to lay on

her right side at night She denies back pain

bull Exam

bull Limited hip ROM in flexion pain with ER

bull Full ROM Lumbar Spine

bull Intact Myotomes Dermatomes Reflexes

Case 2

bull Femoral internal rotation knee valgus foot

pronation with navicular drop during single leg

squat with contralateral hip drop

bull Weak hip abduction 45

bull Pain to palpation at the Greater trochanter

Diagnosis

Treatment

bull Palpation guided corticosteroid injection

ndash 6 weeks of relief

ndash Pain came back worse

ndash Repeat injection

ndash Pain came back

ndash Repeat for a total of 5 steroid injections

ndash Referred to Sports Medicine

Sports Medicine Clinic

bull Continued lateral hip pain

bull Pain to palpation over the GT

bull Trendelenberg gait ndash worsening

bull Hip Abduction 25

bull We obtained an MRI

MRI

MRI

MRI

GTPS

bull Schapira et al

ndash observational study

bull 72 patients followed for 2 years

bull 916 of patients diagnosed with symptomatic

trochanteric bursitis had other associated pathology

ndash osteoarthritis of the ipsilateral hip or lumbar spine

Schapira D Nahir M Scharf Y Trochanteric bursitis a common clinical problem Arch Phys Med Rehabil 1986 67815ndash817

GT MRI

bull Bird et al

ndash Retrospective review of MRI findings in 24 women

with greater trochanteric pain syndrome presenting

with lateral hip pain and point tenderness at the

greater trochanter reported

bull 625 had evidence of gluteus medius tendonitis

bull 458 had gluteus medius tears

bull only 2 patients (83) had objective evidence of

trochanteric bursitis

Bird PA Oakley SP Shnier R et al Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome Arthritis Rheum 2001442138ndash2145

GTPS

bull GTPS

ndash Gluteus medius dysfunction

ndash Gluteus medius or gluteus minimus tendinopathy

ndash Piriformis tendinopathy

ndash Iliotibial tract friction syndrome

ndash Trochanteric bursitis

Lateral Hip - GT

GTPS

bull Steroid ndash 75 success at 1 month

ndash The effect subsided with timebull 51 at 4 months

bull 48 at 15 months

bull Shockwave Therapyndash No benefit to early pain

ndash 68 at 4 months

ndash 74 at 15 months

bull Home PTndash Ineffective initially

ndash 41 at 4 months

ndash 81 at 15 months Am J Sports Med 2009 Oct37(10)1981-90 doi 1011770363546509334374 Epub 2009 May 13Home training local corticosteroid injection or radial shock wave therapy for greater trochanter pain syndromeRompe JD1 Segal NA Cacchio A Furia JP Morral A Maffulli N

Case 2

bull Femoral internal rotation knee valgus foot

pronation with navicular drop during single leg

squat with contralateral hip drop

bull Weak hip abduction 45

bull Pain to palpation at the Greater trochanter

Diagnosis

Treatment

bull Palpation guided corticosteroid injection

ndash 6 weeks of relief

ndash Pain came back worse

ndash Repeat injection

ndash Pain came back

ndash Repeat for a total of 5 steroid injections

ndash Referred to Sports Medicine

Sports Medicine Clinic

bull Continued lateral hip pain

bull Pain to palpation over the GT

bull Trendelenberg gait ndash worsening

bull Hip Abduction 25

bull We obtained an MRI

MRI

MRI

MRI

GTPS

bull Schapira et al

ndash observational study

bull 72 patients followed for 2 years

bull 916 of patients diagnosed with symptomatic

trochanteric bursitis had other associated pathology

ndash osteoarthritis of the ipsilateral hip or lumbar spine

Schapira D Nahir M Scharf Y Trochanteric bursitis a common clinical problem Arch Phys Med Rehabil 1986 67815ndash817

GT MRI

bull Bird et al

ndash Retrospective review of MRI findings in 24 women

with greater trochanteric pain syndrome presenting

with lateral hip pain and point tenderness at the

greater trochanter reported

bull 625 had evidence of gluteus medius tendonitis

bull 458 had gluteus medius tears

bull only 2 patients (83) had objective evidence of

trochanteric bursitis

Bird PA Oakley SP Shnier R et al Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome Arthritis Rheum 2001442138ndash2145

GTPS

bull GTPS

ndash Gluteus medius dysfunction

ndash Gluteus medius or gluteus minimus tendinopathy

ndash Piriformis tendinopathy

ndash Iliotibial tract friction syndrome

ndash Trochanteric bursitis

Lateral Hip - GT

GTPS

bull Steroid ndash 75 success at 1 month

ndash The effect subsided with timebull 51 at 4 months

bull 48 at 15 months

bull Shockwave Therapyndash No benefit to early pain

ndash 68 at 4 months

ndash 74 at 15 months

bull Home PTndash Ineffective initially

ndash 41 at 4 months

ndash 81 at 15 months Am J Sports Med 2009 Oct37(10)1981-90 doi 1011770363546509334374 Epub 2009 May 13Home training local corticosteroid injection or radial shock wave therapy for greater trochanter pain syndromeRompe JD1 Segal NA Cacchio A Furia JP Morral A Maffulli N

Diagnosis

Treatment

bull Palpation guided corticosteroid injection

ndash 6 weeks of relief

ndash Pain came back worse

ndash Repeat injection

ndash Pain came back

ndash Repeat for a total of 5 steroid injections

ndash Referred to Sports Medicine

Sports Medicine Clinic

bull Continued lateral hip pain

bull Pain to palpation over the GT

bull Trendelenberg gait ndash worsening

bull Hip Abduction 25

bull We obtained an MRI

MRI

MRI

MRI

GTPS

bull Schapira et al

ndash observational study

bull 72 patients followed for 2 years

bull 916 of patients diagnosed with symptomatic

trochanteric bursitis had other associated pathology

ndash osteoarthritis of the ipsilateral hip or lumbar spine

Schapira D Nahir M Scharf Y Trochanteric bursitis a common clinical problem Arch Phys Med Rehabil 1986 67815ndash817

GT MRI

bull Bird et al

ndash Retrospective review of MRI findings in 24 women

with greater trochanteric pain syndrome presenting

with lateral hip pain and point tenderness at the

greater trochanter reported

bull 625 had evidence of gluteus medius tendonitis

bull 458 had gluteus medius tears

bull only 2 patients (83) had objective evidence of

trochanteric bursitis

Bird PA Oakley SP Shnier R et al Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome Arthritis Rheum 2001442138ndash2145

GTPS

bull GTPS

ndash Gluteus medius dysfunction

ndash Gluteus medius or gluteus minimus tendinopathy

ndash Piriformis tendinopathy

ndash Iliotibial tract friction syndrome

ndash Trochanteric bursitis

Lateral Hip - GT

GTPS

bull Steroid ndash 75 success at 1 month

ndash The effect subsided with timebull 51 at 4 months

bull 48 at 15 months

bull Shockwave Therapyndash No benefit to early pain

ndash 68 at 4 months

ndash 74 at 15 months

bull Home PTndash Ineffective initially

ndash 41 at 4 months

ndash 81 at 15 months Am J Sports Med 2009 Oct37(10)1981-90 doi 1011770363546509334374 Epub 2009 May 13Home training local corticosteroid injection or radial shock wave therapy for greater trochanter pain syndromeRompe JD1 Segal NA Cacchio A Furia JP Morral A Maffulli N

Treatment

bull Palpation guided corticosteroid injection

ndash 6 weeks of relief

ndash Pain came back worse

ndash Repeat injection

ndash Pain came back

ndash Repeat for a total of 5 steroid injections

ndash Referred to Sports Medicine

Sports Medicine Clinic

bull Continued lateral hip pain

bull Pain to palpation over the GT

bull Trendelenberg gait ndash worsening

bull Hip Abduction 25

bull We obtained an MRI

MRI

MRI

MRI

GTPS

bull Schapira et al

ndash observational study

bull 72 patients followed for 2 years

bull 916 of patients diagnosed with symptomatic

trochanteric bursitis had other associated pathology

ndash osteoarthritis of the ipsilateral hip or lumbar spine

Schapira D Nahir M Scharf Y Trochanteric bursitis a common clinical problem Arch Phys Med Rehabil 1986 67815ndash817

GT MRI

bull Bird et al

ndash Retrospective review of MRI findings in 24 women

with greater trochanteric pain syndrome presenting

with lateral hip pain and point tenderness at the

greater trochanter reported

bull 625 had evidence of gluteus medius tendonitis

bull 458 had gluteus medius tears

bull only 2 patients (83) had objective evidence of

trochanteric bursitis

Bird PA Oakley SP Shnier R et al Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome Arthritis Rheum 2001442138ndash2145

GTPS

bull GTPS

ndash Gluteus medius dysfunction

ndash Gluteus medius or gluteus minimus tendinopathy

ndash Piriformis tendinopathy

ndash Iliotibial tract friction syndrome

ndash Trochanteric bursitis

Lateral Hip - GT

GTPS

bull Steroid ndash 75 success at 1 month

ndash The effect subsided with timebull 51 at 4 months

bull 48 at 15 months

bull Shockwave Therapyndash No benefit to early pain

ndash 68 at 4 months

ndash 74 at 15 months

bull Home PTndash Ineffective initially

ndash 41 at 4 months

ndash 81 at 15 months Am J Sports Med 2009 Oct37(10)1981-90 doi 1011770363546509334374 Epub 2009 May 13Home training local corticosteroid injection or radial shock wave therapy for greater trochanter pain syndromeRompe JD1 Segal NA Cacchio A Furia JP Morral A Maffulli N

Sports Medicine Clinic

bull Continued lateral hip pain

bull Pain to palpation over the GT

bull Trendelenberg gait ndash worsening

bull Hip Abduction 25

bull We obtained an MRI

MRI

MRI

MRI

GTPS

bull Schapira et al

ndash observational study

bull 72 patients followed for 2 years

bull 916 of patients diagnosed with symptomatic

trochanteric bursitis had other associated pathology

ndash osteoarthritis of the ipsilateral hip or lumbar spine

Schapira D Nahir M Scharf Y Trochanteric bursitis a common clinical problem Arch Phys Med Rehabil 1986 67815ndash817

GT MRI

bull Bird et al

ndash Retrospective review of MRI findings in 24 women

with greater trochanteric pain syndrome presenting

with lateral hip pain and point tenderness at the

greater trochanter reported

bull 625 had evidence of gluteus medius tendonitis

bull 458 had gluteus medius tears

bull only 2 patients (83) had objective evidence of

trochanteric bursitis

Bird PA Oakley SP Shnier R et al Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome Arthritis Rheum 2001442138ndash2145

GTPS

bull GTPS

ndash Gluteus medius dysfunction

ndash Gluteus medius or gluteus minimus tendinopathy

ndash Piriformis tendinopathy

ndash Iliotibial tract friction syndrome

ndash Trochanteric bursitis

Lateral Hip - GT

GTPS

bull Steroid ndash 75 success at 1 month

ndash The effect subsided with timebull 51 at 4 months

bull 48 at 15 months

bull Shockwave Therapyndash No benefit to early pain

ndash 68 at 4 months

ndash 74 at 15 months

bull Home PTndash Ineffective initially

ndash 41 at 4 months

ndash 81 at 15 months Am J Sports Med 2009 Oct37(10)1981-90 doi 1011770363546509334374 Epub 2009 May 13Home training local corticosteroid injection or radial shock wave therapy for greater trochanter pain syndromeRompe JD1 Segal NA Cacchio A Furia JP Morral A Maffulli N

MRI

MRI

MRI

GTPS

bull Schapira et al

ndash observational study

bull 72 patients followed for 2 years

bull 916 of patients diagnosed with symptomatic

trochanteric bursitis had other associated pathology

ndash osteoarthritis of the ipsilateral hip or lumbar spine

Schapira D Nahir M Scharf Y Trochanteric bursitis a common clinical problem Arch Phys Med Rehabil 1986 67815ndash817

GT MRI

bull Bird et al

ndash Retrospective review of MRI findings in 24 women

with greater trochanteric pain syndrome presenting

with lateral hip pain and point tenderness at the

greater trochanter reported

bull 625 had evidence of gluteus medius tendonitis

bull 458 had gluteus medius tears

bull only 2 patients (83) had objective evidence of

trochanteric bursitis

Bird PA Oakley SP Shnier R et al Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome Arthritis Rheum 2001442138ndash2145

GTPS

bull GTPS

ndash Gluteus medius dysfunction

ndash Gluteus medius or gluteus minimus tendinopathy

ndash Piriformis tendinopathy

ndash Iliotibial tract friction syndrome

ndash Trochanteric bursitis

Lateral Hip - GT

GTPS

bull Steroid ndash 75 success at 1 month

ndash The effect subsided with timebull 51 at 4 months

bull 48 at 15 months

bull Shockwave Therapyndash No benefit to early pain

ndash 68 at 4 months

ndash 74 at 15 months

bull Home PTndash Ineffective initially

ndash 41 at 4 months

ndash 81 at 15 months Am J Sports Med 2009 Oct37(10)1981-90 doi 1011770363546509334374 Epub 2009 May 13Home training local corticosteroid injection or radial shock wave therapy for greater trochanter pain syndromeRompe JD1 Segal NA Cacchio A Furia JP Morral A Maffulli N

MRI

MRI

GTPS

bull Schapira et al

ndash observational study

bull 72 patients followed for 2 years

bull 916 of patients diagnosed with symptomatic

trochanteric bursitis had other associated pathology

ndash osteoarthritis of the ipsilateral hip or lumbar spine

Schapira D Nahir M Scharf Y Trochanteric bursitis a common clinical problem Arch Phys Med Rehabil 1986 67815ndash817

GT MRI

bull Bird et al

ndash Retrospective review of MRI findings in 24 women

with greater trochanteric pain syndrome presenting

with lateral hip pain and point tenderness at the

greater trochanter reported

bull 625 had evidence of gluteus medius tendonitis

bull 458 had gluteus medius tears

bull only 2 patients (83) had objective evidence of

trochanteric bursitis

Bird PA Oakley SP Shnier R et al Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome Arthritis Rheum 2001442138ndash2145

GTPS

bull GTPS

ndash Gluteus medius dysfunction

ndash Gluteus medius or gluteus minimus tendinopathy

ndash Piriformis tendinopathy

ndash Iliotibial tract friction syndrome

ndash Trochanteric bursitis

Lateral Hip - GT

GTPS

bull Steroid ndash 75 success at 1 month

ndash The effect subsided with timebull 51 at 4 months

bull 48 at 15 months

bull Shockwave Therapyndash No benefit to early pain

ndash 68 at 4 months

ndash 74 at 15 months

bull Home PTndash Ineffective initially

ndash 41 at 4 months

ndash 81 at 15 months Am J Sports Med 2009 Oct37(10)1981-90 doi 1011770363546509334374 Epub 2009 May 13Home training local corticosteroid injection or radial shock wave therapy for greater trochanter pain syndromeRompe JD1 Segal NA Cacchio A Furia JP Morral A Maffulli N

MRI

GTPS

bull Schapira et al

ndash observational study

bull 72 patients followed for 2 years

bull 916 of patients diagnosed with symptomatic

trochanteric bursitis had other associated pathology

ndash osteoarthritis of the ipsilateral hip or lumbar spine

Schapira D Nahir M Scharf Y Trochanteric bursitis a common clinical problem Arch Phys Med Rehabil 1986 67815ndash817

GT MRI

bull Bird et al

ndash Retrospective review of MRI findings in 24 women

with greater trochanteric pain syndrome presenting

with lateral hip pain and point tenderness at the

greater trochanter reported

bull 625 had evidence of gluteus medius tendonitis

bull 458 had gluteus medius tears

bull only 2 patients (83) had objective evidence of

trochanteric bursitis

Bird PA Oakley SP Shnier R et al Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome Arthritis Rheum 2001442138ndash2145

GTPS

bull GTPS

ndash Gluteus medius dysfunction

ndash Gluteus medius or gluteus minimus tendinopathy

ndash Piriformis tendinopathy

ndash Iliotibial tract friction syndrome

ndash Trochanteric bursitis

Lateral Hip - GT

GTPS

bull Steroid ndash 75 success at 1 month

ndash The effect subsided with timebull 51 at 4 months

bull 48 at 15 months

bull Shockwave Therapyndash No benefit to early pain

ndash 68 at 4 months

ndash 74 at 15 months

bull Home PTndash Ineffective initially

ndash 41 at 4 months

ndash 81 at 15 months Am J Sports Med 2009 Oct37(10)1981-90 doi 1011770363546509334374 Epub 2009 May 13Home training local corticosteroid injection or radial shock wave therapy for greater trochanter pain syndromeRompe JD1 Segal NA Cacchio A Furia JP Morral A Maffulli N

GTPS

bull Schapira et al

ndash observational study

bull 72 patients followed for 2 years

bull 916 of patients diagnosed with symptomatic

trochanteric bursitis had other associated pathology

ndash osteoarthritis of the ipsilateral hip or lumbar spine

Schapira D Nahir M Scharf Y Trochanteric bursitis a common clinical problem Arch Phys Med Rehabil 1986 67815ndash817

GT MRI

bull Bird et al

ndash Retrospective review of MRI findings in 24 women

with greater trochanteric pain syndrome presenting

with lateral hip pain and point tenderness at the

greater trochanter reported

bull 625 had evidence of gluteus medius tendonitis

bull 458 had gluteus medius tears

bull only 2 patients (83) had objective evidence of

trochanteric bursitis

Bird PA Oakley SP Shnier R et al Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome Arthritis Rheum 2001442138ndash2145

GTPS

bull GTPS

ndash Gluteus medius dysfunction

ndash Gluteus medius or gluteus minimus tendinopathy

ndash Piriformis tendinopathy

ndash Iliotibial tract friction syndrome

ndash Trochanteric bursitis

Lateral Hip - GT

GTPS

bull Steroid ndash 75 success at 1 month

ndash The effect subsided with timebull 51 at 4 months

bull 48 at 15 months

bull Shockwave Therapyndash No benefit to early pain

ndash 68 at 4 months

ndash 74 at 15 months

bull Home PTndash Ineffective initially

ndash 41 at 4 months

ndash 81 at 15 months Am J Sports Med 2009 Oct37(10)1981-90 doi 1011770363546509334374 Epub 2009 May 13Home training local corticosteroid injection or radial shock wave therapy for greater trochanter pain syndromeRompe JD1 Segal NA Cacchio A Furia JP Morral A Maffulli N

GT MRI

bull Bird et al

ndash Retrospective review of MRI findings in 24 women

with greater trochanteric pain syndrome presenting

with lateral hip pain and point tenderness at the

greater trochanter reported

bull 625 had evidence of gluteus medius tendonitis

bull 458 had gluteus medius tears

bull only 2 patients (83) had objective evidence of

trochanteric bursitis

Bird PA Oakley SP Shnier R et al Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome Arthritis Rheum 2001442138ndash2145

GTPS

bull GTPS

ndash Gluteus medius dysfunction

ndash Gluteus medius or gluteus minimus tendinopathy

ndash Piriformis tendinopathy

ndash Iliotibial tract friction syndrome

ndash Trochanteric bursitis

Lateral Hip - GT

GTPS

bull Steroid ndash 75 success at 1 month

ndash The effect subsided with timebull 51 at 4 months

bull 48 at 15 months

bull Shockwave Therapyndash No benefit to early pain

ndash 68 at 4 months

ndash 74 at 15 months

bull Home PTndash Ineffective initially

ndash 41 at 4 months

ndash 81 at 15 months Am J Sports Med 2009 Oct37(10)1981-90 doi 1011770363546509334374 Epub 2009 May 13Home training local corticosteroid injection or radial shock wave therapy for greater trochanter pain syndromeRompe JD1 Segal NA Cacchio A Furia JP Morral A Maffulli N

GTPS

bull GTPS

ndash Gluteus medius dysfunction

ndash Gluteus medius or gluteus minimus tendinopathy

ndash Piriformis tendinopathy

ndash Iliotibial tract friction syndrome

ndash Trochanteric bursitis

Lateral Hip - GT

GTPS

bull Steroid ndash 75 success at 1 month

ndash The effect subsided with timebull 51 at 4 months

bull 48 at 15 months

bull Shockwave Therapyndash No benefit to early pain

ndash 68 at 4 months

ndash 74 at 15 months

bull Home PTndash Ineffective initially

ndash 41 at 4 months

ndash 81 at 15 months Am J Sports Med 2009 Oct37(10)1981-90 doi 1011770363546509334374 Epub 2009 May 13Home training local corticosteroid injection or radial shock wave therapy for greater trochanter pain syndromeRompe JD1 Segal NA Cacchio A Furia JP Morral A Maffulli N

Lateral Hip - GT

GTPS

bull Steroid ndash 75 success at 1 month

ndash The effect subsided with timebull 51 at 4 months

bull 48 at 15 months

bull Shockwave Therapyndash No benefit to early pain

ndash 68 at 4 months

ndash 74 at 15 months

bull Home PTndash Ineffective initially

ndash 41 at 4 months

ndash 81 at 15 months Am J Sports Med 2009 Oct37(10)1981-90 doi 1011770363546509334374 Epub 2009 May 13Home training local corticosteroid injection or radial shock wave therapy for greater trochanter pain syndromeRompe JD1 Segal NA Cacchio A Furia JP Morral A Maffulli N

GTPS

bull Steroid ndash 75 success at 1 month

ndash The effect subsided with timebull 51 at 4 months

bull 48 at 15 months

bull Shockwave Therapyndash No benefit to early pain

ndash 68 at 4 months

ndash 74 at 15 months

bull Home PTndash Ineffective initially

ndash 41 at 4 months

ndash 81 at 15 months Am J Sports Med 2009 Oct37(10)1981-90 doi 1011770363546509334374 Epub 2009 May 13Home training local corticosteroid injection or radial shock wave therapy for greater trochanter pain syndromeRompe JD1 Segal NA Cacchio A Furia JP Morral A Maffulli N

Why consider orthobiologics

bull $30 billion spent on MSK injuries in the US1

ndash 45 tendon ligament injuries1

ndash Surgical repairs are often unsuccessful2

bull Majority become chronic2

bull Examples

ndash Rotator Cuff Tendonopathy

bull 16 of general population from PCP data 3

bull 21 when including elderly hospital data 4

ndash 30-50 of all sporting injury involves tendons

1 Liu 2011 2 Pennisi 2002 3 Urwin 1998 4 Chad 1991

Why consider orthobiologics

bull Regenerative Medicine Orthobiologics Targets

Muscle

Why consider orthobiologics

bull Tendonopathy1 Tendonitis

bull Inflammation and pain

2 Tendonosisbull Degeneration

bull Multifactorial process ndash Intrinsic factors

bull Age gender anatomy BMI disease

ndash Extrinsic factorsbull Sports occupation environmental

Riley G The pathogenesis of tendinopathy A molecular perspective Rheumatology (Oxford) 2004 43131ndash142 Rees JD Wilson AM Wolman RL Current concepts in the management of tendon disorders Rheumatology (Oxford) 2006 45508ndash521

Why consider orthobiologics

bull ldquoTraditionally tendinitis was treated by

controlling inflammation through conventional

methods including corticosteroid and NSAIDs

with no scientific evidence to support these

treatment modalitiesrdquo

Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132

Why consider orthobiologics

bull ldquoCorticosteroid injections may actually have

deleterious effects after their short term pain

relief rdquo

ndash Beneficial short term 6 weeks

ndash No evidence of improved patient outcomes beyond

6 weeks

ndash Those having injections have INFERIOR long term

results compared to placebo wait and see

N Smidt D A W M van der Windt W J J Assendel W LJMDeville IBCKorthals-deBosandLMBouter ldquoCorticosteroid injections physiotherapy or a wait-and-see policy for lateral epicondylitis A randomised controlled trialrdquo e Lancet vol 359 no 9307 pp 657ndash662 2002 L Bisset N Smidt D A van der Windt et al ldquoConservative treatments for tennis elbowmdashdo subgroups of patients respond diferentlyrdquo Rheumatology vol 46 no 10 pp 1601ndash1605 2007 Kahlenberg CA Knesek M Terry MA New Developments in the Use of Biologics and Other Modalities in the management of Lateral Epicondylitis BioMedRes Int 2015

What has been the

evolution convergence

Image guided regenerative treatment

New treatments veterinary

and surgical

MSK US

Science

Tendon

Joint

Slide Courtesy of Joanne Borg Stein MD

Tendon Healing

Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239

Tendon healing

Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239

Tendon healing

Tissue Normal Injured

Type III Collagen 1 20-30 Superior elasticityinferior strength

Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132

PRP

Platelet Rich Plasma

PRP

bull Conversion of a chronic non healing injury into an acute injury with increased healing potential

bull Contains Growth factors

bull Platelet alpha granules

bull Small peptides that bind to membrane receptors

bull promote downstream biologic pathways

bull Influence chemotaxis and cell migration

bull Induce Mitosis

bull Extracellular matrix production

bull Angiogenesis

bull Cells signal to proliferate influence maturation differentiate ultimately tissue repairowth factors

Case 2

bull 50 year old male with medial right knee pain

He has completed 2 prior marathons Currently

competing in triathlons No trauma Pain and

stiffness is present in the AM improves as the

day goes on worse at night Described as an

dull achy sensation

Case 2

bull Exam

ndash Normal lumbar exam

ndash Intact Myotomes Dermatomes Reflexes

ndash Pain to palpation along the medial joint line

ndash Crepitus

ndash Negative ligamentous testing

Baby Boomers and

ldquotweenersrdquo

bull ldquoIn betweenrdquo normal

joint and arthroplasty

Slide courtesy of Dr Joanne Borg-Stein

Orthobiologics

bull Prolotherapy

bull PRP

bull BMAC

bull Adipose derived

bull Amniotic products

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

Mesenchymal stem cells

bull MSC cells that have the ability to

proliferate and differentiate into

progenitors of different mesenchymal

tissue

bull They have unique cell surface

markers adhesion molecules

cytokines growth factors and

receptors

bull Anti-inflammatory and

immunomodulatory

Obaid et al Cell therapy in tendon disorders

What is the Current evidence

Am J Sports Med 2010 38 (10)

bioscienceorg

Slide Courtesy of Dr Joanne Borg Stein

Mesenchymal stem cells

bull Mesenchymal Stem Cells

1 Bone Marrow Derived MSCs

2 Adipose Tissue Derived MSCs

3 Synovium Derived MSCs

bull De Bari et al 2001

4 Muscle Derived MSCs

bull Williams et al 1999

5 Dermal Fibroblast

1 Connell et al N=12

BMAC

BMAC

bull Hemopoietic stem cells

bull Nonhemopoietic cells Mesenchymal Stem Cells

ndash 0001-001 of total cell population

ndash 100k - 2M MSCs

bull Diminishes with age

Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147

BMAC

bull General Set up

Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939

Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939

BMAC

bull Rate is not greater than that observed with other types of intra-articular injections

bull Annual neoplasm 078 in adults 50 ndash 64 yo

ndash This study showed 014

bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure

bull Only 3 were possibly related to stem cells

BMAC

bull Eight studies focused on focal chondral defects

bull Three studies evaluated for treatment of

osteoarthritis

BMAC

bull Six trials with high risk of bias showed

level-3 or level-4 evidence in favour of stem

cell injections in KOA

BMAC

Author BMAC Pathology NCenteno et al 2008

BMAC meniscus 1 ndash case study MRI showed increased volume

bmac prp x2 and dex with hyalgan

Giannini et al2009

BMAC Talus 48 6121824 mo Second look arthroscopy

New tissue on MRI

Kennedy and Murawski 2011

BMAC Talus 72

Pascual-Garridoet al 2012

BMAC Patellar tendinopathy

8 2-5 year follow up

Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri

Giannini et al 2013

BMAC Talus 20 48mo MRI new tissue

Singh et al 2014 BMAC Lateral epicondyle

30 2612 weeks Sig decrease in PRTEE scores

Centeno et al 2015

BMAC GH OA 115 2 year pain improvement

Prolo bmac and prp

Centeno et al 2015

BMAC ACL 10 cases grade 1-III

Improved MRI findings

Prolo BMAC + prp

Hannon et al 2016

BMAC Talus 34

Shapiro SA et al 2016

BMAC vs saline OA knee N = 25 VASWomackoos

Contralateral knee with saline

Safe well tolerated placebo

ADIPOSE TISSUE

Adipose Tissue

bull Human ADSCs

ndash localize in the stromal vascular fraction

(SVF)

ndash The SVF consists of a heterogeneous

mesenchymal population of cells

bull Adipose stromal stem and progenitor cells

bull Hematopoietic stem and progenitor cells

bull endothelial cells erythrocytes fibroblasts

lymphocytes monocyte macrophages

and pericytes

NIH

-PA

Auth

or M

an

uscrip

tN

IH-P

A A

uth

or M

an

uscrip

tN

IH-P

A A

uth

or M

anu

scrip

t

BOURIN et al Page 13

Table II

Cell populations resident in SVF

Hematopoietic-lineage cells

Stem and progenitor cells lt01

Granulocytes 10ndash15

Monocytes 5ndash15

Lymphocytes 10ndash15

Endothelial cells 10ndash20

Pericytes 3ndash5

Stromal cells 15ndash30

Cytotherapy Author manuscript available in PMC 2014 April 08

Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648

Adipose Tissue

bull The stromal vascular fraction (SVF) is a

heterogeneous cell population derived from

manipulation of adipose tissue

ndash homogenization

ndash enzymatic digestion

ndash differential centrifugation

ndash red blood cells lysis and washing

Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Mesenchymal stem cells

bull Mulitpotent

bull More prone to differentiate

into muscle cells or even

into cardiomyocytes

compared with bone

marrow MSCs

bull Less efficient at osteogenic

and chondrogenic

differentiation

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Adipose Tissue

bull When treated with growth factors

ndash Upregulate expression of tendon related markers

ndash They are found comparable scaffold adherence and

proliferation potential

bull Suggesting AD-MSCs as alternative cell type for tendon

tissue repair

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239

Adipose Tissue

bull Easier to obtain

bull Bioscaffold

Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869

Adipose Tissue

bull General Set up

FDA CLEARANCE AND PRODUCT INFORMATION

TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose

tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure

Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints

middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture

middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents

middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue

middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)

IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha

legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat

isonlytobeusedwithoutanyadditionalmanipulation

Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister

middot LG60cc

middot LG240cc

1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm

120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes

260mlpolycarbonatesyringe2FemaleLuertransferconnectors

LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria

middot TheHCTPisminimallymanipulated

middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)

middot TheHCTPisnotcombinedwithanotherarticleand

middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction

DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016

Adipose Tissue HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer

5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe

6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Local Anesthetic

bull Connect the vacuum syringe to the

blunt 13-gauge Lipoaspiration

cannula

bull Advance and withdraw cannula in a

ldquospokes-of-a-wheelrdquo pattern

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto

createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly

3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand

holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe

canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe

canisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanister

approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

Adipose Tissue

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds

in a vertical motion

ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals

ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent

bull Collection ndash Pull down on the syringe

ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister

ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

HarvestingandProcessingGuide

WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand

rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities

2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion

3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals

4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps

CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach

10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe

clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith

salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull

syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe

Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor

Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection

Adipose Tissue

Adipose Tissue

bull 2002 national survey of 66000 tumescent

liposuction cases

ndash No deaths were reported

ndash Complication rate was 0068 per 1000 cases

Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002

Stem Cell summary

BMAC

bull 100k - 2M MSCs

bull Chondrocyte

bull Osteogenic

bull More painful

bull Volume limit

Adipose

bull 250k - 125M MSCs

bull Bioscaffold

bull Tendon defect filling

bull Less painfull

bull Larger volumes

AMNIOTIC TISSUE

Amniotic Tissue

bull Human Amniotic suspension allografts ndash Human amniotic membrane

ndash Human amniotic fluid-derived cells

bull Contain anti-inflammatory factorsndash IL-10 IL-1

ndash Metrix metalloproteinases 123 and 4

ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen

G5

ndash Hyaluranic Acid and small amount so proteoglycans

Amniotic Tissue

bull Human amniotic membrane

ndash Growth factors including EGF TGF-β and FGF

bull Stimulate epithelial cell migration and proliferation

bull PDGF A and B

ndash Stimulate many metabolic processes

raquo General protein and collagen synthesis collagenase activity

and chemotaxis of fibroblasts and of smooth muscle cells

raquo TGF-β has been shown to significantly increase type I

collagen production by tendon sheath fibroblasts

Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169

Amniotic Tissue

bull N = 6 KL grade 34

bull 12 weeks 3512 months

bull Primary goal feasibility of injection for treatment of OA

bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy

Amniotic Tissue

bull Pain and functional measures

ndash P ADL QOL S SR of the KOOS

ndash Overall KOOS IKDC SANE

bull All scores demonstrated improvement at 1 year

ndash Labs

bull No concerning changes in renal function blood cell

counts or lymphocyte subsets

bull Statistically significant increase in IgG and IgE relative to

baseline but not abnormal level

Amniotic Tissue

bull N23

ndash 14 Corticosteroid

ndash 9 c-hAM

bull Safe and comparable to steroid

Amniotic Tissue

Amniotic Tissue

bull N=470 181

bull VAS WOMAC

bull KL 1-3 OA

bull 30 90 120 days

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

Access this article

Or purchase this article - $20

Print Subscriber Activate your online access now

Welcome Guest Renew Subscribe or Create Account Sign In

HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

Why consider orthobiologics

bull Regenerative Medicine Orthobiologics Targets

Muscle

Why consider orthobiologics

bull Tendonopathy1 Tendonitis

bull Inflammation and pain

2 Tendonosisbull Degeneration

bull Multifactorial process ndash Intrinsic factors

bull Age gender anatomy BMI disease

ndash Extrinsic factorsbull Sports occupation environmental

Riley G The pathogenesis of tendinopathy A molecular perspective Rheumatology (Oxford) 2004 43131ndash142 Rees JD Wilson AM Wolman RL Current concepts in the management of tendon disorders Rheumatology (Oxford) 2006 45508ndash521

Why consider orthobiologics

bull ldquoTraditionally tendinitis was treated by

controlling inflammation through conventional

methods including corticosteroid and NSAIDs

with no scientific evidence to support these

treatment modalitiesrdquo

Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132

Why consider orthobiologics

bull ldquoCorticosteroid injections may actually have

deleterious effects after their short term pain

relief rdquo

ndash Beneficial short term 6 weeks

ndash No evidence of improved patient outcomes beyond

6 weeks

ndash Those having injections have INFERIOR long term

results compared to placebo wait and see

N Smidt D A W M van der Windt W J J Assendel W LJMDeville IBCKorthals-deBosandLMBouter ldquoCorticosteroid injections physiotherapy or a wait-and-see policy for lateral epicondylitis A randomised controlled trialrdquo e Lancet vol 359 no 9307 pp 657ndash662 2002 L Bisset N Smidt D A van der Windt et al ldquoConservative treatments for tennis elbowmdashdo subgroups of patients respond diferentlyrdquo Rheumatology vol 46 no 10 pp 1601ndash1605 2007 Kahlenberg CA Knesek M Terry MA New Developments in the Use of Biologics and Other Modalities in the management of Lateral Epicondylitis BioMedRes Int 2015

What has been the

evolution convergence

Image guided regenerative treatment

New treatments veterinary

and surgical

MSK US

Science

Tendon

Joint

Slide Courtesy of Joanne Borg Stein MD

Tendon Healing

Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239

Tendon healing

Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239

Tendon healing

Tissue Normal Injured

Type III Collagen 1 20-30 Superior elasticityinferior strength

Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132

PRP

Platelet Rich Plasma

PRP

bull Conversion of a chronic non healing injury into an acute injury with increased healing potential

bull Contains Growth factors

bull Platelet alpha granules

bull Small peptides that bind to membrane receptors

bull promote downstream biologic pathways

bull Influence chemotaxis and cell migration

bull Induce Mitosis

bull Extracellular matrix production

bull Angiogenesis

bull Cells signal to proliferate influence maturation differentiate ultimately tissue repairowth factors

Case 2

bull 50 year old male with medial right knee pain

He has completed 2 prior marathons Currently

competing in triathlons No trauma Pain and

stiffness is present in the AM improves as the

day goes on worse at night Described as an

dull achy sensation

Case 2

bull Exam

ndash Normal lumbar exam

ndash Intact Myotomes Dermatomes Reflexes

ndash Pain to palpation along the medial joint line

ndash Crepitus

ndash Negative ligamentous testing

Baby Boomers and

ldquotweenersrdquo

bull ldquoIn betweenrdquo normal

joint and arthroplasty

Slide courtesy of Dr Joanne Borg-Stein

Orthobiologics

bull Prolotherapy

bull PRP

bull BMAC

bull Adipose derived

bull Amniotic products

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

Access this article

Or purchase this article - $20

Print Subscriber Activate your online access now

Welcome Guest Renew Subscribe or Create Account Sign In

HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

Mesenchymal stem cells

bull MSC cells that have the ability to

proliferate and differentiate into

progenitors of different mesenchymal

tissue

bull They have unique cell surface

markers adhesion molecules

cytokines growth factors and

receptors

bull Anti-inflammatory and

immunomodulatory

Obaid et al Cell therapy in tendon disorders

What is the Current evidence

Am J Sports Med 2010 38 (10)

bioscienceorg

Slide Courtesy of Dr Joanne Borg Stein

Mesenchymal stem cells

bull Mesenchymal Stem Cells

1 Bone Marrow Derived MSCs

2 Adipose Tissue Derived MSCs

3 Synovium Derived MSCs

bull De Bari et al 2001

4 Muscle Derived MSCs

bull Williams et al 1999

5 Dermal Fibroblast

1 Connell et al N=12

BMAC

BMAC

bull Hemopoietic stem cells

bull Nonhemopoietic cells Mesenchymal Stem Cells

ndash 0001-001 of total cell population

ndash 100k - 2M MSCs

bull Diminishes with age

Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147

BMAC

bull General Set up

Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939

Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939

BMAC

bull Rate is not greater than that observed with other types of intra-articular injections

bull Annual neoplasm 078 in adults 50 ndash 64 yo

ndash This study showed 014

bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure

bull Only 3 were possibly related to stem cells

BMAC

bull Eight studies focused on focal chondral defects

bull Three studies evaluated for treatment of

osteoarthritis

BMAC

bull Six trials with high risk of bias showed

level-3 or level-4 evidence in favour of stem

cell injections in KOA

BMAC

Author BMAC Pathology NCenteno et al 2008

BMAC meniscus 1 ndash case study MRI showed increased volume

bmac prp x2 and dex with hyalgan

Giannini et al2009

BMAC Talus 48 6121824 mo Second look arthroscopy

New tissue on MRI

Kennedy and Murawski 2011

BMAC Talus 72

Pascual-Garridoet al 2012

BMAC Patellar tendinopathy

8 2-5 year follow up

Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri

Giannini et al 2013

BMAC Talus 20 48mo MRI new tissue

Singh et al 2014 BMAC Lateral epicondyle

30 2612 weeks Sig decrease in PRTEE scores

Centeno et al 2015

BMAC GH OA 115 2 year pain improvement

Prolo bmac and prp

Centeno et al 2015

BMAC ACL 10 cases grade 1-III

Improved MRI findings

Prolo BMAC + prp

Hannon et al 2016

BMAC Talus 34

Shapiro SA et al 2016

BMAC vs saline OA knee N = 25 VASWomackoos

Contralateral knee with saline

Safe well tolerated placebo

ADIPOSE TISSUE

Adipose Tissue

bull Human ADSCs

ndash localize in the stromal vascular fraction

(SVF)

ndash The SVF consists of a heterogeneous

mesenchymal population of cells

bull Adipose stromal stem and progenitor cells

bull Hematopoietic stem and progenitor cells

bull endothelial cells erythrocytes fibroblasts

lymphocytes monocyte macrophages

and pericytes

NIH

-PA

Auth

or M

an

uscrip

tN

IH-P

A A

uth

or M

an

uscrip

tN

IH-P

A A

uth

or M

anu

scrip

t

BOURIN et al Page 13

Table II

Cell populations resident in SVF

Hematopoietic-lineage cells

Stem and progenitor cells lt01

Granulocytes 10ndash15

Monocytes 5ndash15

Lymphocytes 10ndash15

Endothelial cells 10ndash20

Pericytes 3ndash5

Stromal cells 15ndash30

Cytotherapy Author manuscript available in PMC 2014 April 08

Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648

Adipose Tissue

bull The stromal vascular fraction (SVF) is a

heterogeneous cell population derived from

manipulation of adipose tissue

ndash homogenization

ndash enzymatic digestion

ndash differential centrifugation

ndash red blood cells lysis and washing

Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Mesenchymal stem cells

bull Mulitpotent

bull More prone to differentiate

into muscle cells or even

into cardiomyocytes

compared with bone

marrow MSCs

bull Less efficient at osteogenic

and chondrogenic

differentiation

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Adipose Tissue

bull When treated with growth factors

ndash Upregulate expression of tendon related markers

ndash They are found comparable scaffold adherence and

proliferation potential

bull Suggesting AD-MSCs as alternative cell type for tendon

tissue repair

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239

Adipose Tissue

bull Easier to obtain

bull Bioscaffold

Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869

Adipose Tissue

bull General Set up

FDA CLEARANCE AND PRODUCT INFORMATION

TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose

tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure

Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints

middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture

middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents

middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue

middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)

IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha

legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat

isonlytobeusedwithoutanyadditionalmanipulation

Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister

middot LG60cc

middot LG240cc

1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm

120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes

260mlpolycarbonatesyringe2FemaleLuertransferconnectors

LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria

middot TheHCTPisminimallymanipulated

middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)

middot TheHCTPisnotcombinedwithanotherarticleand

middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction

DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016

Adipose Tissue HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer

5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe

6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Local Anesthetic

bull Connect the vacuum syringe to the

blunt 13-gauge Lipoaspiration

cannula

bull Advance and withdraw cannula in a

ldquospokes-of-a-wheelrdquo pattern

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto

createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly

3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand

holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe

canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe

canisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanister

approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

Adipose Tissue

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds

in a vertical motion

ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals

ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent

bull Collection ndash Pull down on the syringe

ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister

ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

HarvestingandProcessingGuide

WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand

rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities

2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion

3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals

4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps

CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach

10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe

clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith

salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull

syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe

Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor

Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection

Adipose Tissue

Adipose Tissue

bull 2002 national survey of 66000 tumescent

liposuction cases

ndash No deaths were reported

ndash Complication rate was 0068 per 1000 cases

Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002

Stem Cell summary

BMAC

bull 100k - 2M MSCs

bull Chondrocyte

bull Osteogenic

bull More painful

bull Volume limit

Adipose

bull 250k - 125M MSCs

bull Bioscaffold

bull Tendon defect filling

bull Less painfull

bull Larger volumes

AMNIOTIC TISSUE

Amniotic Tissue

bull Human Amniotic suspension allografts ndash Human amniotic membrane

ndash Human amniotic fluid-derived cells

bull Contain anti-inflammatory factorsndash IL-10 IL-1

ndash Metrix metalloproteinases 123 and 4

ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen

G5

ndash Hyaluranic Acid and small amount so proteoglycans

Amniotic Tissue

bull Human amniotic membrane

ndash Growth factors including EGF TGF-β and FGF

bull Stimulate epithelial cell migration and proliferation

bull PDGF A and B

ndash Stimulate many metabolic processes

raquo General protein and collagen synthesis collagenase activity

and chemotaxis of fibroblasts and of smooth muscle cells

raquo TGF-β has been shown to significantly increase type I

collagen production by tendon sheath fibroblasts

Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169

Amniotic Tissue

bull N = 6 KL grade 34

bull 12 weeks 3512 months

bull Primary goal feasibility of injection for treatment of OA

bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy

Amniotic Tissue

bull Pain and functional measures

ndash P ADL QOL S SR of the KOOS

ndash Overall KOOS IKDC SANE

bull All scores demonstrated improvement at 1 year

ndash Labs

bull No concerning changes in renal function blood cell

counts or lymphocyte subsets

bull Statistically significant increase in IgG and IgE relative to

baseline but not abnormal level

Amniotic Tissue

bull N23

ndash 14 Corticosteroid

ndash 9 c-hAM

bull Safe and comparable to steroid

Amniotic Tissue

Amniotic Tissue

bull N=470 181

bull VAS WOMAC

bull KL 1-3 OA

bull 30 90 120 days

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

Why consider orthobiologics

bull Tendonopathy1 Tendonitis

bull Inflammation and pain

2 Tendonosisbull Degeneration

bull Multifactorial process ndash Intrinsic factors

bull Age gender anatomy BMI disease

ndash Extrinsic factorsbull Sports occupation environmental

Riley G The pathogenesis of tendinopathy A molecular perspective Rheumatology (Oxford) 2004 43131ndash142 Rees JD Wilson AM Wolman RL Current concepts in the management of tendon disorders Rheumatology (Oxford) 2006 45508ndash521

Why consider orthobiologics

bull ldquoTraditionally tendinitis was treated by

controlling inflammation through conventional

methods including corticosteroid and NSAIDs

with no scientific evidence to support these

treatment modalitiesrdquo

Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132

Why consider orthobiologics

bull ldquoCorticosteroid injections may actually have

deleterious effects after their short term pain

relief rdquo

ndash Beneficial short term 6 weeks

ndash No evidence of improved patient outcomes beyond

6 weeks

ndash Those having injections have INFERIOR long term

results compared to placebo wait and see

N Smidt D A W M van der Windt W J J Assendel W LJMDeville IBCKorthals-deBosandLMBouter ldquoCorticosteroid injections physiotherapy or a wait-and-see policy for lateral epicondylitis A randomised controlled trialrdquo e Lancet vol 359 no 9307 pp 657ndash662 2002 L Bisset N Smidt D A van der Windt et al ldquoConservative treatments for tennis elbowmdashdo subgroups of patients respond diferentlyrdquo Rheumatology vol 46 no 10 pp 1601ndash1605 2007 Kahlenberg CA Knesek M Terry MA New Developments in the Use of Biologics and Other Modalities in the management of Lateral Epicondylitis BioMedRes Int 2015

What has been the

evolution convergence

Image guided regenerative treatment

New treatments veterinary

and surgical

MSK US

Science

Tendon

Joint

Slide Courtesy of Joanne Borg Stein MD

Tendon Healing

Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239

Tendon healing

Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239

Tendon healing

Tissue Normal Injured

Type III Collagen 1 20-30 Superior elasticityinferior strength

Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132

PRP

Platelet Rich Plasma

PRP

bull Conversion of a chronic non healing injury into an acute injury with increased healing potential

bull Contains Growth factors

bull Platelet alpha granules

bull Small peptides that bind to membrane receptors

bull promote downstream biologic pathways

bull Influence chemotaxis and cell migration

bull Induce Mitosis

bull Extracellular matrix production

bull Angiogenesis

bull Cells signal to proliferate influence maturation differentiate ultimately tissue repairowth factors

Case 2

bull 50 year old male with medial right knee pain

He has completed 2 prior marathons Currently

competing in triathlons No trauma Pain and

stiffness is present in the AM improves as the

day goes on worse at night Described as an

dull achy sensation

Case 2

bull Exam

ndash Normal lumbar exam

ndash Intact Myotomes Dermatomes Reflexes

ndash Pain to palpation along the medial joint line

ndash Crepitus

ndash Negative ligamentous testing

Baby Boomers and

ldquotweenersrdquo

bull ldquoIn betweenrdquo normal

joint and arthroplasty

Slide courtesy of Dr Joanne Borg-Stein

Orthobiologics

bull Prolotherapy

bull PRP

bull BMAC

bull Adipose derived

bull Amniotic products

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

Mesenchymal stem cells

bull MSC cells that have the ability to

proliferate and differentiate into

progenitors of different mesenchymal

tissue

bull They have unique cell surface

markers adhesion molecules

cytokines growth factors and

receptors

bull Anti-inflammatory and

immunomodulatory

Obaid et al Cell therapy in tendon disorders

What is the Current evidence

Am J Sports Med 2010 38 (10)

bioscienceorg

Slide Courtesy of Dr Joanne Borg Stein

Mesenchymal stem cells

bull Mesenchymal Stem Cells

1 Bone Marrow Derived MSCs

2 Adipose Tissue Derived MSCs

3 Synovium Derived MSCs

bull De Bari et al 2001

4 Muscle Derived MSCs

bull Williams et al 1999

5 Dermal Fibroblast

1 Connell et al N=12

BMAC

BMAC

bull Hemopoietic stem cells

bull Nonhemopoietic cells Mesenchymal Stem Cells

ndash 0001-001 of total cell population

ndash 100k - 2M MSCs

bull Diminishes with age

Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147

BMAC

bull General Set up

Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939

Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939

BMAC

bull Rate is not greater than that observed with other types of intra-articular injections

bull Annual neoplasm 078 in adults 50 ndash 64 yo

ndash This study showed 014

bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure

bull Only 3 were possibly related to stem cells

BMAC

bull Eight studies focused on focal chondral defects

bull Three studies evaluated for treatment of

osteoarthritis

BMAC

bull Six trials with high risk of bias showed

level-3 or level-4 evidence in favour of stem

cell injections in KOA

BMAC

Author BMAC Pathology NCenteno et al 2008

BMAC meniscus 1 ndash case study MRI showed increased volume

bmac prp x2 and dex with hyalgan

Giannini et al2009

BMAC Talus 48 6121824 mo Second look arthroscopy

New tissue on MRI

Kennedy and Murawski 2011

BMAC Talus 72

Pascual-Garridoet al 2012

BMAC Patellar tendinopathy

8 2-5 year follow up

Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri

Giannini et al 2013

BMAC Talus 20 48mo MRI new tissue

Singh et al 2014 BMAC Lateral epicondyle

30 2612 weeks Sig decrease in PRTEE scores

Centeno et al 2015

BMAC GH OA 115 2 year pain improvement

Prolo bmac and prp

Centeno et al 2015

BMAC ACL 10 cases grade 1-III

Improved MRI findings

Prolo BMAC + prp

Hannon et al 2016

BMAC Talus 34

Shapiro SA et al 2016

BMAC vs saline OA knee N = 25 VASWomackoos

Contralateral knee with saline

Safe well tolerated placebo

ADIPOSE TISSUE

Adipose Tissue

bull Human ADSCs

ndash localize in the stromal vascular fraction

(SVF)

ndash The SVF consists of a heterogeneous

mesenchymal population of cells

bull Adipose stromal stem and progenitor cells

bull Hematopoietic stem and progenitor cells

bull endothelial cells erythrocytes fibroblasts

lymphocytes monocyte macrophages

and pericytes

NIH

-PA

Auth

or M

an

uscrip

tN

IH-P

A A

uth

or M

an

uscrip

tN

IH-P

A A

uth

or M

anu

scrip

t

BOURIN et al Page 13

Table II

Cell populations resident in SVF

Hematopoietic-lineage cells

Stem and progenitor cells lt01

Granulocytes 10ndash15

Monocytes 5ndash15

Lymphocytes 10ndash15

Endothelial cells 10ndash20

Pericytes 3ndash5

Stromal cells 15ndash30

Cytotherapy Author manuscript available in PMC 2014 April 08

Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648

Adipose Tissue

bull The stromal vascular fraction (SVF) is a

heterogeneous cell population derived from

manipulation of adipose tissue

ndash homogenization

ndash enzymatic digestion

ndash differential centrifugation

ndash red blood cells lysis and washing

Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Mesenchymal stem cells

bull Mulitpotent

bull More prone to differentiate

into muscle cells or even

into cardiomyocytes

compared with bone

marrow MSCs

bull Less efficient at osteogenic

and chondrogenic

differentiation

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Adipose Tissue

bull When treated with growth factors

ndash Upregulate expression of tendon related markers

ndash They are found comparable scaffold adherence and

proliferation potential

bull Suggesting AD-MSCs as alternative cell type for tendon

tissue repair

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239

Adipose Tissue

bull Easier to obtain

bull Bioscaffold

Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869

Adipose Tissue

bull General Set up

FDA CLEARANCE AND PRODUCT INFORMATION

TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose

tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure

Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints

middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture

middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents

middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue

middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)

IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha

legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat

isonlytobeusedwithoutanyadditionalmanipulation

Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister

middot LG60cc

middot LG240cc

1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm

120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes

260mlpolycarbonatesyringe2FemaleLuertransferconnectors

LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria

middot TheHCTPisminimallymanipulated

middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)

middot TheHCTPisnotcombinedwithanotherarticleand

middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction

DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016

Adipose Tissue HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer

5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe

6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Local Anesthetic

bull Connect the vacuum syringe to the

blunt 13-gauge Lipoaspiration

cannula

bull Advance and withdraw cannula in a

ldquospokes-of-a-wheelrdquo pattern

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto

createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly

3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand

holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe

canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe

canisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanister

approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

Adipose Tissue

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds

in a vertical motion

ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals

ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent

bull Collection ndash Pull down on the syringe

ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister

ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

HarvestingandProcessingGuide

WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand

rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities

2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion

3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals

4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps

CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach

10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe

clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith

salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull

syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe

Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor

Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection

Adipose Tissue

Adipose Tissue

bull 2002 national survey of 66000 tumescent

liposuction cases

ndash No deaths were reported

ndash Complication rate was 0068 per 1000 cases

Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002

Stem Cell summary

BMAC

bull 100k - 2M MSCs

bull Chondrocyte

bull Osteogenic

bull More painful

bull Volume limit

Adipose

bull 250k - 125M MSCs

bull Bioscaffold

bull Tendon defect filling

bull Less painfull

bull Larger volumes

AMNIOTIC TISSUE

Amniotic Tissue

bull Human Amniotic suspension allografts ndash Human amniotic membrane

ndash Human amniotic fluid-derived cells

bull Contain anti-inflammatory factorsndash IL-10 IL-1

ndash Metrix metalloproteinases 123 and 4

ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen

G5

ndash Hyaluranic Acid and small amount so proteoglycans

Amniotic Tissue

bull Human amniotic membrane

ndash Growth factors including EGF TGF-β and FGF

bull Stimulate epithelial cell migration and proliferation

bull PDGF A and B

ndash Stimulate many metabolic processes

raquo General protein and collagen synthesis collagenase activity

and chemotaxis of fibroblasts and of smooth muscle cells

raquo TGF-β has been shown to significantly increase type I

collagen production by tendon sheath fibroblasts

Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169

Amniotic Tissue

bull N = 6 KL grade 34

bull 12 weeks 3512 months

bull Primary goal feasibility of injection for treatment of OA

bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy

Amniotic Tissue

bull Pain and functional measures

ndash P ADL QOL S SR of the KOOS

ndash Overall KOOS IKDC SANE

bull All scores demonstrated improvement at 1 year

ndash Labs

bull No concerning changes in renal function blood cell

counts or lymphocyte subsets

bull Statistically significant increase in IgG and IgE relative to

baseline but not abnormal level

Amniotic Tissue

bull N23

ndash 14 Corticosteroid

ndash 9 c-hAM

bull Safe and comparable to steroid

Amniotic Tissue

Amniotic Tissue

bull N=470 181

bull VAS WOMAC

bull KL 1-3 OA

bull 30 90 120 days

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

Access this article

Or purchase this article - $20

Print Subscriber Activate your online access now

Welcome Guest Renew Subscribe or Create Account Sign In

HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

Why consider orthobiologics

bull ldquoTraditionally tendinitis was treated by

controlling inflammation through conventional

methods including corticosteroid and NSAIDs

with no scientific evidence to support these

treatment modalitiesrdquo

Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132

Why consider orthobiologics

bull ldquoCorticosteroid injections may actually have

deleterious effects after their short term pain

relief rdquo

ndash Beneficial short term 6 weeks

ndash No evidence of improved patient outcomes beyond

6 weeks

ndash Those having injections have INFERIOR long term

results compared to placebo wait and see

N Smidt D A W M van der Windt W J J Assendel W LJMDeville IBCKorthals-deBosandLMBouter ldquoCorticosteroid injections physiotherapy or a wait-and-see policy for lateral epicondylitis A randomised controlled trialrdquo e Lancet vol 359 no 9307 pp 657ndash662 2002 L Bisset N Smidt D A van der Windt et al ldquoConservative treatments for tennis elbowmdashdo subgroups of patients respond diferentlyrdquo Rheumatology vol 46 no 10 pp 1601ndash1605 2007 Kahlenberg CA Knesek M Terry MA New Developments in the Use of Biologics and Other Modalities in the management of Lateral Epicondylitis BioMedRes Int 2015

What has been the

evolution convergence

Image guided regenerative treatment

New treatments veterinary

and surgical

MSK US

Science

Tendon

Joint

Slide Courtesy of Joanne Borg Stein MD

Tendon Healing

Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239

Tendon healing

Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239

Tendon healing

Tissue Normal Injured

Type III Collagen 1 20-30 Superior elasticityinferior strength

Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132

PRP

Platelet Rich Plasma

PRP

bull Conversion of a chronic non healing injury into an acute injury with increased healing potential

bull Contains Growth factors

bull Platelet alpha granules

bull Small peptides that bind to membrane receptors

bull promote downstream biologic pathways

bull Influence chemotaxis and cell migration

bull Induce Mitosis

bull Extracellular matrix production

bull Angiogenesis

bull Cells signal to proliferate influence maturation differentiate ultimately tissue repairowth factors

Case 2

bull 50 year old male with medial right knee pain

He has completed 2 prior marathons Currently

competing in triathlons No trauma Pain and

stiffness is present in the AM improves as the

day goes on worse at night Described as an

dull achy sensation

Case 2

bull Exam

ndash Normal lumbar exam

ndash Intact Myotomes Dermatomes Reflexes

ndash Pain to palpation along the medial joint line

ndash Crepitus

ndash Negative ligamentous testing

Baby Boomers and

ldquotweenersrdquo

bull ldquoIn betweenrdquo normal

joint and arthroplasty

Slide courtesy of Dr Joanne Borg-Stein

Orthobiologics

bull Prolotherapy

bull PRP

bull BMAC

bull Adipose derived

bull Amniotic products

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

Access this article

Or purchase this article - $20

Print Subscriber Activate your online access now

Welcome Guest Renew Subscribe or Create Account Sign In

HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

Mesenchymal stem cells

bull MSC cells that have the ability to

proliferate and differentiate into

progenitors of different mesenchymal

tissue

bull They have unique cell surface

markers adhesion molecules

cytokines growth factors and

receptors

bull Anti-inflammatory and

immunomodulatory

Obaid et al Cell therapy in tendon disorders

What is the Current evidence

Am J Sports Med 2010 38 (10)

bioscienceorg

Slide Courtesy of Dr Joanne Borg Stein

Mesenchymal stem cells

bull Mesenchymal Stem Cells

1 Bone Marrow Derived MSCs

2 Adipose Tissue Derived MSCs

3 Synovium Derived MSCs

bull De Bari et al 2001

4 Muscle Derived MSCs

bull Williams et al 1999

5 Dermal Fibroblast

1 Connell et al N=12

BMAC

BMAC

bull Hemopoietic stem cells

bull Nonhemopoietic cells Mesenchymal Stem Cells

ndash 0001-001 of total cell population

ndash 100k - 2M MSCs

bull Diminishes with age

Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147

BMAC

bull General Set up

Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939

Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939

BMAC

bull Rate is not greater than that observed with other types of intra-articular injections

bull Annual neoplasm 078 in adults 50 ndash 64 yo

ndash This study showed 014

bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure

bull Only 3 were possibly related to stem cells

BMAC

bull Eight studies focused on focal chondral defects

bull Three studies evaluated for treatment of

osteoarthritis

BMAC

bull Six trials with high risk of bias showed

level-3 or level-4 evidence in favour of stem

cell injections in KOA

BMAC

Author BMAC Pathology NCenteno et al 2008

BMAC meniscus 1 ndash case study MRI showed increased volume

bmac prp x2 and dex with hyalgan

Giannini et al2009

BMAC Talus 48 6121824 mo Second look arthroscopy

New tissue on MRI

Kennedy and Murawski 2011

BMAC Talus 72

Pascual-Garridoet al 2012

BMAC Patellar tendinopathy

8 2-5 year follow up

Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri

Giannini et al 2013

BMAC Talus 20 48mo MRI new tissue

Singh et al 2014 BMAC Lateral epicondyle

30 2612 weeks Sig decrease in PRTEE scores

Centeno et al 2015

BMAC GH OA 115 2 year pain improvement

Prolo bmac and prp

Centeno et al 2015

BMAC ACL 10 cases grade 1-III

Improved MRI findings

Prolo BMAC + prp

Hannon et al 2016

BMAC Talus 34

Shapiro SA et al 2016

BMAC vs saline OA knee N = 25 VASWomackoos

Contralateral knee with saline

Safe well tolerated placebo

ADIPOSE TISSUE

Adipose Tissue

bull Human ADSCs

ndash localize in the stromal vascular fraction

(SVF)

ndash The SVF consists of a heterogeneous

mesenchymal population of cells

bull Adipose stromal stem and progenitor cells

bull Hematopoietic stem and progenitor cells

bull endothelial cells erythrocytes fibroblasts

lymphocytes monocyte macrophages

and pericytes

NIH

-PA

Auth

or M

an

uscrip

tN

IH-P

A A

uth

or M

an

uscrip

tN

IH-P

A A

uth

or M

anu

scrip

t

BOURIN et al Page 13

Table II

Cell populations resident in SVF

Hematopoietic-lineage cells

Stem and progenitor cells lt01

Granulocytes 10ndash15

Monocytes 5ndash15

Lymphocytes 10ndash15

Endothelial cells 10ndash20

Pericytes 3ndash5

Stromal cells 15ndash30

Cytotherapy Author manuscript available in PMC 2014 April 08

Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648

Adipose Tissue

bull The stromal vascular fraction (SVF) is a

heterogeneous cell population derived from

manipulation of adipose tissue

ndash homogenization

ndash enzymatic digestion

ndash differential centrifugation

ndash red blood cells lysis and washing

Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Mesenchymal stem cells

bull Mulitpotent

bull More prone to differentiate

into muscle cells or even

into cardiomyocytes

compared with bone

marrow MSCs

bull Less efficient at osteogenic

and chondrogenic

differentiation

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Adipose Tissue

bull When treated with growth factors

ndash Upregulate expression of tendon related markers

ndash They are found comparable scaffold adherence and

proliferation potential

bull Suggesting AD-MSCs as alternative cell type for tendon

tissue repair

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239

Adipose Tissue

bull Easier to obtain

bull Bioscaffold

Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869

Adipose Tissue

bull General Set up

FDA CLEARANCE AND PRODUCT INFORMATION

TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose

tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure

Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints

middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture

middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents

middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue

middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)

IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha

legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat

isonlytobeusedwithoutanyadditionalmanipulation

Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister

middot LG60cc

middot LG240cc

1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm

120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes

260mlpolycarbonatesyringe2FemaleLuertransferconnectors

LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria

middot TheHCTPisminimallymanipulated

middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)

middot TheHCTPisnotcombinedwithanotherarticleand

middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction

DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016

Adipose Tissue HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer

5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe

6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Local Anesthetic

bull Connect the vacuum syringe to the

blunt 13-gauge Lipoaspiration

cannula

bull Advance and withdraw cannula in a

ldquospokes-of-a-wheelrdquo pattern

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto

createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly

3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand

holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe

canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe

canisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanister

approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

Adipose Tissue

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds

in a vertical motion

ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals

ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent

bull Collection ndash Pull down on the syringe

ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister

ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

HarvestingandProcessingGuide

WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand

rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities

2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion

3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals

4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps

CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach

10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe

clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith

salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull

syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe

Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor

Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection

Adipose Tissue

Adipose Tissue

bull 2002 national survey of 66000 tumescent

liposuction cases

ndash No deaths were reported

ndash Complication rate was 0068 per 1000 cases

Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002

Stem Cell summary

BMAC

bull 100k - 2M MSCs

bull Chondrocyte

bull Osteogenic

bull More painful

bull Volume limit

Adipose

bull 250k - 125M MSCs

bull Bioscaffold

bull Tendon defect filling

bull Less painfull

bull Larger volumes

AMNIOTIC TISSUE

Amniotic Tissue

bull Human Amniotic suspension allografts ndash Human amniotic membrane

ndash Human amniotic fluid-derived cells

bull Contain anti-inflammatory factorsndash IL-10 IL-1

ndash Metrix metalloproteinases 123 and 4

ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen

G5

ndash Hyaluranic Acid and small amount so proteoglycans

Amniotic Tissue

bull Human amniotic membrane

ndash Growth factors including EGF TGF-β and FGF

bull Stimulate epithelial cell migration and proliferation

bull PDGF A and B

ndash Stimulate many metabolic processes

raquo General protein and collagen synthesis collagenase activity

and chemotaxis of fibroblasts and of smooth muscle cells

raquo TGF-β has been shown to significantly increase type I

collagen production by tendon sheath fibroblasts

Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169

Amniotic Tissue

bull N = 6 KL grade 34

bull 12 weeks 3512 months

bull Primary goal feasibility of injection for treatment of OA

bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy

Amniotic Tissue

bull Pain and functional measures

ndash P ADL QOL S SR of the KOOS

ndash Overall KOOS IKDC SANE

bull All scores demonstrated improvement at 1 year

ndash Labs

bull No concerning changes in renal function blood cell

counts or lymphocyte subsets

bull Statistically significant increase in IgG and IgE relative to

baseline but not abnormal level

Amniotic Tissue

bull N23

ndash 14 Corticosteroid

ndash 9 c-hAM

bull Safe and comparable to steroid

Amniotic Tissue

Amniotic Tissue

bull N=470 181

bull VAS WOMAC

bull KL 1-3 OA

bull 30 90 120 days

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

Access this article

Or purchase this article - $20

Print Subscriber Activate your online access now

Welcome Guest Renew Subscribe or Create Account Sign In

HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

Why consider orthobiologics

bull ldquoCorticosteroid injections may actually have

deleterious effects after their short term pain

relief rdquo

ndash Beneficial short term 6 weeks

ndash No evidence of improved patient outcomes beyond

6 weeks

ndash Those having injections have INFERIOR long term

results compared to placebo wait and see

N Smidt D A W M van der Windt W J J Assendel W LJMDeville IBCKorthals-deBosandLMBouter ldquoCorticosteroid injections physiotherapy or a wait-and-see policy for lateral epicondylitis A randomised controlled trialrdquo e Lancet vol 359 no 9307 pp 657ndash662 2002 L Bisset N Smidt D A van der Windt et al ldquoConservative treatments for tennis elbowmdashdo subgroups of patients respond diferentlyrdquo Rheumatology vol 46 no 10 pp 1601ndash1605 2007 Kahlenberg CA Knesek M Terry MA New Developments in the Use of Biologics and Other Modalities in the management of Lateral Epicondylitis BioMedRes Int 2015

What has been the

evolution convergence

Image guided regenerative treatment

New treatments veterinary

and surgical

MSK US

Science

Tendon

Joint

Slide Courtesy of Joanne Borg Stein MD

Tendon Healing

Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239

Tendon healing

Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239

Tendon healing

Tissue Normal Injured

Type III Collagen 1 20-30 Superior elasticityinferior strength

Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132

PRP

Platelet Rich Plasma

PRP

bull Conversion of a chronic non healing injury into an acute injury with increased healing potential

bull Contains Growth factors

bull Platelet alpha granules

bull Small peptides that bind to membrane receptors

bull promote downstream biologic pathways

bull Influence chemotaxis and cell migration

bull Induce Mitosis

bull Extracellular matrix production

bull Angiogenesis

bull Cells signal to proliferate influence maturation differentiate ultimately tissue repairowth factors

Case 2

bull 50 year old male with medial right knee pain

He has completed 2 prior marathons Currently

competing in triathlons No trauma Pain and

stiffness is present in the AM improves as the

day goes on worse at night Described as an

dull achy sensation

Case 2

bull Exam

ndash Normal lumbar exam

ndash Intact Myotomes Dermatomes Reflexes

ndash Pain to palpation along the medial joint line

ndash Crepitus

ndash Negative ligamentous testing

Baby Boomers and

ldquotweenersrdquo

bull ldquoIn betweenrdquo normal

joint and arthroplasty

Slide courtesy of Dr Joanne Borg-Stein

Orthobiologics

bull Prolotherapy

bull PRP

bull BMAC

bull Adipose derived

bull Amniotic products

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

Access this article

Or purchase this article - $20

Print Subscriber Activate your online access now

Welcome Guest Renew Subscribe or Create Account Sign In

HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

Mesenchymal stem cells

bull MSC cells that have the ability to

proliferate and differentiate into

progenitors of different mesenchymal

tissue

bull They have unique cell surface

markers adhesion molecules

cytokines growth factors and

receptors

bull Anti-inflammatory and

immunomodulatory

Obaid et al Cell therapy in tendon disorders

What is the Current evidence

Am J Sports Med 2010 38 (10)

bioscienceorg

Slide Courtesy of Dr Joanne Borg Stein

Mesenchymal stem cells

bull Mesenchymal Stem Cells

1 Bone Marrow Derived MSCs

2 Adipose Tissue Derived MSCs

3 Synovium Derived MSCs

bull De Bari et al 2001

4 Muscle Derived MSCs

bull Williams et al 1999

5 Dermal Fibroblast

1 Connell et al N=12

BMAC

BMAC

bull Hemopoietic stem cells

bull Nonhemopoietic cells Mesenchymal Stem Cells

ndash 0001-001 of total cell population

ndash 100k - 2M MSCs

bull Diminishes with age

Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147

BMAC

bull General Set up

Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939

Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939

BMAC

bull Rate is not greater than that observed with other types of intra-articular injections

bull Annual neoplasm 078 in adults 50 ndash 64 yo

ndash This study showed 014

bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure

bull Only 3 were possibly related to stem cells

BMAC

bull Eight studies focused on focal chondral defects

bull Three studies evaluated for treatment of

osteoarthritis

BMAC

bull Six trials with high risk of bias showed

level-3 or level-4 evidence in favour of stem

cell injections in KOA

BMAC

Author BMAC Pathology NCenteno et al 2008

BMAC meniscus 1 ndash case study MRI showed increased volume

bmac prp x2 and dex with hyalgan

Giannini et al2009

BMAC Talus 48 6121824 mo Second look arthroscopy

New tissue on MRI

Kennedy and Murawski 2011

BMAC Talus 72

Pascual-Garridoet al 2012

BMAC Patellar tendinopathy

8 2-5 year follow up

Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri

Giannini et al 2013

BMAC Talus 20 48mo MRI new tissue

Singh et al 2014 BMAC Lateral epicondyle

30 2612 weeks Sig decrease in PRTEE scores

Centeno et al 2015

BMAC GH OA 115 2 year pain improvement

Prolo bmac and prp

Centeno et al 2015

BMAC ACL 10 cases grade 1-III

Improved MRI findings

Prolo BMAC + prp

Hannon et al 2016

BMAC Talus 34

Shapiro SA et al 2016

BMAC vs saline OA knee N = 25 VASWomackoos

Contralateral knee with saline

Safe well tolerated placebo

ADIPOSE TISSUE

Adipose Tissue

bull Human ADSCs

ndash localize in the stromal vascular fraction

(SVF)

ndash The SVF consists of a heterogeneous

mesenchymal population of cells

bull Adipose stromal stem and progenitor cells

bull Hematopoietic stem and progenitor cells

bull endothelial cells erythrocytes fibroblasts

lymphocytes monocyte macrophages

and pericytes

NIH

-PA

Auth

or M

an

uscrip

tN

IH-P

A A

uth

or M

an

uscrip

tN

IH-P

A A

uth

or M

anu

scrip

t

BOURIN et al Page 13

Table II

Cell populations resident in SVF

Hematopoietic-lineage cells

Stem and progenitor cells lt01

Granulocytes 10ndash15

Monocytes 5ndash15

Lymphocytes 10ndash15

Endothelial cells 10ndash20

Pericytes 3ndash5

Stromal cells 15ndash30

Cytotherapy Author manuscript available in PMC 2014 April 08

Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648

Adipose Tissue

bull The stromal vascular fraction (SVF) is a

heterogeneous cell population derived from

manipulation of adipose tissue

ndash homogenization

ndash enzymatic digestion

ndash differential centrifugation

ndash red blood cells lysis and washing

Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Mesenchymal stem cells

bull Mulitpotent

bull More prone to differentiate

into muscle cells or even

into cardiomyocytes

compared with bone

marrow MSCs

bull Less efficient at osteogenic

and chondrogenic

differentiation

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Adipose Tissue

bull When treated with growth factors

ndash Upregulate expression of tendon related markers

ndash They are found comparable scaffold adherence and

proliferation potential

bull Suggesting AD-MSCs as alternative cell type for tendon

tissue repair

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239

Adipose Tissue

bull Easier to obtain

bull Bioscaffold

Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869

Adipose Tissue

bull General Set up

FDA CLEARANCE AND PRODUCT INFORMATION

TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose

tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure

Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints

middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture

middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents

middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue

middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)

IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha

legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat

isonlytobeusedwithoutanyadditionalmanipulation

Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister

middot LG60cc

middot LG240cc

1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm

120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes

260mlpolycarbonatesyringe2FemaleLuertransferconnectors

LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria

middot TheHCTPisminimallymanipulated

middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)

middot TheHCTPisnotcombinedwithanotherarticleand

middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction

DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016

Adipose Tissue HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer

5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe

6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Local Anesthetic

bull Connect the vacuum syringe to the

blunt 13-gauge Lipoaspiration

cannula

bull Advance and withdraw cannula in a

ldquospokes-of-a-wheelrdquo pattern

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto

createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly

3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand

holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe

canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe

canisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanister

approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

Adipose Tissue

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds

in a vertical motion

ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals

ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent

bull Collection ndash Pull down on the syringe

ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister

ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

HarvestingandProcessingGuide

WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand

rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities

2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion

3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals

4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps

CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach

10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe

clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith

salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull

syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe

Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor

Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection

Adipose Tissue

Adipose Tissue

bull 2002 national survey of 66000 tumescent

liposuction cases

ndash No deaths were reported

ndash Complication rate was 0068 per 1000 cases

Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002

Stem Cell summary

BMAC

bull 100k - 2M MSCs

bull Chondrocyte

bull Osteogenic

bull More painful

bull Volume limit

Adipose

bull 250k - 125M MSCs

bull Bioscaffold

bull Tendon defect filling

bull Less painfull

bull Larger volumes

AMNIOTIC TISSUE

Amniotic Tissue

bull Human Amniotic suspension allografts ndash Human amniotic membrane

ndash Human amniotic fluid-derived cells

bull Contain anti-inflammatory factorsndash IL-10 IL-1

ndash Metrix metalloproteinases 123 and 4

ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen

G5

ndash Hyaluranic Acid and small amount so proteoglycans

Amniotic Tissue

bull Human amniotic membrane

ndash Growth factors including EGF TGF-β and FGF

bull Stimulate epithelial cell migration and proliferation

bull PDGF A and B

ndash Stimulate many metabolic processes

raquo General protein and collagen synthesis collagenase activity

and chemotaxis of fibroblasts and of smooth muscle cells

raquo TGF-β has been shown to significantly increase type I

collagen production by tendon sheath fibroblasts

Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169

Amniotic Tissue

bull N = 6 KL grade 34

bull 12 weeks 3512 months

bull Primary goal feasibility of injection for treatment of OA

bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy

Amniotic Tissue

bull Pain and functional measures

ndash P ADL QOL S SR of the KOOS

ndash Overall KOOS IKDC SANE

bull All scores demonstrated improvement at 1 year

ndash Labs

bull No concerning changes in renal function blood cell

counts or lymphocyte subsets

bull Statistically significant increase in IgG and IgE relative to

baseline but not abnormal level

Amniotic Tissue

bull N23

ndash 14 Corticosteroid

ndash 9 c-hAM

bull Safe and comparable to steroid

Amniotic Tissue

Amniotic Tissue

bull N=470 181

bull VAS WOMAC

bull KL 1-3 OA

bull 30 90 120 days

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

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Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

What has been the

evolution convergence

Image guided regenerative treatment

New treatments veterinary

and surgical

MSK US

Science

Tendon

Joint

Slide Courtesy of Joanne Borg Stein MD

Tendon Healing

Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239

Tendon healing

Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239

Tendon healing

Tissue Normal Injured

Type III Collagen 1 20-30 Superior elasticityinferior strength

Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132

PRP

Platelet Rich Plasma

PRP

bull Conversion of a chronic non healing injury into an acute injury with increased healing potential

bull Contains Growth factors

bull Platelet alpha granules

bull Small peptides that bind to membrane receptors

bull promote downstream biologic pathways

bull Influence chemotaxis and cell migration

bull Induce Mitosis

bull Extracellular matrix production

bull Angiogenesis

bull Cells signal to proliferate influence maturation differentiate ultimately tissue repairowth factors

Case 2

bull 50 year old male with medial right knee pain

He has completed 2 prior marathons Currently

competing in triathlons No trauma Pain and

stiffness is present in the AM improves as the

day goes on worse at night Described as an

dull achy sensation

Case 2

bull Exam

ndash Normal lumbar exam

ndash Intact Myotomes Dermatomes Reflexes

ndash Pain to palpation along the medial joint line

ndash Crepitus

ndash Negative ligamentous testing

Baby Boomers and

ldquotweenersrdquo

bull ldquoIn betweenrdquo normal

joint and arthroplasty

Slide courtesy of Dr Joanne Borg-Stein

Orthobiologics

bull Prolotherapy

bull PRP

bull BMAC

bull Adipose derived

bull Amniotic products

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

Mesenchymal stem cells

bull MSC cells that have the ability to

proliferate and differentiate into

progenitors of different mesenchymal

tissue

bull They have unique cell surface

markers adhesion molecules

cytokines growth factors and

receptors

bull Anti-inflammatory and

immunomodulatory

Obaid et al Cell therapy in tendon disorders

What is the Current evidence

Am J Sports Med 2010 38 (10)

bioscienceorg

Slide Courtesy of Dr Joanne Borg Stein

Mesenchymal stem cells

bull Mesenchymal Stem Cells

1 Bone Marrow Derived MSCs

2 Adipose Tissue Derived MSCs

3 Synovium Derived MSCs

bull De Bari et al 2001

4 Muscle Derived MSCs

bull Williams et al 1999

5 Dermal Fibroblast

1 Connell et al N=12

BMAC

BMAC

bull Hemopoietic stem cells

bull Nonhemopoietic cells Mesenchymal Stem Cells

ndash 0001-001 of total cell population

ndash 100k - 2M MSCs

bull Diminishes with age

Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147

BMAC

bull General Set up

Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939

Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939

BMAC

bull Rate is not greater than that observed with other types of intra-articular injections

bull Annual neoplasm 078 in adults 50 ndash 64 yo

ndash This study showed 014

bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure

bull Only 3 were possibly related to stem cells

BMAC

bull Eight studies focused on focal chondral defects

bull Three studies evaluated for treatment of

osteoarthritis

BMAC

bull Six trials with high risk of bias showed

level-3 or level-4 evidence in favour of stem

cell injections in KOA

BMAC

Author BMAC Pathology NCenteno et al 2008

BMAC meniscus 1 ndash case study MRI showed increased volume

bmac prp x2 and dex with hyalgan

Giannini et al2009

BMAC Talus 48 6121824 mo Second look arthroscopy

New tissue on MRI

Kennedy and Murawski 2011

BMAC Talus 72

Pascual-Garridoet al 2012

BMAC Patellar tendinopathy

8 2-5 year follow up

Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri

Giannini et al 2013

BMAC Talus 20 48mo MRI new tissue

Singh et al 2014 BMAC Lateral epicondyle

30 2612 weeks Sig decrease in PRTEE scores

Centeno et al 2015

BMAC GH OA 115 2 year pain improvement

Prolo bmac and prp

Centeno et al 2015

BMAC ACL 10 cases grade 1-III

Improved MRI findings

Prolo BMAC + prp

Hannon et al 2016

BMAC Talus 34

Shapiro SA et al 2016

BMAC vs saline OA knee N = 25 VASWomackoos

Contralateral knee with saline

Safe well tolerated placebo

ADIPOSE TISSUE

Adipose Tissue

bull Human ADSCs

ndash localize in the stromal vascular fraction

(SVF)

ndash The SVF consists of a heterogeneous

mesenchymal population of cells

bull Adipose stromal stem and progenitor cells

bull Hematopoietic stem and progenitor cells

bull endothelial cells erythrocytes fibroblasts

lymphocytes monocyte macrophages

and pericytes

NIH

-PA

Auth

or M

an

uscrip

tN

IH-P

A A

uth

or M

an

uscrip

tN

IH-P

A A

uth

or M

anu

scrip

t

BOURIN et al Page 13

Table II

Cell populations resident in SVF

Hematopoietic-lineage cells

Stem and progenitor cells lt01

Granulocytes 10ndash15

Monocytes 5ndash15

Lymphocytes 10ndash15

Endothelial cells 10ndash20

Pericytes 3ndash5

Stromal cells 15ndash30

Cytotherapy Author manuscript available in PMC 2014 April 08

Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648

Adipose Tissue

bull The stromal vascular fraction (SVF) is a

heterogeneous cell population derived from

manipulation of adipose tissue

ndash homogenization

ndash enzymatic digestion

ndash differential centrifugation

ndash red blood cells lysis and washing

Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Mesenchymal stem cells

bull Mulitpotent

bull More prone to differentiate

into muscle cells or even

into cardiomyocytes

compared with bone

marrow MSCs

bull Less efficient at osteogenic

and chondrogenic

differentiation

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Adipose Tissue

bull When treated with growth factors

ndash Upregulate expression of tendon related markers

ndash They are found comparable scaffold adherence and

proliferation potential

bull Suggesting AD-MSCs as alternative cell type for tendon

tissue repair

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239

Adipose Tissue

bull Easier to obtain

bull Bioscaffold

Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869

Adipose Tissue

bull General Set up

FDA CLEARANCE AND PRODUCT INFORMATION

TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose

tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure

Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints

middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture

middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents

middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue

middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)

IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha

legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat

isonlytobeusedwithoutanyadditionalmanipulation

Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister

middot LG60cc

middot LG240cc

1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm

120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes

260mlpolycarbonatesyringe2FemaleLuertransferconnectors

LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria

middot TheHCTPisminimallymanipulated

middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)

middot TheHCTPisnotcombinedwithanotherarticleand

middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction

DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016

Adipose Tissue HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer

5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe

6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Local Anesthetic

bull Connect the vacuum syringe to the

blunt 13-gauge Lipoaspiration

cannula

bull Advance and withdraw cannula in a

ldquospokes-of-a-wheelrdquo pattern

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto

createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly

3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand

holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe

canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe

canisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanister

approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

Adipose Tissue

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds

in a vertical motion

ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals

ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent

bull Collection ndash Pull down on the syringe

ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister

ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

HarvestingandProcessingGuide

WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand

rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities

2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion

3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals

4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps

CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach

10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe

clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith

salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull

syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe

Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor

Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection

Adipose Tissue

Adipose Tissue

bull 2002 national survey of 66000 tumescent

liposuction cases

ndash No deaths were reported

ndash Complication rate was 0068 per 1000 cases

Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002

Stem Cell summary

BMAC

bull 100k - 2M MSCs

bull Chondrocyte

bull Osteogenic

bull More painful

bull Volume limit

Adipose

bull 250k - 125M MSCs

bull Bioscaffold

bull Tendon defect filling

bull Less painfull

bull Larger volumes

AMNIOTIC TISSUE

Amniotic Tissue

bull Human Amniotic suspension allografts ndash Human amniotic membrane

ndash Human amniotic fluid-derived cells

bull Contain anti-inflammatory factorsndash IL-10 IL-1

ndash Metrix metalloproteinases 123 and 4

ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen

G5

ndash Hyaluranic Acid and small amount so proteoglycans

Amniotic Tissue

bull Human amniotic membrane

ndash Growth factors including EGF TGF-β and FGF

bull Stimulate epithelial cell migration and proliferation

bull PDGF A and B

ndash Stimulate many metabolic processes

raquo General protein and collagen synthesis collagenase activity

and chemotaxis of fibroblasts and of smooth muscle cells

raquo TGF-β has been shown to significantly increase type I

collagen production by tendon sheath fibroblasts

Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169

Amniotic Tissue

bull N = 6 KL grade 34

bull 12 weeks 3512 months

bull Primary goal feasibility of injection for treatment of OA

bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy

Amniotic Tissue

bull Pain and functional measures

ndash P ADL QOL S SR of the KOOS

ndash Overall KOOS IKDC SANE

bull All scores demonstrated improvement at 1 year

ndash Labs

bull No concerning changes in renal function blood cell

counts or lymphocyte subsets

bull Statistically significant increase in IgG and IgE relative to

baseline but not abnormal level

Amniotic Tissue

bull N23

ndash 14 Corticosteroid

ndash 9 c-hAM

bull Safe and comparable to steroid

Amniotic Tissue

Amniotic Tissue

bull N=470 181

bull VAS WOMAC

bull KL 1-3 OA

bull 30 90 120 days

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

Access this article

Or purchase this article - $20

Print Subscriber Activate your online access now

Welcome Guest Renew Subscribe or Create Account Sign In

HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

Tendon Healing

Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239

Tendon healing

Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239

Tendon healing

Tissue Normal Injured

Type III Collagen 1 20-30 Superior elasticityinferior strength

Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132

PRP

Platelet Rich Plasma

PRP

bull Conversion of a chronic non healing injury into an acute injury with increased healing potential

bull Contains Growth factors

bull Platelet alpha granules

bull Small peptides that bind to membrane receptors

bull promote downstream biologic pathways

bull Influence chemotaxis and cell migration

bull Induce Mitosis

bull Extracellular matrix production

bull Angiogenesis

bull Cells signal to proliferate influence maturation differentiate ultimately tissue repairowth factors

Case 2

bull 50 year old male with medial right knee pain

He has completed 2 prior marathons Currently

competing in triathlons No trauma Pain and

stiffness is present in the AM improves as the

day goes on worse at night Described as an

dull achy sensation

Case 2

bull Exam

ndash Normal lumbar exam

ndash Intact Myotomes Dermatomes Reflexes

ndash Pain to palpation along the medial joint line

ndash Crepitus

ndash Negative ligamentous testing

Baby Boomers and

ldquotweenersrdquo

bull ldquoIn betweenrdquo normal

joint and arthroplasty

Slide courtesy of Dr Joanne Borg-Stein

Orthobiologics

bull Prolotherapy

bull PRP

bull BMAC

bull Adipose derived

bull Amniotic products

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

Access this article

Or purchase this article - $20

Print Subscriber Activate your online access now

Welcome Guest Renew Subscribe or Create Account Sign In

HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

Mesenchymal stem cells

bull MSC cells that have the ability to

proliferate and differentiate into

progenitors of different mesenchymal

tissue

bull They have unique cell surface

markers adhesion molecules

cytokines growth factors and

receptors

bull Anti-inflammatory and

immunomodulatory

Obaid et al Cell therapy in tendon disorders

What is the Current evidence

Am J Sports Med 2010 38 (10)

bioscienceorg

Slide Courtesy of Dr Joanne Borg Stein

Mesenchymal stem cells

bull Mesenchymal Stem Cells

1 Bone Marrow Derived MSCs

2 Adipose Tissue Derived MSCs

3 Synovium Derived MSCs

bull De Bari et al 2001

4 Muscle Derived MSCs

bull Williams et al 1999

5 Dermal Fibroblast

1 Connell et al N=12

BMAC

BMAC

bull Hemopoietic stem cells

bull Nonhemopoietic cells Mesenchymal Stem Cells

ndash 0001-001 of total cell population

ndash 100k - 2M MSCs

bull Diminishes with age

Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147

BMAC

bull General Set up

Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939

Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939

BMAC

bull Rate is not greater than that observed with other types of intra-articular injections

bull Annual neoplasm 078 in adults 50 ndash 64 yo

ndash This study showed 014

bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure

bull Only 3 were possibly related to stem cells

BMAC

bull Eight studies focused on focal chondral defects

bull Three studies evaluated for treatment of

osteoarthritis

BMAC

bull Six trials with high risk of bias showed

level-3 or level-4 evidence in favour of stem

cell injections in KOA

BMAC

Author BMAC Pathology NCenteno et al 2008

BMAC meniscus 1 ndash case study MRI showed increased volume

bmac prp x2 and dex with hyalgan

Giannini et al2009

BMAC Talus 48 6121824 mo Second look arthroscopy

New tissue on MRI

Kennedy and Murawski 2011

BMAC Talus 72

Pascual-Garridoet al 2012

BMAC Patellar tendinopathy

8 2-5 year follow up

Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri

Giannini et al 2013

BMAC Talus 20 48mo MRI new tissue

Singh et al 2014 BMAC Lateral epicondyle

30 2612 weeks Sig decrease in PRTEE scores

Centeno et al 2015

BMAC GH OA 115 2 year pain improvement

Prolo bmac and prp

Centeno et al 2015

BMAC ACL 10 cases grade 1-III

Improved MRI findings

Prolo BMAC + prp

Hannon et al 2016

BMAC Talus 34

Shapiro SA et al 2016

BMAC vs saline OA knee N = 25 VASWomackoos

Contralateral knee with saline

Safe well tolerated placebo

ADIPOSE TISSUE

Adipose Tissue

bull Human ADSCs

ndash localize in the stromal vascular fraction

(SVF)

ndash The SVF consists of a heterogeneous

mesenchymal population of cells

bull Adipose stromal stem and progenitor cells

bull Hematopoietic stem and progenitor cells

bull endothelial cells erythrocytes fibroblasts

lymphocytes monocyte macrophages

and pericytes

NIH

-PA

Auth

or M

an

uscrip

tN

IH-P

A A

uth

or M

an

uscrip

tN

IH-P

A A

uth

or M

anu

scrip

t

BOURIN et al Page 13

Table II

Cell populations resident in SVF

Hematopoietic-lineage cells

Stem and progenitor cells lt01

Granulocytes 10ndash15

Monocytes 5ndash15

Lymphocytes 10ndash15

Endothelial cells 10ndash20

Pericytes 3ndash5

Stromal cells 15ndash30

Cytotherapy Author manuscript available in PMC 2014 April 08

Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648

Adipose Tissue

bull The stromal vascular fraction (SVF) is a

heterogeneous cell population derived from

manipulation of adipose tissue

ndash homogenization

ndash enzymatic digestion

ndash differential centrifugation

ndash red blood cells lysis and washing

Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Mesenchymal stem cells

bull Mulitpotent

bull More prone to differentiate

into muscle cells or even

into cardiomyocytes

compared with bone

marrow MSCs

bull Less efficient at osteogenic

and chondrogenic

differentiation

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Adipose Tissue

bull When treated with growth factors

ndash Upregulate expression of tendon related markers

ndash They are found comparable scaffold adherence and

proliferation potential

bull Suggesting AD-MSCs as alternative cell type for tendon

tissue repair

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239

Adipose Tissue

bull Easier to obtain

bull Bioscaffold

Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869

Adipose Tissue

bull General Set up

FDA CLEARANCE AND PRODUCT INFORMATION

TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose

tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure

Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints

middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture

middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents

middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue

middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)

IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha

legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat

isonlytobeusedwithoutanyadditionalmanipulation

Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister

middot LG60cc

middot LG240cc

1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm

120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes

260mlpolycarbonatesyringe2FemaleLuertransferconnectors

LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria

middot TheHCTPisminimallymanipulated

middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)

middot TheHCTPisnotcombinedwithanotherarticleand

middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction

DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016

Adipose Tissue HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer

5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe

6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Local Anesthetic

bull Connect the vacuum syringe to the

blunt 13-gauge Lipoaspiration

cannula

bull Advance and withdraw cannula in a

ldquospokes-of-a-wheelrdquo pattern

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto

createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly

3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand

holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe

canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe

canisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanister

approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

Adipose Tissue

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds

in a vertical motion

ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals

ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent

bull Collection ndash Pull down on the syringe

ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister

ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

HarvestingandProcessingGuide

WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand

rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities

2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion

3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals

4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps

CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach

10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe

clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith

salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull

syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe

Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor

Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection

Adipose Tissue

Adipose Tissue

bull 2002 national survey of 66000 tumescent

liposuction cases

ndash No deaths were reported

ndash Complication rate was 0068 per 1000 cases

Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002

Stem Cell summary

BMAC

bull 100k - 2M MSCs

bull Chondrocyte

bull Osteogenic

bull More painful

bull Volume limit

Adipose

bull 250k - 125M MSCs

bull Bioscaffold

bull Tendon defect filling

bull Less painfull

bull Larger volumes

AMNIOTIC TISSUE

Amniotic Tissue

bull Human Amniotic suspension allografts ndash Human amniotic membrane

ndash Human amniotic fluid-derived cells

bull Contain anti-inflammatory factorsndash IL-10 IL-1

ndash Metrix metalloproteinases 123 and 4

ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen

G5

ndash Hyaluranic Acid and small amount so proteoglycans

Amniotic Tissue

bull Human amniotic membrane

ndash Growth factors including EGF TGF-β and FGF

bull Stimulate epithelial cell migration and proliferation

bull PDGF A and B

ndash Stimulate many metabolic processes

raquo General protein and collagen synthesis collagenase activity

and chemotaxis of fibroblasts and of smooth muscle cells

raquo TGF-β has been shown to significantly increase type I

collagen production by tendon sheath fibroblasts

Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169

Amniotic Tissue

bull N = 6 KL grade 34

bull 12 weeks 3512 months

bull Primary goal feasibility of injection for treatment of OA

bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy

Amniotic Tissue

bull Pain and functional measures

ndash P ADL QOL S SR of the KOOS

ndash Overall KOOS IKDC SANE

bull All scores demonstrated improvement at 1 year

ndash Labs

bull No concerning changes in renal function blood cell

counts or lymphocyte subsets

bull Statistically significant increase in IgG and IgE relative to

baseline but not abnormal level

Amniotic Tissue

bull N23

ndash 14 Corticosteroid

ndash 9 c-hAM

bull Safe and comparable to steroid

Amniotic Tissue

Amniotic Tissue

bull N=470 181

bull VAS WOMAC

bull KL 1-3 OA

bull 30 90 120 days

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

Access this article

Or purchase this article - $20

Print Subscriber Activate your online access now

Welcome Guest Renew Subscribe or Create Account Sign In

HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

Tendon healing

Docheva D et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239

Tendon healing

Tissue Normal Injured

Type III Collagen 1 20-30 Superior elasticityinferior strength

Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132

PRP

Platelet Rich Plasma

PRP

bull Conversion of a chronic non healing injury into an acute injury with increased healing potential

bull Contains Growth factors

bull Platelet alpha granules

bull Small peptides that bind to membrane receptors

bull promote downstream biologic pathways

bull Influence chemotaxis and cell migration

bull Induce Mitosis

bull Extracellular matrix production

bull Angiogenesis

bull Cells signal to proliferate influence maturation differentiate ultimately tissue repairowth factors

Case 2

bull 50 year old male with medial right knee pain

He has completed 2 prior marathons Currently

competing in triathlons No trauma Pain and

stiffness is present in the AM improves as the

day goes on worse at night Described as an

dull achy sensation

Case 2

bull Exam

ndash Normal lumbar exam

ndash Intact Myotomes Dermatomes Reflexes

ndash Pain to palpation along the medial joint line

ndash Crepitus

ndash Negative ligamentous testing

Baby Boomers and

ldquotweenersrdquo

bull ldquoIn betweenrdquo normal

joint and arthroplasty

Slide courtesy of Dr Joanne Borg-Stein

Orthobiologics

bull Prolotherapy

bull PRP

bull BMAC

bull Adipose derived

bull Amniotic products

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

Access this article

Or purchase this article - $20

Print Subscriber Activate your online access now

Welcome Guest Renew Subscribe or Create Account Sign In

HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

Mesenchymal stem cells

bull MSC cells that have the ability to

proliferate and differentiate into

progenitors of different mesenchymal

tissue

bull They have unique cell surface

markers adhesion molecules

cytokines growth factors and

receptors

bull Anti-inflammatory and

immunomodulatory

Obaid et al Cell therapy in tendon disorders

What is the Current evidence

Am J Sports Med 2010 38 (10)

bioscienceorg

Slide Courtesy of Dr Joanne Borg Stein

Mesenchymal stem cells

bull Mesenchymal Stem Cells

1 Bone Marrow Derived MSCs

2 Adipose Tissue Derived MSCs

3 Synovium Derived MSCs

bull De Bari et al 2001

4 Muscle Derived MSCs

bull Williams et al 1999

5 Dermal Fibroblast

1 Connell et al N=12

BMAC

BMAC

bull Hemopoietic stem cells

bull Nonhemopoietic cells Mesenchymal Stem Cells

ndash 0001-001 of total cell population

ndash 100k - 2M MSCs

bull Diminishes with age

Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147

BMAC

bull General Set up

Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939

Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939

BMAC

bull Rate is not greater than that observed with other types of intra-articular injections

bull Annual neoplasm 078 in adults 50 ndash 64 yo

ndash This study showed 014

bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure

bull Only 3 were possibly related to stem cells

BMAC

bull Eight studies focused on focal chondral defects

bull Three studies evaluated for treatment of

osteoarthritis

BMAC

bull Six trials with high risk of bias showed

level-3 or level-4 evidence in favour of stem

cell injections in KOA

BMAC

Author BMAC Pathology NCenteno et al 2008

BMAC meniscus 1 ndash case study MRI showed increased volume

bmac prp x2 and dex with hyalgan

Giannini et al2009

BMAC Talus 48 6121824 mo Second look arthroscopy

New tissue on MRI

Kennedy and Murawski 2011

BMAC Talus 72

Pascual-Garridoet al 2012

BMAC Patellar tendinopathy

8 2-5 year follow up

Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri

Giannini et al 2013

BMAC Talus 20 48mo MRI new tissue

Singh et al 2014 BMAC Lateral epicondyle

30 2612 weeks Sig decrease in PRTEE scores

Centeno et al 2015

BMAC GH OA 115 2 year pain improvement

Prolo bmac and prp

Centeno et al 2015

BMAC ACL 10 cases grade 1-III

Improved MRI findings

Prolo BMAC + prp

Hannon et al 2016

BMAC Talus 34

Shapiro SA et al 2016

BMAC vs saline OA knee N = 25 VASWomackoos

Contralateral knee with saline

Safe well tolerated placebo

ADIPOSE TISSUE

Adipose Tissue

bull Human ADSCs

ndash localize in the stromal vascular fraction

(SVF)

ndash The SVF consists of a heterogeneous

mesenchymal population of cells

bull Adipose stromal stem and progenitor cells

bull Hematopoietic stem and progenitor cells

bull endothelial cells erythrocytes fibroblasts

lymphocytes monocyte macrophages

and pericytes

NIH

-PA

Auth

or M

an

uscrip

tN

IH-P

A A

uth

or M

an

uscrip

tN

IH-P

A A

uth

or M

anu

scrip

t

BOURIN et al Page 13

Table II

Cell populations resident in SVF

Hematopoietic-lineage cells

Stem and progenitor cells lt01

Granulocytes 10ndash15

Monocytes 5ndash15

Lymphocytes 10ndash15

Endothelial cells 10ndash20

Pericytes 3ndash5

Stromal cells 15ndash30

Cytotherapy Author manuscript available in PMC 2014 April 08

Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648

Adipose Tissue

bull The stromal vascular fraction (SVF) is a

heterogeneous cell population derived from

manipulation of adipose tissue

ndash homogenization

ndash enzymatic digestion

ndash differential centrifugation

ndash red blood cells lysis and washing

Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Mesenchymal stem cells

bull Mulitpotent

bull More prone to differentiate

into muscle cells or even

into cardiomyocytes

compared with bone

marrow MSCs

bull Less efficient at osteogenic

and chondrogenic

differentiation

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Adipose Tissue

bull When treated with growth factors

ndash Upregulate expression of tendon related markers

ndash They are found comparable scaffold adherence and

proliferation potential

bull Suggesting AD-MSCs as alternative cell type for tendon

tissue repair

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239

Adipose Tissue

bull Easier to obtain

bull Bioscaffold

Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869

Adipose Tissue

bull General Set up

FDA CLEARANCE AND PRODUCT INFORMATION

TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose

tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure

Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints

middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture

middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents

middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue

middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)

IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha

legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat

isonlytobeusedwithoutanyadditionalmanipulation

Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister

middot LG60cc

middot LG240cc

1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm

120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes

260mlpolycarbonatesyringe2FemaleLuertransferconnectors

LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria

middot TheHCTPisminimallymanipulated

middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)

middot TheHCTPisnotcombinedwithanotherarticleand

middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction

DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016

Adipose Tissue HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer

5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe

6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Local Anesthetic

bull Connect the vacuum syringe to the

blunt 13-gauge Lipoaspiration

cannula

bull Advance and withdraw cannula in a

ldquospokes-of-a-wheelrdquo pattern

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto

createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly

3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand

holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe

canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe

canisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanister

approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

Adipose Tissue

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds

in a vertical motion

ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals

ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent

bull Collection ndash Pull down on the syringe

ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister

ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

HarvestingandProcessingGuide

WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand

rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities

2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion

3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals

4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps

CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach

10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe

clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith

salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull

syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe

Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor

Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection

Adipose Tissue

Adipose Tissue

bull 2002 national survey of 66000 tumescent

liposuction cases

ndash No deaths were reported

ndash Complication rate was 0068 per 1000 cases

Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002

Stem Cell summary

BMAC

bull 100k - 2M MSCs

bull Chondrocyte

bull Osteogenic

bull More painful

bull Volume limit

Adipose

bull 250k - 125M MSCs

bull Bioscaffold

bull Tendon defect filling

bull Less painfull

bull Larger volumes

AMNIOTIC TISSUE

Amniotic Tissue

bull Human Amniotic suspension allografts ndash Human amniotic membrane

ndash Human amniotic fluid-derived cells

bull Contain anti-inflammatory factorsndash IL-10 IL-1

ndash Metrix metalloproteinases 123 and 4

ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen

G5

ndash Hyaluranic Acid and small amount so proteoglycans

Amniotic Tissue

bull Human amniotic membrane

ndash Growth factors including EGF TGF-β and FGF

bull Stimulate epithelial cell migration and proliferation

bull PDGF A and B

ndash Stimulate many metabolic processes

raquo General protein and collagen synthesis collagenase activity

and chemotaxis of fibroblasts and of smooth muscle cells

raquo TGF-β has been shown to significantly increase type I

collagen production by tendon sheath fibroblasts

Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169

Amniotic Tissue

bull N = 6 KL grade 34

bull 12 weeks 3512 months

bull Primary goal feasibility of injection for treatment of OA

bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy

Amniotic Tissue

bull Pain and functional measures

ndash P ADL QOL S SR of the KOOS

ndash Overall KOOS IKDC SANE

bull All scores demonstrated improvement at 1 year

ndash Labs

bull No concerning changes in renal function blood cell

counts or lymphocyte subsets

bull Statistically significant increase in IgG and IgE relative to

baseline but not abnormal level

Amniotic Tissue

bull N23

ndash 14 Corticosteroid

ndash 9 c-hAM

bull Safe and comparable to steroid

Amniotic Tissue

Amniotic Tissue

bull N=470 181

bull VAS WOMAC

bull KL 1-3 OA

bull 30 90 120 days

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

Tendon healing

Tissue Normal Injured

Type III Collagen 1 20-30 Superior elasticityinferior strength

Obaid H Connell D Cell Therapy in Tendon Disorders AJSM 2010 3810 2123-2132

PRP

Platelet Rich Plasma

PRP

bull Conversion of a chronic non healing injury into an acute injury with increased healing potential

bull Contains Growth factors

bull Platelet alpha granules

bull Small peptides that bind to membrane receptors

bull promote downstream biologic pathways

bull Influence chemotaxis and cell migration

bull Induce Mitosis

bull Extracellular matrix production

bull Angiogenesis

bull Cells signal to proliferate influence maturation differentiate ultimately tissue repairowth factors

Case 2

bull 50 year old male with medial right knee pain

He has completed 2 prior marathons Currently

competing in triathlons No trauma Pain and

stiffness is present in the AM improves as the

day goes on worse at night Described as an

dull achy sensation

Case 2

bull Exam

ndash Normal lumbar exam

ndash Intact Myotomes Dermatomes Reflexes

ndash Pain to palpation along the medial joint line

ndash Crepitus

ndash Negative ligamentous testing

Baby Boomers and

ldquotweenersrdquo

bull ldquoIn betweenrdquo normal

joint and arthroplasty

Slide courtesy of Dr Joanne Borg-Stein

Orthobiologics

bull Prolotherapy

bull PRP

bull BMAC

bull Adipose derived

bull Amniotic products

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

Mesenchymal stem cells

bull MSC cells that have the ability to

proliferate and differentiate into

progenitors of different mesenchymal

tissue

bull They have unique cell surface

markers adhesion molecules

cytokines growth factors and

receptors

bull Anti-inflammatory and

immunomodulatory

Obaid et al Cell therapy in tendon disorders

What is the Current evidence

Am J Sports Med 2010 38 (10)

bioscienceorg

Slide Courtesy of Dr Joanne Borg Stein

Mesenchymal stem cells

bull Mesenchymal Stem Cells

1 Bone Marrow Derived MSCs

2 Adipose Tissue Derived MSCs

3 Synovium Derived MSCs

bull De Bari et al 2001

4 Muscle Derived MSCs

bull Williams et al 1999

5 Dermal Fibroblast

1 Connell et al N=12

BMAC

BMAC

bull Hemopoietic stem cells

bull Nonhemopoietic cells Mesenchymal Stem Cells

ndash 0001-001 of total cell population

ndash 100k - 2M MSCs

bull Diminishes with age

Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147

BMAC

bull General Set up

Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939

Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939

BMAC

bull Rate is not greater than that observed with other types of intra-articular injections

bull Annual neoplasm 078 in adults 50 ndash 64 yo

ndash This study showed 014

bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure

bull Only 3 were possibly related to stem cells

BMAC

bull Eight studies focused on focal chondral defects

bull Three studies evaluated for treatment of

osteoarthritis

BMAC

bull Six trials with high risk of bias showed

level-3 or level-4 evidence in favour of stem

cell injections in KOA

BMAC

Author BMAC Pathology NCenteno et al 2008

BMAC meniscus 1 ndash case study MRI showed increased volume

bmac prp x2 and dex with hyalgan

Giannini et al2009

BMAC Talus 48 6121824 mo Second look arthroscopy

New tissue on MRI

Kennedy and Murawski 2011

BMAC Talus 72

Pascual-Garridoet al 2012

BMAC Patellar tendinopathy

8 2-5 year follow up

Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri

Giannini et al 2013

BMAC Talus 20 48mo MRI new tissue

Singh et al 2014 BMAC Lateral epicondyle

30 2612 weeks Sig decrease in PRTEE scores

Centeno et al 2015

BMAC GH OA 115 2 year pain improvement

Prolo bmac and prp

Centeno et al 2015

BMAC ACL 10 cases grade 1-III

Improved MRI findings

Prolo BMAC + prp

Hannon et al 2016

BMAC Talus 34

Shapiro SA et al 2016

BMAC vs saline OA knee N = 25 VASWomackoos

Contralateral knee with saline

Safe well tolerated placebo

ADIPOSE TISSUE

Adipose Tissue

bull Human ADSCs

ndash localize in the stromal vascular fraction

(SVF)

ndash The SVF consists of a heterogeneous

mesenchymal population of cells

bull Adipose stromal stem and progenitor cells

bull Hematopoietic stem and progenitor cells

bull endothelial cells erythrocytes fibroblasts

lymphocytes monocyte macrophages

and pericytes

NIH

-PA

Auth

or M

an

uscrip

tN

IH-P

A A

uth

or M

an

uscrip

tN

IH-P

A A

uth

or M

anu

scrip

t

BOURIN et al Page 13

Table II

Cell populations resident in SVF

Hematopoietic-lineage cells

Stem and progenitor cells lt01

Granulocytes 10ndash15

Monocytes 5ndash15

Lymphocytes 10ndash15

Endothelial cells 10ndash20

Pericytes 3ndash5

Stromal cells 15ndash30

Cytotherapy Author manuscript available in PMC 2014 April 08

Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648

Adipose Tissue

bull The stromal vascular fraction (SVF) is a

heterogeneous cell population derived from

manipulation of adipose tissue

ndash homogenization

ndash enzymatic digestion

ndash differential centrifugation

ndash red blood cells lysis and washing

Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Mesenchymal stem cells

bull Mulitpotent

bull More prone to differentiate

into muscle cells or even

into cardiomyocytes

compared with bone

marrow MSCs

bull Less efficient at osteogenic

and chondrogenic

differentiation

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Adipose Tissue

bull When treated with growth factors

ndash Upregulate expression of tendon related markers

ndash They are found comparable scaffold adherence and

proliferation potential

bull Suggesting AD-MSCs as alternative cell type for tendon

tissue repair

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239

Adipose Tissue

bull Easier to obtain

bull Bioscaffold

Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869

Adipose Tissue

bull General Set up

FDA CLEARANCE AND PRODUCT INFORMATION

TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose

tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure

Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints

middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture

middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents

middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue

middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)

IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha

legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat

isonlytobeusedwithoutanyadditionalmanipulation

Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister

middot LG60cc

middot LG240cc

1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm

120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes

260mlpolycarbonatesyringe2FemaleLuertransferconnectors

LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria

middot TheHCTPisminimallymanipulated

middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)

middot TheHCTPisnotcombinedwithanotherarticleand

middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction

DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016

Adipose Tissue HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer

5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe

6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Local Anesthetic

bull Connect the vacuum syringe to the

blunt 13-gauge Lipoaspiration

cannula

bull Advance and withdraw cannula in a

ldquospokes-of-a-wheelrdquo pattern

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto

createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly

3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand

holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe

canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe

canisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanister

approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

Adipose Tissue

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds

in a vertical motion

ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals

ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent

bull Collection ndash Pull down on the syringe

ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister

ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

HarvestingandProcessingGuide

WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand

rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities

2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion

3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals

4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps

CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach

10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe

clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith

salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull

syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe

Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor

Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection

Adipose Tissue

Adipose Tissue

bull 2002 national survey of 66000 tumescent

liposuction cases

ndash No deaths were reported

ndash Complication rate was 0068 per 1000 cases

Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002

Stem Cell summary

BMAC

bull 100k - 2M MSCs

bull Chondrocyte

bull Osteogenic

bull More painful

bull Volume limit

Adipose

bull 250k - 125M MSCs

bull Bioscaffold

bull Tendon defect filling

bull Less painfull

bull Larger volumes

AMNIOTIC TISSUE

Amniotic Tissue

bull Human Amniotic suspension allografts ndash Human amniotic membrane

ndash Human amniotic fluid-derived cells

bull Contain anti-inflammatory factorsndash IL-10 IL-1

ndash Metrix metalloproteinases 123 and 4

ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen

G5

ndash Hyaluranic Acid and small amount so proteoglycans

Amniotic Tissue

bull Human amniotic membrane

ndash Growth factors including EGF TGF-β and FGF

bull Stimulate epithelial cell migration and proliferation

bull PDGF A and B

ndash Stimulate many metabolic processes

raquo General protein and collagen synthesis collagenase activity

and chemotaxis of fibroblasts and of smooth muscle cells

raquo TGF-β has been shown to significantly increase type I

collagen production by tendon sheath fibroblasts

Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169

Amniotic Tissue

bull N = 6 KL grade 34

bull 12 weeks 3512 months

bull Primary goal feasibility of injection for treatment of OA

bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy

Amniotic Tissue

bull Pain and functional measures

ndash P ADL QOL S SR of the KOOS

ndash Overall KOOS IKDC SANE

bull All scores demonstrated improvement at 1 year

ndash Labs

bull No concerning changes in renal function blood cell

counts or lymphocyte subsets

bull Statistically significant increase in IgG and IgE relative to

baseline but not abnormal level

Amniotic Tissue

bull N23

ndash 14 Corticosteroid

ndash 9 c-hAM

bull Safe and comparable to steroid

Amniotic Tissue

Amniotic Tissue

bull N=470 181

bull VAS WOMAC

bull KL 1-3 OA

bull 30 90 120 days

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

Access this article

Or purchase this article - $20

Print Subscriber Activate your online access now

Welcome Guest Renew Subscribe or Create Account Sign In

HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

PRP

Platelet Rich Plasma

PRP

bull Conversion of a chronic non healing injury into an acute injury with increased healing potential

bull Contains Growth factors

bull Platelet alpha granules

bull Small peptides that bind to membrane receptors

bull promote downstream biologic pathways

bull Influence chemotaxis and cell migration

bull Induce Mitosis

bull Extracellular matrix production

bull Angiogenesis

bull Cells signal to proliferate influence maturation differentiate ultimately tissue repairowth factors

Case 2

bull 50 year old male with medial right knee pain

He has completed 2 prior marathons Currently

competing in triathlons No trauma Pain and

stiffness is present in the AM improves as the

day goes on worse at night Described as an

dull achy sensation

Case 2

bull Exam

ndash Normal lumbar exam

ndash Intact Myotomes Dermatomes Reflexes

ndash Pain to palpation along the medial joint line

ndash Crepitus

ndash Negative ligamentous testing

Baby Boomers and

ldquotweenersrdquo

bull ldquoIn betweenrdquo normal

joint and arthroplasty

Slide courtesy of Dr Joanne Borg-Stein

Orthobiologics

bull Prolotherapy

bull PRP

bull BMAC

bull Adipose derived

bull Amniotic products

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

Access this article

Or purchase this article - $20

Print Subscriber Activate your online access now

Welcome Guest Renew Subscribe or Create Account Sign In

HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

Mesenchymal stem cells

bull MSC cells that have the ability to

proliferate and differentiate into

progenitors of different mesenchymal

tissue

bull They have unique cell surface

markers adhesion molecules

cytokines growth factors and

receptors

bull Anti-inflammatory and

immunomodulatory

Obaid et al Cell therapy in tendon disorders

What is the Current evidence

Am J Sports Med 2010 38 (10)

bioscienceorg

Slide Courtesy of Dr Joanne Borg Stein

Mesenchymal stem cells

bull Mesenchymal Stem Cells

1 Bone Marrow Derived MSCs

2 Adipose Tissue Derived MSCs

3 Synovium Derived MSCs

bull De Bari et al 2001

4 Muscle Derived MSCs

bull Williams et al 1999

5 Dermal Fibroblast

1 Connell et al N=12

BMAC

BMAC

bull Hemopoietic stem cells

bull Nonhemopoietic cells Mesenchymal Stem Cells

ndash 0001-001 of total cell population

ndash 100k - 2M MSCs

bull Diminishes with age

Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147

BMAC

bull General Set up

Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939

Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939

BMAC

bull Rate is not greater than that observed with other types of intra-articular injections

bull Annual neoplasm 078 in adults 50 ndash 64 yo

ndash This study showed 014

bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure

bull Only 3 were possibly related to stem cells

BMAC

bull Eight studies focused on focal chondral defects

bull Three studies evaluated for treatment of

osteoarthritis

BMAC

bull Six trials with high risk of bias showed

level-3 or level-4 evidence in favour of stem

cell injections in KOA

BMAC

Author BMAC Pathology NCenteno et al 2008

BMAC meniscus 1 ndash case study MRI showed increased volume

bmac prp x2 and dex with hyalgan

Giannini et al2009

BMAC Talus 48 6121824 mo Second look arthroscopy

New tissue on MRI

Kennedy and Murawski 2011

BMAC Talus 72

Pascual-Garridoet al 2012

BMAC Patellar tendinopathy

8 2-5 year follow up

Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri

Giannini et al 2013

BMAC Talus 20 48mo MRI new tissue

Singh et al 2014 BMAC Lateral epicondyle

30 2612 weeks Sig decrease in PRTEE scores

Centeno et al 2015

BMAC GH OA 115 2 year pain improvement

Prolo bmac and prp

Centeno et al 2015

BMAC ACL 10 cases grade 1-III

Improved MRI findings

Prolo BMAC + prp

Hannon et al 2016

BMAC Talus 34

Shapiro SA et al 2016

BMAC vs saline OA knee N = 25 VASWomackoos

Contralateral knee with saline

Safe well tolerated placebo

ADIPOSE TISSUE

Adipose Tissue

bull Human ADSCs

ndash localize in the stromal vascular fraction

(SVF)

ndash The SVF consists of a heterogeneous

mesenchymal population of cells

bull Adipose stromal stem and progenitor cells

bull Hematopoietic stem and progenitor cells

bull endothelial cells erythrocytes fibroblasts

lymphocytes monocyte macrophages

and pericytes

NIH

-PA

Auth

or M

an

uscrip

tN

IH-P

A A

uth

or M

an

uscrip

tN

IH-P

A A

uth

or M

anu

scrip

t

BOURIN et al Page 13

Table II

Cell populations resident in SVF

Hematopoietic-lineage cells

Stem and progenitor cells lt01

Granulocytes 10ndash15

Monocytes 5ndash15

Lymphocytes 10ndash15

Endothelial cells 10ndash20

Pericytes 3ndash5

Stromal cells 15ndash30

Cytotherapy Author manuscript available in PMC 2014 April 08

Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648

Adipose Tissue

bull The stromal vascular fraction (SVF) is a

heterogeneous cell population derived from

manipulation of adipose tissue

ndash homogenization

ndash enzymatic digestion

ndash differential centrifugation

ndash red blood cells lysis and washing

Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Mesenchymal stem cells

bull Mulitpotent

bull More prone to differentiate

into muscle cells or even

into cardiomyocytes

compared with bone

marrow MSCs

bull Less efficient at osteogenic

and chondrogenic

differentiation

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Adipose Tissue

bull When treated with growth factors

ndash Upregulate expression of tendon related markers

ndash They are found comparable scaffold adherence and

proliferation potential

bull Suggesting AD-MSCs as alternative cell type for tendon

tissue repair

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239

Adipose Tissue

bull Easier to obtain

bull Bioscaffold

Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869

Adipose Tissue

bull General Set up

FDA CLEARANCE AND PRODUCT INFORMATION

TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose

tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure

Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints

middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture

middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents

middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue

middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)

IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha

legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat

isonlytobeusedwithoutanyadditionalmanipulation

Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister

middot LG60cc

middot LG240cc

1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm

120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes

260mlpolycarbonatesyringe2FemaleLuertransferconnectors

LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria

middot TheHCTPisminimallymanipulated

middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)

middot TheHCTPisnotcombinedwithanotherarticleand

middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction

DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016

Adipose Tissue HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer

5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe

6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Local Anesthetic

bull Connect the vacuum syringe to the

blunt 13-gauge Lipoaspiration

cannula

bull Advance and withdraw cannula in a

ldquospokes-of-a-wheelrdquo pattern

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto

createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly

3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand

holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe

canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe

canisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanister

approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

Adipose Tissue

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds

in a vertical motion

ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals

ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent

bull Collection ndash Pull down on the syringe

ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister

ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

HarvestingandProcessingGuide

WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand

rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities

2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion

3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals

4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps

CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach

10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe

clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith

salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull

syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe

Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor

Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection

Adipose Tissue

Adipose Tissue

bull 2002 national survey of 66000 tumescent

liposuction cases

ndash No deaths were reported

ndash Complication rate was 0068 per 1000 cases

Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002

Stem Cell summary

BMAC

bull 100k - 2M MSCs

bull Chondrocyte

bull Osteogenic

bull More painful

bull Volume limit

Adipose

bull 250k - 125M MSCs

bull Bioscaffold

bull Tendon defect filling

bull Less painfull

bull Larger volumes

AMNIOTIC TISSUE

Amniotic Tissue

bull Human Amniotic suspension allografts ndash Human amniotic membrane

ndash Human amniotic fluid-derived cells

bull Contain anti-inflammatory factorsndash IL-10 IL-1

ndash Metrix metalloproteinases 123 and 4

ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen

G5

ndash Hyaluranic Acid and small amount so proteoglycans

Amniotic Tissue

bull Human amniotic membrane

ndash Growth factors including EGF TGF-β and FGF

bull Stimulate epithelial cell migration and proliferation

bull PDGF A and B

ndash Stimulate many metabolic processes

raquo General protein and collagen synthesis collagenase activity

and chemotaxis of fibroblasts and of smooth muscle cells

raquo TGF-β has been shown to significantly increase type I

collagen production by tendon sheath fibroblasts

Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169

Amniotic Tissue

bull N = 6 KL grade 34

bull 12 weeks 3512 months

bull Primary goal feasibility of injection for treatment of OA

bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy

Amniotic Tissue

bull Pain and functional measures

ndash P ADL QOL S SR of the KOOS

ndash Overall KOOS IKDC SANE

bull All scores demonstrated improvement at 1 year

ndash Labs

bull No concerning changes in renal function blood cell

counts or lymphocyte subsets

bull Statistically significant increase in IgG and IgE relative to

baseline but not abnormal level

Amniotic Tissue

bull N23

ndash 14 Corticosteroid

ndash 9 c-hAM

bull Safe and comparable to steroid

Amniotic Tissue

Amniotic Tissue

bull N=470 181

bull VAS WOMAC

bull KL 1-3 OA

bull 30 90 120 days

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

Access this article

Or purchase this article - $20

Print Subscriber Activate your online access now

Welcome Guest Renew Subscribe or Create Account Sign In

HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

Platelet Rich Plasma

PRP

bull Conversion of a chronic non healing injury into an acute injury with increased healing potential

bull Contains Growth factors

bull Platelet alpha granules

bull Small peptides that bind to membrane receptors

bull promote downstream biologic pathways

bull Influence chemotaxis and cell migration

bull Induce Mitosis

bull Extracellular matrix production

bull Angiogenesis

bull Cells signal to proliferate influence maturation differentiate ultimately tissue repairowth factors

Case 2

bull 50 year old male with medial right knee pain

He has completed 2 prior marathons Currently

competing in triathlons No trauma Pain and

stiffness is present in the AM improves as the

day goes on worse at night Described as an

dull achy sensation

Case 2

bull Exam

ndash Normal lumbar exam

ndash Intact Myotomes Dermatomes Reflexes

ndash Pain to palpation along the medial joint line

ndash Crepitus

ndash Negative ligamentous testing

Baby Boomers and

ldquotweenersrdquo

bull ldquoIn betweenrdquo normal

joint and arthroplasty

Slide courtesy of Dr Joanne Borg-Stein

Orthobiologics

bull Prolotherapy

bull PRP

bull BMAC

bull Adipose derived

bull Amniotic products

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

Access this article

Or purchase this article - $20

Print Subscriber Activate your online access now

Welcome Guest Renew Subscribe or Create Account Sign In

HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

Mesenchymal stem cells

bull MSC cells that have the ability to

proliferate and differentiate into

progenitors of different mesenchymal

tissue

bull They have unique cell surface

markers adhesion molecules

cytokines growth factors and

receptors

bull Anti-inflammatory and

immunomodulatory

Obaid et al Cell therapy in tendon disorders

What is the Current evidence

Am J Sports Med 2010 38 (10)

bioscienceorg

Slide Courtesy of Dr Joanne Borg Stein

Mesenchymal stem cells

bull Mesenchymal Stem Cells

1 Bone Marrow Derived MSCs

2 Adipose Tissue Derived MSCs

3 Synovium Derived MSCs

bull De Bari et al 2001

4 Muscle Derived MSCs

bull Williams et al 1999

5 Dermal Fibroblast

1 Connell et al N=12

BMAC

BMAC

bull Hemopoietic stem cells

bull Nonhemopoietic cells Mesenchymal Stem Cells

ndash 0001-001 of total cell population

ndash 100k - 2M MSCs

bull Diminishes with age

Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147

BMAC

bull General Set up

Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939

Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939

BMAC

bull Rate is not greater than that observed with other types of intra-articular injections

bull Annual neoplasm 078 in adults 50 ndash 64 yo

ndash This study showed 014

bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure

bull Only 3 were possibly related to stem cells

BMAC

bull Eight studies focused on focal chondral defects

bull Three studies evaluated for treatment of

osteoarthritis

BMAC

bull Six trials with high risk of bias showed

level-3 or level-4 evidence in favour of stem

cell injections in KOA

BMAC

Author BMAC Pathology NCenteno et al 2008

BMAC meniscus 1 ndash case study MRI showed increased volume

bmac prp x2 and dex with hyalgan

Giannini et al2009

BMAC Talus 48 6121824 mo Second look arthroscopy

New tissue on MRI

Kennedy and Murawski 2011

BMAC Talus 72

Pascual-Garridoet al 2012

BMAC Patellar tendinopathy

8 2-5 year follow up

Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri

Giannini et al 2013

BMAC Talus 20 48mo MRI new tissue

Singh et al 2014 BMAC Lateral epicondyle

30 2612 weeks Sig decrease in PRTEE scores

Centeno et al 2015

BMAC GH OA 115 2 year pain improvement

Prolo bmac and prp

Centeno et al 2015

BMAC ACL 10 cases grade 1-III

Improved MRI findings

Prolo BMAC + prp

Hannon et al 2016

BMAC Talus 34

Shapiro SA et al 2016

BMAC vs saline OA knee N = 25 VASWomackoos

Contralateral knee with saline

Safe well tolerated placebo

ADIPOSE TISSUE

Adipose Tissue

bull Human ADSCs

ndash localize in the stromal vascular fraction

(SVF)

ndash The SVF consists of a heterogeneous

mesenchymal population of cells

bull Adipose stromal stem and progenitor cells

bull Hematopoietic stem and progenitor cells

bull endothelial cells erythrocytes fibroblasts

lymphocytes monocyte macrophages

and pericytes

NIH

-PA

Auth

or M

an

uscrip

tN

IH-P

A A

uth

or M

an

uscrip

tN

IH-P

A A

uth

or M

anu

scrip

t

BOURIN et al Page 13

Table II

Cell populations resident in SVF

Hematopoietic-lineage cells

Stem and progenitor cells lt01

Granulocytes 10ndash15

Monocytes 5ndash15

Lymphocytes 10ndash15

Endothelial cells 10ndash20

Pericytes 3ndash5

Stromal cells 15ndash30

Cytotherapy Author manuscript available in PMC 2014 April 08

Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648

Adipose Tissue

bull The stromal vascular fraction (SVF) is a

heterogeneous cell population derived from

manipulation of adipose tissue

ndash homogenization

ndash enzymatic digestion

ndash differential centrifugation

ndash red blood cells lysis and washing

Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Mesenchymal stem cells

bull Mulitpotent

bull More prone to differentiate

into muscle cells or even

into cardiomyocytes

compared with bone

marrow MSCs

bull Less efficient at osteogenic

and chondrogenic

differentiation

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Adipose Tissue

bull When treated with growth factors

ndash Upregulate expression of tendon related markers

ndash They are found comparable scaffold adherence and

proliferation potential

bull Suggesting AD-MSCs as alternative cell type for tendon

tissue repair

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239

Adipose Tissue

bull Easier to obtain

bull Bioscaffold

Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869

Adipose Tissue

bull General Set up

FDA CLEARANCE AND PRODUCT INFORMATION

TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose

tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure

Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints

middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture

middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents

middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue

middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)

IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha

legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat

isonlytobeusedwithoutanyadditionalmanipulation

Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister

middot LG60cc

middot LG240cc

1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm

120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes

260mlpolycarbonatesyringe2FemaleLuertransferconnectors

LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria

middot TheHCTPisminimallymanipulated

middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)

middot TheHCTPisnotcombinedwithanotherarticleand

middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction

DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016

Adipose Tissue HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer

5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe

6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Local Anesthetic

bull Connect the vacuum syringe to the

blunt 13-gauge Lipoaspiration

cannula

bull Advance and withdraw cannula in a

ldquospokes-of-a-wheelrdquo pattern

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto

createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly

3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand

holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe

canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe

canisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanister

approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

Adipose Tissue

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds

in a vertical motion

ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals

ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent

bull Collection ndash Pull down on the syringe

ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister

ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

HarvestingandProcessingGuide

WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand

rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities

2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion

3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals

4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps

CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach

10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe

clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith

salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull

syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe

Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor

Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection

Adipose Tissue

Adipose Tissue

bull 2002 national survey of 66000 tumescent

liposuction cases

ndash No deaths were reported

ndash Complication rate was 0068 per 1000 cases

Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002

Stem Cell summary

BMAC

bull 100k - 2M MSCs

bull Chondrocyte

bull Osteogenic

bull More painful

bull Volume limit

Adipose

bull 250k - 125M MSCs

bull Bioscaffold

bull Tendon defect filling

bull Less painfull

bull Larger volumes

AMNIOTIC TISSUE

Amniotic Tissue

bull Human Amniotic suspension allografts ndash Human amniotic membrane

ndash Human amniotic fluid-derived cells

bull Contain anti-inflammatory factorsndash IL-10 IL-1

ndash Metrix metalloproteinases 123 and 4

ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen

G5

ndash Hyaluranic Acid and small amount so proteoglycans

Amniotic Tissue

bull Human amniotic membrane

ndash Growth factors including EGF TGF-β and FGF

bull Stimulate epithelial cell migration and proliferation

bull PDGF A and B

ndash Stimulate many metabolic processes

raquo General protein and collagen synthesis collagenase activity

and chemotaxis of fibroblasts and of smooth muscle cells

raquo TGF-β has been shown to significantly increase type I

collagen production by tendon sheath fibroblasts

Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169

Amniotic Tissue

bull N = 6 KL grade 34

bull 12 weeks 3512 months

bull Primary goal feasibility of injection for treatment of OA

bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy

Amniotic Tissue

bull Pain and functional measures

ndash P ADL QOL S SR of the KOOS

ndash Overall KOOS IKDC SANE

bull All scores demonstrated improvement at 1 year

ndash Labs

bull No concerning changes in renal function blood cell

counts or lymphocyte subsets

bull Statistically significant increase in IgG and IgE relative to

baseline but not abnormal level

Amniotic Tissue

bull N23

ndash 14 Corticosteroid

ndash 9 c-hAM

bull Safe and comparable to steroid

Amniotic Tissue

Amniotic Tissue

bull N=470 181

bull VAS WOMAC

bull KL 1-3 OA

bull 30 90 120 days

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

PRP

bull Conversion of a chronic non healing injury into an acute injury with increased healing potential

bull Contains Growth factors

bull Platelet alpha granules

bull Small peptides that bind to membrane receptors

bull promote downstream biologic pathways

bull Influence chemotaxis and cell migration

bull Induce Mitosis

bull Extracellular matrix production

bull Angiogenesis

bull Cells signal to proliferate influence maturation differentiate ultimately tissue repairowth factors

Case 2

bull 50 year old male with medial right knee pain

He has completed 2 prior marathons Currently

competing in triathlons No trauma Pain and

stiffness is present in the AM improves as the

day goes on worse at night Described as an

dull achy sensation

Case 2

bull Exam

ndash Normal lumbar exam

ndash Intact Myotomes Dermatomes Reflexes

ndash Pain to palpation along the medial joint line

ndash Crepitus

ndash Negative ligamentous testing

Baby Boomers and

ldquotweenersrdquo

bull ldquoIn betweenrdquo normal

joint and arthroplasty

Slide courtesy of Dr Joanne Borg-Stein

Orthobiologics

bull Prolotherapy

bull PRP

bull BMAC

bull Adipose derived

bull Amniotic products

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

Mesenchymal stem cells

bull MSC cells that have the ability to

proliferate and differentiate into

progenitors of different mesenchymal

tissue

bull They have unique cell surface

markers adhesion molecules

cytokines growth factors and

receptors

bull Anti-inflammatory and

immunomodulatory

Obaid et al Cell therapy in tendon disorders

What is the Current evidence

Am J Sports Med 2010 38 (10)

bioscienceorg

Slide Courtesy of Dr Joanne Borg Stein

Mesenchymal stem cells

bull Mesenchymal Stem Cells

1 Bone Marrow Derived MSCs

2 Adipose Tissue Derived MSCs

3 Synovium Derived MSCs

bull De Bari et al 2001

4 Muscle Derived MSCs

bull Williams et al 1999

5 Dermal Fibroblast

1 Connell et al N=12

BMAC

BMAC

bull Hemopoietic stem cells

bull Nonhemopoietic cells Mesenchymal Stem Cells

ndash 0001-001 of total cell population

ndash 100k - 2M MSCs

bull Diminishes with age

Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147

BMAC

bull General Set up

Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939

Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939

BMAC

bull Rate is not greater than that observed with other types of intra-articular injections

bull Annual neoplasm 078 in adults 50 ndash 64 yo

ndash This study showed 014

bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure

bull Only 3 were possibly related to stem cells

BMAC

bull Eight studies focused on focal chondral defects

bull Three studies evaluated for treatment of

osteoarthritis

BMAC

bull Six trials with high risk of bias showed

level-3 or level-4 evidence in favour of stem

cell injections in KOA

BMAC

Author BMAC Pathology NCenteno et al 2008

BMAC meniscus 1 ndash case study MRI showed increased volume

bmac prp x2 and dex with hyalgan

Giannini et al2009

BMAC Talus 48 6121824 mo Second look arthroscopy

New tissue on MRI

Kennedy and Murawski 2011

BMAC Talus 72

Pascual-Garridoet al 2012

BMAC Patellar tendinopathy

8 2-5 year follow up

Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri

Giannini et al 2013

BMAC Talus 20 48mo MRI new tissue

Singh et al 2014 BMAC Lateral epicondyle

30 2612 weeks Sig decrease in PRTEE scores

Centeno et al 2015

BMAC GH OA 115 2 year pain improvement

Prolo bmac and prp

Centeno et al 2015

BMAC ACL 10 cases grade 1-III

Improved MRI findings

Prolo BMAC + prp

Hannon et al 2016

BMAC Talus 34

Shapiro SA et al 2016

BMAC vs saline OA knee N = 25 VASWomackoos

Contralateral knee with saline

Safe well tolerated placebo

ADIPOSE TISSUE

Adipose Tissue

bull Human ADSCs

ndash localize in the stromal vascular fraction

(SVF)

ndash The SVF consists of a heterogeneous

mesenchymal population of cells

bull Adipose stromal stem and progenitor cells

bull Hematopoietic stem and progenitor cells

bull endothelial cells erythrocytes fibroblasts

lymphocytes monocyte macrophages

and pericytes

NIH

-PA

Auth

or M

an

uscrip

tN

IH-P

A A

uth

or M

an

uscrip

tN

IH-P

A A

uth

or M

anu

scrip

t

BOURIN et al Page 13

Table II

Cell populations resident in SVF

Hematopoietic-lineage cells

Stem and progenitor cells lt01

Granulocytes 10ndash15

Monocytes 5ndash15

Lymphocytes 10ndash15

Endothelial cells 10ndash20

Pericytes 3ndash5

Stromal cells 15ndash30

Cytotherapy Author manuscript available in PMC 2014 April 08

Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648

Adipose Tissue

bull The stromal vascular fraction (SVF) is a

heterogeneous cell population derived from

manipulation of adipose tissue

ndash homogenization

ndash enzymatic digestion

ndash differential centrifugation

ndash red blood cells lysis and washing

Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Mesenchymal stem cells

bull Mulitpotent

bull More prone to differentiate

into muscle cells or even

into cardiomyocytes

compared with bone

marrow MSCs

bull Less efficient at osteogenic

and chondrogenic

differentiation

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Adipose Tissue

bull When treated with growth factors

ndash Upregulate expression of tendon related markers

ndash They are found comparable scaffold adherence and

proliferation potential

bull Suggesting AD-MSCs as alternative cell type for tendon

tissue repair

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239

Adipose Tissue

bull Easier to obtain

bull Bioscaffold

Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869

Adipose Tissue

bull General Set up

FDA CLEARANCE AND PRODUCT INFORMATION

TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose

tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure

Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints

middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture

middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents

middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue

middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)

IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha

legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat

isonlytobeusedwithoutanyadditionalmanipulation

Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister

middot LG60cc

middot LG240cc

1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm

120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes

260mlpolycarbonatesyringe2FemaleLuertransferconnectors

LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria

middot TheHCTPisminimallymanipulated

middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)

middot TheHCTPisnotcombinedwithanotherarticleand

middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction

DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016

Adipose Tissue HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer

5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe

6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Local Anesthetic

bull Connect the vacuum syringe to the

blunt 13-gauge Lipoaspiration

cannula

bull Advance and withdraw cannula in a

ldquospokes-of-a-wheelrdquo pattern

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto

createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly

3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand

holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe

canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe

canisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanister

approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

Adipose Tissue

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds

in a vertical motion

ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals

ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent

bull Collection ndash Pull down on the syringe

ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister

ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

HarvestingandProcessingGuide

WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand

rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities

2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion

3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals

4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps

CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach

10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe

clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith

salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull

syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe

Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor

Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection

Adipose Tissue

Adipose Tissue

bull 2002 national survey of 66000 tumescent

liposuction cases

ndash No deaths were reported

ndash Complication rate was 0068 per 1000 cases

Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002

Stem Cell summary

BMAC

bull 100k - 2M MSCs

bull Chondrocyte

bull Osteogenic

bull More painful

bull Volume limit

Adipose

bull 250k - 125M MSCs

bull Bioscaffold

bull Tendon defect filling

bull Less painfull

bull Larger volumes

AMNIOTIC TISSUE

Amniotic Tissue

bull Human Amniotic suspension allografts ndash Human amniotic membrane

ndash Human amniotic fluid-derived cells

bull Contain anti-inflammatory factorsndash IL-10 IL-1

ndash Metrix metalloproteinases 123 and 4

ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen

G5

ndash Hyaluranic Acid and small amount so proteoglycans

Amniotic Tissue

bull Human amniotic membrane

ndash Growth factors including EGF TGF-β and FGF

bull Stimulate epithelial cell migration and proliferation

bull PDGF A and B

ndash Stimulate many metabolic processes

raquo General protein and collagen synthesis collagenase activity

and chemotaxis of fibroblasts and of smooth muscle cells

raquo TGF-β has been shown to significantly increase type I

collagen production by tendon sheath fibroblasts

Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169

Amniotic Tissue

bull N = 6 KL grade 34

bull 12 weeks 3512 months

bull Primary goal feasibility of injection for treatment of OA

bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy

Amniotic Tissue

bull Pain and functional measures

ndash P ADL QOL S SR of the KOOS

ndash Overall KOOS IKDC SANE

bull All scores demonstrated improvement at 1 year

ndash Labs

bull No concerning changes in renal function blood cell

counts or lymphocyte subsets

bull Statistically significant increase in IgG and IgE relative to

baseline but not abnormal level

Amniotic Tissue

bull N23

ndash 14 Corticosteroid

ndash 9 c-hAM

bull Safe and comparable to steroid

Amniotic Tissue

Amniotic Tissue

bull N=470 181

bull VAS WOMAC

bull KL 1-3 OA

bull 30 90 120 days

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

Access this article

Or purchase this article - $20

Print Subscriber Activate your online access now

Welcome Guest Renew Subscribe or Create Account Sign In

HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

Case 2

bull 50 year old male with medial right knee pain

He has completed 2 prior marathons Currently

competing in triathlons No trauma Pain and

stiffness is present in the AM improves as the

day goes on worse at night Described as an

dull achy sensation

Case 2

bull Exam

ndash Normal lumbar exam

ndash Intact Myotomes Dermatomes Reflexes

ndash Pain to palpation along the medial joint line

ndash Crepitus

ndash Negative ligamentous testing

Baby Boomers and

ldquotweenersrdquo

bull ldquoIn betweenrdquo normal

joint and arthroplasty

Slide courtesy of Dr Joanne Borg-Stein

Orthobiologics

bull Prolotherapy

bull PRP

bull BMAC

bull Adipose derived

bull Amniotic products

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

Access this article

Or purchase this article - $20

Print Subscriber Activate your online access now

Welcome Guest Renew Subscribe or Create Account Sign In

HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

Mesenchymal stem cells

bull MSC cells that have the ability to

proliferate and differentiate into

progenitors of different mesenchymal

tissue

bull They have unique cell surface

markers adhesion molecules

cytokines growth factors and

receptors

bull Anti-inflammatory and

immunomodulatory

Obaid et al Cell therapy in tendon disorders

What is the Current evidence

Am J Sports Med 2010 38 (10)

bioscienceorg

Slide Courtesy of Dr Joanne Borg Stein

Mesenchymal stem cells

bull Mesenchymal Stem Cells

1 Bone Marrow Derived MSCs

2 Adipose Tissue Derived MSCs

3 Synovium Derived MSCs

bull De Bari et al 2001

4 Muscle Derived MSCs

bull Williams et al 1999

5 Dermal Fibroblast

1 Connell et al N=12

BMAC

BMAC

bull Hemopoietic stem cells

bull Nonhemopoietic cells Mesenchymal Stem Cells

ndash 0001-001 of total cell population

ndash 100k - 2M MSCs

bull Diminishes with age

Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147

BMAC

bull General Set up

Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939

Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939

BMAC

bull Rate is not greater than that observed with other types of intra-articular injections

bull Annual neoplasm 078 in adults 50 ndash 64 yo

ndash This study showed 014

bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure

bull Only 3 were possibly related to stem cells

BMAC

bull Eight studies focused on focal chondral defects

bull Three studies evaluated for treatment of

osteoarthritis

BMAC

bull Six trials with high risk of bias showed

level-3 or level-4 evidence in favour of stem

cell injections in KOA

BMAC

Author BMAC Pathology NCenteno et al 2008

BMAC meniscus 1 ndash case study MRI showed increased volume

bmac prp x2 and dex with hyalgan

Giannini et al2009

BMAC Talus 48 6121824 mo Second look arthroscopy

New tissue on MRI

Kennedy and Murawski 2011

BMAC Talus 72

Pascual-Garridoet al 2012

BMAC Patellar tendinopathy

8 2-5 year follow up

Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri

Giannini et al 2013

BMAC Talus 20 48mo MRI new tissue

Singh et al 2014 BMAC Lateral epicondyle

30 2612 weeks Sig decrease in PRTEE scores

Centeno et al 2015

BMAC GH OA 115 2 year pain improvement

Prolo bmac and prp

Centeno et al 2015

BMAC ACL 10 cases grade 1-III

Improved MRI findings

Prolo BMAC + prp

Hannon et al 2016

BMAC Talus 34

Shapiro SA et al 2016

BMAC vs saline OA knee N = 25 VASWomackoos

Contralateral knee with saline

Safe well tolerated placebo

ADIPOSE TISSUE

Adipose Tissue

bull Human ADSCs

ndash localize in the stromal vascular fraction

(SVF)

ndash The SVF consists of a heterogeneous

mesenchymal population of cells

bull Adipose stromal stem and progenitor cells

bull Hematopoietic stem and progenitor cells

bull endothelial cells erythrocytes fibroblasts

lymphocytes monocyte macrophages

and pericytes

NIH

-PA

Auth

or M

an

uscrip

tN

IH-P

A A

uth

or M

an

uscrip

tN

IH-P

A A

uth

or M

anu

scrip

t

BOURIN et al Page 13

Table II

Cell populations resident in SVF

Hematopoietic-lineage cells

Stem and progenitor cells lt01

Granulocytes 10ndash15

Monocytes 5ndash15

Lymphocytes 10ndash15

Endothelial cells 10ndash20

Pericytes 3ndash5

Stromal cells 15ndash30

Cytotherapy Author manuscript available in PMC 2014 April 08

Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648

Adipose Tissue

bull The stromal vascular fraction (SVF) is a

heterogeneous cell population derived from

manipulation of adipose tissue

ndash homogenization

ndash enzymatic digestion

ndash differential centrifugation

ndash red blood cells lysis and washing

Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Mesenchymal stem cells

bull Mulitpotent

bull More prone to differentiate

into muscle cells or even

into cardiomyocytes

compared with bone

marrow MSCs

bull Less efficient at osteogenic

and chondrogenic

differentiation

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Adipose Tissue

bull When treated with growth factors

ndash Upregulate expression of tendon related markers

ndash They are found comparable scaffold adherence and

proliferation potential

bull Suggesting AD-MSCs as alternative cell type for tendon

tissue repair

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239

Adipose Tissue

bull Easier to obtain

bull Bioscaffold

Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869

Adipose Tissue

bull General Set up

FDA CLEARANCE AND PRODUCT INFORMATION

TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose

tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure

Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints

middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture

middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents

middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue

middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)

IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha

legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat

isonlytobeusedwithoutanyadditionalmanipulation

Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister

middot LG60cc

middot LG240cc

1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm

120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes

260mlpolycarbonatesyringe2FemaleLuertransferconnectors

LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria

middot TheHCTPisminimallymanipulated

middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)

middot TheHCTPisnotcombinedwithanotherarticleand

middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction

DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016

Adipose Tissue HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer

5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe

6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Local Anesthetic

bull Connect the vacuum syringe to the

blunt 13-gauge Lipoaspiration

cannula

bull Advance and withdraw cannula in a

ldquospokes-of-a-wheelrdquo pattern

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto

createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly

3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand

holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe

canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe

canisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanister

approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

Adipose Tissue

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds

in a vertical motion

ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals

ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent

bull Collection ndash Pull down on the syringe

ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister

ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

HarvestingandProcessingGuide

WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand

rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities

2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion

3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals

4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps

CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach

10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe

clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith

salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull

syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe

Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor

Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection

Adipose Tissue

Adipose Tissue

bull 2002 national survey of 66000 tumescent

liposuction cases

ndash No deaths were reported

ndash Complication rate was 0068 per 1000 cases

Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002

Stem Cell summary

BMAC

bull 100k - 2M MSCs

bull Chondrocyte

bull Osteogenic

bull More painful

bull Volume limit

Adipose

bull 250k - 125M MSCs

bull Bioscaffold

bull Tendon defect filling

bull Less painfull

bull Larger volumes

AMNIOTIC TISSUE

Amniotic Tissue

bull Human Amniotic suspension allografts ndash Human amniotic membrane

ndash Human amniotic fluid-derived cells

bull Contain anti-inflammatory factorsndash IL-10 IL-1

ndash Metrix metalloproteinases 123 and 4

ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen

G5

ndash Hyaluranic Acid and small amount so proteoglycans

Amniotic Tissue

bull Human amniotic membrane

ndash Growth factors including EGF TGF-β and FGF

bull Stimulate epithelial cell migration and proliferation

bull PDGF A and B

ndash Stimulate many metabolic processes

raquo General protein and collagen synthesis collagenase activity

and chemotaxis of fibroblasts and of smooth muscle cells

raquo TGF-β has been shown to significantly increase type I

collagen production by tendon sheath fibroblasts

Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169

Amniotic Tissue

bull N = 6 KL grade 34

bull 12 weeks 3512 months

bull Primary goal feasibility of injection for treatment of OA

bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy

Amniotic Tissue

bull Pain and functional measures

ndash P ADL QOL S SR of the KOOS

ndash Overall KOOS IKDC SANE

bull All scores demonstrated improvement at 1 year

ndash Labs

bull No concerning changes in renal function blood cell

counts or lymphocyte subsets

bull Statistically significant increase in IgG and IgE relative to

baseline but not abnormal level

Amniotic Tissue

bull N23

ndash 14 Corticosteroid

ndash 9 c-hAM

bull Safe and comparable to steroid

Amniotic Tissue

Amniotic Tissue

bull N=470 181

bull VAS WOMAC

bull KL 1-3 OA

bull 30 90 120 days

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

Access this article

Or purchase this article - $20

Print Subscriber Activate your online access now

Welcome Guest Renew Subscribe or Create Account Sign In

HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

Case 2

bull Exam

ndash Normal lumbar exam

ndash Intact Myotomes Dermatomes Reflexes

ndash Pain to palpation along the medial joint line

ndash Crepitus

ndash Negative ligamentous testing

Baby Boomers and

ldquotweenersrdquo

bull ldquoIn betweenrdquo normal

joint and arthroplasty

Slide courtesy of Dr Joanne Borg-Stein

Orthobiologics

bull Prolotherapy

bull PRP

bull BMAC

bull Adipose derived

bull Amniotic products

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

Access this article

Or purchase this article - $20

Print Subscriber Activate your online access now

Welcome Guest Renew Subscribe or Create Account Sign In

HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

Mesenchymal stem cells

bull MSC cells that have the ability to

proliferate and differentiate into

progenitors of different mesenchymal

tissue

bull They have unique cell surface

markers adhesion molecules

cytokines growth factors and

receptors

bull Anti-inflammatory and

immunomodulatory

Obaid et al Cell therapy in tendon disorders

What is the Current evidence

Am J Sports Med 2010 38 (10)

bioscienceorg

Slide Courtesy of Dr Joanne Borg Stein

Mesenchymal stem cells

bull Mesenchymal Stem Cells

1 Bone Marrow Derived MSCs

2 Adipose Tissue Derived MSCs

3 Synovium Derived MSCs

bull De Bari et al 2001

4 Muscle Derived MSCs

bull Williams et al 1999

5 Dermal Fibroblast

1 Connell et al N=12

BMAC

BMAC

bull Hemopoietic stem cells

bull Nonhemopoietic cells Mesenchymal Stem Cells

ndash 0001-001 of total cell population

ndash 100k - 2M MSCs

bull Diminishes with age

Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147

BMAC

bull General Set up

Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939

Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939

BMAC

bull Rate is not greater than that observed with other types of intra-articular injections

bull Annual neoplasm 078 in adults 50 ndash 64 yo

ndash This study showed 014

bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure

bull Only 3 were possibly related to stem cells

BMAC

bull Eight studies focused on focal chondral defects

bull Three studies evaluated for treatment of

osteoarthritis

BMAC

bull Six trials with high risk of bias showed

level-3 or level-4 evidence in favour of stem

cell injections in KOA

BMAC

Author BMAC Pathology NCenteno et al 2008

BMAC meniscus 1 ndash case study MRI showed increased volume

bmac prp x2 and dex with hyalgan

Giannini et al2009

BMAC Talus 48 6121824 mo Second look arthroscopy

New tissue on MRI

Kennedy and Murawski 2011

BMAC Talus 72

Pascual-Garridoet al 2012

BMAC Patellar tendinopathy

8 2-5 year follow up

Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri

Giannini et al 2013

BMAC Talus 20 48mo MRI new tissue

Singh et al 2014 BMAC Lateral epicondyle

30 2612 weeks Sig decrease in PRTEE scores

Centeno et al 2015

BMAC GH OA 115 2 year pain improvement

Prolo bmac and prp

Centeno et al 2015

BMAC ACL 10 cases grade 1-III

Improved MRI findings

Prolo BMAC + prp

Hannon et al 2016

BMAC Talus 34

Shapiro SA et al 2016

BMAC vs saline OA knee N = 25 VASWomackoos

Contralateral knee with saline

Safe well tolerated placebo

ADIPOSE TISSUE

Adipose Tissue

bull Human ADSCs

ndash localize in the stromal vascular fraction

(SVF)

ndash The SVF consists of a heterogeneous

mesenchymal population of cells

bull Adipose stromal stem and progenitor cells

bull Hematopoietic stem and progenitor cells

bull endothelial cells erythrocytes fibroblasts

lymphocytes monocyte macrophages

and pericytes

NIH

-PA

Auth

or M

an

uscrip

tN

IH-P

A A

uth

or M

an

uscrip

tN

IH-P

A A

uth

or M

anu

scrip

t

BOURIN et al Page 13

Table II

Cell populations resident in SVF

Hematopoietic-lineage cells

Stem and progenitor cells lt01

Granulocytes 10ndash15

Monocytes 5ndash15

Lymphocytes 10ndash15

Endothelial cells 10ndash20

Pericytes 3ndash5

Stromal cells 15ndash30

Cytotherapy Author manuscript available in PMC 2014 April 08

Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648

Adipose Tissue

bull The stromal vascular fraction (SVF) is a

heterogeneous cell population derived from

manipulation of adipose tissue

ndash homogenization

ndash enzymatic digestion

ndash differential centrifugation

ndash red blood cells lysis and washing

Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Mesenchymal stem cells

bull Mulitpotent

bull More prone to differentiate

into muscle cells or even

into cardiomyocytes

compared with bone

marrow MSCs

bull Less efficient at osteogenic

and chondrogenic

differentiation

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Adipose Tissue

bull When treated with growth factors

ndash Upregulate expression of tendon related markers

ndash They are found comparable scaffold adherence and

proliferation potential

bull Suggesting AD-MSCs as alternative cell type for tendon

tissue repair

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239

Adipose Tissue

bull Easier to obtain

bull Bioscaffold

Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869

Adipose Tissue

bull General Set up

FDA CLEARANCE AND PRODUCT INFORMATION

TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose

tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure

Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints

middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture

middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents

middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue

middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)

IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha

legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat

isonlytobeusedwithoutanyadditionalmanipulation

Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister

middot LG60cc

middot LG240cc

1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm

120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes

260mlpolycarbonatesyringe2FemaleLuertransferconnectors

LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria

middot TheHCTPisminimallymanipulated

middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)

middot TheHCTPisnotcombinedwithanotherarticleand

middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction

DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016

Adipose Tissue HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer

5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe

6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Local Anesthetic

bull Connect the vacuum syringe to the

blunt 13-gauge Lipoaspiration

cannula

bull Advance and withdraw cannula in a

ldquospokes-of-a-wheelrdquo pattern

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto

createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly

3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand

holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe

canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe

canisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanister

approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

Adipose Tissue

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds

in a vertical motion

ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals

ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent

bull Collection ndash Pull down on the syringe

ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister

ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

HarvestingandProcessingGuide

WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand

rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities

2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion

3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals

4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps

CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach

10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe

clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith

salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull

syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe

Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor

Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection

Adipose Tissue

Adipose Tissue

bull 2002 national survey of 66000 tumescent

liposuction cases

ndash No deaths were reported

ndash Complication rate was 0068 per 1000 cases

Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002

Stem Cell summary

BMAC

bull 100k - 2M MSCs

bull Chondrocyte

bull Osteogenic

bull More painful

bull Volume limit

Adipose

bull 250k - 125M MSCs

bull Bioscaffold

bull Tendon defect filling

bull Less painfull

bull Larger volumes

AMNIOTIC TISSUE

Amniotic Tissue

bull Human Amniotic suspension allografts ndash Human amniotic membrane

ndash Human amniotic fluid-derived cells

bull Contain anti-inflammatory factorsndash IL-10 IL-1

ndash Metrix metalloproteinases 123 and 4

ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen

G5

ndash Hyaluranic Acid and small amount so proteoglycans

Amniotic Tissue

bull Human amniotic membrane

ndash Growth factors including EGF TGF-β and FGF

bull Stimulate epithelial cell migration and proliferation

bull PDGF A and B

ndash Stimulate many metabolic processes

raquo General protein and collagen synthesis collagenase activity

and chemotaxis of fibroblasts and of smooth muscle cells

raquo TGF-β has been shown to significantly increase type I

collagen production by tendon sheath fibroblasts

Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169

Amniotic Tissue

bull N = 6 KL grade 34

bull 12 weeks 3512 months

bull Primary goal feasibility of injection for treatment of OA

bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy

Amniotic Tissue

bull Pain and functional measures

ndash P ADL QOL S SR of the KOOS

ndash Overall KOOS IKDC SANE

bull All scores demonstrated improvement at 1 year

ndash Labs

bull No concerning changes in renal function blood cell

counts or lymphocyte subsets

bull Statistically significant increase in IgG and IgE relative to

baseline but not abnormal level

Amniotic Tissue

bull N23

ndash 14 Corticosteroid

ndash 9 c-hAM

bull Safe and comparable to steroid

Amniotic Tissue

Amniotic Tissue

bull N=470 181

bull VAS WOMAC

bull KL 1-3 OA

bull 30 90 120 days

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

Access this article

Or purchase this article - $20

Print Subscriber Activate your online access now

Welcome Guest Renew Subscribe or Create Account Sign In

HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

Baby Boomers and

ldquotweenersrdquo

bull ldquoIn betweenrdquo normal

joint and arthroplasty

Slide courtesy of Dr Joanne Borg-Stein

Orthobiologics

bull Prolotherapy

bull PRP

bull BMAC

bull Adipose derived

bull Amniotic products

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

Access this article

Or purchase this article - $20

Print Subscriber Activate your online access now

Welcome Guest Renew Subscribe or Create Account Sign In

HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

Mesenchymal stem cells

bull MSC cells that have the ability to

proliferate and differentiate into

progenitors of different mesenchymal

tissue

bull They have unique cell surface

markers adhesion molecules

cytokines growth factors and

receptors

bull Anti-inflammatory and

immunomodulatory

Obaid et al Cell therapy in tendon disorders

What is the Current evidence

Am J Sports Med 2010 38 (10)

bioscienceorg

Slide Courtesy of Dr Joanne Borg Stein

Mesenchymal stem cells

bull Mesenchymal Stem Cells

1 Bone Marrow Derived MSCs

2 Adipose Tissue Derived MSCs

3 Synovium Derived MSCs

bull De Bari et al 2001

4 Muscle Derived MSCs

bull Williams et al 1999

5 Dermal Fibroblast

1 Connell et al N=12

BMAC

BMAC

bull Hemopoietic stem cells

bull Nonhemopoietic cells Mesenchymal Stem Cells

ndash 0001-001 of total cell population

ndash 100k - 2M MSCs

bull Diminishes with age

Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147

BMAC

bull General Set up

Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939

Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939

BMAC

bull Rate is not greater than that observed with other types of intra-articular injections

bull Annual neoplasm 078 in adults 50 ndash 64 yo

ndash This study showed 014

bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure

bull Only 3 were possibly related to stem cells

BMAC

bull Eight studies focused on focal chondral defects

bull Three studies evaluated for treatment of

osteoarthritis

BMAC

bull Six trials with high risk of bias showed

level-3 or level-4 evidence in favour of stem

cell injections in KOA

BMAC

Author BMAC Pathology NCenteno et al 2008

BMAC meniscus 1 ndash case study MRI showed increased volume

bmac prp x2 and dex with hyalgan

Giannini et al2009

BMAC Talus 48 6121824 mo Second look arthroscopy

New tissue on MRI

Kennedy and Murawski 2011

BMAC Talus 72

Pascual-Garridoet al 2012

BMAC Patellar tendinopathy

8 2-5 year follow up

Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri

Giannini et al 2013

BMAC Talus 20 48mo MRI new tissue

Singh et al 2014 BMAC Lateral epicondyle

30 2612 weeks Sig decrease in PRTEE scores

Centeno et al 2015

BMAC GH OA 115 2 year pain improvement

Prolo bmac and prp

Centeno et al 2015

BMAC ACL 10 cases grade 1-III

Improved MRI findings

Prolo BMAC + prp

Hannon et al 2016

BMAC Talus 34

Shapiro SA et al 2016

BMAC vs saline OA knee N = 25 VASWomackoos

Contralateral knee with saline

Safe well tolerated placebo

ADIPOSE TISSUE

Adipose Tissue

bull Human ADSCs

ndash localize in the stromal vascular fraction

(SVF)

ndash The SVF consists of a heterogeneous

mesenchymal population of cells

bull Adipose stromal stem and progenitor cells

bull Hematopoietic stem and progenitor cells

bull endothelial cells erythrocytes fibroblasts

lymphocytes monocyte macrophages

and pericytes

NIH

-PA

Auth

or M

an

uscrip

tN

IH-P

A A

uth

or M

an

uscrip

tN

IH-P

A A

uth

or M

anu

scrip

t

BOURIN et al Page 13

Table II

Cell populations resident in SVF

Hematopoietic-lineage cells

Stem and progenitor cells lt01

Granulocytes 10ndash15

Monocytes 5ndash15

Lymphocytes 10ndash15

Endothelial cells 10ndash20

Pericytes 3ndash5

Stromal cells 15ndash30

Cytotherapy Author manuscript available in PMC 2014 April 08

Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648

Adipose Tissue

bull The stromal vascular fraction (SVF) is a

heterogeneous cell population derived from

manipulation of adipose tissue

ndash homogenization

ndash enzymatic digestion

ndash differential centrifugation

ndash red blood cells lysis and washing

Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Mesenchymal stem cells

bull Mulitpotent

bull More prone to differentiate

into muscle cells or even

into cardiomyocytes

compared with bone

marrow MSCs

bull Less efficient at osteogenic

and chondrogenic

differentiation

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Adipose Tissue

bull When treated with growth factors

ndash Upregulate expression of tendon related markers

ndash They are found comparable scaffold adherence and

proliferation potential

bull Suggesting AD-MSCs as alternative cell type for tendon

tissue repair

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239

Adipose Tissue

bull Easier to obtain

bull Bioscaffold

Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869

Adipose Tissue

bull General Set up

FDA CLEARANCE AND PRODUCT INFORMATION

TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose

tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure

Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints

middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture

middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents

middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue

middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)

IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha

legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat

isonlytobeusedwithoutanyadditionalmanipulation

Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister

middot LG60cc

middot LG240cc

1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm

120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes

260mlpolycarbonatesyringe2FemaleLuertransferconnectors

LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria

middot TheHCTPisminimallymanipulated

middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)

middot TheHCTPisnotcombinedwithanotherarticleand

middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction

DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016

Adipose Tissue HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer

5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe

6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Local Anesthetic

bull Connect the vacuum syringe to the

blunt 13-gauge Lipoaspiration

cannula

bull Advance and withdraw cannula in a

ldquospokes-of-a-wheelrdquo pattern

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto

createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly

3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand

holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe

canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe

canisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanister

approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

Adipose Tissue

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds

in a vertical motion

ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals

ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent

bull Collection ndash Pull down on the syringe

ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister

ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

HarvestingandProcessingGuide

WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand

rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities

2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion

3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals

4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps

CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach

10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe

clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith

salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull

syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe

Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor

Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection

Adipose Tissue

Adipose Tissue

bull 2002 national survey of 66000 tumescent

liposuction cases

ndash No deaths were reported

ndash Complication rate was 0068 per 1000 cases

Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002

Stem Cell summary

BMAC

bull 100k - 2M MSCs

bull Chondrocyte

bull Osteogenic

bull More painful

bull Volume limit

Adipose

bull 250k - 125M MSCs

bull Bioscaffold

bull Tendon defect filling

bull Less painfull

bull Larger volumes

AMNIOTIC TISSUE

Amniotic Tissue

bull Human Amniotic suspension allografts ndash Human amniotic membrane

ndash Human amniotic fluid-derived cells

bull Contain anti-inflammatory factorsndash IL-10 IL-1

ndash Metrix metalloproteinases 123 and 4

ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen

G5

ndash Hyaluranic Acid and small amount so proteoglycans

Amniotic Tissue

bull Human amniotic membrane

ndash Growth factors including EGF TGF-β and FGF

bull Stimulate epithelial cell migration and proliferation

bull PDGF A and B

ndash Stimulate many metabolic processes

raquo General protein and collagen synthesis collagenase activity

and chemotaxis of fibroblasts and of smooth muscle cells

raquo TGF-β has been shown to significantly increase type I

collagen production by tendon sheath fibroblasts

Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169

Amniotic Tissue

bull N = 6 KL grade 34

bull 12 weeks 3512 months

bull Primary goal feasibility of injection for treatment of OA

bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy

Amniotic Tissue

bull Pain and functional measures

ndash P ADL QOL S SR of the KOOS

ndash Overall KOOS IKDC SANE

bull All scores demonstrated improvement at 1 year

ndash Labs

bull No concerning changes in renal function blood cell

counts or lymphocyte subsets

bull Statistically significant increase in IgG and IgE relative to

baseline but not abnormal level

Amniotic Tissue

bull N23

ndash 14 Corticosteroid

ndash 9 c-hAM

bull Safe and comparable to steroid

Amniotic Tissue

Amniotic Tissue

bull N=470 181

bull VAS WOMAC

bull KL 1-3 OA

bull 30 90 120 days

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

Access this article

Or purchase this article - $20

Print Subscriber Activate your online access now

Welcome Guest Renew Subscribe or Create Account Sign In

HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

Orthobiologics

bull Prolotherapy

bull PRP

bull BMAC

bull Adipose derived

bull Amniotic products

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

Access this article

Or purchase this article - $20

Print Subscriber Activate your online access now

Welcome Guest Renew Subscribe or Create Account Sign In

HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

Mesenchymal stem cells

bull MSC cells that have the ability to

proliferate and differentiate into

progenitors of different mesenchymal

tissue

bull They have unique cell surface

markers adhesion molecules

cytokines growth factors and

receptors

bull Anti-inflammatory and

immunomodulatory

Obaid et al Cell therapy in tendon disorders

What is the Current evidence

Am J Sports Med 2010 38 (10)

bioscienceorg

Slide Courtesy of Dr Joanne Borg Stein

Mesenchymal stem cells

bull Mesenchymal Stem Cells

1 Bone Marrow Derived MSCs

2 Adipose Tissue Derived MSCs

3 Synovium Derived MSCs

bull De Bari et al 2001

4 Muscle Derived MSCs

bull Williams et al 1999

5 Dermal Fibroblast

1 Connell et al N=12

BMAC

BMAC

bull Hemopoietic stem cells

bull Nonhemopoietic cells Mesenchymal Stem Cells

ndash 0001-001 of total cell population

ndash 100k - 2M MSCs

bull Diminishes with age

Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147

BMAC

bull General Set up

Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939

Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939

BMAC

bull Rate is not greater than that observed with other types of intra-articular injections

bull Annual neoplasm 078 in adults 50 ndash 64 yo

ndash This study showed 014

bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure

bull Only 3 were possibly related to stem cells

BMAC

bull Eight studies focused on focal chondral defects

bull Three studies evaluated for treatment of

osteoarthritis

BMAC

bull Six trials with high risk of bias showed

level-3 or level-4 evidence in favour of stem

cell injections in KOA

BMAC

Author BMAC Pathology NCenteno et al 2008

BMAC meniscus 1 ndash case study MRI showed increased volume

bmac prp x2 and dex with hyalgan

Giannini et al2009

BMAC Talus 48 6121824 mo Second look arthroscopy

New tissue on MRI

Kennedy and Murawski 2011

BMAC Talus 72

Pascual-Garridoet al 2012

BMAC Patellar tendinopathy

8 2-5 year follow up

Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri

Giannini et al 2013

BMAC Talus 20 48mo MRI new tissue

Singh et al 2014 BMAC Lateral epicondyle

30 2612 weeks Sig decrease in PRTEE scores

Centeno et al 2015

BMAC GH OA 115 2 year pain improvement

Prolo bmac and prp

Centeno et al 2015

BMAC ACL 10 cases grade 1-III

Improved MRI findings

Prolo BMAC + prp

Hannon et al 2016

BMAC Talus 34

Shapiro SA et al 2016

BMAC vs saline OA knee N = 25 VASWomackoos

Contralateral knee with saline

Safe well tolerated placebo

ADIPOSE TISSUE

Adipose Tissue

bull Human ADSCs

ndash localize in the stromal vascular fraction

(SVF)

ndash The SVF consists of a heterogeneous

mesenchymal population of cells

bull Adipose stromal stem and progenitor cells

bull Hematopoietic stem and progenitor cells

bull endothelial cells erythrocytes fibroblasts

lymphocytes monocyte macrophages

and pericytes

NIH

-PA

Auth

or M

an

uscrip

tN

IH-P

A A

uth

or M

an

uscrip

tN

IH-P

A A

uth

or M

anu

scrip

t

BOURIN et al Page 13

Table II

Cell populations resident in SVF

Hematopoietic-lineage cells

Stem and progenitor cells lt01

Granulocytes 10ndash15

Monocytes 5ndash15

Lymphocytes 10ndash15

Endothelial cells 10ndash20

Pericytes 3ndash5

Stromal cells 15ndash30

Cytotherapy Author manuscript available in PMC 2014 April 08

Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648

Adipose Tissue

bull The stromal vascular fraction (SVF) is a

heterogeneous cell population derived from

manipulation of adipose tissue

ndash homogenization

ndash enzymatic digestion

ndash differential centrifugation

ndash red blood cells lysis and washing

Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Mesenchymal stem cells

bull Mulitpotent

bull More prone to differentiate

into muscle cells or even

into cardiomyocytes

compared with bone

marrow MSCs

bull Less efficient at osteogenic

and chondrogenic

differentiation

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Adipose Tissue

bull When treated with growth factors

ndash Upregulate expression of tendon related markers

ndash They are found comparable scaffold adherence and

proliferation potential

bull Suggesting AD-MSCs as alternative cell type for tendon

tissue repair

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239

Adipose Tissue

bull Easier to obtain

bull Bioscaffold

Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869

Adipose Tissue

bull General Set up

FDA CLEARANCE AND PRODUCT INFORMATION

TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose

tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure

Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints

middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture

middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents

middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue

middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)

IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha

legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat

isonlytobeusedwithoutanyadditionalmanipulation

Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister

middot LG60cc

middot LG240cc

1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm

120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes

260mlpolycarbonatesyringe2FemaleLuertransferconnectors

LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria

middot TheHCTPisminimallymanipulated

middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)

middot TheHCTPisnotcombinedwithanotherarticleand

middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction

DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016

Adipose Tissue HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer

5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe

6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Local Anesthetic

bull Connect the vacuum syringe to the

blunt 13-gauge Lipoaspiration

cannula

bull Advance and withdraw cannula in a

ldquospokes-of-a-wheelrdquo pattern

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto

createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly

3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand

holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe

canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe

canisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanister

approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

Adipose Tissue

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds

in a vertical motion

ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals

ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent

bull Collection ndash Pull down on the syringe

ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister

ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

HarvestingandProcessingGuide

WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand

rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities

2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion

3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals

4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps

CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach

10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe

clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith

salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull

syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe

Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor

Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection

Adipose Tissue

Adipose Tissue

bull 2002 national survey of 66000 tumescent

liposuction cases

ndash No deaths were reported

ndash Complication rate was 0068 per 1000 cases

Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002

Stem Cell summary

BMAC

bull 100k - 2M MSCs

bull Chondrocyte

bull Osteogenic

bull More painful

bull Volume limit

Adipose

bull 250k - 125M MSCs

bull Bioscaffold

bull Tendon defect filling

bull Less painfull

bull Larger volumes

AMNIOTIC TISSUE

Amniotic Tissue

bull Human Amniotic suspension allografts ndash Human amniotic membrane

ndash Human amniotic fluid-derived cells

bull Contain anti-inflammatory factorsndash IL-10 IL-1

ndash Metrix metalloproteinases 123 and 4

ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen

G5

ndash Hyaluranic Acid and small amount so proteoglycans

Amniotic Tissue

bull Human amniotic membrane

ndash Growth factors including EGF TGF-β and FGF

bull Stimulate epithelial cell migration and proliferation

bull PDGF A and B

ndash Stimulate many metabolic processes

raquo General protein and collagen synthesis collagenase activity

and chemotaxis of fibroblasts and of smooth muscle cells

raquo TGF-β has been shown to significantly increase type I

collagen production by tendon sheath fibroblasts

Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169

Amniotic Tissue

bull N = 6 KL grade 34

bull 12 weeks 3512 months

bull Primary goal feasibility of injection for treatment of OA

bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy

Amniotic Tissue

bull Pain and functional measures

ndash P ADL QOL S SR of the KOOS

ndash Overall KOOS IKDC SANE

bull All scores demonstrated improvement at 1 year

ndash Labs

bull No concerning changes in renal function blood cell

counts or lymphocyte subsets

bull Statistically significant increase in IgG and IgE relative to

baseline but not abnormal level

Amniotic Tissue

bull N23

ndash 14 Corticosteroid

ndash 9 c-hAM

bull Safe and comparable to steroid

Amniotic Tissue

Amniotic Tissue

bull N=470 181

bull VAS WOMAC

bull KL 1-3 OA

bull 30 90 120 days

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

Access this article

Or purchase this article - $20

Print Subscriber Activate your online access now

Welcome Guest Renew Subscribe or Create Account Sign In

HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

Access this article

Or purchase this article - $20

Print Subscriber Activate your online access now

Welcome Guest Renew Subscribe or Create Account Sign In

HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

Mesenchymal stem cells

bull MSC cells that have the ability to

proliferate and differentiate into

progenitors of different mesenchymal

tissue

bull They have unique cell surface

markers adhesion molecules

cytokines growth factors and

receptors

bull Anti-inflammatory and

immunomodulatory

Obaid et al Cell therapy in tendon disorders

What is the Current evidence

Am J Sports Med 2010 38 (10)

bioscienceorg

Slide Courtesy of Dr Joanne Borg Stein

Mesenchymal stem cells

bull Mesenchymal Stem Cells

1 Bone Marrow Derived MSCs

2 Adipose Tissue Derived MSCs

3 Synovium Derived MSCs

bull De Bari et al 2001

4 Muscle Derived MSCs

bull Williams et al 1999

5 Dermal Fibroblast

1 Connell et al N=12

BMAC

BMAC

bull Hemopoietic stem cells

bull Nonhemopoietic cells Mesenchymal Stem Cells

ndash 0001-001 of total cell population

ndash 100k - 2M MSCs

bull Diminishes with age

Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147

BMAC

bull General Set up

Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939

Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939

BMAC

bull Rate is not greater than that observed with other types of intra-articular injections

bull Annual neoplasm 078 in adults 50 ndash 64 yo

ndash This study showed 014

bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure

bull Only 3 were possibly related to stem cells

BMAC

bull Eight studies focused on focal chondral defects

bull Three studies evaluated for treatment of

osteoarthritis

BMAC

bull Six trials with high risk of bias showed

level-3 or level-4 evidence in favour of stem

cell injections in KOA

BMAC

Author BMAC Pathology NCenteno et al 2008

BMAC meniscus 1 ndash case study MRI showed increased volume

bmac prp x2 and dex with hyalgan

Giannini et al2009

BMAC Talus 48 6121824 mo Second look arthroscopy

New tissue on MRI

Kennedy and Murawski 2011

BMAC Talus 72

Pascual-Garridoet al 2012

BMAC Patellar tendinopathy

8 2-5 year follow up

Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri

Giannini et al 2013

BMAC Talus 20 48mo MRI new tissue

Singh et al 2014 BMAC Lateral epicondyle

30 2612 weeks Sig decrease in PRTEE scores

Centeno et al 2015

BMAC GH OA 115 2 year pain improvement

Prolo bmac and prp

Centeno et al 2015

BMAC ACL 10 cases grade 1-III

Improved MRI findings

Prolo BMAC + prp

Hannon et al 2016

BMAC Talus 34

Shapiro SA et al 2016

BMAC vs saline OA knee N = 25 VASWomackoos

Contralateral knee with saline

Safe well tolerated placebo

ADIPOSE TISSUE

Adipose Tissue

bull Human ADSCs

ndash localize in the stromal vascular fraction

(SVF)

ndash The SVF consists of a heterogeneous

mesenchymal population of cells

bull Adipose stromal stem and progenitor cells

bull Hematopoietic stem and progenitor cells

bull endothelial cells erythrocytes fibroblasts

lymphocytes monocyte macrophages

and pericytes

NIH

-PA

Auth

or M

an

uscrip

tN

IH-P

A A

uth

or M

an

uscrip

tN

IH-P

A A

uth

or M

anu

scrip

t

BOURIN et al Page 13

Table II

Cell populations resident in SVF

Hematopoietic-lineage cells

Stem and progenitor cells lt01

Granulocytes 10ndash15

Monocytes 5ndash15

Lymphocytes 10ndash15

Endothelial cells 10ndash20

Pericytes 3ndash5

Stromal cells 15ndash30

Cytotherapy Author manuscript available in PMC 2014 April 08

Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648

Adipose Tissue

bull The stromal vascular fraction (SVF) is a

heterogeneous cell population derived from

manipulation of adipose tissue

ndash homogenization

ndash enzymatic digestion

ndash differential centrifugation

ndash red blood cells lysis and washing

Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Mesenchymal stem cells

bull Mulitpotent

bull More prone to differentiate

into muscle cells or even

into cardiomyocytes

compared with bone

marrow MSCs

bull Less efficient at osteogenic

and chondrogenic

differentiation

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Adipose Tissue

bull When treated with growth factors

ndash Upregulate expression of tendon related markers

ndash They are found comparable scaffold adherence and

proliferation potential

bull Suggesting AD-MSCs as alternative cell type for tendon

tissue repair

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239

Adipose Tissue

bull Easier to obtain

bull Bioscaffold

Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869

Adipose Tissue

bull General Set up

FDA CLEARANCE AND PRODUCT INFORMATION

TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose

tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure

Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints

middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture

middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents

middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue

middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)

IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha

legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat

isonlytobeusedwithoutanyadditionalmanipulation

Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister

middot LG60cc

middot LG240cc

1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm

120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes

260mlpolycarbonatesyringe2FemaleLuertransferconnectors

LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria

middot TheHCTPisminimallymanipulated

middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)

middot TheHCTPisnotcombinedwithanotherarticleand

middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction

DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016

Adipose Tissue HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer

5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe

6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Local Anesthetic

bull Connect the vacuum syringe to the

blunt 13-gauge Lipoaspiration

cannula

bull Advance and withdraw cannula in a

ldquospokes-of-a-wheelrdquo pattern

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto

createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly

3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand

holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe

canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe

canisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanister

approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

Adipose Tissue

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds

in a vertical motion

ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals

ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent

bull Collection ndash Pull down on the syringe

ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister

ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

HarvestingandProcessingGuide

WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand

rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities

2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion

3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals

4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps

CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach

10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe

clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith

salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull

syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe

Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor

Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection

Adipose Tissue

Adipose Tissue

bull 2002 national survey of 66000 tumescent

liposuction cases

ndash No deaths were reported

ndash Complication rate was 0068 per 1000 cases

Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002

Stem Cell summary

BMAC

bull 100k - 2M MSCs

bull Chondrocyte

bull Osteogenic

bull More painful

bull Volume limit

Adipose

bull 250k - 125M MSCs

bull Bioscaffold

bull Tendon defect filling

bull Less painfull

bull Larger volumes

AMNIOTIC TISSUE

Amniotic Tissue

bull Human Amniotic suspension allografts ndash Human amniotic membrane

ndash Human amniotic fluid-derived cells

bull Contain anti-inflammatory factorsndash IL-10 IL-1

ndash Metrix metalloproteinases 123 and 4

ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen

G5

ndash Hyaluranic Acid and small amount so proteoglycans

Amniotic Tissue

bull Human amniotic membrane

ndash Growth factors including EGF TGF-β and FGF

bull Stimulate epithelial cell migration and proliferation

bull PDGF A and B

ndash Stimulate many metabolic processes

raquo General protein and collagen synthesis collagenase activity

and chemotaxis of fibroblasts and of smooth muscle cells

raquo TGF-β has been shown to significantly increase type I

collagen production by tendon sheath fibroblasts

Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169

Amniotic Tissue

bull N = 6 KL grade 34

bull 12 weeks 3512 months

bull Primary goal feasibility of injection for treatment of OA

bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy

Amniotic Tissue

bull Pain and functional measures

ndash P ADL QOL S SR of the KOOS

ndash Overall KOOS IKDC SANE

bull All scores demonstrated improvement at 1 year

ndash Labs

bull No concerning changes in renal function blood cell

counts or lymphocyte subsets

bull Statistically significant increase in IgG and IgE relative to

baseline but not abnormal level

Amniotic Tissue

bull N23

ndash 14 Corticosteroid

ndash 9 c-hAM

bull Safe and comparable to steroid

Amniotic Tissue

Amniotic Tissue

bull N=470 181

bull VAS WOMAC

bull KL 1-3 OA

bull 30 90 120 days

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

Access this article

Or purchase this article - $20

Print Subscriber Activate your online access now

Welcome Guest Renew Subscribe or Create Account Sign In

HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

Access this article

Or purchase this article - $20

Print Subscriber Activate your online access now

Welcome Guest Renew Subscribe or Create Account Sign In

HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

Mesenchymal stem cells

bull MSC cells that have the ability to

proliferate and differentiate into

progenitors of different mesenchymal

tissue

bull They have unique cell surface

markers adhesion molecules

cytokines growth factors and

receptors

bull Anti-inflammatory and

immunomodulatory

Obaid et al Cell therapy in tendon disorders

What is the Current evidence

Am J Sports Med 2010 38 (10)

bioscienceorg

Slide Courtesy of Dr Joanne Borg Stein

Mesenchymal stem cells

bull Mesenchymal Stem Cells

1 Bone Marrow Derived MSCs

2 Adipose Tissue Derived MSCs

3 Synovium Derived MSCs

bull De Bari et al 2001

4 Muscle Derived MSCs

bull Williams et al 1999

5 Dermal Fibroblast

1 Connell et al N=12

BMAC

BMAC

bull Hemopoietic stem cells

bull Nonhemopoietic cells Mesenchymal Stem Cells

ndash 0001-001 of total cell population

ndash 100k - 2M MSCs

bull Diminishes with age

Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147

BMAC

bull General Set up

Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939

Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939

BMAC

bull Rate is not greater than that observed with other types of intra-articular injections

bull Annual neoplasm 078 in adults 50 ndash 64 yo

ndash This study showed 014

bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure

bull Only 3 were possibly related to stem cells

BMAC

bull Eight studies focused on focal chondral defects

bull Three studies evaluated for treatment of

osteoarthritis

BMAC

bull Six trials with high risk of bias showed

level-3 or level-4 evidence in favour of stem

cell injections in KOA

BMAC

Author BMAC Pathology NCenteno et al 2008

BMAC meniscus 1 ndash case study MRI showed increased volume

bmac prp x2 and dex with hyalgan

Giannini et al2009

BMAC Talus 48 6121824 mo Second look arthroscopy

New tissue on MRI

Kennedy and Murawski 2011

BMAC Talus 72

Pascual-Garridoet al 2012

BMAC Patellar tendinopathy

8 2-5 year follow up

Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri

Giannini et al 2013

BMAC Talus 20 48mo MRI new tissue

Singh et al 2014 BMAC Lateral epicondyle

30 2612 weeks Sig decrease in PRTEE scores

Centeno et al 2015

BMAC GH OA 115 2 year pain improvement

Prolo bmac and prp

Centeno et al 2015

BMAC ACL 10 cases grade 1-III

Improved MRI findings

Prolo BMAC + prp

Hannon et al 2016

BMAC Talus 34

Shapiro SA et al 2016

BMAC vs saline OA knee N = 25 VASWomackoos

Contralateral knee with saline

Safe well tolerated placebo

ADIPOSE TISSUE

Adipose Tissue

bull Human ADSCs

ndash localize in the stromal vascular fraction

(SVF)

ndash The SVF consists of a heterogeneous

mesenchymal population of cells

bull Adipose stromal stem and progenitor cells

bull Hematopoietic stem and progenitor cells

bull endothelial cells erythrocytes fibroblasts

lymphocytes monocyte macrophages

and pericytes

NIH

-PA

Auth

or M

an

uscrip

tN

IH-P

A A

uth

or M

an

uscrip

tN

IH-P

A A

uth

or M

anu

scrip

t

BOURIN et al Page 13

Table II

Cell populations resident in SVF

Hematopoietic-lineage cells

Stem and progenitor cells lt01

Granulocytes 10ndash15

Monocytes 5ndash15

Lymphocytes 10ndash15

Endothelial cells 10ndash20

Pericytes 3ndash5

Stromal cells 15ndash30

Cytotherapy Author manuscript available in PMC 2014 April 08

Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648

Adipose Tissue

bull The stromal vascular fraction (SVF) is a

heterogeneous cell population derived from

manipulation of adipose tissue

ndash homogenization

ndash enzymatic digestion

ndash differential centrifugation

ndash red blood cells lysis and washing

Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Mesenchymal stem cells

bull Mulitpotent

bull More prone to differentiate

into muscle cells or even

into cardiomyocytes

compared with bone

marrow MSCs

bull Less efficient at osteogenic

and chondrogenic

differentiation

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Adipose Tissue

bull When treated with growth factors

ndash Upregulate expression of tendon related markers

ndash They are found comparable scaffold adherence and

proliferation potential

bull Suggesting AD-MSCs as alternative cell type for tendon

tissue repair

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239

Adipose Tissue

bull Easier to obtain

bull Bioscaffold

Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869

Adipose Tissue

bull General Set up

FDA CLEARANCE AND PRODUCT INFORMATION

TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose

tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure

Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints

middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture

middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents

middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue

middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)

IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha

legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat

isonlytobeusedwithoutanyadditionalmanipulation

Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister

middot LG60cc

middot LG240cc

1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm

120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes

260mlpolycarbonatesyringe2FemaleLuertransferconnectors

LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria

middot TheHCTPisminimallymanipulated

middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)

middot TheHCTPisnotcombinedwithanotherarticleand

middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction

DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016

Adipose Tissue HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer

5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe

6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Local Anesthetic

bull Connect the vacuum syringe to the

blunt 13-gauge Lipoaspiration

cannula

bull Advance and withdraw cannula in a

ldquospokes-of-a-wheelrdquo pattern

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto

createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly

3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand

holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe

canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe

canisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanister

approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

Adipose Tissue

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds

in a vertical motion

ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals

ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent

bull Collection ndash Pull down on the syringe

ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister

ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

HarvestingandProcessingGuide

WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand

rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities

2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion

3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals

4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps

CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach

10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe

clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith

salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull

syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe

Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor

Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection

Adipose Tissue

Adipose Tissue

bull 2002 national survey of 66000 tumescent

liposuction cases

ndash No deaths were reported

ndash Complication rate was 0068 per 1000 cases

Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002

Stem Cell summary

BMAC

bull 100k - 2M MSCs

bull Chondrocyte

bull Osteogenic

bull More painful

bull Volume limit

Adipose

bull 250k - 125M MSCs

bull Bioscaffold

bull Tendon defect filling

bull Less painfull

bull Larger volumes

AMNIOTIC TISSUE

Amniotic Tissue

bull Human Amniotic suspension allografts ndash Human amniotic membrane

ndash Human amniotic fluid-derived cells

bull Contain anti-inflammatory factorsndash IL-10 IL-1

ndash Metrix metalloproteinases 123 and 4

ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen

G5

ndash Hyaluranic Acid and small amount so proteoglycans

Amniotic Tissue

bull Human amniotic membrane

ndash Growth factors including EGF TGF-β and FGF

bull Stimulate epithelial cell migration and proliferation

bull PDGF A and B

ndash Stimulate many metabolic processes

raquo General protein and collagen synthesis collagenase activity

and chemotaxis of fibroblasts and of smooth muscle cells

raquo TGF-β has been shown to significantly increase type I

collagen production by tendon sheath fibroblasts

Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169

Amniotic Tissue

bull N = 6 KL grade 34

bull 12 weeks 3512 months

bull Primary goal feasibility of injection for treatment of OA

bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy

Amniotic Tissue

bull Pain and functional measures

ndash P ADL QOL S SR of the KOOS

ndash Overall KOOS IKDC SANE

bull All scores demonstrated improvement at 1 year

ndash Labs

bull No concerning changes in renal function blood cell

counts or lymphocyte subsets

bull Statistically significant increase in IgG and IgE relative to

baseline but not abnormal level

Amniotic Tissue

bull N23

ndash 14 Corticosteroid

ndash 9 c-hAM

bull Safe and comparable to steroid

Amniotic Tissue

Amniotic Tissue

bull N=470 181

bull VAS WOMAC

bull KL 1-3 OA

bull 30 90 120 days

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

Mesenchymal stem cells

bull MSC cells that have the ability to

proliferate and differentiate into

progenitors of different mesenchymal

tissue

bull They have unique cell surface

markers adhesion molecules

cytokines growth factors and

receptors

bull Anti-inflammatory and

immunomodulatory

Obaid et al Cell therapy in tendon disorders

What is the Current evidence

Am J Sports Med 2010 38 (10)

bioscienceorg

Slide Courtesy of Dr Joanne Borg Stein

Mesenchymal stem cells

bull Mesenchymal Stem Cells

1 Bone Marrow Derived MSCs

2 Adipose Tissue Derived MSCs

3 Synovium Derived MSCs

bull De Bari et al 2001

4 Muscle Derived MSCs

bull Williams et al 1999

5 Dermal Fibroblast

1 Connell et al N=12

BMAC

BMAC

bull Hemopoietic stem cells

bull Nonhemopoietic cells Mesenchymal Stem Cells

ndash 0001-001 of total cell population

ndash 100k - 2M MSCs

bull Diminishes with age

Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147

BMAC

bull General Set up

Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939

Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939

BMAC

bull Rate is not greater than that observed with other types of intra-articular injections

bull Annual neoplasm 078 in adults 50 ndash 64 yo

ndash This study showed 014

bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure

bull Only 3 were possibly related to stem cells

BMAC

bull Eight studies focused on focal chondral defects

bull Three studies evaluated for treatment of

osteoarthritis

BMAC

bull Six trials with high risk of bias showed

level-3 or level-4 evidence in favour of stem

cell injections in KOA

BMAC

Author BMAC Pathology NCenteno et al 2008

BMAC meniscus 1 ndash case study MRI showed increased volume

bmac prp x2 and dex with hyalgan

Giannini et al2009

BMAC Talus 48 6121824 mo Second look arthroscopy

New tissue on MRI

Kennedy and Murawski 2011

BMAC Talus 72

Pascual-Garridoet al 2012

BMAC Patellar tendinopathy

8 2-5 year follow up

Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri

Giannini et al 2013

BMAC Talus 20 48mo MRI new tissue

Singh et al 2014 BMAC Lateral epicondyle

30 2612 weeks Sig decrease in PRTEE scores

Centeno et al 2015

BMAC GH OA 115 2 year pain improvement

Prolo bmac and prp

Centeno et al 2015

BMAC ACL 10 cases grade 1-III

Improved MRI findings

Prolo BMAC + prp

Hannon et al 2016

BMAC Talus 34

Shapiro SA et al 2016

BMAC vs saline OA knee N = 25 VASWomackoos

Contralateral knee with saline

Safe well tolerated placebo

ADIPOSE TISSUE

Adipose Tissue

bull Human ADSCs

ndash localize in the stromal vascular fraction

(SVF)

ndash The SVF consists of a heterogeneous

mesenchymal population of cells

bull Adipose stromal stem and progenitor cells

bull Hematopoietic stem and progenitor cells

bull endothelial cells erythrocytes fibroblasts

lymphocytes monocyte macrophages

and pericytes

NIH

-PA

Auth

or M

an

uscrip

tN

IH-P

A A

uth

or M

an

uscrip

tN

IH-P

A A

uth

or M

anu

scrip

t

BOURIN et al Page 13

Table II

Cell populations resident in SVF

Hematopoietic-lineage cells

Stem and progenitor cells lt01

Granulocytes 10ndash15

Monocytes 5ndash15

Lymphocytes 10ndash15

Endothelial cells 10ndash20

Pericytes 3ndash5

Stromal cells 15ndash30

Cytotherapy Author manuscript available in PMC 2014 April 08

Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648

Adipose Tissue

bull The stromal vascular fraction (SVF) is a

heterogeneous cell population derived from

manipulation of adipose tissue

ndash homogenization

ndash enzymatic digestion

ndash differential centrifugation

ndash red blood cells lysis and washing

Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Mesenchymal stem cells

bull Mulitpotent

bull More prone to differentiate

into muscle cells or even

into cardiomyocytes

compared with bone

marrow MSCs

bull Less efficient at osteogenic

and chondrogenic

differentiation

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Adipose Tissue

bull When treated with growth factors

ndash Upregulate expression of tendon related markers

ndash They are found comparable scaffold adherence and

proliferation potential

bull Suggesting AD-MSCs as alternative cell type for tendon

tissue repair

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239

Adipose Tissue

bull Easier to obtain

bull Bioscaffold

Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869

Adipose Tissue

bull General Set up

FDA CLEARANCE AND PRODUCT INFORMATION

TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose

tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure

Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints

middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture

middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents

middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue

middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)

IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha

legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat

isonlytobeusedwithoutanyadditionalmanipulation

Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister

middot LG60cc

middot LG240cc

1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm

120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes

260mlpolycarbonatesyringe2FemaleLuertransferconnectors

LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria

middot TheHCTPisminimallymanipulated

middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)

middot TheHCTPisnotcombinedwithanotherarticleand

middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction

DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016

Adipose Tissue HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer

5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe

6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Local Anesthetic

bull Connect the vacuum syringe to the

blunt 13-gauge Lipoaspiration

cannula

bull Advance and withdraw cannula in a

ldquospokes-of-a-wheelrdquo pattern

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto

createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly

3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand

holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe

canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe

canisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanister

approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

Adipose Tissue

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds

in a vertical motion

ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals

ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent

bull Collection ndash Pull down on the syringe

ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister

ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

HarvestingandProcessingGuide

WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand

rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities

2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion

3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals

4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps

CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach

10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe

clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith

salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull

syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe

Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor

Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection

Adipose Tissue

Adipose Tissue

bull 2002 national survey of 66000 tumescent

liposuction cases

ndash No deaths were reported

ndash Complication rate was 0068 per 1000 cases

Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002

Stem Cell summary

BMAC

bull 100k - 2M MSCs

bull Chondrocyte

bull Osteogenic

bull More painful

bull Volume limit

Adipose

bull 250k - 125M MSCs

bull Bioscaffold

bull Tendon defect filling

bull Less painfull

bull Larger volumes

AMNIOTIC TISSUE

Amniotic Tissue

bull Human Amniotic suspension allografts ndash Human amniotic membrane

ndash Human amniotic fluid-derived cells

bull Contain anti-inflammatory factorsndash IL-10 IL-1

ndash Metrix metalloproteinases 123 and 4

ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen

G5

ndash Hyaluranic Acid and small amount so proteoglycans

Amniotic Tissue

bull Human amniotic membrane

ndash Growth factors including EGF TGF-β and FGF

bull Stimulate epithelial cell migration and proliferation

bull PDGF A and B

ndash Stimulate many metabolic processes

raquo General protein and collagen synthesis collagenase activity

and chemotaxis of fibroblasts and of smooth muscle cells

raquo TGF-β has been shown to significantly increase type I

collagen production by tendon sheath fibroblasts

Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169

Amniotic Tissue

bull N = 6 KL grade 34

bull 12 weeks 3512 months

bull Primary goal feasibility of injection for treatment of OA

bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy

Amniotic Tissue

bull Pain and functional measures

ndash P ADL QOL S SR of the KOOS

ndash Overall KOOS IKDC SANE

bull All scores demonstrated improvement at 1 year

ndash Labs

bull No concerning changes in renal function blood cell

counts or lymphocyte subsets

bull Statistically significant increase in IgG and IgE relative to

baseline but not abnormal level

Amniotic Tissue

bull N23

ndash 14 Corticosteroid

ndash 9 c-hAM

bull Safe and comparable to steroid

Amniotic Tissue

Amniotic Tissue

bull N=470 181

bull VAS WOMAC

bull KL 1-3 OA

bull 30 90 120 days

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

Mesenchymal stem cells

bull MSC cells that have the ability to

proliferate and differentiate into

progenitors of different mesenchymal

tissue

bull They have unique cell surface

markers adhesion molecules

cytokines growth factors and

receptors

bull Anti-inflammatory and

immunomodulatory

Obaid et al Cell therapy in tendon disorders

What is the Current evidence

Am J Sports Med 2010 38 (10)

bioscienceorg

Slide Courtesy of Dr Joanne Borg Stein

Mesenchymal stem cells

bull Mesenchymal Stem Cells

1 Bone Marrow Derived MSCs

2 Adipose Tissue Derived MSCs

3 Synovium Derived MSCs

bull De Bari et al 2001

4 Muscle Derived MSCs

bull Williams et al 1999

5 Dermal Fibroblast

1 Connell et al N=12

BMAC

BMAC

bull Hemopoietic stem cells

bull Nonhemopoietic cells Mesenchymal Stem Cells

ndash 0001-001 of total cell population

ndash 100k - 2M MSCs

bull Diminishes with age

Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147

BMAC

bull General Set up

Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939

Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939

BMAC

bull Rate is not greater than that observed with other types of intra-articular injections

bull Annual neoplasm 078 in adults 50 ndash 64 yo

ndash This study showed 014

bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure

bull Only 3 were possibly related to stem cells

BMAC

bull Eight studies focused on focal chondral defects

bull Three studies evaluated for treatment of

osteoarthritis

BMAC

bull Six trials with high risk of bias showed

level-3 or level-4 evidence in favour of stem

cell injections in KOA

BMAC

Author BMAC Pathology NCenteno et al 2008

BMAC meniscus 1 ndash case study MRI showed increased volume

bmac prp x2 and dex with hyalgan

Giannini et al2009

BMAC Talus 48 6121824 mo Second look arthroscopy

New tissue on MRI

Kennedy and Murawski 2011

BMAC Talus 72

Pascual-Garridoet al 2012

BMAC Patellar tendinopathy

8 2-5 year follow up

Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri

Giannini et al 2013

BMAC Talus 20 48mo MRI new tissue

Singh et al 2014 BMAC Lateral epicondyle

30 2612 weeks Sig decrease in PRTEE scores

Centeno et al 2015

BMAC GH OA 115 2 year pain improvement

Prolo bmac and prp

Centeno et al 2015

BMAC ACL 10 cases grade 1-III

Improved MRI findings

Prolo BMAC + prp

Hannon et al 2016

BMAC Talus 34

Shapiro SA et al 2016

BMAC vs saline OA knee N = 25 VASWomackoos

Contralateral knee with saline

Safe well tolerated placebo

ADIPOSE TISSUE

Adipose Tissue

bull Human ADSCs

ndash localize in the stromal vascular fraction

(SVF)

ndash The SVF consists of a heterogeneous

mesenchymal population of cells

bull Adipose stromal stem and progenitor cells

bull Hematopoietic stem and progenitor cells

bull endothelial cells erythrocytes fibroblasts

lymphocytes monocyte macrophages

and pericytes

NIH

-PA

Auth

or M

an

uscrip

tN

IH-P

A A

uth

or M

an

uscrip

tN

IH-P

A A

uth

or M

anu

scrip

t

BOURIN et al Page 13

Table II

Cell populations resident in SVF

Hematopoietic-lineage cells

Stem and progenitor cells lt01

Granulocytes 10ndash15

Monocytes 5ndash15

Lymphocytes 10ndash15

Endothelial cells 10ndash20

Pericytes 3ndash5

Stromal cells 15ndash30

Cytotherapy Author manuscript available in PMC 2014 April 08

Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648

Adipose Tissue

bull The stromal vascular fraction (SVF) is a

heterogeneous cell population derived from

manipulation of adipose tissue

ndash homogenization

ndash enzymatic digestion

ndash differential centrifugation

ndash red blood cells lysis and washing

Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Mesenchymal stem cells

bull Mulitpotent

bull More prone to differentiate

into muscle cells or even

into cardiomyocytes

compared with bone

marrow MSCs

bull Less efficient at osteogenic

and chondrogenic

differentiation

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Adipose Tissue

bull When treated with growth factors

ndash Upregulate expression of tendon related markers

ndash They are found comparable scaffold adherence and

proliferation potential

bull Suggesting AD-MSCs as alternative cell type for tendon

tissue repair

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239

Adipose Tissue

bull Easier to obtain

bull Bioscaffold

Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869

Adipose Tissue

bull General Set up

FDA CLEARANCE AND PRODUCT INFORMATION

TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose

tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure

Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints

middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture

middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents

middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue

middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)

IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha

legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat

isonlytobeusedwithoutanyadditionalmanipulation

Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister

middot LG60cc

middot LG240cc

1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm

120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes

260mlpolycarbonatesyringe2FemaleLuertransferconnectors

LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria

middot TheHCTPisminimallymanipulated

middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)

middot TheHCTPisnotcombinedwithanotherarticleand

middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction

DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016

Adipose Tissue HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer

5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe

6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Local Anesthetic

bull Connect the vacuum syringe to the

blunt 13-gauge Lipoaspiration

cannula

bull Advance and withdraw cannula in a

ldquospokes-of-a-wheelrdquo pattern

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto

createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly

3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand

holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe

canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe

canisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanister

approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

Adipose Tissue

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds

in a vertical motion

ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals

ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent

bull Collection ndash Pull down on the syringe

ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister

ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

HarvestingandProcessingGuide

WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand

rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities

2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion

3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals

4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps

CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach

10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe

clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith

salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull

syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe

Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor

Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection

Adipose Tissue

Adipose Tissue

bull 2002 national survey of 66000 tumescent

liposuction cases

ndash No deaths were reported

ndash Complication rate was 0068 per 1000 cases

Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002

Stem Cell summary

BMAC

bull 100k - 2M MSCs

bull Chondrocyte

bull Osteogenic

bull More painful

bull Volume limit

Adipose

bull 250k - 125M MSCs

bull Bioscaffold

bull Tendon defect filling

bull Less painfull

bull Larger volumes

AMNIOTIC TISSUE

Amniotic Tissue

bull Human Amniotic suspension allografts ndash Human amniotic membrane

ndash Human amniotic fluid-derived cells

bull Contain anti-inflammatory factorsndash IL-10 IL-1

ndash Metrix metalloproteinases 123 and 4

ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen

G5

ndash Hyaluranic Acid and small amount so proteoglycans

Amniotic Tissue

bull Human amniotic membrane

ndash Growth factors including EGF TGF-β and FGF

bull Stimulate epithelial cell migration and proliferation

bull PDGF A and B

ndash Stimulate many metabolic processes

raquo General protein and collagen synthesis collagenase activity

and chemotaxis of fibroblasts and of smooth muscle cells

raquo TGF-β has been shown to significantly increase type I

collagen production by tendon sheath fibroblasts

Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169

Amniotic Tissue

bull N = 6 KL grade 34

bull 12 weeks 3512 months

bull Primary goal feasibility of injection for treatment of OA

bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy

Amniotic Tissue

bull Pain and functional measures

ndash P ADL QOL S SR of the KOOS

ndash Overall KOOS IKDC SANE

bull All scores demonstrated improvement at 1 year

ndash Labs

bull No concerning changes in renal function blood cell

counts or lymphocyte subsets

bull Statistically significant increase in IgG and IgE relative to

baseline but not abnormal level

Amniotic Tissue

bull N23

ndash 14 Corticosteroid

ndash 9 c-hAM

bull Safe and comparable to steroid

Amniotic Tissue

Amniotic Tissue

bull N=470 181

bull VAS WOMAC

bull KL 1-3 OA

bull 30 90 120 days

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

Mesenchymal stem cells

bull Mesenchymal Stem Cells

1 Bone Marrow Derived MSCs

2 Adipose Tissue Derived MSCs

3 Synovium Derived MSCs

bull De Bari et al 2001

4 Muscle Derived MSCs

bull Williams et al 1999

5 Dermal Fibroblast

1 Connell et al N=12

BMAC

BMAC

bull Hemopoietic stem cells

bull Nonhemopoietic cells Mesenchymal Stem Cells

ndash 0001-001 of total cell population

ndash 100k - 2M MSCs

bull Diminishes with age

Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147

BMAC

bull General Set up

Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939

Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939

BMAC

bull Rate is not greater than that observed with other types of intra-articular injections

bull Annual neoplasm 078 in adults 50 ndash 64 yo

ndash This study showed 014

bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure

bull Only 3 were possibly related to stem cells

BMAC

bull Eight studies focused on focal chondral defects

bull Three studies evaluated for treatment of

osteoarthritis

BMAC

bull Six trials with high risk of bias showed

level-3 or level-4 evidence in favour of stem

cell injections in KOA

BMAC

Author BMAC Pathology NCenteno et al 2008

BMAC meniscus 1 ndash case study MRI showed increased volume

bmac prp x2 and dex with hyalgan

Giannini et al2009

BMAC Talus 48 6121824 mo Second look arthroscopy

New tissue on MRI

Kennedy and Murawski 2011

BMAC Talus 72

Pascual-Garridoet al 2012

BMAC Patellar tendinopathy

8 2-5 year follow up

Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri

Giannini et al 2013

BMAC Talus 20 48mo MRI new tissue

Singh et al 2014 BMAC Lateral epicondyle

30 2612 weeks Sig decrease in PRTEE scores

Centeno et al 2015

BMAC GH OA 115 2 year pain improvement

Prolo bmac and prp

Centeno et al 2015

BMAC ACL 10 cases grade 1-III

Improved MRI findings

Prolo BMAC + prp

Hannon et al 2016

BMAC Talus 34

Shapiro SA et al 2016

BMAC vs saline OA knee N = 25 VASWomackoos

Contralateral knee with saline

Safe well tolerated placebo

ADIPOSE TISSUE

Adipose Tissue

bull Human ADSCs

ndash localize in the stromal vascular fraction

(SVF)

ndash The SVF consists of a heterogeneous

mesenchymal population of cells

bull Adipose stromal stem and progenitor cells

bull Hematopoietic stem and progenitor cells

bull endothelial cells erythrocytes fibroblasts

lymphocytes monocyte macrophages

and pericytes

NIH

-PA

Auth

or M

an

uscrip

tN

IH-P

A A

uth

or M

an

uscrip

tN

IH-P

A A

uth

or M

anu

scrip

t

BOURIN et al Page 13

Table II

Cell populations resident in SVF

Hematopoietic-lineage cells

Stem and progenitor cells lt01

Granulocytes 10ndash15

Monocytes 5ndash15

Lymphocytes 10ndash15

Endothelial cells 10ndash20

Pericytes 3ndash5

Stromal cells 15ndash30

Cytotherapy Author manuscript available in PMC 2014 April 08

Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648

Adipose Tissue

bull The stromal vascular fraction (SVF) is a

heterogeneous cell population derived from

manipulation of adipose tissue

ndash homogenization

ndash enzymatic digestion

ndash differential centrifugation

ndash red blood cells lysis and washing

Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Mesenchymal stem cells

bull Mulitpotent

bull More prone to differentiate

into muscle cells or even

into cardiomyocytes

compared with bone

marrow MSCs

bull Less efficient at osteogenic

and chondrogenic

differentiation

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Adipose Tissue

bull When treated with growth factors

ndash Upregulate expression of tendon related markers

ndash They are found comparable scaffold adherence and

proliferation potential

bull Suggesting AD-MSCs as alternative cell type for tendon

tissue repair

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239

Adipose Tissue

bull Easier to obtain

bull Bioscaffold

Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869

Adipose Tissue

bull General Set up

FDA CLEARANCE AND PRODUCT INFORMATION

TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose

tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure

Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints

middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture

middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents

middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue

middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)

IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha

legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat

isonlytobeusedwithoutanyadditionalmanipulation

Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister

middot LG60cc

middot LG240cc

1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm

120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes

260mlpolycarbonatesyringe2FemaleLuertransferconnectors

LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria

middot TheHCTPisminimallymanipulated

middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)

middot TheHCTPisnotcombinedwithanotherarticleand

middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction

DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016

Adipose Tissue HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer

5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe

6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Local Anesthetic

bull Connect the vacuum syringe to the

blunt 13-gauge Lipoaspiration

cannula

bull Advance and withdraw cannula in a

ldquospokes-of-a-wheelrdquo pattern

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto

createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly

3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand

holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe

canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe

canisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanister

approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

Adipose Tissue

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds

in a vertical motion

ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals

ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent

bull Collection ndash Pull down on the syringe

ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister

ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

HarvestingandProcessingGuide

WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand

rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities

2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion

3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals

4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps

CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach

10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe

clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith

salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull

syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe

Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor

Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection

Adipose Tissue

Adipose Tissue

bull 2002 national survey of 66000 tumescent

liposuction cases

ndash No deaths were reported

ndash Complication rate was 0068 per 1000 cases

Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002

Stem Cell summary

BMAC

bull 100k - 2M MSCs

bull Chondrocyte

bull Osteogenic

bull More painful

bull Volume limit

Adipose

bull 250k - 125M MSCs

bull Bioscaffold

bull Tendon defect filling

bull Less painfull

bull Larger volumes

AMNIOTIC TISSUE

Amniotic Tissue

bull Human Amniotic suspension allografts ndash Human amniotic membrane

ndash Human amniotic fluid-derived cells

bull Contain anti-inflammatory factorsndash IL-10 IL-1

ndash Metrix metalloproteinases 123 and 4

ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen

G5

ndash Hyaluranic Acid and small amount so proteoglycans

Amniotic Tissue

bull Human amniotic membrane

ndash Growth factors including EGF TGF-β and FGF

bull Stimulate epithelial cell migration and proliferation

bull PDGF A and B

ndash Stimulate many metabolic processes

raquo General protein and collagen synthesis collagenase activity

and chemotaxis of fibroblasts and of smooth muscle cells

raquo TGF-β has been shown to significantly increase type I

collagen production by tendon sheath fibroblasts

Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169

Amniotic Tissue

bull N = 6 KL grade 34

bull 12 weeks 3512 months

bull Primary goal feasibility of injection for treatment of OA

bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy

Amniotic Tissue

bull Pain and functional measures

ndash P ADL QOL S SR of the KOOS

ndash Overall KOOS IKDC SANE

bull All scores demonstrated improvement at 1 year

ndash Labs

bull No concerning changes in renal function blood cell

counts or lymphocyte subsets

bull Statistically significant increase in IgG and IgE relative to

baseline but not abnormal level

Amniotic Tissue

bull N23

ndash 14 Corticosteroid

ndash 9 c-hAM

bull Safe and comparable to steroid

Amniotic Tissue

Amniotic Tissue

bull N=470 181

bull VAS WOMAC

bull KL 1-3 OA

bull 30 90 120 days

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

BMAC

BMAC

bull Hemopoietic stem cells

bull Nonhemopoietic cells Mesenchymal Stem Cells

ndash 0001-001 of total cell population

ndash 100k - 2M MSCs

bull Diminishes with age

Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147

BMAC

bull General Set up

Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939

Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939

BMAC

bull Rate is not greater than that observed with other types of intra-articular injections

bull Annual neoplasm 078 in adults 50 ndash 64 yo

ndash This study showed 014

bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure

bull Only 3 were possibly related to stem cells

BMAC

bull Eight studies focused on focal chondral defects

bull Three studies evaluated for treatment of

osteoarthritis

BMAC

bull Six trials with high risk of bias showed

level-3 or level-4 evidence in favour of stem

cell injections in KOA

BMAC

Author BMAC Pathology NCenteno et al 2008

BMAC meniscus 1 ndash case study MRI showed increased volume

bmac prp x2 and dex with hyalgan

Giannini et al2009

BMAC Talus 48 6121824 mo Second look arthroscopy

New tissue on MRI

Kennedy and Murawski 2011

BMAC Talus 72

Pascual-Garridoet al 2012

BMAC Patellar tendinopathy

8 2-5 year follow up

Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri

Giannini et al 2013

BMAC Talus 20 48mo MRI new tissue

Singh et al 2014 BMAC Lateral epicondyle

30 2612 weeks Sig decrease in PRTEE scores

Centeno et al 2015

BMAC GH OA 115 2 year pain improvement

Prolo bmac and prp

Centeno et al 2015

BMAC ACL 10 cases grade 1-III

Improved MRI findings

Prolo BMAC + prp

Hannon et al 2016

BMAC Talus 34

Shapiro SA et al 2016

BMAC vs saline OA knee N = 25 VASWomackoos

Contralateral knee with saline

Safe well tolerated placebo

ADIPOSE TISSUE

Adipose Tissue

bull Human ADSCs

ndash localize in the stromal vascular fraction

(SVF)

ndash The SVF consists of a heterogeneous

mesenchymal population of cells

bull Adipose stromal stem and progenitor cells

bull Hematopoietic stem and progenitor cells

bull endothelial cells erythrocytes fibroblasts

lymphocytes monocyte macrophages

and pericytes

NIH

-PA

Auth

or M

an

uscrip

tN

IH-P

A A

uth

or M

an

uscrip

tN

IH-P

A A

uth

or M

anu

scrip

t

BOURIN et al Page 13

Table II

Cell populations resident in SVF

Hematopoietic-lineage cells

Stem and progenitor cells lt01

Granulocytes 10ndash15

Monocytes 5ndash15

Lymphocytes 10ndash15

Endothelial cells 10ndash20

Pericytes 3ndash5

Stromal cells 15ndash30

Cytotherapy Author manuscript available in PMC 2014 April 08

Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648

Adipose Tissue

bull The stromal vascular fraction (SVF) is a

heterogeneous cell population derived from

manipulation of adipose tissue

ndash homogenization

ndash enzymatic digestion

ndash differential centrifugation

ndash red blood cells lysis and washing

Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Mesenchymal stem cells

bull Mulitpotent

bull More prone to differentiate

into muscle cells or even

into cardiomyocytes

compared with bone

marrow MSCs

bull Less efficient at osteogenic

and chondrogenic

differentiation

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Adipose Tissue

bull When treated with growth factors

ndash Upregulate expression of tendon related markers

ndash They are found comparable scaffold adherence and

proliferation potential

bull Suggesting AD-MSCs as alternative cell type for tendon

tissue repair

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239

Adipose Tissue

bull Easier to obtain

bull Bioscaffold

Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869

Adipose Tissue

bull General Set up

FDA CLEARANCE AND PRODUCT INFORMATION

TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose

tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure

Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints

middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture

middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents

middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue

middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)

IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha

legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat

isonlytobeusedwithoutanyadditionalmanipulation

Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister

middot LG60cc

middot LG240cc

1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm

120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes

260mlpolycarbonatesyringe2FemaleLuertransferconnectors

LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria

middot TheHCTPisminimallymanipulated

middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)

middot TheHCTPisnotcombinedwithanotherarticleand

middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction

DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016

Adipose Tissue HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer

5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe

6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Local Anesthetic

bull Connect the vacuum syringe to the

blunt 13-gauge Lipoaspiration

cannula

bull Advance and withdraw cannula in a

ldquospokes-of-a-wheelrdquo pattern

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto

createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly

3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand

holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe

canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe

canisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanister

approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

Adipose Tissue

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds

in a vertical motion

ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals

ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent

bull Collection ndash Pull down on the syringe

ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister

ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

HarvestingandProcessingGuide

WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand

rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities

2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion

3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals

4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps

CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach

10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe

clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith

salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull

syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe

Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor

Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection

Adipose Tissue

Adipose Tissue

bull 2002 national survey of 66000 tumescent

liposuction cases

ndash No deaths were reported

ndash Complication rate was 0068 per 1000 cases

Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002

Stem Cell summary

BMAC

bull 100k - 2M MSCs

bull Chondrocyte

bull Osteogenic

bull More painful

bull Volume limit

Adipose

bull 250k - 125M MSCs

bull Bioscaffold

bull Tendon defect filling

bull Less painfull

bull Larger volumes

AMNIOTIC TISSUE

Amniotic Tissue

bull Human Amniotic suspension allografts ndash Human amniotic membrane

ndash Human amniotic fluid-derived cells

bull Contain anti-inflammatory factorsndash IL-10 IL-1

ndash Metrix metalloproteinases 123 and 4

ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen

G5

ndash Hyaluranic Acid and small amount so proteoglycans

Amniotic Tissue

bull Human amniotic membrane

ndash Growth factors including EGF TGF-β and FGF

bull Stimulate epithelial cell migration and proliferation

bull PDGF A and B

ndash Stimulate many metabolic processes

raquo General protein and collagen synthesis collagenase activity

and chemotaxis of fibroblasts and of smooth muscle cells

raquo TGF-β has been shown to significantly increase type I

collagen production by tendon sheath fibroblasts

Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169

Amniotic Tissue

bull N = 6 KL grade 34

bull 12 weeks 3512 months

bull Primary goal feasibility of injection for treatment of OA

bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy

Amniotic Tissue

bull Pain and functional measures

ndash P ADL QOL S SR of the KOOS

ndash Overall KOOS IKDC SANE

bull All scores demonstrated improvement at 1 year

ndash Labs

bull No concerning changes in renal function blood cell

counts or lymphocyte subsets

bull Statistically significant increase in IgG and IgE relative to

baseline but not abnormal level

Amniotic Tissue

bull N23

ndash 14 Corticosteroid

ndash 9 c-hAM

bull Safe and comparable to steroid

Amniotic Tissue

Amniotic Tissue

bull N=470 181

bull VAS WOMAC

bull KL 1-3 OA

bull 30 90 120 days

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

BMAC

bull Hemopoietic stem cells

bull Nonhemopoietic cells Mesenchymal Stem Cells

ndash 0001-001 of total cell population

ndash 100k - 2M MSCs

bull Diminishes with age

Bocker W Yin Z Drosse I Haasters F Rossmann O Wierer M Popov C Locher M Mutschler W Docheva D Schieker M Introducing a single-cell-derived human mesenchymal stem cell line expressing hTERT after lentiviral gene transfer J Cell Mol Med 2008 121347ndash1359 Pettenger MF Mackay AM Beck SC et al Multilineage potential of adult human mesenchymal stem cells Science 1999284(5411)143-147

BMAC

bull General Set up

Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939

Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939

BMAC

bull Rate is not greater than that observed with other types of intra-articular injections

bull Annual neoplasm 078 in adults 50 ndash 64 yo

ndash This study showed 014

bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure

bull Only 3 were possibly related to stem cells

BMAC

bull Eight studies focused on focal chondral defects

bull Three studies evaluated for treatment of

osteoarthritis

BMAC

bull Six trials with high risk of bias showed

level-3 or level-4 evidence in favour of stem

cell injections in KOA

BMAC

Author BMAC Pathology NCenteno et al 2008

BMAC meniscus 1 ndash case study MRI showed increased volume

bmac prp x2 and dex with hyalgan

Giannini et al2009

BMAC Talus 48 6121824 mo Second look arthroscopy

New tissue on MRI

Kennedy and Murawski 2011

BMAC Talus 72

Pascual-Garridoet al 2012

BMAC Patellar tendinopathy

8 2-5 year follow up

Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri

Giannini et al 2013

BMAC Talus 20 48mo MRI new tissue

Singh et al 2014 BMAC Lateral epicondyle

30 2612 weeks Sig decrease in PRTEE scores

Centeno et al 2015

BMAC GH OA 115 2 year pain improvement

Prolo bmac and prp

Centeno et al 2015

BMAC ACL 10 cases grade 1-III

Improved MRI findings

Prolo BMAC + prp

Hannon et al 2016

BMAC Talus 34

Shapiro SA et al 2016

BMAC vs saline OA knee N = 25 VASWomackoos

Contralateral knee with saline

Safe well tolerated placebo

ADIPOSE TISSUE

Adipose Tissue

bull Human ADSCs

ndash localize in the stromal vascular fraction

(SVF)

ndash The SVF consists of a heterogeneous

mesenchymal population of cells

bull Adipose stromal stem and progenitor cells

bull Hematopoietic stem and progenitor cells

bull endothelial cells erythrocytes fibroblasts

lymphocytes monocyte macrophages

and pericytes

NIH

-PA

Auth

or M

an

uscrip

tN

IH-P

A A

uth

or M

an

uscrip

tN

IH-P

A A

uth

or M

anu

scrip

t

BOURIN et al Page 13

Table II

Cell populations resident in SVF

Hematopoietic-lineage cells

Stem and progenitor cells lt01

Granulocytes 10ndash15

Monocytes 5ndash15

Lymphocytes 10ndash15

Endothelial cells 10ndash20

Pericytes 3ndash5

Stromal cells 15ndash30

Cytotherapy Author manuscript available in PMC 2014 April 08

Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648

Adipose Tissue

bull The stromal vascular fraction (SVF) is a

heterogeneous cell population derived from

manipulation of adipose tissue

ndash homogenization

ndash enzymatic digestion

ndash differential centrifugation

ndash red blood cells lysis and washing

Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Mesenchymal stem cells

bull Mulitpotent

bull More prone to differentiate

into muscle cells or even

into cardiomyocytes

compared with bone

marrow MSCs

bull Less efficient at osteogenic

and chondrogenic

differentiation

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Adipose Tissue

bull When treated with growth factors

ndash Upregulate expression of tendon related markers

ndash They are found comparable scaffold adherence and

proliferation potential

bull Suggesting AD-MSCs as alternative cell type for tendon

tissue repair

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239

Adipose Tissue

bull Easier to obtain

bull Bioscaffold

Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869

Adipose Tissue

bull General Set up

FDA CLEARANCE AND PRODUCT INFORMATION

TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose

tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure

Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints

middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture

middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents

middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue

middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)

IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha

legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat

isonlytobeusedwithoutanyadditionalmanipulation

Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister

middot LG60cc

middot LG240cc

1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm

120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes

260mlpolycarbonatesyringe2FemaleLuertransferconnectors

LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria

middot TheHCTPisminimallymanipulated

middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)

middot TheHCTPisnotcombinedwithanotherarticleand

middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction

DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016

Adipose Tissue HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer

5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe

6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Local Anesthetic

bull Connect the vacuum syringe to the

blunt 13-gauge Lipoaspiration

cannula

bull Advance and withdraw cannula in a

ldquospokes-of-a-wheelrdquo pattern

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto

createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly

3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand

holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe

canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe

canisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanister

approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

Adipose Tissue

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds

in a vertical motion

ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals

ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent

bull Collection ndash Pull down on the syringe

ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister

ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

HarvestingandProcessingGuide

WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand

rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities

2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion

3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals

4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps

CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach

10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe

clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith

salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull

syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe

Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor

Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection

Adipose Tissue

Adipose Tissue

bull 2002 national survey of 66000 tumescent

liposuction cases

ndash No deaths were reported

ndash Complication rate was 0068 per 1000 cases

Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002

Stem Cell summary

BMAC

bull 100k - 2M MSCs

bull Chondrocyte

bull Osteogenic

bull More painful

bull Volume limit

Adipose

bull 250k - 125M MSCs

bull Bioscaffold

bull Tendon defect filling

bull Less painfull

bull Larger volumes

AMNIOTIC TISSUE

Amniotic Tissue

bull Human Amniotic suspension allografts ndash Human amniotic membrane

ndash Human amniotic fluid-derived cells

bull Contain anti-inflammatory factorsndash IL-10 IL-1

ndash Metrix metalloproteinases 123 and 4

ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen

G5

ndash Hyaluranic Acid and small amount so proteoglycans

Amniotic Tissue

bull Human amniotic membrane

ndash Growth factors including EGF TGF-β and FGF

bull Stimulate epithelial cell migration and proliferation

bull PDGF A and B

ndash Stimulate many metabolic processes

raquo General protein and collagen synthesis collagenase activity

and chemotaxis of fibroblasts and of smooth muscle cells

raquo TGF-β has been shown to significantly increase type I

collagen production by tendon sheath fibroblasts

Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169

Amniotic Tissue

bull N = 6 KL grade 34

bull 12 weeks 3512 months

bull Primary goal feasibility of injection for treatment of OA

bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy

Amniotic Tissue

bull Pain and functional measures

ndash P ADL QOL S SR of the KOOS

ndash Overall KOOS IKDC SANE

bull All scores demonstrated improvement at 1 year

ndash Labs

bull No concerning changes in renal function blood cell

counts or lymphocyte subsets

bull Statistically significant increase in IgG and IgE relative to

baseline but not abnormal level

Amniotic Tissue

bull N23

ndash 14 Corticosteroid

ndash 9 c-hAM

bull Safe and comparable to steroid

Amniotic Tissue

Amniotic Tissue

bull N=470 181

bull VAS WOMAC

bull KL 1-3 OA

bull 30 90 120 days

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

BMAC

bull General Set up

Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939

Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939

BMAC

bull Rate is not greater than that observed with other types of intra-articular injections

bull Annual neoplasm 078 in adults 50 ndash 64 yo

ndash This study showed 014

bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure

bull Only 3 were possibly related to stem cells

BMAC

bull Eight studies focused on focal chondral defects

bull Three studies evaluated for treatment of

osteoarthritis

BMAC

bull Six trials with high risk of bias showed

level-3 or level-4 evidence in favour of stem

cell injections in KOA

BMAC

Author BMAC Pathology NCenteno et al 2008

BMAC meniscus 1 ndash case study MRI showed increased volume

bmac prp x2 and dex with hyalgan

Giannini et al2009

BMAC Talus 48 6121824 mo Second look arthroscopy

New tissue on MRI

Kennedy and Murawski 2011

BMAC Talus 72

Pascual-Garridoet al 2012

BMAC Patellar tendinopathy

8 2-5 year follow up

Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri

Giannini et al 2013

BMAC Talus 20 48mo MRI new tissue

Singh et al 2014 BMAC Lateral epicondyle

30 2612 weeks Sig decrease in PRTEE scores

Centeno et al 2015

BMAC GH OA 115 2 year pain improvement

Prolo bmac and prp

Centeno et al 2015

BMAC ACL 10 cases grade 1-III

Improved MRI findings

Prolo BMAC + prp

Hannon et al 2016

BMAC Talus 34

Shapiro SA et al 2016

BMAC vs saline OA knee N = 25 VASWomackoos

Contralateral knee with saline

Safe well tolerated placebo

ADIPOSE TISSUE

Adipose Tissue

bull Human ADSCs

ndash localize in the stromal vascular fraction

(SVF)

ndash The SVF consists of a heterogeneous

mesenchymal population of cells

bull Adipose stromal stem and progenitor cells

bull Hematopoietic stem and progenitor cells

bull endothelial cells erythrocytes fibroblasts

lymphocytes monocyte macrophages

and pericytes

NIH

-PA

Auth

or M

an

uscrip

tN

IH-P

A A

uth

or M

an

uscrip

tN

IH-P

A A

uth

or M

anu

scrip

t

BOURIN et al Page 13

Table II

Cell populations resident in SVF

Hematopoietic-lineage cells

Stem and progenitor cells lt01

Granulocytes 10ndash15

Monocytes 5ndash15

Lymphocytes 10ndash15

Endothelial cells 10ndash20

Pericytes 3ndash5

Stromal cells 15ndash30

Cytotherapy Author manuscript available in PMC 2014 April 08

Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648

Adipose Tissue

bull The stromal vascular fraction (SVF) is a

heterogeneous cell population derived from

manipulation of adipose tissue

ndash homogenization

ndash enzymatic digestion

ndash differential centrifugation

ndash red blood cells lysis and washing

Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Mesenchymal stem cells

bull Mulitpotent

bull More prone to differentiate

into muscle cells or even

into cardiomyocytes

compared with bone

marrow MSCs

bull Less efficient at osteogenic

and chondrogenic

differentiation

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Adipose Tissue

bull When treated with growth factors

ndash Upregulate expression of tendon related markers

ndash They are found comparable scaffold adherence and

proliferation potential

bull Suggesting AD-MSCs as alternative cell type for tendon

tissue repair

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239

Adipose Tissue

bull Easier to obtain

bull Bioscaffold

Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869

Adipose Tissue

bull General Set up

FDA CLEARANCE AND PRODUCT INFORMATION

TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose

tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure

Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints

middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture

middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents

middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue

middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)

IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha

legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat

isonlytobeusedwithoutanyadditionalmanipulation

Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister

middot LG60cc

middot LG240cc

1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm

120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes

260mlpolycarbonatesyringe2FemaleLuertransferconnectors

LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria

middot TheHCTPisminimallymanipulated

middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)

middot TheHCTPisnotcombinedwithanotherarticleand

middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction

DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016

Adipose Tissue HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer

5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe

6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Local Anesthetic

bull Connect the vacuum syringe to the

blunt 13-gauge Lipoaspiration

cannula

bull Advance and withdraw cannula in a

ldquospokes-of-a-wheelrdquo pattern

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto

createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly

3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand

holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe

canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe

canisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanister

approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

Adipose Tissue

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds

in a vertical motion

ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals

ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent

bull Collection ndash Pull down on the syringe

ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister

ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

HarvestingandProcessingGuide

WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand

rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities

2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion

3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals

4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps

CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach

10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe

clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith

salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull

syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe

Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor

Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection

Adipose Tissue

Adipose Tissue

bull 2002 national survey of 66000 tumescent

liposuction cases

ndash No deaths were reported

ndash Complication rate was 0068 per 1000 cases

Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002

Stem Cell summary

BMAC

bull 100k - 2M MSCs

bull Chondrocyte

bull Osteogenic

bull More painful

bull Volume limit

Adipose

bull 250k - 125M MSCs

bull Bioscaffold

bull Tendon defect filling

bull Less painfull

bull Larger volumes

AMNIOTIC TISSUE

Amniotic Tissue

bull Human Amniotic suspension allografts ndash Human amniotic membrane

ndash Human amniotic fluid-derived cells

bull Contain anti-inflammatory factorsndash IL-10 IL-1

ndash Metrix metalloproteinases 123 and 4

ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen

G5

ndash Hyaluranic Acid and small amount so proteoglycans

Amniotic Tissue

bull Human amniotic membrane

ndash Growth factors including EGF TGF-β and FGF

bull Stimulate epithelial cell migration and proliferation

bull PDGF A and B

ndash Stimulate many metabolic processes

raquo General protein and collagen synthesis collagenase activity

and chemotaxis of fibroblasts and of smooth muscle cells

raquo TGF-β has been shown to significantly increase type I

collagen production by tendon sheath fibroblasts

Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169

Amniotic Tissue

bull N = 6 KL grade 34

bull 12 weeks 3512 months

bull Primary goal feasibility of injection for treatment of OA

bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy

Amniotic Tissue

bull Pain and functional measures

ndash P ADL QOL S SR of the KOOS

ndash Overall KOOS IKDC SANE

bull All scores demonstrated improvement at 1 year

ndash Labs

bull No concerning changes in renal function blood cell

counts or lymphocyte subsets

bull Statistically significant increase in IgG and IgE relative to

baseline but not abnormal level

Amniotic Tissue

bull N23

ndash 14 Corticosteroid

ndash 9 c-hAM

bull Safe and comparable to steroid

Amniotic Tissue

Amniotic Tissue

bull N=470 181

bull VAS WOMAC

bull KL 1-3 OA

bull 30 90 120 days

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

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Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

Friedlis MF Centeno CJ Performing a Better Bone Marrow Aspiration phys med rehabil clin N AM 27 (2016) 919-939

BMAC

bull Rate is not greater than that observed with other types of intra-articular injections

bull Annual neoplasm 078 in adults 50 ndash 64 yo

ndash This study showed 014

bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure

bull Only 3 were possibly related to stem cells

BMAC

bull Eight studies focused on focal chondral defects

bull Three studies evaluated for treatment of

osteoarthritis

BMAC

bull Six trials with high risk of bias showed

level-3 or level-4 evidence in favour of stem

cell injections in KOA

BMAC

Author BMAC Pathology NCenteno et al 2008

BMAC meniscus 1 ndash case study MRI showed increased volume

bmac prp x2 and dex with hyalgan

Giannini et al2009

BMAC Talus 48 6121824 mo Second look arthroscopy

New tissue on MRI

Kennedy and Murawski 2011

BMAC Talus 72

Pascual-Garridoet al 2012

BMAC Patellar tendinopathy

8 2-5 year follow up

Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri

Giannini et al 2013

BMAC Talus 20 48mo MRI new tissue

Singh et al 2014 BMAC Lateral epicondyle

30 2612 weeks Sig decrease in PRTEE scores

Centeno et al 2015

BMAC GH OA 115 2 year pain improvement

Prolo bmac and prp

Centeno et al 2015

BMAC ACL 10 cases grade 1-III

Improved MRI findings

Prolo BMAC + prp

Hannon et al 2016

BMAC Talus 34

Shapiro SA et al 2016

BMAC vs saline OA knee N = 25 VASWomackoos

Contralateral knee with saline

Safe well tolerated placebo

ADIPOSE TISSUE

Adipose Tissue

bull Human ADSCs

ndash localize in the stromal vascular fraction

(SVF)

ndash The SVF consists of a heterogeneous

mesenchymal population of cells

bull Adipose stromal stem and progenitor cells

bull Hematopoietic stem and progenitor cells

bull endothelial cells erythrocytes fibroblasts

lymphocytes monocyte macrophages

and pericytes

NIH

-PA

Auth

or M

an

uscrip

tN

IH-P

A A

uth

or M

an

uscrip

tN

IH-P

A A

uth

or M

anu

scrip

t

BOURIN et al Page 13

Table II

Cell populations resident in SVF

Hematopoietic-lineage cells

Stem and progenitor cells lt01

Granulocytes 10ndash15

Monocytes 5ndash15

Lymphocytes 10ndash15

Endothelial cells 10ndash20

Pericytes 3ndash5

Stromal cells 15ndash30

Cytotherapy Author manuscript available in PMC 2014 April 08

Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648

Adipose Tissue

bull The stromal vascular fraction (SVF) is a

heterogeneous cell population derived from

manipulation of adipose tissue

ndash homogenization

ndash enzymatic digestion

ndash differential centrifugation

ndash red blood cells lysis and washing

Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Mesenchymal stem cells

bull Mulitpotent

bull More prone to differentiate

into muscle cells or even

into cardiomyocytes

compared with bone

marrow MSCs

bull Less efficient at osteogenic

and chondrogenic

differentiation

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Adipose Tissue

bull When treated with growth factors

ndash Upregulate expression of tendon related markers

ndash They are found comparable scaffold adherence and

proliferation potential

bull Suggesting AD-MSCs as alternative cell type for tendon

tissue repair

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239

Adipose Tissue

bull Easier to obtain

bull Bioscaffold

Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869

Adipose Tissue

bull General Set up

FDA CLEARANCE AND PRODUCT INFORMATION

TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose

tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure

Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints

middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture

middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents

middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue

middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)

IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha

legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat

isonlytobeusedwithoutanyadditionalmanipulation

Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister

middot LG60cc

middot LG240cc

1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm

120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes

260mlpolycarbonatesyringe2FemaleLuertransferconnectors

LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria

middot TheHCTPisminimallymanipulated

middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)

middot TheHCTPisnotcombinedwithanotherarticleand

middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction

DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016

Adipose Tissue HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer

5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe

6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Local Anesthetic

bull Connect the vacuum syringe to the

blunt 13-gauge Lipoaspiration

cannula

bull Advance and withdraw cannula in a

ldquospokes-of-a-wheelrdquo pattern

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto

createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly

3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand

holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe

canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe

canisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanister

approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

Adipose Tissue

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds

in a vertical motion

ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals

ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent

bull Collection ndash Pull down on the syringe

ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister

ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

HarvestingandProcessingGuide

WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand

rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities

2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion

3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals

4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps

CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach

10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe

clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith

salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull

syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe

Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor

Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection

Adipose Tissue

Adipose Tissue

bull 2002 national survey of 66000 tumescent

liposuction cases

ndash No deaths were reported

ndash Complication rate was 0068 per 1000 cases

Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002

Stem Cell summary

BMAC

bull 100k - 2M MSCs

bull Chondrocyte

bull Osteogenic

bull More painful

bull Volume limit

Adipose

bull 250k - 125M MSCs

bull Bioscaffold

bull Tendon defect filling

bull Less painfull

bull Larger volumes

AMNIOTIC TISSUE

Amniotic Tissue

bull Human Amniotic suspension allografts ndash Human amniotic membrane

ndash Human amniotic fluid-derived cells

bull Contain anti-inflammatory factorsndash IL-10 IL-1

ndash Metrix metalloproteinases 123 and 4

ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen

G5

ndash Hyaluranic Acid and small amount so proteoglycans

Amniotic Tissue

bull Human amniotic membrane

ndash Growth factors including EGF TGF-β and FGF

bull Stimulate epithelial cell migration and proliferation

bull PDGF A and B

ndash Stimulate many metabolic processes

raquo General protein and collagen synthesis collagenase activity

and chemotaxis of fibroblasts and of smooth muscle cells

raquo TGF-β has been shown to significantly increase type I

collagen production by tendon sheath fibroblasts

Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169

Amniotic Tissue

bull N = 6 KL grade 34

bull 12 weeks 3512 months

bull Primary goal feasibility of injection for treatment of OA

bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy

Amniotic Tissue

bull Pain and functional measures

ndash P ADL QOL S SR of the KOOS

ndash Overall KOOS IKDC SANE

bull All scores demonstrated improvement at 1 year

ndash Labs

bull No concerning changes in renal function blood cell

counts or lymphocyte subsets

bull Statistically significant increase in IgG and IgE relative to

baseline but not abnormal level

Amniotic Tissue

bull N23

ndash 14 Corticosteroid

ndash 9 c-hAM

bull Safe and comparable to steroid

Amniotic Tissue

Amniotic Tissue

bull N=470 181

bull VAS WOMAC

bull KL 1-3 OA

bull 30 90 120 days

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

BMAC

bull Rate is not greater than that observed with other types of intra-articular injections

bull Annual neoplasm 078 in adults 50 ndash 64 yo

ndash This study showed 014

bull 13 possibly related SAEs among 2372 approximately 055 and only 4 of these SAE (017) were deemed definitely related to the procedure

bull Only 3 were possibly related to stem cells

BMAC

bull Eight studies focused on focal chondral defects

bull Three studies evaluated for treatment of

osteoarthritis

BMAC

bull Six trials with high risk of bias showed

level-3 or level-4 evidence in favour of stem

cell injections in KOA

BMAC

Author BMAC Pathology NCenteno et al 2008

BMAC meniscus 1 ndash case study MRI showed increased volume

bmac prp x2 and dex with hyalgan

Giannini et al2009

BMAC Talus 48 6121824 mo Second look arthroscopy

New tissue on MRI

Kennedy and Murawski 2011

BMAC Talus 72

Pascual-Garridoet al 2012

BMAC Patellar tendinopathy

8 2-5 year follow up

Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri

Giannini et al 2013

BMAC Talus 20 48mo MRI new tissue

Singh et al 2014 BMAC Lateral epicondyle

30 2612 weeks Sig decrease in PRTEE scores

Centeno et al 2015

BMAC GH OA 115 2 year pain improvement

Prolo bmac and prp

Centeno et al 2015

BMAC ACL 10 cases grade 1-III

Improved MRI findings

Prolo BMAC + prp

Hannon et al 2016

BMAC Talus 34

Shapiro SA et al 2016

BMAC vs saline OA knee N = 25 VASWomackoos

Contralateral knee with saline

Safe well tolerated placebo

ADIPOSE TISSUE

Adipose Tissue

bull Human ADSCs

ndash localize in the stromal vascular fraction

(SVF)

ndash The SVF consists of a heterogeneous

mesenchymal population of cells

bull Adipose stromal stem and progenitor cells

bull Hematopoietic stem and progenitor cells

bull endothelial cells erythrocytes fibroblasts

lymphocytes monocyte macrophages

and pericytes

NIH

-PA

Auth

or M

an

uscrip

tN

IH-P

A A

uth

or M

an

uscrip

tN

IH-P

A A

uth

or M

anu

scrip

t

BOURIN et al Page 13

Table II

Cell populations resident in SVF

Hematopoietic-lineage cells

Stem and progenitor cells lt01

Granulocytes 10ndash15

Monocytes 5ndash15

Lymphocytes 10ndash15

Endothelial cells 10ndash20

Pericytes 3ndash5

Stromal cells 15ndash30

Cytotherapy Author manuscript available in PMC 2014 April 08

Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648

Adipose Tissue

bull The stromal vascular fraction (SVF) is a

heterogeneous cell population derived from

manipulation of adipose tissue

ndash homogenization

ndash enzymatic digestion

ndash differential centrifugation

ndash red blood cells lysis and washing

Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Mesenchymal stem cells

bull Mulitpotent

bull More prone to differentiate

into muscle cells or even

into cardiomyocytes

compared with bone

marrow MSCs

bull Less efficient at osteogenic

and chondrogenic

differentiation

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Adipose Tissue

bull When treated with growth factors

ndash Upregulate expression of tendon related markers

ndash They are found comparable scaffold adherence and

proliferation potential

bull Suggesting AD-MSCs as alternative cell type for tendon

tissue repair

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239

Adipose Tissue

bull Easier to obtain

bull Bioscaffold

Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869

Adipose Tissue

bull General Set up

FDA CLEARANCE AND PRODUCT INFORMATION

TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose

tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure

Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints

middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture

middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents

middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue

middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)

IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha

legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat

isonlytobeusedwithoutanyadditionalmanipulation

Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister

middot LG60cc

middot LG240cc

1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm

120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes

260mlpolycarbonatesyringe2FemaleLuertransferconnectors

LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria

middot TheHCTPisminimallymanipulated

middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)

middot TheHCTPisnotcombinedwithanotherarticleand

middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction

DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016

Adipose Tissue HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer

5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe

6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Local Anesthetic

bull Connect the vacuum syringe to the

blunt 13-gauge Lipoaspiration

cannula

bull Advance and withdraw cannula in a

ldquospokes-of-a-wheelrdquo pattern

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto

createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly

3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand

holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe

canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe

canisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanister

approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

Adipose Tissue

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds

in a vertical motion

ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals

ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent

bull Collection ndash Pull down on the syringe

ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister

ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

HarvestingandProcessingGuide

WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand

rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities

2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion

3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals

4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps

CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach

10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe

clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith

salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull

syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe

Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor

Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection

Adipose Tissue

Adipose Tissue

bull 2002 national survey of 66000 tumescent

liposuction cases

ndash No deaths were reported

ndash Complication rate was 0068 per 1000 cases

Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002

Stem Cell summary

BMAC

bull 100k - 2M MSCs

bull Chondrocyte

bull Osteogenic

bull More painful

bull Volume limit

Adipose

bull 250k - 125M MSCs

bull Bioscaffold

bull Tendon defect filling

bull Less painfull

bull Larger volumes

AMNIOTIC TISSUE

Amniotic Tissue

bull Human Amniotic suspension allografts ndash Human amniotic membrane

ndash Human amniotic fluid-derived cells

bull Contain anti-inflammatory factorsndash IL-10 IL-1

ndash Metrix metalloproteinases 123 and 4

ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen

G5

ndash Hyaluranic Acid and small amount so proteoglycans

Amniotic Tissue

bull Human amniotic membrane

ndash Growth factors including EGF TGF-β and FGF

bull Stimulate epithelial cell migration and proliferation

bull PDGF A and B

ndash Stimulate many metabolic processes

raquo General protein and collagen synthesis collagenase activity

and chemotaxis of fibroblasts and of smooth muscle cells

raquo TGF-β has been shown to significantly increase type I

collagen production by tendon sheath fibroblasts

Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169

Amniotic Tissue

bull N = 6 KL grade 34

bull 12 weeks 3512 months

bull Primary goal feasibility of injection for treatment of OA

bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy

Amniotic Tissue

bull Pain and functional measures

ndash P ADL QOL S SR of the KOOS

ndash Overall KOOS IKDC SANE

bull All scores demonstrated improvement at 1 year

ndash Labs

bull No concerning changes in renal function blood cell

counts or lymphocyte subsets

bull Statistically significant increase in IgG and IgE relative to

baseline but not abnormal level

Amniotic Tissue

bull N23

ndash 14 Corticosteroid

ndash 9 c-hAM

bull Safe and comparable to steroid

Amniotic Tissue

Amniotic Tissue

bull N=470 181

bull VAS WOMAC

bull KL 1-3 OA

bull 30 90 120 days

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

BMAC

bull Eight studies focused on focal chondral defects

bull Three studies evaluated for treatment of

osteoarthritis

BMAC

bull Six trials with high risk of bias showed

level-3 or level-4 evidence in favour of stem

cell injections in KOA

BMAC

Author BMAC Pathology NCenteno et al 2008

BMAC meniscus 1 ndash case study MRI showed increased volume

bmac prp x2 and dex with hyalgan

Giannini et al2009

BMAC Talus 48 6121824 mo Second look arthroscopy

New tissue on MRI

Kennedy and Murawski 2011

BMAC Talus 72

Pascual-Garridoet al 2012

BMAC Patellar tendinopathy

8 2-5 year follow up

Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri

Giannini et al 2013

BMAC Talus 20 48mo MRI new tissue

Singh et al 2014 BMAC Lateral epicondyle

30 2612 weeks Sig decrease in PRTEE scores

Centeno et al 2015

BMAC GH OA 115 2 year pain improvement

Prolo bmac and prp

Centeno et al 2015

BMAC ACL 10 cases grade 1-III

Improved MRI findings

Prolo BMAC + prp

Hannon et al 2016

BMAC Talus 34

Shapiro SA et al 2016

BMAC vs saline OA knee N = 25 VASWomackoos

Contralateral knee with saline

Safe well tolerated placebo

ADIPOSE TISSUE

Adipose Tissue

bull Human ADSCs

ndash localize in the stromal vascular fraction

(SVF)

ndash The SVF consists of a heterogeneous

mesenchymal population of cells

bull Adipose stromal stem and progenitor cells

bull Hematopoietic stem and progenitor cells

bull endothelial cells erythrocytes fibroblasts

lymphocytes monocyte macrophages

and pericytes

NIH

-PA

Auth

or M

an

uscrip

tN

IH-P

A A

uth

or M

an

uscrip

tN

IH-P

A A

uth

or M

anu

scrip

t

BOURIN et al Page 13

Table II

Cell populations resident in SVF

Hematopoietic-lineage cells

Stem and progenitor cells lt01

Granulocytes 10ndash15

Monocytes 5ndash15

Lymphocytes 10ndash15

Endothelial cells 10ndash20

Pericytes 3ndash5

Stromal cells 15ndash30

Cytotherapy Author manuscript available in PMC 2014 April 08

Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648

Adipose Tissue

bull The stromal vascular fraction (SVF) is a

heterogeneous cell population derived from

manipulation of adipose tissue

ndash homogenization

ndash enzymatic digestion

ndash differential centrifugation

ndash red blood cells lysis and washing

Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Mesenchymal stem cells

bull Mulitpotent

bull More prone to differentiate

into muscle cells or even

into cardiomyocytes

compared with bone

marrow MSCs

bull Less efficient at osteogenic

and chondrogenic

differentiation

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Adipose Tissue

bull When treated with growth factors

ndash Upregulate expression of tendon related markers

ndash They are found comparable scaffold adherence and

proliferation potential

bull Suggesting AD-MSCs as alternative cell type for tendon

tissue repair

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239

Adipose Tissue

bull Easier to obtain

bull Bioscaffold

Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869

Adipose Tissue

bull General Set up

FDA CLEARANCE AND PRODUCT INFORMATION

TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose

tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure

Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints

middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture

middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents

middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue

middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)

IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha

legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat

isonlytobeusedwithoutanyadditionalmanipulation

Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister

middot LG60cc

middot LG240cc

1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm

120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes

260mlpolycarbonatesyringe2FemaleLuertransferconnectors

LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria

middot TheHCTPisminimallymanipulated

middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)

middot TheHCTPisnotcombinedwithanotherarticleand

middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction

DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016

Adipose Tissue HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer

5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe

6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Local Anesthetic

bull Connect the vacuum syringe to the

blunt 13-gauge Lipoaspiration

cannula

bull Advance and withdraw cannula in a

ldquospokes-of-a-wheelrdquo pattern

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto

createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly

3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand

holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe

canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe

canisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanister

approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

Adipose Tissue

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds

in a vertical motion

ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals

ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent

bull Collection ndash Pull down on the syringe

ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister

ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

HarvestingandProcessingGuide

WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand

rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities

2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion

3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals

4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps

CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach

10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe

clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith

salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull

syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe

Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor

Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection

Adipose Tissue

Adipose Tissue

bull 2002 national survey of 66000 tumescent

liposuction cases

ndash No deaths were reported

ndash Complication rate was 0068 per 1000 cases

Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002

Stem Cell summary

BMAC

bull 100k - 2M MSCs

bull Chondrocyte

bull Osteogenic

bull More painful

bull Volume limit

Adipose

bull 250k - 125M MSCs

bull Bioscaffold

bull Tendon defect filling

bull Less painfull

bull Larger volumes

AMNIOTIC TISSUE

Amniotic Tissue

bull Human Amniotic suspension allografts ndash Human amniotic membrane

ndash Human amniotic fluid-derived cells

bull Contain anti-inflammatory factorsndash IL-10 IL-1

ndash Metrix metalloproteinases 123 and 4

ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen

G5

ndash Hyaluranic Acid and small amount so proteoglycans

Amniotic Tissue

bull Human amniotic membrane

ndash Growth factors including EGF TGF-β and FGF

bull Stimulate epithelial cell migration and proliferation

bull PDGF A and B

ndash Stimulate many metabolic processes

raquo General protein and collagen synthesis collagenase activity

and chemotaxis of fibroblasts and of smooth muscle cells

raquo TGF-β has been shown to significantly increase type I

collagen production by tendon sheath fibroblasts

Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169

Amniotic Tissue

bull N = 6 KL grade 34

bull 12 weeks 3512 months

bull Primary goal feasibility of injection for treatment of OA

bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy

Amniotic Tissue

bull Pain and functional measures

ndash P ADL QOL S SR of the KOOS

ndash Overall KOOS IKDC SANE

bull All scores demonstrated improvement at 1 year

ndash Labs

bull No concerning changes in renal function blood cell

counts or lymphocyte subsets

bull Statistically significant increase in IgG and IgE relative to

baseline but not abnormal level

Amniotic Tissue

bull N23

ndash 14 Corticosteroid

ndash 9 c-hAM

bull Safe and comparable to steroid

Amniotic Tissue

Amniotic Tissue

bull N=470 181

bull VAS WOMAC

bull KL 1-3 OA

bull 30 90 120 days

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

BMAC

bull Six trials with high risk of bias showed

level-3 or level-4 evidence in favour of stem

cell injections in KOA

BMAC

Author BMAC Pathology NCenteno et al 2008

BMAC meniscus 1 ndash case study MRI showed increased volume

bmac prp x2 and dex with hyalgan

Giannini et al2009

BMAC Talus 48 6121824 mo Second look arthroscopy

New tissue on MRI

Kennedy and Murawski 2011

BMAC Talus 72

Pascual-Garridoet al 2012

BMAC Patellar tendinopathy

8 2-5 year follow up

Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri

Giannini et al 2013

BMAC Talus 20 48mo MRI new tissue

Singh et al 2014 BMAC Lateral epicondyle

30 2612 weeks Sig decrease in PRTEE scores

Centeno et al 2015

BMAC GH OA 115 2 year pain improvement

Prolo bmac and prp

Centeno et al 2015

BMAC ACL 10 cases grade 1-III

Improved MRI findings

Prolo BMAC + prp

Hannon et al 2016

BMAC Talus 34

Shapiro SA et al 2016

BMAC vs saline OA knee N = 25 VASWomackoos

Contralateral knee with saline

Safe well tolerated placebo

ADIPOSE TISSUE

Adipose Tissue

bull Human ADSCs

ndash localize in the stromal vascular fraction

(SVF)

ndash The SVF consists of a heterogeneous

mesenchymal population of cells

bull Adipose stromal stem and progenitor cells

bull Hematopoietic stem and progenitor cells

bull endothelial cells erythrocytes fibroblasts

lymphocytes monocyte macrophages

and pericytes

NIH

-PA

Auth

or M

an

uscrip

tN

IH-P

A A

uth

or M

an

uscrip

tN

IH-P

A A

uth

or M

anu

scrip

t

BOURIN et al Page 13

Table II

Cell populations resident in SVF

Hematopoietic-lineage cells

Stem and progenitor cells lt01

Granulocytes 10ndash15

Monocytes 5ndash15

Lymphocytes 10ndash15

Endothelial cells 10ndash20

Pericytes 3ndash5

Stromal cells 15ndash30

Cytotherapy Author manuscript available in PMC 2014 April 08

Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648

Adipose Tissue

bull The stromal vascular fraction (SVF) is a

heterogeneous cell population derived from

manipulation of adipose tissue

ndash homogenization

ndash enzymatic digestion

ndash differential centrifugation

ndash red blood cells lysis and washing

Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Mesenchymal stem cells

bull Mulitpotent

bull More prone to differentiate

into muscle cells or even

into cardiomyocytes

compared with bone

marrow MSCs

bull Less efficient at osteogenic

and chondrogenic

differentiation

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Adipose Tissue

bull When treated with growth factors

ndash Upregulate expression of tendon related markers

ndash They are found comparable scaffold adherence and

proliferation potential

bull Suggesting AD-MSCs as alternative cell type for tendon

tissue repair

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239

Adipose Tissue

bull Easier to obtain

bull Bioscaffold

Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869

Adipose Tissue

bull General Set up

FDA CLEARANCE AND PRODUCT INFORMATION

TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose

tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure

Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints

middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture

middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents

middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue

middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)

IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha

legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat

isonlytobeusedwithoutanyadditionalmanipulation

Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister

middot LG60cc

middot LG240cc

1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm

120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes

260mlpolycarbonatesyringe2FemaleLuertransferconnectors

LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria

middot TheHCTPisminimallymanipulated

middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)

middot TheHCTPisnotcombinedwithanotherarticleand

middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction

DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016

Adipose Tissue HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer

5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe

6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Local Anesthetic

bull Connect the vacuum syringe to the

blunt 13-gauge Lipoaspiration

cannula

bull Advance and withdraw cannula in a

ldquospokes-of-a-wheelrdquo pattern

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto

createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly

3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand

holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe

canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe

canisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanister

approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

Adipose Tissue

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds

in a vertical motion

ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals

ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent

bull Collection ndash Pull down on the syringe

ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister

ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

HarvestingandProcessingGuide

WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand

rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities

2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion

3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals

4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps

CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach

10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe

clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith

salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull

syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe

Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor

Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection

Adipose Tissue

Adipose Tissue

bull 2002 national survey of 66000 tumescent

liposuction cases

ndash No deaths were reported

ndash Complication rate was 0068 per 1000 cases

Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002

Stem Cell summary

BMAC

bull 100k - 2M MSCs

bull Chondrocyte

bull Osteogenic

bull More painful

bull Volume limit

Adipose

bull 250k - 125M MSCs

bull Bioscaffold

bull Tendon defect filling

bull Less painfull

bull Larger volumes

AMNIOTIC TISSUE

Amniotic Tissue

bull Human Amniotic suspension allografts ndash Human amniotic membrane

ndash Human amniotic fluid-derived cells

bull Contain anti-inflammatory factorsndash IL-10 IL-1

ndash Metrix metalloproteinases 123 and 4

ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen

G5

ndash Hyaluranic Acid and small amount so proteoglycans

Amniotic Tissue

bull Human amniotic membrane

ndash Growth factors including EGF TGF-β and FGF

bull Stimulate epithelial cell migration and proliferation

bull PDGF A and B

ndash Stimulate many metabolic processes

raquo General protein and collagen synthesis collagenase activity

and chemotaxis of fibroblasts and of smooth muscle cells

raquo TGF-β has been shown to significantly increase type I

collagen production by tendon sheath fibroblasts

Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169

Amniotic Tissue

bull N = 6 KL grade 34

bull 12 weeks 3512 months

bull Primary goal feasibility of injection for treatment of OA

bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy

Amniotic Tissue

bull Pain and functional measures

ndash P ADL QOL S SR of the KOOS

ndash Overall KOOS IKDC SANE

bull All scores demonstrated improvement at 1 year

ndash Labs

bull No concerning changes in renal function blood cell

counts or lymphocyte subsets

bull Statistically significant increase in IgG and IgE relative to

baseline but not abnormal level

Amniotic Tissue

bull N23

ndash 14 Corticosteroid

ndash 9 c-hAM

bull Safe and comparable to steroid

Amniotic Tissue

Amniotic Tissue

bull N=470 181

bull VAS WOMAC

bull KL 1-3 OA

bull 30 90 120 days

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

BMAC

Author BMAC Pathology NCenteno et al 2008

BMAC meniscus 1 ndash case study MRI showed increased volume

bmac prp x2 and dex with hyalgan

Giannini et al2009

BMAC Talus 48 6121824 mo Second look arthroscopy

New tissue on MRI

Kennedy and Murawski 2011

BMAC Talus 72

Pascual-Garridoet al 2012

BMAC Patellar tendinopathy

8 2-5 year follow up

Koos SF 12IKDC No recurrence in 5 yrs recurrence rate usually 12-27 ultrasound evidence of healing more accurate than mri

Giannini et al 2013

BMAC Talus 20 48mo MRI new tissue

Singh et al 2014 BMAC Lateral epicondyle

30 2612 weeks Sig decrease in PRTEE scores

Centeno et al 2015

BMAC GH OA 115 2 year pain improvement

Prolo bmac and prp

Centeno et al 2015

BMAC ACL 10 cases grade 1-III

Improved MRI findings

Prolo BMAC + prp

Hannon et al 2016

BMAC Talus 34

Shapiro SA et al 2016

BMAC vs saline OA knee N = 25 VASWomackoos

Contralateral knee with saline

Safe well tolerated placebo

ADIPOSE TISSUE

Adipose Tissue

bull Human ADSCs

ndash localize in the stromal vascular fraction

(SVF)

ndash The SVF consists of a heterogeneous

mesenchymal population of cells

bull Adipose stromal stem and progenitor cells

bull Hematopoietic stem and progenitor cells

bull endothelial cells erythrocytes fibroblasts

lymphocytes monocyte macrophages

and pericytes

NIH

-PA

Auth

or M

an

uscrip

tN

IH-P

A A

uth

or M

an

uscrip

tN

IH-P

A A

uth

or M

anu

scrip

t

BOURIN et al Page 13

Table II

Cell populations resident in SVF

Hematopoietic-lineage cells

Stem and progenitor cells lt01

Granulocytes 10ndash15

Monocytes 5ndash15

Lymphocytes 10ndash15

Endothelial cells 10ndash20

Pericytes 3ndash5

Stromal cells 15ndash30

Cytotherapy Author manuscript available in PMC 2014 April 08

Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648

Adipose Tissue

bull The stromal vascular fraction (SVF) is a

heterogeneous cell population derived from

manipulation of adipose tissue

ndash homogenization

ndash enzymatic digestion

ndash differential centrifugation

ndash red blood cells lysis and washing

Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Mesenchymal stem cells

bull Mulitpotent

bull More prone to differentiate

into muscle cells or even

into cardiomyocytes

compared with bone

marrow MSCs

bull Less efficient at osteogenic

and chondrogenic

differentiation

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Adipose Tissue

bull When treated with growth factors

ndash Upregulate expression of tendon related markers

ndash They are found comparable scaffold adherence and

proliferation potential

bull Suggesting AD-MSCs as alternative cell type for tendon

tissue repair

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239

Adipose Tissue

bull Easier to obtain

bull Bioscaffold

Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869

Adipose Tissue

bull General Set up

FDA CLEARANCE AND PRODUCT INFORMATION

TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose

tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure

Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints

middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture

middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents

middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue

middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)

IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha

legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat

isonlytobeusedwithoutanyadditionalmanipulation

Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister

middot LG60cc

middot LG240cc

1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm

120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes

260mlpolycarbonatesyringe2FemaleLuertransferconnectors

LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria

middot TheHCTPisminimallymanipulated

middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)

middot TheHCTPisnotcombinedwithanotherarticleand

middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction

DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016

Adipose Tissue HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer

5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe

6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Local Anesthetic

bull Connect the vacuum syringe to the

blunt 13-gauge Lipoaspiration

cannula

bull Advance and withdraw cannula in a

ldquospokes-of-a-wheelrdquo pattern

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto

createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly

3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand

holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe

canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe

canisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanister

approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

Adipose Tissue

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds

in a vertical motion

ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals

ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent

bull Collection ndash Pull down on the syringe

ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister

ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

HarvestingandProcessingGuide

WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand

rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities

2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion

3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals

4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps

CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach

10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe

clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith

salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull

syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe

Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor

Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection

Adipose Tissue

Adipose Tissue

bull 2002 national survey of 66000 tumescent

liposuction cases

ndash No deaths were reported

ndash Complication rate was 0068 per 1000 cases

Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002

Stem Cell summary

BMAC

bull 100k - 2M MSCs

bull Chondrocyte

bull Osteogenic

bull More painful

bull Volume limit

Adipose

bull 250k - 125M MSCs

bull Bioscaffold

bull Tendon defect filling

bull Less painfull

bull Larger volumes

AMNIOTIC TISSUE

Amniotic Tissue

bull Human Amniotic suspension allografts ndash Human amniotic membrane

ndash Human amniotic fluid-derived cells

bull Contain anti-inflammatory factorsndash IL-10 IL-1

ndash Metrix metalloproteinases 123 and 4

ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen

G5

ndash Hyaluranic Acid and small amount so proteoglycans

Amniotic Tissue

bull Human amniotic membrane

ndash Growth factors including EGF TGF-β and FGF

bull Stimulate epithelial cell migration and proliferation

bull PDGF A and B

ndash Stimulate many metabolic processes

raquo General protein and collagen synthesis collagenase activity

and chemotaxis of fibroblasts and of smooth muscle cells

raquo TGF-β has been shown to significantly increase type I

collagen production by tendon sheath fibroblasts

Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169

Amniotic Tissue

bull N = 6 KL grade 34

bull 12 weeks 3512 months

bull Primary goal feasibility of injection for treatment of OA

bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy

Amniotic Tissue

bull Pain and functional measures

ndash P ADL QOL S SR of the KOOS

ndash Overall KOOS IKDC SANE

bull All scores demonstrated improvement at 1 year

ndash Labs

bull No concerning changes in renal function blood cell

counts or lymphocyte subsets

bull Statistically significant increase in IgG and IgE relative to

baseline but not abnormal level

Amniotic Tissue

bull N23

ndash 14 Corticosteroid

ndash 9 c-hAM

bull Safe and comparable to steroid

Amniotic Tissue

Amniotic Tissue

bull N=470 181

bull VAS WOMAC

bull KL 1-3 OA

bull 30 90 120 days

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

ADIPOSE TISSUE

Adipose Tissue

bull Human ADSCs

ndash localize in the stromal vascular fraction

(SVF)

ndash The SVF consists of a heterogeneous

mesenchymal population of cells

bull Adipose stromal stem and progenitor cells

bull Hematopoietic stem and progenitor cells

bull endothelial cells erythrocytes fibroblasts

lymphocytes monocyte macrophages

and pericytes

NIH

-PA

Auth

or M

an

uscrip

tN

IH-P

A A

uth

or M

an

uscrip

tN

IH-P

A A

uth

or M

anu

scrip

t

BOURIN et al Page 13

Table II

Cell populations resident in SVF

Hematopoietic-lineage cells

Stem and progenitor cells lt01

Granulocytes 10ndash15

Monocytes 5ndash15

Lymphocytes 10ndash15

Endothelial cells 10ndash20

Pericytes 3ndash5

Stromal cells 15ndash30

Cytotherapy Author manuscript available in PMC 2014 April 08

Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648

Adipose Tissue

bull The stromal vascular fraction (SVF) is a

heterogeneous cell population derived from

manipulation of adipose tissue

ndash homogenization

ndash enzymatic digestion

ndash differential centrifugation

ndash red blood cells lysis and washing

Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Mesenchymal stem cells

bull Mulitpotent

bull More prone to differentiate

into muscle cells or even

into cardiomyocytes

compared with bone

marrow MSCs

bull Less efficient at osteogenic

and chondrogenic

differentiation

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Adipose Tissue

bull When treated with growth factors

ndash Upregulate expression of tendon related markers

ndash They are found comparable scaffold adherence and

proliferation potential

bull Suggesting AD-MSCs as alternative cell type for tendon

tissue repair

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239

Adipose Tissue

bull Easier to obtain

bull Bioscaffold

Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869

Adipose Tissue

bull General Set up

FDA CLEARANCE AND PRODUCT INFORMATION

TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose

tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure

Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints

middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture

middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents

middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue

middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)

IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha

legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat

isonlytobeusedwithoutanyadditionalmanipulation

Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister

middot LG60cc

middot LG240cc

1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm

120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes

260mlpolycarbonatesyringe2FemaleLuertransferconnectors

LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria

middot TheHCTPisminimallymanipulated

middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)

middot TheHCTPisnotcombinedwithanotherarticleand

middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction

DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016

Adipose Tissue HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer

5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe

6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Local Anesthetic

bull Connect the vacuum syringe to the

blunt 13-gauge Lipoaspiration

cannula

bull Advance and withdraw cannula in a

ldquospokes-of-a-wheelrdquo pattern

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto

createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly

3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand

holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe

canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe

canisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanister

approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

Adipose Tissue

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds

in a vertical motion

ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals

ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent

bull Collection ndash Pull down on the syringe

ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister

ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

HarvestingandProcessingGuide

WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand

rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities

2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion

3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals

4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps

CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach

10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe

clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith

salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull

syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe

Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor

Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection

Adipose Tissue

Adipose Tissue

bull 2002 national survey of 66000 tumescent

liposuction cases

ndash No deaths were reported

ndash Complication rate was 0068 per 1000 cases

Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002

Stem Cell summary

BMAC

bull 100k - 2M MSCs

bull Chondrocyte

bull Osteogenic

bull More painful

bull Volume limit

Adipose

bull 250k - 125M MSCs

bull Bioscaffold

bull Tendon defect filling

bull Less painfull

bull Larger volumes

AMNIOTIC TISSUE

Amniotic Tissue

bull Human Amniotic suspension allografts ndash Human amniotic membrane

ndash Human amniotic fluid-derived cells

bull Contain anti-inflammatory factorsndash IL-10 IL-1

ndash Metrix metalloproteinases 123 and 4

ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen

G5

ndash Hyaluranic Acid and small amount so proteoglycans

Amniotic Tissue

bull Human amniotic membrane

ndash Growth factors including EGF TGF-β and FGF

bull Stimulate epithelial cell migration and proliferation

bull PDGF A and B

ndash Stimulate many metabolic processes

raquo General protein and collagen synthesis collagenase activity

and chemotaxis of fibroblasts and of smooth muscle cells

raquo TGF-β has been shown to significantly increase type I

collagen production by tendon sheath fibroblasts

Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169

Amniotic Tissue

bull N = 6 KL grade 34

bull 12 weeks 3512 months

bull Primary goal feasibility of injection for treatment of OA

bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy

Amniotic Tissue

bull Pain and functional measures

ndash P ADL QOL S SR of the KOOS

ndash Overall KOOS IKDC SANE

bull All scores demonstrated improvement at 1 year

ndash Labs

bull No concerning changes in renal function blood cell

counts or lymphocyte subsets

bull Statistically significant increase in IgG and IgE relative to

baseline but not abnormal level

Amniotic Tissue

bull N23

ndash 14 Corticosteroid

ndash 9 c-hAM

bull Safe and comparable to steroid

Amniotic Tissue

Amniotic Tissue

bull N=470 181

bull VAS WOMAC

bull KL 1-3 OA

bull 30 90 120 days

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

Adipose Tissue

bull Human ADSCs

ndash localize in the stromal vascular fraction

(SVF)

ndash The SVF consists of a heterogeneous

mesenchymal population of cells

bull Adipose stromal stem and progenitor cells

bull Hematopoietic stem and progenitor cells

bull endothelial cells erythrocytes fibroblasts

lymphocytes monocyte macrophages

and pericytes

NIH

-PA

Auth

or M

an

uscrip

tN

IH-P

A A

uth

or M

an

uscrip

tN

IH-P

A A

uth

or M

anu

scrip

t

BOURIN et al Page 13

Table II

Cell populations resident in SVF

Hematopoietic-lineage cells

Stem and progenitor cells lt01

Granulocytes 10ndash15

Monocytes 5ndash15

Lymphocytes 10ndash15

Endothelial cells 10ndash20

Pericytes 3ndash5

Stromal cells 15ndash30

Cytotherapy Author manuscript available in PMC 2014 April 08

Bourin P Bunnell BA et al Cytotherapy 2013 June 15(6) 641ndash648

Adipose Tissue

bull The stromal vascular fraction (SVF) is a

heterogeneous cell population derived from

manipulation of adipose tissue

ndash homogenization

ndash enzymatic digestion

ndash differential centrifugation

ndash red blood cells lysis and washing

Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Mesenchymal stem cells

bull Mulitpotent

bull More prone to differentiate

into muscle cells or even

into cardiomyocytes

compared with bone

marrow MSCs

bull Less efficient at osteogenic

and chondrogenic

differentiation

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Adipose Tissue

bull When treated with growth factors

ndash Upregulate expression of tendon related markers

ndash They are found comparable scaffold adherence and

proliferation potential

bull Suggesting AD-MSCs as alternative cell type for tendon

tissue repair

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239

Adipose Tissue

bull Easier to obtain

bull Bioscaffold

Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869

Adipose Tissue

bull General Set up

FDA CLEARANCE AND PRODUCT INFORMATION

TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose

tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure

Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints

middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture

middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents

middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue

middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)

IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha

legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat

isonlytobeusedwithoutanyadditionalmanipulation

Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister

middot LG60cc

middot LG240cc

1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm

120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes

260mlpolycarbonatesyringe2FemaleLuertransferconnectors

LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria

middot TheHCTPisminimallymanipulated

middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)

middot TheHCTPisnotcombinedwithanotherarticleand

middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction

DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016

Adipose Tissue HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer

5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe

6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Local Anesthetic

bull Connect the vacuum syringe to the

blunt 13-gauge Lipoaspiration

cannula

bull Advance and withdraw cannula in a

ldquospokes-of-a-wheelrdquo pattern

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto

createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly

3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand

holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe

canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe

canisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanister

approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

Adipose Tissue

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds

in a vertical motion

ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals

ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent

bull Collection ndash Pull down on the syringe

ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister

ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

HarvestingandProcessingGuide

WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand

rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities

2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion

3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals

4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps

CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach

10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe

clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith

salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull

syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe

Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor

Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection

Adipose Tissue

Adipose Tissue

bull 2002 national survey of 66000 tumescent

liposuction cases

ndash No deaths were reported

ndash Complication rate was 0068 per 1000 cases

Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002

Stem Cell summary

BMAC

bull 100k - 2M MSCs

bull Chondrocyte

bull Osteogenic

bull More painful

bull Volume limit

Adipose

bull 250k - 125M MSCs

bull Bioscaffold

bull Tendon defect filling

bull Less painfull

bull Larger volumes

AMNIOTIC TISSUE

Amniotic Tissue

bull Human Amniotic suspension allografts ndash Human amniotic membrane

ndash Human amniotic fluid-derived cells

bull Contain anti-inflammatory factorsndash IL-10 IL-1

ndash Metrix metalloproteinases 123 and 4

ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen

G5

ndash Hyaluranic Acid and small amount so proteoglycans

Amniotic Tissue

bull Human amniotic membrane

ndash Growth factors including EGF TGF-β and FGF

bull Stimulate epithelial cell migration and proliferation

bull PDGF A and B

ndash Stimulate many metabolic processes

raquo General protein and collagen synthesis collagenase activity

and chemotaxis of fibroblasts and of smooth muscle cells

raquo TGF-β has been shown to significantly increase type I

collagen production by tendon sheath fibroblasts

Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169

Amniotic Tissue

bull N = 6 KL grade 34

bull 12 weeks 3512 months

bull Primary goal feasibility of injection for treatment of OA

bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy

Amniotic Tissue

bull Pain and functional measures

ndash P ADL QOL S SR of the KOOS

ndash Overall KOOS IKDC SANE

bull All scores demonstrated improvement at 1 year

ndash Labs

bull No concerning changes in renal function blood cell

counts or lymphocyte subsets

bull Statistically significant increase in IgG and IgE relative to

baseline but not abnormal level

Amniotic Tissue

bull N23

ndash 14 Corticosteroid

ndash 9 c-hAM

bull Safe and comparable to steroid

Amniotic Tissue

Amniotic Tissue

bull N=470 181

bull VAS WOMAC

bull KL 1-3 OA

bull 30 90 120 days

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

Adipose Tissue

bull The stromal vascular fraction (SVF) is a

heterogeneous cell population derived from

manipulation of adipose tissue

ndash homogenization

ndash enzymatic digestion

ndash differential centrifugation

ndash red blood cells lysis and washing

Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Mesenchymal stem cells

bull Mulitpotent

bull More prone to differentiate

into muscle cells or even

into cardiomyocytes

compared with bone

marrow MSCs

bull Less efficient at osteogenic

and chondrogenic

differentiation

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Adipose Tissue

bull When treated with growth factors

ndash Upregulate expression of tendon related markers

ndash They are found comparable scaffold adherence and

proliferation potential

bull Suggesting AD-MSCs as alternative cell type for tendon

tissue repair

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239

Adipose Tissue

bull Easier to obtain

bull Bioscaffold

Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869

Adipose Tissue

bull General Set up

FDA CLEARANCE AND PRODUCT INFORMATION

TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose

tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure

Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints

middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture

middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents

middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue

middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)

IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha

legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat

isonlytobeusedwithoutanyadditionalmanipulation

Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister

middot LG60cc

middot LG240cc

1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm

120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes

260mlpolycarbonatesyringe2FemaleLuertransferconnectors

LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria

middot TheHCTPisminimallymanipulated

middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)

middot TheHCTPisnotcombinedwithanotherarticleand

middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction

DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016

Adipose Tissue HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer

5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe

6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Local Anesthetic

bull Connect the vacuum syringe to the

blunt 13-gauge Lipoaspiration

cannula

bull Advance and withdraw cannula in a

ldquospokes-of-a-wheelrdquo pattern

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto

createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly

3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand

holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe

canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe

canisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanister

approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

Adipose Tissue

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds

in a vertical motion

ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals

ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent

bull Collection ndash Pull down on the syringe

ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister

ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

HarvestingandProcessingGuide

WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand

rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities

2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion

3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals

4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps

CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach

10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe

clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith

salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull

syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe

Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor

Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection

Adipose Tissue

Adipose Tissue

bull 2002 national survey of 66000 tumescent

liposuction cases

ndash No deaths were reported

ndash Complication rate was 0068 per 1000 cases

Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002

Stem Cell summary

BMAC

bull 100k - 2M MSCs

bull Chondrocyte

bull Osteogenic

bull More painful

bull Volume limit

Adipose

bull 250k - 125M MSCs

bull Bioscaffold

bull Tendon defect filling

bull Less painfull

bull Larger volumes

AMNIOTIC TISSUE

Amniotic Tissue

bull Human Amniotic suspension allografts ndash Human amniotic membrane

ndash Human amniotic fluid-derived cells

bull Contain anti-inflammatory factorsndash IL-10 IL-1

ndash Metrix metalloproteinases 123 and 4

ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen

G5

ndash Hyaluranic Acid and small amount so proteoglycans

Amniotic Tissue

bull Human amniotic membrane

ndash Growth factors including EGF TGF-β and FGF

bull Stimulate epithelial cell migration and proliferation

bull PDGF A and B

ndash Stimulate many metabolic processes

raquo General protein and collagen synthesis collagenase activity

and chemotaxis of fibroblasts and of smooth muscle cells

raquo TGF-β has been shown to significantly increase type I

collagen production by tendon sheath fibroblasts

Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169

Amniotic Tissue

bull N = 6 KL grade 34

bull 12 weeks 3512 months

bull Primary goal feasibility of injection for treatment of OA

bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy

Amniotic Tissue

bull Pain and functional measures

ndash P ADL QOL S SR of the KOOS

ndash Overall KOOS IKDC SANE

bull All scores demonstrated improvement at 1 year

ndash Labs

bull No concerning changes in renal function blood cell

counts or lymphocyte subsets

bull Statistically significant increase in IgG and IgE relative to

baseline but not abnormal level

Amniotic Tissue

bull N23

ndash 14 Corticosteroid

ndash 9 c-hAM

bull Safe and comparable to steroid

Amniotic Tissue

Amniotic Tissue

bull N=470 181

bull VAS WOMAC

bull KL 1-3 OA

bull 30 90 120 days

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

Access this article

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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

Mesenchymal stem cells

bull Mulitpotent

bull More prone to differentiate

into muscle cells or even

into cardiomyocytes

compared with bone

marrow MSCs

bull Less efficient at osteogenic

and chondrogenic

differentiation

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239Astori G et al In vitro and multicolor phenotypic characterization of cell subpopulations identified in fresh human adipose tissue stromal vascular fraction and in the derived mesenchymal stem cells Journal of Translational Medicine 2007 555

Adipose Tissue

bull When treated with growth factors

ndash Upregulate expression of tendon related markers

ndash They are found comparable scaffold adherence and

proliferation potential

bull Suggesting AD-MSCs as alternative cell type for tendon

tissue repair

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239

Adipose Tissue

bull Easier to obtain

bull Bioscaffold

Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869

Adipose Tissue

bull General Set up

FDA CLEARANCE AND PRODUCT INFORMATION

TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose

tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure

Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints

middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture

middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents

middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue

middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)

IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha

legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat

isonlytobeusedwithoutanyadditionalmanipulation

Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister

middot LG60cc

middot LG240cc

1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm

120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes

260mlpolycarbonatesyringe2FemaleLuertransferconnectors

LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria

middot TheHCTPisminimallymanipulated

middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)

middot TheHCTPisnotcombinedwithanotherarticleand

middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction

DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016

Adipose Tissue HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer

5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe

6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Local Anesthetic

bull Connect the vacuum syringe to the

blunt 13-gauge Lipoaspiration

cannula

bull Advance and withdraw cannula in a

ldquospokes-of-a-wheelrdquo pattern

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto

createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly

3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand

holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe

canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe

canisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanister

approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

Adipose Tissue

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds

in a vertical motion

ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals

ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent

bull Collection ndash Pull down on the syringe

ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister

ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

HarvestingandProcessingGuide

WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand

rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities

2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion

3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals

4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps

CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach

10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe

clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith

salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull

syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe

Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor

Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection

Adipose Tissue

Adipose Tissue

bull 2002 national survey of 66000 tumescent

liposuction cases

ndash No deaths were reported

ndash Complication rate was 0068 per 1000 cases

Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002

Stem Cell summary

BMAC

bull 100k - 2M MSCs

bull Chondrocyte

bull Osteogenic

bull More painful

bull Volume limit

Adipose

bull 250k - 125M MSCs

bull Bioscaffold

bull Tendon defect filling

bull Less painfull

bull Larger volumes

AMNIOTIC TISSUE

Amniotic Tissue

bull Human Amniotic suspension allografts ndash Human amniotic membrane

ndash Human amniotic fluid-derived cells

bull Contain anti-inflammatory factorsndash IL-10 IL-1

ndash Metrix metalloproteinases 123 and 4

ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen

G5

ndash Hyaluranic Acid and small amount so proteoglycans

Amniotic Tissue

bull Human amniotic membrane

ndash Growth factors including EGF TGF-β and FGF

bull Stimulate epithelial cell migration and proliferation

bull PDGF A and B

ndash Stimulate many metabolic processes

raquo General protein and collagen synthesis collagenase activity

and chemotaxis of fibroblasts and of smooth muscle cells

raquo TGF-β has been shown to significantly increase type I

collagen production by tendon sheath fibroblasts

Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169

Amniotic Tissue

bull N = 6 KL grade 34

bull 12 weeks 3512 months

bull Primary goal feasibility of injection for treatment of OA

bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy

Amniotic Tissue

bull Pain and functional measures

ndash P ADL QOL S SR of the KOOS

ndash Overall KOOS IKDC SANE

bull All scores demonstrated improvement at 1 year

ndash Labs

bull No concerning changes in renal function blood cell

counts or lymphocyte subsets

bull Statistically significant increase in IgG and IgE relative to

baseline but not abnormal level

Amniotic Tissue

bull N23

ndash 14 Corticosteroid

ndash 9 c-hAM

bull Safe and comparable to steroid

Amniotic Tissue

Amniotic Tissue

bull N=470 181

bull VAS WOMAC

bull KL 1-3 OA

bull 30 90 120 days

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

Adipose Tissue

bull When treated with growth factors

ndash Upregulate expression of tendon related markers

ndash They are found comparable scaffold adherence and

proliferation potential

bull Suggesting AD-MSCs as alternative cell type for tendon

tissue repair

D Docheva Et al Biologics for tendon repair Adv Drug Deliv Rev 2015 April 84 222ndash239

Adipose Tissue

bull Easier to obtain

bull Bioscaffold

Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869

Adipose Tissue

bull General Set up

FDA CLEARANCE AND PRODUCT INFORMATION

TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose

tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure

Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints

middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture

middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents

middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue

middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)

IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha

legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat

isonlytobeusedwithoutanyadditionalmanipulation

Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister

middot LG60cc

middot LG240cc

1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm

120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes

260mlpolycarbonatesyringe2FemaleLuertransferconnectors

LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria

middot TheHCTPisminimallymanipulated

middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)

middot TheHCTPisnotcombinedwithanotherarticleand

middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction

DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016

Adipose Tissue HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer

5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe

6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Local Anesthetic

bull Connect the vacuum syringe to the

blunt 13-gauge Lipoaspiration

cannula

bull Advance and withdraw cannula in a

ldquospokes-of-a-wheelrdquo pattern

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto

createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly

3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand

holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe

canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe

canisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanister

approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

Adipose Tissue

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds

in a vertical motion

ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals

ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent

bull Collection ndash Pull down on the syringe

ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister

ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

HarvestingandProcessingGuide

WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand

rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities

2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion

3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals

4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps

CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach

10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe

clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith

salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull

syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe

Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor

Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection

Adipose Tissue

Adipose Tissue

bull 2002 national survey of 66000 tumescent

liposuction cases

ndash No deaths were reported

ndash Complication rate was 0068 per 1000 cases

Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002

Stem Cell summary

BMAC

bull 100k - 2M MSCs

bull Chondrocyte

bull Osteogenic

bull More painful

bull Volume limit

Adipose

bull 250k - 125M MSCs

bull Bioscaffold

bull Tendon defect filling

bull Less painfull

bull Larger volumes

AMNIOTIC TISSUE

Amniotic Tissue

bull Human Amniotic suspension allografts ndash Human amniotic membrane

ndash Human amniotic fluid-derived cells

bull Contain anti-inflammatory factorsndash IL-10 IL-1

ndash Metrix metalloproteinases 123 and 4

ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen

G5

ndash Hyaluranic Acid and small amount so proteoglycans

Amniotic Tissue

bull Human amniotic membrane

ndash Growth factors including EGF TGF-β and FGF

bull Stimulate epithelial cell migration and proliferation

bull PDGF A and B

ndash Stimulate many metabolic processes

raquo General protein and collagen synthesis collagenase activity

and chemotaxis of fibroblasts and of smooth muscle cells

raquo TGF-β has been shown to significantly increase type I

collagen production by tendon sheath fibroblasts

Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169

Amniotic Tissue

bull N = 6 KL grade 34

bull 12 weeks 3512 months

bull Primary goal feasibility of injection for treatment of OA

bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy

Amniotic Tissue

bull Pain and functional measures

ndash P ADL QOL S SR of the KOOS

ndash Overall KOOS IKDC SANE

bull All scores demonstrated improvement at 1 year

ndash Labs

bull No concerning changes in renal function blood cell

counts or lymphocyte subsets

bull Statistically significant increase in IgG and IgE relative to

baseline but not abnormal level

Amniotic Tissue

bull N23

ndash 14 Corticosteroid

ndash 9 c-hAM

bull Safe and comparable to steroid

Amniotic Tissue

Amniotic Tissue

bull N=470 181

bull VAS WOMAC

bull KL 1-3 OA

bull 30 90 120 days

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

Adipose Tissue

bull Easier to obtain

bull Bioscaffold

Alexander RW Understanding ad-svf cell biology amp use a concise review Journal of Prolotherapy 20124e855-e869

Adipose Tissue

bull General Set up

FDA CLEARANCE AND PRODUCT INFORMATION

TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose

tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure

Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints

middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture

middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents

middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue

middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)

IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha

legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat

isonlytobeusedwithoutanyadditionalmanipulation

Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister

middot LG60cc

middot LG240cc

1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm

120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes

260mlpolycarbonatesyringe2FemaleLuertransferconnectors

LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria

middot TheHCTPisminimallymanipulated

middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)

middot TheHCTPisnotcombinedwithanotherarticleand

middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction

DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016

Adipose Tissue HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer

5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe

6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Local Anesthetic

bull Connect the vacuum syringe to the

blunt 13-gauge Lipoaspiration

cannula

bull Advance and withdraw cannula in a

ldquospokes-of-a-wheelrdquo pattern

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto

createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly

3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand

holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe

canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe

canisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanister

approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

Adipose Tissue

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds

in a vertical motion

ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals

ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent

bull Collection ndash Pull down on the syringe

ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister

ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

HarvestingandProcessingGuide

WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand

rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities

2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion

3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals

4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps

CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach

10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe

clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith

salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull

syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe

Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor

Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection

Adipose Tissue

Adipose Tissue

bull 2002 national survey of 66000 tumescent

liposuction cases

ndash No deaths were reported

ndash Complication rate was 0068 per 1000 cases

Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002

Stem Cell summary

BMAC

bull 100k - 2M MSCs

bull Chondrocyte

bull Osteogenic

bull More painful

bull Volume limit

Adipose

bull 250k - 125M MSCs

bull Bioscaffold

bull Tendon defect filling

bull Less painfull

bull Larger volumes

AMNIOTIC TISSUE

Amniotic Tissue

bull Human Amniotic suspension allografts ndash Human amniotic membrane

ndash Human amniotic fluid-derived cells

bull Contain anti-inflammatory factorsndash IL-10 IL-1

ndash Metrix metalloproteinases 123 and 4

ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen

G5

ndash Hyaluranic Acid and small amount so proteoglycans

Amniotic Tissue

bull Human amniotic membrane

ndash Growth factors including EGF TGF-β and FGF

bull Stimulate epithelial cell migration and proliferation

bull PDGF A and B

ndash Stimulate many metabolic processes

raquo General protein and collagen synthesis collagenase activity

and chemotaxis of fibroblasts and of smooth muscle cells

raquo TGF-β has been shown to significantly increase type I

collagen production by tendon sheath fibroblasts

Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169

Amniotic Tissue

bull N = 6 KL grade 34

bull 12 weeks 3512 months

bull Primary goal feasibility of injection for treatment of OA

bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy

Amniotic Tissue

bull Pain and functional measures

ndash P ADL QOL S SR of the KOOS

ndash Overall KOOS IKDC SANE

bull All scores demonstrated improvement at 1 year

ndash Labs

bull No concerning changes in renal function blood cell

counts or lymphocyte subsets

bull Statistically significant increase in IgG and IgE relative to

baseline but not abnormal level

Amniotic Tissue

bull N23

ndash 14 Corticosteroid

ndash 9 c-hAM

bull Safe and comparable to steroid

Amniotic Tissue

Amniotic Tissue

bull N=470 181

bull VAS WOMAC

bull KL 1-3 OA

bull 30 90 120 days

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

Adipose Tissue

bull General Set up

FDA CLEARANCE AND PRODUCT INFORMATION

TheLipogemstechnologyprovidesasingle-usedisposabledevicewhichprocessesautologousadiposetissueforuseasanalternativeandorasanadjuncttosurgerytopromotehealingandtissuerepairinorthopaedicsandanumberofothersurgicalspecialtiesTheresultofprocessingwiththeLipogemsSystemiswashedandmicro-fragmentedadipose

tissuewhichallowsapatientrsquosownsubcutaneousfattobeprocessedforautologousreinjectionasapoint-of-careprocedure

Lipogemsreceivedoriginal510(k)FDAClearanceinDecember2014andsubsequentlyworkedwiththeFDAtoupdatetheFDAClearanceinNovember2016whichcanbesummarizedinthefollowingprimarypoints

middot ThenewclearanceisforanadiposetissuetransferwheretheLipogemssystemwashesrinsesresizesandconcentratestheadiposetissuewhilepreservingthecellandtissuemicroarchitecture

middot Thecontinuousflowofnormalsalinesolutionduringprocessingeliminatesresiduesofoilemulsionandanyremainingbloodcomponents

middot ThenewclearancealsospecificallystatesthattheLipogemsprocessisldquominimalmanipulationofadiposetissuerdquoanddoesnotaltertherelevantcharacteristicsofthetissue

middot IfsurgeryisnecessarythenewclearanceexpandstheindicationsforLipogemsintoarthroscopy(ieminimallyinvasivesurgeryinjoints)

IndicationsforUseIntendedUseTheLipogemsSystemisasterilemedicaldeviceintendedfortheclosed-loopprocessingoflipoaspiratetissueinmedicalproceduresinvolvingtheharvestingconcentratingandtransferringofautologousadiposetissueharvestedwitha

legallymarketedlipoplastysystemThedeviceisintendedforuseinthefollowingsurgicalspecialtieswhenthetransferofharvestedadiposetissueisdesiredorthopedicsurgeryarthroscopicsurgeryneurosurgerygastrointestinalandaffiliatedorgansurgeryurologicalsurgerygeneralsurgerygynecologicalsurgerythoracicsurgerylaparoscopicsurgeryandplasticandreconstructivesurgerywhenaestheticbodycontouringisdesiredOnlylegallymarketedaccessoryitemssuchassyringesshouldbeusedwiththesystemIfharvestedfatistobetransferredtheharvestedfat

isonlytobeusedwithoutanyadditionalmanipulation

Lipogemskitcontents(single-use)1Pre-assembledProcessingCanister

middot LG60cc

middot LG240cc

1Lipoaspirationcannula13Gx185mm1Anestheticinfiltrationcannula17Gx185mm

120mLVAC110polycarbonatevacuumsyringe31mlpolycarbonatesyringes410mlpolycarbonatesyringes

260mlpolycarbonatesyringe2FemaleLuertransferconnectors

LIPOGEMSregisregulatedbytheFDAasldquoHumanCellsTissuesandCellularandTissue-BasedProductsrdquo(HCTPs)underSection361ofthePublicHealthServiceActinTitle21oftheCodeoftheFederalRegulations(CFR)Part127CertainHCTPsrequirenopremarketreviewiftheymeetthefollowingcriteria

middot TheHCTPisminimallymanipulated

middot TheHCTPisintendedforhomologoususeonly(definedastheproductperformingthesamebasicfunctioninthedonorandintherecipient)

middot TheHCTPisnotcombinedwithanotherarticleand

middot TheHCTPdoesnotdependonthemetabolicactivityoflivingcellsforitsprimaryfunction

DepartmentofHealthandHumanServicesFoodandDrugAdministrationLipogemsSystem510(k)K161636November2016

Adipose Tissue HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer

5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe

6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Local Anesthetic

bull Connect the vacuum syringe to the

blunt 13-gauge Lipoaspiration

cannula

bull Advance and withdraw cannula in a

ldquospokes-of-a-wheelrdquo pattern

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto

createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly

3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand

holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe

canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe

canisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanister

approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

Adipose Tissue

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds

in a vertical motion

ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals

ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent

bull Collection ndash Pull down on the syringe

ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister

ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

HarvestingandProcessingGuide

WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand

rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities

2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion

3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals

4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps

CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach

10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe

clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith

salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull

syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe

Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor

Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection

Adipose Tissue

Adipose Tissue

bull 2002 national survey of 66000 tumescent

liposuction cases

ndash No deaths were reported

ndash Complication rate was 0068 per 1000 cases

Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002

Stem Cell summary

BMAC

bull 100k - 2M MSCs

bull Chondrocyte

bull Osteogenic

bull More painful

bull Volume limit

Adipose

bull 250k - 125M MSCs

bull Bioscaffold

bull Tendon defect filling

bull Less painfull

bull Larger volumes

AMNIOTIC TISSUE

Amniotic Tissue

bull Human Amniotic suspension allografts ndash Human amniotic membrane

ndash Human amniotic fluid-derived cells

bull Contain anti-inflammatory factorsndash IL-10 IL-1

ndash Metrix metalloproteinases 123 and 4

ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen

G5

ndash Hyaluranic Acid and small amount so proteoglycans

Amniotic Tissue

bull Human amniotic membrane

ndash Growth factors including EGF TGF-β and FGF

bull Stimulate epithelial cell migration and proliferation

bull PDGF A and B

ndash Stimulate many metabolic processes

raquo General protein and collagen synthesis collagenase activity

and chemotaxis of fibroblasts and of smooth muscle cells

raquo TGF-β has been shown to significantly increase type I

collagen production by tendon sheath fibroblasts

Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169

Amniotic Tissue

bull N = 6 KL grade 34

bull 12 weeks 3512 months

bull Primary goal feasibility of injection for treatment of OA

bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy

Amniotic Tissue

bull Pain and functional measures

ndash P ADL QOL S SR of the KOOS

ndash Overall KOOS IKDC SANE

bull All scores demonstrated improvement at 1 year

ndash Labs

bull No concerning changes in renal function blood cell

counts or lymphocyte subsets

bull Statistically significant increase in IgG and IgE relative to

baseline but not abnormal level

Amniotic Tissue

bull N23

ndash 14 Corticosteroid

ndash 9 c-hAM

bull Safe and comparable to steroid

Amniotic Tissue

Amniotic Tissue

bull N=470 181

bull VAS WOMAC

bull KL 1-3 OA

bull 30 90 120 days

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

Adipose Tissue HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningforthecannulatopassthroughtheskinintothesubcutaneousadiposelayer

5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthesubcutaneoustissueandattachfluid-filledsyringe

6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Local Anesthetic

bull Connect the vacuum syringe to the

blunt 13-gauge Lipoaspiration

cannula

bull Advance and withdraw cannula in a

ldquospokes-of-a-wheelrdquo pattern

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedleto

createaskinwhealwithlocalanestheticattheinsertionsite4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly

3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuerLockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayand

holdcanistersothattheygreysideispointingupward4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthe

canistergentlytoremoveairbubbles5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthe

canisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanister

approximatelyfrac14fullNoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

Adipose Tissue

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds

in a vertical motion

ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals

ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent

bull Collection ndash Pull down on the syringe

ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister

ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

HarvestingandProcessingGuide

WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand

rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities

2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion

3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals

4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps

CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach

10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe

clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith

salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull

syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe

Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor

Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection

Adipose Tissue

Adipose Tissue

bull 2002 national survey of 66000 tumescent

liposuction cases

ndash No deaths were reported

ndash Complication rate was 0068 per 1000 cases

Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002

Stem Cell summary

BMAC

bull 100k - 2M MSCs

bull Chondrocyte

bull Osteogenic

bull More painful

bull Volume limit

Adipose

bull 250k - 125M MSCs

bull Bioscaffold

bull Tendon defect filling

bull Less painfull

bull Larger volumes

AMNIOTIC TISSUE

Amniotic Tissue

bull Human Amniotic suspension allografts ndash Human amniotic membrane

ndash Human amniotic fluid-derived cells

bull Contain anti-inflammatory factorsndash IL-10 IL-1

ndash Metrix metalloproteinases 123 and 4

ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen

G5

ndash Hyaluranic Acid and small amount so proteoglycans

Amniotic Tissue

bull Human amniotic membrane

ndash Growth factors including EGF TGF-β and FGF

bull Stimulate epithelial cell migration and proliferation

bull PDGF A and B

ndash Stimulate many metabolic processes

raquo General protein and collagen synthesis collagenase activity

and chemotaxis of fibroblasts and of smooth muscle cells

raquo TGF-β has been shown to significantly increase type I

collagen production by tendon sheath fibroblasts

Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169

Amniotic Tissue

bull N = 6 KL grade 34

bull 12 weeks 3512 months

bull Primary goal feasibility of injection for treatment of OA

bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy

Amniotic Tissue

bull Pain and functional measures

ndash P ADL QOL S SR of the KOOS

ndash Overall KOOS IKDC SANE

bull All scores demonstrated improvement at 1 year

ndash Labs

bull No concerning changes in renal function blood cell

counts or lymphocyte subsets

bull Statistically significant increase in IgG and IgE relative to

baseline but not abnormal level

Amniotic Tissue

bull N23

ndash 14 Corticosteroid

ndash 9 c-hAM

bull Safe and comparable to steroid

Amniotic Tissue

Amniotic Tissue

bull N=470 181

bull VAS WOMAC

bull KL 1-3 OA

bull 30 90 120 days

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

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HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

Adipose Tissue

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluid

beforeaspirationNoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthe

desiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlock

valveattachmentremainstightenedontothecanister

bull Wash and Rinse ndash Shake vigorously at regular intervals of 30 seconds

in a vertical motion

ndash Re-open both clamps and allow saline to rinse through device and clear the canister of debris between intervals

ndash Repeat the shaking for at least 1-2 minutes until the adipose tissue appears light yellow and the saline solution is transparent

bull Collection ndash Pull down on the syringe

ndash Holding the canister vertically quickly squeeze the flanges on the full syringe with saline into the canister

ndash Take the syringe containing Lipoaspiration off and repeat until all of the Lipoaspiration is removed from the device

HarvestingandProcessingGuide

ProcedureStepsInfiltrationofAnestheticSolution1 Markandoutlinetissueharvestareawhilepatientisstanding2 Prepareanestheticsolutionandtransferinto60mLsyringesonsterile

field(volumeofanestheticsolutionusedwilldependonvolumeofadiposetissuedesiredandsizeofharvestarea)

3 Locateincisionsiteforcannulainsertionandusea25-gaugeneedletocreateaskinwhealwithlocalanestheticattheinsertionsite

4 UsingaNo11bladeor18-gaugeneedlecreateaverysmallopeningfor

thecannulatopassthroughtheskinintothesubcutaneousadiposelayer5 Insertblunt17-gaugeinfiltrationcannulaintothemiddleofthe

subcutaneoustissueandattachfluid-filledsyringe6 Whilewithdrawingthecannulainjectanestheticfluidinaldquospokes-of-a-

wheelrdquopatternanddisperseevenlythroughsubcutaneoustissue

7 Waitaminimumof15minutesfollowinginfiltrationofanestheticfluidbeforeaspiration

NoteItisrecommendedtoinfiltratenolessthan120mLofanestheticfluidperharvestarea

AspirationofAdiposeTissue1 Connectthevacuumsyringetotheblunt13-gaugeLipoaspirationcannula

andlockintoplaceafterinsertionintothesubcutaneoustissue2 Advanceandwithdrawcannulainaldquospokes-of-a-wheelrdquopatterntocollect

tissueevenly3 TransfercollectedlipoaspirateintoalargersyringeusingaprovidedLuer

Lockconnectordecantthelipoaspirate

4 Collectapproximately4xtheamountoflipoaspirate(decanted)asthedesiredvolumeofLipogemsforinjection(iecollect40mLofdecantedlipoaspirateif10mLofLipogemsisdesired)

LipogemsDevicePreparation1 OpensterileLipogemsdeviceandensurethatwastebagissecurely

attachedandthatthetwoclearblueluerlockvalveattachmentsaretightened

2 normalIVsalinebag(DONOTSUBSTITUTEWITHANYOTHERPHYSIOLOGICSOLUTIONSUCHASLACTATEDRINGERS)

3 Squeezeplastictubeunderspikeuntilsalinefillsdripchamberhalfwayandholdcanistersothattheygreysideispointingupward

4 Openalloftheclampsandallowthesystemtofillwithsalineagitatingthecanistergentlytoremoveairbubbles

5 Oncecompletelyfilledwithsalineclosetheclampsonbothendsofthecanisterandensuretherearenolargeairbubblesinthecanister

PrimaryTissueClusterResizing1 Rotatethecanistersothatthebrightlycoloredendispointingupwardand

openthetubeclamponthegreyend2 Connectthesyringecontainingthelipoaspirateverticallytothebrightly

coloredendofthecanisterandinjectthetissuetofillthecanisterapproximatelyfrac14full

NoteWhenremovingsyringefromcanisterensurethattheclearblueluerlockvalveattachmentremainstightenedontothecanister

HarvestingandProcessingGuide

WashandRinse1 Re-opentheclamponthebrightlycoloredendandallowsalinetoflowand

rinsethetissueuntilthesalineclearssomeoftheoilyandbloodyimpurities

2 Closebothtubeclampsandshakevigorouslyatregularintervalsof30secondsinaverticalmotion

3 Re-openbothclampsandallowsalinetorinsethroughdeviceandclearthecanisterofdebrisbetweenintervals

4 Repeattheshakingforatleast1-2minutesuntiltheadiposetissueappearslightyellowandthesalinesolutionistransparentthenclosebothtubeclamps

CollectingLipogemsFinalTissueClusterResizing1 Rotatethecanistersothatthegreyendispointingupwardandattach

10mLsyringestobothends2 Opentheclamponthebrightlycoloredendofthecanisterandleavethe

clamponthegreyendclosed3 Pulldownonthesyringeattachedtothebrightlycoloredendandfillwith

salinethenclosetheclamponthecoloredend4 Whileholdingthecanisterverticallyquicklysqueezetheflangesonthefull

syringewithsalineintothecanisterwithasmoothandsteadyforce5 TakethesyringecontainingLipogemsoffandrepeatuntilallofthe

Lipogemsisremovedfromthedevice6 Thesyringeshouldbeallowedtodecant(vertically)forafewminutesfor

Thesyringetransferconnectorsmaybeusedtotransfertoasmallersyringeforinjection

Adipose Tissue

Adipose Tissue

bull 2002 national survey of 66000 tumescent

liposuction cases

ndash No deaths were reported

ndash Complication rate was 0068 per 1000 cases

Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002

Stem Cell summary

BMAC

bull 100k - 2M MSCs

bull Chondrocyte

bull Osteogenic

bull More painful

bull Volume limit

Adipose

bull 250k - 125M MSCs

bull Bioscaffold

bull Tendon defect filling

bull Less painfull

bull Larger volumes

AMNIOTIC TISSUE

Amniotic Tissue

bull Human Amniotic suspension allografts ndash Human amniotic membrane

ndash Human amniotic fluid-derived cells

bull Contain anti-inflammatory factorsndash IL-10 IL-1

ndash Metrix metalloproteinases 123 and 4

ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen

G5

ndash Hyaluranic Acid and small amount so proteoglycans

Amniotic Tissue

bull Human amniotic membrane

ndash Growth factors including EGF TGF-β and FGF

bull Stimulate epithelial cell migration and proliferation

bull PDGF A and B

ndash Stimulate many metabolic processes

raquo General protein and collagen synthesis collagenase activity

and chemotaxis of fibroblasts and of smooth muscle cells

raquo TGF-β has been shown to significantly increase type I

collagen production by tendon sheath fibroblasts

Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169

Amniotic Tissue

bull N = 6 KL grade 34

bull 12 weeks 3512 months

bull Primary goal feasibility of injection for treatment of OA

bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy

Amniotic Tissue

bull Pain and functional measures

ndash P ADL QOL S SR of the KOOS

ndash Overall KOOS IKDC SANE

bull All scores demonstrated improvement at 1 year

ndash Labs

bull No concerning changes in renal function blood cell

counts or lymphocyte subsets

bull Statistically significant increase in IgG and IgE relative to

baseline but not abnormal level

Amniotic Tissue

bull N23

ndash 14 Corticosteroid

ndash 9 c-hAM

bull Safe and comparable to steroid

Amniotic Tissue

Amniotic Tissue

bull N=470 181

bull VAS WOMAC

bull KL 1-3 OA

bull 30 90 120 days

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

Access this article

Or purchase this article - $20

Print Subscriber Activate your online access now

Welcome Guest Renew Subscribe or Create Account Sign In

HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

Adipose Tissue

Adipose Tissue

bull 2002 national survey of 66000 tumescent

liposuction cases

ndash No deaths were reported

ndash Complication rate was 0068 per 1000 cases

Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002

Stem Cell summary

BMAC

bull 100k - 2M MSCs

bull Chondrocyte

bull Osteogenic

bull More painful

bull Volume limit

Adipose

bull 250k - 125M MSCs

bull Bioscaffold

bull Tendon defect filling

bull Less painfull

bull Larger volumes

AMNIOTIC TISSUE

Amniotic Tissue

bull Human Amniotic suspension allografts ndash Human amniotic membrane

ndash Human amniotic fluid-derived cells

bull Contain anti-inflammatory factorsndash IL-10 IL-1

ndash Metrix metalloproteinases 123 and 4

ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen

G5

ndash Hyaluranic Acid and small amount so proteoglycans

Amniotic Tissue

bull Human amniotic membrane

ndash Growth factors including EGF TGF-β and FGF

bull Stimulate epithelial cell migration and proliferation

bull PDGF A and B

ndash Stimulate many metabolic processes

raquo General protein and collagen synthesis collagenase activity

and chemotaxis of fibroblasts and of smooth muscle cells

raquo TGF-β has been shown to significantly increase type I

collagen production by tendon sheath fibroblasts

Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169

Amniotic Tissue

bull N = 6 KL grade 34

bull 12 weeks 3512 months

bull Primary goal feasibility of injection for treatment of OA

bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy

Amniotic Tissue

bull Pain and functional measures

ndash P ADL QOL S SR of the KOOS

ndash Overall KOOS IKDC SANE

bull All scores demonstrated improvement at 1 year

ndash Labs

bull No concerning changes in renal function blood cell

counts or lymphocyte subsets

bull Statistically significant increase in IgG and IgE relative to

baseline but not abnormal level

Amniotic Tissue

bull N23

ndash 14 Corticosteroid

ndash 9 c-hAM

bull Safe and comparable to steroid

Amniotic Tissue

Amniotic Tissue

bull N=470 181

bull VAS WOMAC

bull KL 1-3 OA

bull 30 90 120 days

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

Access this article

Or purchase this article - $20

Print Subscriber Activate your online access now

Welcome Guest Renew Subscribe or Create Account Sign In

HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

Adipose Tissue

bull 2002 national survey of 66000 tumescent

liposuction cases

ndash No deaths were reported

ndash Complication rate was 0068 per 1000 cases

Housman TS et al The safety of liposuction results of a national survey Dermatol Surg 2002

Stem Cell summary

BMAC

bull 100k - 2M MSCs

bull Chondrocyte

bull Osteogenic

bull More painful

bull Volume limit

Adipose

bull 250k - 125M MSCs

bull Bioscaffold

bull Tendon defect filling

bull Less painfull

bull Larger volumes

AMNIOTIC TISSUE

Amniotic Tissue

bull Human Amniotic suspension allografts ndash Human amniotic membrane

ndash Human amniotic fluid-derived cells

bull Contain anti-inflammatory factorsndash IL-10 IL-1

ndash Metrix metalloproteinases 123 and 4

ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen

G5

ndash Hyaluranic Acid and small amount so proteoglycans

Amniotic Tissue

bull Human amniotic membrane

ndash Growth factors including EGF TGF-β and FGF

bull Stimulate epithelial cell migration and proliferation

bull PDGF A and B

ndash Stimulate many metabolic processes

raquo General protein and collagen synthesis collagenase activity

and chemotaxis of fibroblasts and of smooth muscle cells

raquo TGF-β has been shown to significantly increase type I

collagen production by tendon sheath fibroblasts

Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169

Amniotic Tissue

bull N = 6 KL grade 34

bull 12 weeks 3512 months

bull Primary goal feasibility of injection for treatment of OA

bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy

Amniotic Tissue

bull Pain and functional measures

ndash P ADL QOL S SR of the KOOS

ndash Overall KOOS IKDC SANE

bull All scores demonstrated improvement at 1 year

ndash Labs

bull No concerning changes in renal function blood cell

counts or lymphocyte subsets

bull Statistically significant increase in IgG and IgE relative to

baseline but not abnormal level

Amniotic Tissue

bull N23

ndash 14 Corticosteroid

ndash 9 c-hAM

bull Safe and comparable to steroid

Amniotic Tissue

Amniotic Tissue

bull N=470 181

bull VAS WOMAC

bull KL 1-3 OA

bull 30 90 120 days

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

Access this article

Or purchase this article - $20

Print Subscriber Activate your online access now

Welcome Guest Renew Subscribe or Create Account Sign In

HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

Stem Cell summary

BMAC

bull 100k - 2M MSCs

bull Chondrocyte

bull Osteogenic

bull More painful

bull Volume limit

Adipose

bull 250k - 125M MSCs

bull Bioscaffold

bull Tendon defect filling

bull Less painfull

bull Larger volumes

AMNIOTIC TISSUE

Amniotic Tissue

bull Human Amniotic suspension allografts ndash Human amniotic membrane

ndash Human amniotic fluid-derived cells

bull Contain anti-inflammatory factorsndash IL-10 IL-1

ndash Metrix metalloproteinases 123 and 4

ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen

G5

ndash Hyaluranic Acid and small amount so proteoglycans

Amniotic Tissue

bull Human amniotic membrane

ndash Growth factors including EGF TGF-β and FGF

bull Stimulate epithelial cell migration and proliferation

bull PDGF A and B

ndash Stimulate many metabolic processes

raquo General protein and collagen synthesis collagenase activity

and chemotaxis of fibroblasts and of smooth muscle cells

raquo TGF-β has been shown to significantly increase type I

collagen production by tendon sheath fibroblasts

Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169

Amniotic Tissue

bull N = 6 KL grade 34

bull 12 weeks 3512 months

bull Primary goal feasibility of injection for treatment of OA

bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy

Amniotic Tissue

bull Pain and functional measures

ndash P ADL QOL S SR of the KOOS

ndash Overall KOOS IKDC SANE

bull All scores demonstrated improvement at 1 year

ndash Labs

bull No concerning changes in renal function blood cell

counts or lymphocyte subsets

bull Statistically significant increase in IgG and IgE relative to

baseline but not abnormal level

Amniotic Tissue

bull N23

ndash 14 Corticosteroid

ndash 9 c-hAM

bull Safe and comparable to steroid

Amniotic Tissue

Amniotic Tissue

bull N=470 181

bull VAS WOMAC

bull KL 1-3 OA

bull 30 90 120 days

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

Access this article

Or purchase this article - $20

Print Subscriber Activate your online access now

Welcome Guest Renew Subscribe or Create Account Sign In

HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

AMNIOTIC TISSUE

Amniotic Tissue

bull Human Amniotic suspension allografts ndash Human amniotic membrane

ndash Human amniotic fluid-derived cells

bull Contain anti-inflammatory factorsndash IL-10 IL-1

ndash Metrix metalloproteinases 123 and 4

ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen

G5

ndash Hyaluranic Acid and small amount so proteoglycans

Amniotic Tissue

bull Human amniotic membrane

ndash Growth factors including EGF TGF-β and FGF

bull Stimulate epithelial cell migration and proliferation

bull PDGF A and B

ndash Stimulate many metabolic processes

raquo General protein and collagen synthesis collagenase activity

and chemotaxis of fibroblasts and of smooth muscle cells

raquo TGF-β has been shown to significantly increase type I

collagen production by tendon sheath fibroblasts

Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169

Amniotic Tissue

bull N = 6 KL grade 34

bull 12 weeks 3512 months

bull Primary goal feasibility of injection for treatment of OA

bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy

Amniotic Tissue

bull Pain and functional measures

ndash P ADL QOL S SR of the KOOS

ndash Overall KOOS IKDC SANE

bull All scores demonstrated improvement at 1 year

ndash Labs

bull No concerning changes in renal function blood cell

counts or lymphocyte subsets

bull Statistically significant increase in IgG and IgE relative to

baseline but not abnormal level

Amniotic Tissue

bull N23

ndash 14 Corticosteroid

ndash 9 c-hAM

bull Safe and comparable to steroid

Amniotic Tissue

Amniotic Tissue

bull N=470 181

bull VAS WOMAC

bull KL 1-3 OA

bull 30 90 120 days

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

Access this article

Or purchase this article - $20

Print Subscriber Activate your online access now

Welcome Guest Renew Subscribe or Create Account Sign In

HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

Amniotic Tissue

bull Human Amniotic suspension allografts ndash Human amniotic membrane

ndash Human amniotic fluid-derived cells

bull Contain anti-inflammatory factorsndash IL-10 IL-1

ndash Metrix metalloproteinases 123 and 4

ndash HAFCs upregulate anti-inflammatory pathwaysbull IL-10 Doleamine 23-dioxygenase TGF-B1 leukocyte antigen

G5

ndash Hyaluranic Acid and small amount so proteoglycans

Amniotic Tissue

bull Human amniotic membrane

ndash Growth factors including EGF TGF-β and FGF

bull Stimulate epithelial cell migration and proliferation

bull PDGF A and B

ndash Stimulate many metabolic processes

raquo General protein and collagen synthesis collagenase activity

and chemotaxis of fibroblasts and of smooth muscle cells

raquo TGF-β has been shown to significantly increase type I

collagen production by tendon sheath fibroblasts

Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169

Amniotic Tissue

bull N = 6 KL grade 34

bull 12 weeks 3512 months

bull Primary goal feasibility of injection for treatment of OA

bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy

Amniotic Tissue

bull Pain and functional measures

ndash P ADL QOL S SR of the KOOS

ndash Overall KOOS IKDC SANE

bull All scores demonstrated improvement at 1 year

ndash Labs

bull No concerning changes in renal function blood cell

counts or lymphocyte subsets

bull Statistically significant increase in IgG and IgE relative to

baseline but not abnormal level

Amniotic Tissue

bull N23

ndash 14 Corticosteroid

ndash 9 c-hAM

bull Safe and comparable to steroid

Amniotic Tissue

Amniotic Tissue

bull N=470 181

bull VAS WOMAC

bull KL 1-3 OA

bull 30 90 120 days

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

Access this article

Or purchase this article - $20

Print Subscriber Activate your online access now

Welcome Guest Renew Subscribe or Create Account Sign In

HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

Amniotic Tissue

bull Human amniotic membrane

ndash Growth factors including EGF TGF-β and FGF

bull Stimulate epithelial cell migration and proliferation

bull PDGF A and B

ndash Stimulate many metabolic processes

raquo General protein and collagen synthesis collagenase activity

and chemotaxis of fibroblasts and of smooth muscle cells

raquo TGF-β has been shown to significantly increase type I

collagen production by tendon sheath fibroblasts

Zelen C Poka A Andrews J Prospective Randomized Blinded Comparative study of injectable micronized dehydrated amnioticchornionic membrane allograft for plantar fasciitis ndash A feasibility study 2013 34(10) 1332-1339 Parolini O Solomon A Evangelista M Soncini M Human term placenta as a therapeutic agent from the first clinical applications to future perspectives In Berven E ed Human Placenta Structure and Development Hauppauge NY Nova Science 20101-48 Peerbooms JC van Laar W Faber F et al Use of plate- let rich plasma to treat plantar fasciitis design of a multi centre randomized controlled trial BMC Musculoskelet Disord 20101169 httpwwwbiomedcentralcom1471- 24741169

Amniotic Tissue

bull N = 6 KL grade 34

bull 12 weeks 3512 months

bull Primary goal feasibility of injection for treatment of OA

bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy

Amniotic Tissue

bull Pain and functional measures

ndash P ADL QOL S SR of the KOOS

ndash Overall KOOS IKDC SANE

bull All scores demonstrated improvement at 1 year

ndash Labs

bull No concerning changes in renal function blood cell

counts or lymphocyte subsets

bull Statistically significant increase in IgG and IgE relative to

baseline but not abnormal level

Amniotic Tissue

bull N23

ndash 14 Corticosteroid

ndash 9 c-hAM

bull Safe and comparable to steroid

Amniotic Tissue

Amniotic Tissue

bull N=470 181

bull VAS WOMAC

bull KL 1-3 OA

bull 30 90 120 days

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

Access this article

Or purchase this article - $20

Print Subscriber Activate your online access now

Welcome Guest Renew Subscribe or Create Account Sign In

HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

Amniotic Tissue

bull N = 6 KL grade 34

bull 12 weeks 3512 months

bull Primary goal feasibility of injection for treatment of OA

bull Secondary goal assessing safety and obtaining Preliminary data on safety and efficacy

Amniotic Tissue

bull Pain and functional measures

ndash P ADL QOL S SR of the KOOS

ndash Overall KOOS IKDC SANE

bull All scores demonstrated improvement at 1 year

ndash Labs

bull No concerning changes in renal function blood cell

counts or lymphocyte subsets

bull Statistically significant increase in IgG and IgE relative to

baseline but not abnormal level

Amniotic Tissue

bull N23

ndash 14 Corticosteroid

ndash 9 c-hAM

bull Safe and comparable to steroid

Amniotic Tissue

Amniotic Tissue

bull N=470 181

bull VAS WOMAC

bull KL 1-3 OA

bull 30 90 120 days

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

Access this article

Or purchase this article - $20

Print Subscriber Activate your online access now

Welcome Guest Renew Subscribe or Create Account Sign In

HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

Amniotic Tissue

bull Pain and functional measures

ndash P ADL QOL S SR of the KOOS

ndash Overall KOOS IKDC SANE

bull All scores demonstrated improvement at 1 year

ndash Labs

bull No concerning changes in renal function blood cell

counts or lymphocyte subsets

bull Statistically significant increase in IgG and IgE relative to

baseline but not abnormal level

Amniotic Tissue

bull N23

ndash 14 Corticosteroid

ndash 9 c-hAM

bull Safe and comparable to steroid

Amniotic Tissue

Amniotic Tissue

bull N=470 181

bull VAS WOMAC

bull KL 1-3 OA

bull 30 90 120 days

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

Access this article

Or purchase this article - $20

Print Subscriber Activate your online access now

Welcome Guest Renew Subscribe or Create Account Sign In

HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

Amniotic Tissue

bull N23

ndash 14 Corticosteroid

ndash 9 c-hAM

bull Safe and comparable to steroid

Amniotic Tissue

Amniotic Tissue

bull N=470 181

bull VAS WOMAC

bull KL 1-3 OA

bull 30 90 120 days

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

Access this article

Or purchase this article - $20

Print Subscriber Activate your online access now

Welcome Guest Renew Subscribe or Create Account Sign In

HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

Amniotic Tissue

Amniotic Tissue

bull N=470 181

bull VAS WOMAC

bull KL 1-3 OA

bull 30 90 120 days

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

Access this article

Or purchase this article - $20

Print Subscriber Activate your online access now

Welcome Guest Renew Subscribe or Create Account Sign In

HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

Amniotic Tissue

bull N=470 181

bull VAS WOMAC

bull KL 1-3 OA

bull 30 90 120 days

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Page 1 of 2

Interim Analysis of Prospective Multi-Center Outcome Observational Cohort Registry of Amniotic Fluid Treatment for Osteoarthritis of the Knee

Douglas Beall MD and Sri Nalamachu MD

Clinical Radiology of Oklahoma Edmond OK International Clinical Research Institute Overland Park KS

Summary

Interim analysis of the first 181 patients in a Registry Study (1) designed for 470 patients suggest that use of a processed amniotic fluid allograft may offer a safe and effective treatment for osteoarthritis (OA) of the knee Measurements of Mean VAS (2) and WOMAC (3) scores and subscores showed high statistical significance (plt0005 or less) Over 75 of patients showed sustained

improvement at 90 days Mean scores for each measure and all patients showed about 60 improvement compared to Time 0 baseline The study will continue to evaluate patients through 180 days

Study Design

Patients with Kellgren Lawrence Grade 1-3 OA via radiologic examination were eligible for enrollment Excluded patients were lt 35 years had BMI gt 45 or had received Hyaluronic Acid (HA) injections in the previous six months or steroid or platelet rich plasma (PRP) injections in the preceding three months There were no threshold pain inclusion or exclusion criteria Eligible patients were injected with 4cc of a minimally processed amniotic fluid tissue product (AmnioVisctrade (4) Liventa Bioscience West Conshohocken PA) into the affected knee Primary study

efficacy endpoints are VAS scores and WOMAC Overall Score and WOMAC subscore scales for Pain Stiffness and Difficulty (function) These are measured during office visits at baseline and at 30 90 and 180 days

Results

To date over 420 of the planned 470 Registry enrollees have been treated This interim analysis shows captured data from the first 181 patients to attain day 30 and 51 patients to attain day 90 follow up For early and later time points and all measures there was a direct inverse correlation of the declining pain scores with the patientsrsquo improvements Different patients had outcomes that were averaged for VAS overall WOMAC or the separate WOMAC measures At the follow up visits of 30 and 90 days patient outcomes improved by Means of 60 + 4 at 30 days compared to Time 0 Percentages of scores or subscores were either maintained or improved through 90 days (Figures 1 2 4)

OMEGA Statistics (Murieta CA) did Analysis of Variance (ANOVA) and other statistical analyses for all the endpoint measures to explore the treatment impact at Time 0 compared to the measures at 30 days and 90 days Analyses of within-subjects effects for all endpoints and across the three time points

evaluated showed high statistical significance (p values lt

0005 or less) for the mean scores from t=0 to t=30 days or t=90 days Measurable improvements were seen by 14 days with a gradual increase when at least 75 of patients showing improvement at 90 days (Figure 3)

Among 181 patients returning for 30 day visits only 4 treatment-related adverse events (22) were reported This was noted as transient pain and tenderness which in all cases resolved within days with no treatment

Figure 3 WOMAC Scores and Overall Patient Population Improvement

Figure 1 Mean VAS Score and Percent Improvement

Figure 2 Overall WOMAC Score and Percent Improvement

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

Access this article

Or purchase this article - $20

Print Subscriber Activate your online access now

Welcome Guest Renew Subscribe or Create Account Sign In

HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

Amniotic Tissue

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

Access this article

Or purchase this article - $20

Print Subscriber Activate your online access now

Welcome Guest Renew Subscribe or Create Account Sign In

HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

Amniotic Tissue

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

Access this article

Or purchase this article - $20

Print Subscriber Activate your online access now

Welcome Guest Renew Subscribe or Create Account Sign In

HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

Amniotic Tissue

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

Access this article

Or purchase this article - $20

Print Subscriber Activate your online access now

Welcome Guest Renew Subscribe or Create Account Sign In

HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

FDA

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

Access this article

Or purchase this article - $20

Print Subscriber Activate your online access now

Welcome Guest Renew Subscribe or Create Account Sign In

HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

Slide Courtesy of Dr Joanne Borg Stein

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

Access this article

Or purchase this article - $20

Print Subscriber Activate your online access now

Welcome Guest Renew Subscribe or Create Account Sign In

HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

FDA ndash NEJM Perspective

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

Access this article

Or purchase this article - $20

Print Subscriber Activate your online access now

Welcome Guest Renew Subscribe or Create Account Sign In

HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

Adipose Tissue

31717 8 (53 AMVision Loss af ter Int ravit real Inject ion of Autologous ldquo Stem Cellsrdquo for AMD mdash NEJM

Page 1 of 2ht tp wwwnejmorgdoi full101056NEJMoa1609583viewType=PrintampviewClass=Print

Access this article

Or purchase this article - $20

Print Subscriber Activate your online access now

Welcome Guest Renew Subscribe or Create Account Sign In

HOME ARTICLES amp MULTIMEDIA ISSUES SPECIALTIES amp TOPICS FOR AUTHORS CME Keyword Title Author or CitationAdvancedSearch

Share

Free Preview PRINT E-MAIL DOWNLOAD CITATION PERMISSIONS

Adipose tissuendashderived ldquostem cellsrdquo have been increasingly used by

ldquostem-cell clinicsrdquo in the United States and elsewhere to treat a variety

of disorders We evaluated three patients in whom severe bilateral

visual loss developed after they received intravitreal injections of

autologous adipose tissuendashderived ldquostem cellsrdquo at one such clinic in

the United States In these three patients the last documented visual

acuity on the Snellen eye chart before the injection ranged from 2030

to 20200 The patientsrsquo severe visual loss after the injection was

associated with ocular hypertension hemorrhagic retinopathy

vitreous hemorrhage combined traction and rhegmatogenous retinal

detachment or lens dislocation After 1 year the patientsrsquo visual

acuity ranged from 20200 to no light perception

Supported by grants from the National Institutes of Health (Center Core grant

P30EY014801) Research to Prevent Blindness the Department of Defense

(W81XWH-09-1-0675) and the Klorfine Foundation (to Dr Albini) The funders

named were not associated with the clinical trial described

Disclosure forms provided by the authors are available with the full text of this

article at NEJMorg

This article was updated on March 16 2017 at NEJMorg

We thank Jeffrey S Heier MD chair of the Research and Safety in Therapeutics

This article is available to subscribersSign in now if youre a subscriber

ORIGINAL ARTICLE

Vision Loss after Intravitreal Injection of Autologous ldquoStemCellsrdquo for AMDAjay E Kuriyan MD Thomas A Albini MD Justin H Townsend MD Marianeli Rodriguez MD PhD Hemang

K Pandya MD Robert E Leonard II MD M Brandon Parrott MD PhD Philip J Rosenfeld MD PhD Harry

W Flynn Jr MD and Jeffrey L Goldberg MD PhD

N Engl J Med 2017 3761047-1053 March 16 2017 DOI 101056NEJMoa1609583

MEDIA IN THISARTICLE

FIGURE 1

Findings onOphthalmologicExamination in Patient1

FIGURE 2

Findings onOphthalmologicExamination inPatients 2 and 3

ARTICLE ACTIVITY

1 article has cited this

article

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

FDA

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

FDA

bull Regulation of Biologic productsndash 1913 ndash Virus-Serum Toxin Act

ndash 1942 ndash Public Health Service Act

bull Cells ldquodevicesrdquo ldquotransplantrdquondash 1990s Regulatory change

bull 1995 Carticel ndash autologous cartilage cells cultured expanded for osteochondral flap

ndash FDA approved as new medical device

bull 1996 Center for Biologics Evaluation and Research ndash Listed as Biologic

ndash 1990s Classify allogenic cultured cells using the BLA drug Pathway

ndash 2006 ndash Changed regulatory focus ndash expanding regulation

ndash 2016 ndash Meeting in september

Centeno CJ Bashir J Safety and Regulatory Issues Regarding stem cell therapies one clinicrsquos perspective PMR 7 (2015) S4-S7

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

FDA

bull 21 CFR 1271

ndash Not all autologous cells are drugs

bull HCTP (human cells tissues and cellular and tissue

based products)

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

FDA

1 More than Minimally Manipulated

ndash Centrifugation crystalloids water cuttingshaping

2 Homologous use

ndash Same structure function

3 Processed in isolation

ndash Same surgical procedure no combinations

4 Limited systemic effect

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

Summary

bull Indicationsndash Cartilage defects

ndash Osteoarthritis

ndash Tendonopathies

bull Patient selectionndash Completed standard of care

bull physical therapy program

bull Other injectables

bull NSAIDs

ndash Age and medical factors

ndash Continued disease impact on QoL

ndash Peri vs intra-articular

bull Severity and location

ndash Knee hip shoulder

ndash Not a surgical candidate

bull Ie Medical surgeon patient

ndash Patient preference

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

Physical Therapy

ndash Phase 1 ndash Inflammation proliferation phase

bull Weeks 0-2 = rest low load

ndash Phase 2 ndash Proliferation phase

bull Weeks 2-4 = active exercise increase load

ndash Phase 3 ndash Remodeling phase

bull Weeks 5-6 = expanded active exercise (eccentrics)

ndash Phase 4 ndash Integration phase

bull Weeks 7-8 = exercise progression run walk rep max

ndash Phase 5 ndash Sport specific

bull Weeks gt8 = sport specificHead P Rehabilitation considerations in regenerative medicine Phys Med Rehabil Clin N Am 27 (2016) 1043-1054

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

Future

bull Vectors

bull Bioscaffolds

bull Gene Therapy

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

Personalized Regenerative

Sports Medicine

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

Conclusion

bull Let us not be governed today by what we did

yesterday nor tomorrow by what we do today for

day by day we must show progress

ndash AT Still

Thank you

bull Questions

Thank you

bull Questions