The above diagram shows the difference between a normal cell and a cell which is in a senescent state. A senescent cell is a cell that has stopped replicating. Although senescent cells can no longer replicate, they remain metabolically active and commonly adopt a pattern of secreting pro-inflammatory cytokines, the up-regulation of immune ligands, which means fooling the immune system to not attack them. In general, these cells are trouble makers!
Recently there was a significant announcement of a discovery by a consortium. This discovery is called UBX0101. UBX 0101 has some remarkable tributes. It is a drug that may delay, prevent, or even reverse the progression of osteoarthritis. It has a rather interesting mechanism of action. We now know that osteoarthritis is an inflammatory process that is age related. There is a medication UBX0101 that will eliminate a senescent cell. Again remember, healthy cells that experience stress can enter a state known as cellular senescence. In this state, cells stop dividing and profoundly alter their metabolism, appearance, and interactions with their environment. The subcellular damage itself does not directly cause the visible signs of aging, but rather, as the damage accumulates and reaches a critical mass, cells cease to proliferate and acquire the deleterious “senescence-associated secretory phenotype” (fancy way of saying the cells have changed character and altered the compounds they produce) which then leads to the consequences of tissue breakdown to create an aged cell. Thus, senescence is a precondition for tissue aging, and this explains why aging is a gradual process that remains largely invisible during most of its progression. The subcellular damage includes shortening of telomeres, damage to mitochondria, and DNA double-strand breaks triggered by various genetic, and environmental factors.
The senescent cells will accumulate over time. These cells are capable of doing damage on a molecular level. They will accumulate growth factors, proteases, and inflammatory factors that disrupt normal tissue function. Senescent cells comprise a small number of the total cells. Senescent cells have long been implicated in aging. Some rapidly dividing cells reach a point when they can no longer safely replicate; their telomeres become too short to protect the cell’s DNA. At this point, a cell will either destroy itself through a process called apoptosis, become dysfunctional (and potentially cancer-prone), or turn replication off but continues to survive. The cells that turn off are known as senescent. They can perform some functions, but they also release molecules that may increase risk for a variety of diseases, including cancer.
These cells are capable of producing those cytokines which are responsible for pain and inflammation in a joint or even worse cause systemic problems such as diabetes. Cytokines are molecules which act as signals for the cells telling them what to do. Some of these cytokines are “bad”. They are named Interleukin-1, Interleukin-6, and Tumor Necrosis Factor. They are called master inflammatory cytokines. One of the cornerstones of PRP and stem cell regenerative theories are that they can overpower these inflammatory cytokines. Many times, they will make certain anti-inflammatory cytokines such as Interleukin-1 antagonist, Interleukin -10, Insulin-Growth Factor-1. The can be considered the master anti-inflammatory cytokines. Unfortunately, the inflammation war may not always be won. The bad cytokines will over whelm the good ones and repair will come to a standstill. Perhaps this is where UXB0101 may come into play.
It has been discovered that these senescent cells accumulate in the joint and do their bad deeds. UXB0101 will selectively kill these cells. In cartilage grown from human knees with advanced OA, UBX0101 selectively eliminated senescent cells, increased proliferation of healthy chondrocytes, and induced new cartilage growth. This represents a new group of therapies called senolytic medicines to selectively eliminate senescent cells and thereby treat age-related afflictions such as osteoarthritis, atherosclerosis, eye diseases. When I did further investigation, I discovered that there are a number of compounds that have senolytic activities. Many of these are over the counter supplements. There is a good bit of interest in these compounds.
This brings us to a whole new field of possible therapeutic agents that may help with aging and Regenerative Medicine. These senolytic agents are generating a good bit of scientific interest. These agents may be a tremendous asset for anti-aging. There is now a race to study some drugs that can have senolytic properties. I did a good bit of investigating and found some supplements that have senolytic properties. Studies have shown the benefits of combining tocotrienols with quercetin, a flavonol. Flavonols are phytochemical compounds found in high concentrations in a variety of plant-based foods and beverages. They are common in many fruits and vegetables. Quercetin also has dual and complementary actions with regards to aging cells. Like tocotrienols, quercetin can induce senescence and promote cell death in numerous types of cancer cells. Like tocotrienols, quercetin has the opposite effect in healthy cells, delaying senescence in younger cells and rejuvenating older cells to rid them of their abnormal, age-promoting function. Tocotrienols are members of the vitamin E family of essential nutrients, naturally found in grains and nuts. However, newer information indicates that for other activities including antioxidant, cholesterol lowering, and anti-cancer effects that the tocotrienols (T3s), especially delta-tocotrienol (delta T3) exert more profound effects. I found some interesting information concerning the strengths of Vitamin E. So, while in terms of vitamin E activity the order of potency would be: alpha T > beta T > gamma T > alpha T3 > delta T > gamma T3 > delta T3.
We can see that the T3 tocotrienol has the most potency and the probable best chance of being a senolytic agent. Let us take a better look at Vitamin E more specifically Vitamin E T3. Here are some helpful diagrams.
The different forms of Vitamin E are what causes controversy in studies. Some forms of Vitamin E have very different actions. The Tocotrienol form, especially T3 is a very potent anti-inflammatory agent in addition to being a senolytic agent.
When one looks at some the most recent studies there is evidence that tocotrienols and quercetin reduce levels in the blood of inflammatory cytokines. When these inflammatory cytokines are suppressed than systemic inflammation is reduced.
Another promising senolytic agent is fisetin. Fisetin is flavonoid (a plant pigment that gives plants color, smell etc.) derived from various fruits such as strawberries. Fisetin also has direct activity as a reducing agent, chemically reacting with reactive oxygen free radicals to neutralize them. Based on lab studies, it appears that fisetin lodges in cell membranes and prevents oxidative damage to lipids in the cell membrane.
Now comes the tricky part. We do not think it is best to continue on some of these supplements on an indefinite basis. I suspect it would be best to take them on an occasional basis. We feel the best method would be to combine a few of these supplements in a propriety manner. This would eliminate a good number of the senescent cells. This elimination would hopefully have a cascade effect. This effect would significantly help reduce inflammatory cytokines. Essentially what we are doing is allowing the regenerative cells to have a better chance of achieving success. We now feel we are ready to launch a program to achieve a reduction in the senescent cell population.
Will senolytic agents be a game changer? Only time will tell. I am not a betting man but if I were a betting man I would bet on them. They might take us one step closer to the promised land. Thanks Dr. P
BOSTON BIOLIFE MEETING
The above pictures may be confusing to those who are history buffs. I am mentioning the Boston Biolife meeting yet I am showing pictures of Constitution Hall in Philadelphia. The simple reason for this was that the Boston Biolife Meeting was held in Philadelphia.
This was the first time I gave a lecture in conjunction with Boston Biolife. I must say I believe they have their act together. They have an excellent array of speakers including both PHD’s such as Dr. Peter Everts and Dr. Dmitry Shvartsman and an array of physicians some of whom were new to me and some who were old friends. Unlike any other field in medicine, Regenerative Medicine is one where there is a strong bond between PHD’s and MDs. It is only if we work together can we bring this specialty to the forefront of medicine. The target audience were those physicians who want get in depth information about the Regenerative Medicine field. They seemed ready, willing, and able to learn. What I believed these physicians realized is what can be found in the Boston Biolife insignia. In Regenerative Medicine, we need to be a physician, a scientist, a technician, and finally a physician who can bridge all these fields. We need to start as a physician. Having had the training as a physician, we need to understand the science and why we do what we do (scientist). Once we master these steps we need to know how to do the procedures properly (technician). When we achieve these goals we than need to act as a translational physician. A translational physician needs to put it all together. Many people may be asking what is a “translational medicine (TM)”? The Wikipedia definition is as follows: “an interdisciplinary branch of the biomedical field supported by three main pillars: bench side, bedside and community. The goal of TM is to combine disciplines, resources, expertise, and techniques within these pillars to promote enhancements in prevention, diagnosis, and therapies. Accordingly, TM is a highly interdisciplinary field, the primary goal of which is to coalesce assets of various natures within the individual pillars in order to improve the global healthcare system significantly”. These are the pillars of the Boston Biolife program. They teach science, techniques, and decision making. If I could have had these concepts when I started out it would have made an easier path for me.
I heard a good number of talks about spinal problems including the treatments of disk problems. Some good science was mentioned. We still have a way to go concerning the discs of the spine. Discs represent one of the harshest environments in the body for stem cells. Most will perish very quickly in the environment of a disc. I feel that perhaps one way to treat this problem might involve MUSE cells. Muse cells are very forgiving and actually seem to thrive in a stressful environment. We have a propriety way of obtaining the MUSE cells and are looking forward to utilizing them in a disc. This will be the subject of another blog. I did present some new information concerning a comparison of centrifuged vs non-centrifuged bone marrow aspirate. The non-centrifuged aspirate seemed to perform better on a number of different levels. The apparent reasons for this are mentioned in one of my other blogs. I suspect the field will ultimately move in the direction of non-centrifuged or at least some hybrid form of bone marrow aspirate. One other talk that rang true to me was that of Dr. Peter Everts. Dr. Everts spoke about Platelet Rich Plasma (PRP). He echoed my thoughts that there is much more to PRP than just platelets. Actually, a portion of my lecture was devoted to “Scary Urban Legends” concerning PRP. I showed some scientific reasons why we need to consider all components of the blood when we are discussing PRP.
The other aspect of the course was the practical aspects of the course. The actual preforming procedures such as a bone marrow aspiration on a cadaver. I happened to put my two cents in on certain techniques. One such technique were methods of performing a bone marrow aspiration which seems to give both higher numbers of regenerative cells and better clinical results.
All in all, this was a very good meeting representing different viewpoints but having a consensus of what seems to be important for the fledgling Regenerative Medicine doctor to grasp and learn. I had a very positive experience at this meeting. I think the same could be said about the physicians in the audience. Finally, the course organizer, Joseph Krieger gave some advice to the audience that I have been preaching for years. I actually have a slide on this. The saying is “the more we know the more we don’t know”. As my knowledge in the field expands so does my lack of knowledge. Thanks Dr. P
ARE ALL PRPs THE SAME? WHAT ABOUT PRXP?
In the Regenerative Medicine field, there has for some time been controversy concerning certain aspects of Platelet Rich Plasma or PRP as it is called. There seems to be a misconception in some circles that some components of a PRP are bad. There is a belief amongst many Regenerative Medicine doctors that a leukocyte poor (LP) PRP is more effective than a PRP product that contains leukocytes. Leukocytes are the white blood cells found in blood. Moreover, there is a perception that the only important component of a PRP are the platelets which contain the growth factors. When one delves deeper into the science of PRP we understand that this is far from the truth. As a matter of fact, there is little scientific literature to support the idea that LP-PRP is preferred over the Leukocyte Rich (LR) PRP. However, there is a copious amount of literature to support the concept that all components of the blood are necessary to achieve an optimal result.
Recently I read an article by Dr. William R. Parrish. The title of his article was: "Platelet rich plasma in osteoarthritis: more than a growth factor therapy". This title certainly rang true to my beliefs. I have been stating for years that having a PRP product with a minimal amount of white blood cells (Leukocytes) was probably not a good thing. Furthermore, Dr. Parrish stated that there is a notion (not his own) that other blood products such as red blood cells also contribute to an increased inflammatory response in a PRP product. The one concept that was ignored was that these studies that lead to the concept that WBCs and RBCs were detrimental were studies performed in the lab (in vitro).
Studies in the lab many times produce far different results than those in real life (in vivo). When we are studying a lab situation this is far different than real life. The environment is far different and thus the results can be far different. A review of the literature shows little in the way of support for the use of low concentrations of WBCs. The pendulum of research now supports the idea that greater concentrations of leukocyte and RBCs yielded a greater therapeutic effect on the patient. This is something I have known for the last ten years or so. I will concede that there may a bit more discomfort from a LR-PRP but at most this may last a day or so. We also have some propriety methods to help reduce this inflammation.
What is potentially so special about these other blood components. One thing we know is that platelets require some form of activation. Typically, when platelets come into contact with tissue (collagen) they become activated. RBCs help in platelet activation. RBCs will help generate additional amounts of thrombin. Thrombin is a very potent stimulator of platelet activation. When some stem cell processes are given intravenously the platelets are mixed with thrombin so that they will release their growth factors. We would not want to use platelets intravenously since they could form a blood clot in a vein leading to serious consequences. The growth factors would not be a problem.
Other factors that lead to the importance of RBCs is their content. RBCs are considered a sink of Nitric Oxide. (NO) is a gas which has numerous effects on cells. NO is a multifaceted compound that can act as a growth, immune and neuro-stimulator as well as causing angiogenesis (formation of blood vessels). They also contain Glutathione. Glutathione is a very potent antioxidant that can alter cell functions in a very positive way. It can help disable some free radicals at the site of injury. Free radicals rob the cells of energy and alter cell function in a negative way.
As Dr. Parrish pointed out eventually, the RBCs will be attacked by WBCs. When this occurs, the WBCs will release a variety of anti-inflammatory growth factors which will quell the inflammatory response and allow healing to occur. Many regenerative medicine docs continue to have the idea that RBCs cause an inflammatory response. Perhaps under certain conditions this might be true. However, this is usually not the case. A good clinical example of RBCs not causing an inflammatory response in what is called a "blood patch". A blood patch is used when a patient had a spinal tap (typically by accident) and then develops a severe headache. The headache results from leaking spinal fluid. A blood patch occurs when whole blood is taken from a vein and injected into the area of the spinal leak. The blood plugs the leak and the headache goes away. Moreover, the blood which is in direct contact with the spinal cord covering (dura) does not cause any type of inflammation. A similar example occurs when a patient suffers a bleed inside the knee. This bleed might be traumatic in nature such as an ACL tear. The blood in the joint does not cause an inflammatory response.
The leukocytes (WBCs) have a very important aspect in the overall scheme of regenerative therapies. As was pointed out in Dr. Parrish’s article there is an extremely important relationship between platelets and neutrophils. It seems that these two cells will work in a type of symbiosis helping to limit the magnitude and duration of the inflammatory response. These two cells work together to form an entity called a lipoxin. The lipoxin is produced by the platelet. Lipoxins are very potent anti-inflammatory molecules. The limit the neutrophil activation. They have far reaching effects but the bottom line is that they foster an anti-inflammatory environment.
What else might be thrown away when producing a PRP? One discard might be a macrophage. Macrophages come in two forms. They are an M-1 and M-2 macrophage. These are very important in our immune system. The following slides are from one of my lectures
In the above we can see the macrophages at work in their normal environment. Interestingly enough the mesenchymal stem cell can have a direct effect on these cells depending upon the environment. However, if we remove these cells from the PRP product than we cannot cause these reactions to occur. The second slide explains these actions.
Another type of white blood cell which is very important is called a neutrophil. Neutrophils have been for years thought to be culprits to instigate inflammation. Under certain circumstances this is true. In the course of a PRP injection neutrophils can have an opposite effect. They can actually quell an inflammation and help release anti-inflammatory compounds. Once the platelets become activated they will “prime” the neutrophils. A primed neutrophil will help to release anti-inflammatory growth factors and limit the inflammatory response. This is very important for otherwise more neutrophils would be called to the area and cause more inflammation.
We must also realize that there are some stem cells in a PRP product. These cells are called Hematopoietic Stem cells (HSCs). We now think that the HSCs are probably the cells that may help direct tissue repair. When we are trying to make a PRP product which is devoid in leucocytes we are also “throwing away” these valuable cells. A tantalizing thought is to give some medications that are able to help mobilize more of these stem cells into the circulation. There are some cancer therapies which stimulate the bone marrow to release more stem cells to the circulation but they have significant problems such as cost and potential side effects. We have come across a supplement which has a similar effect with a very reasonable cost and essentially no side effects. Some food for thought about the numbers of stem cells in a typical PRP product. HSCs (represent 0.06% of circulating TNCs) translates into 3-7K HSCs per ml of blood processed. Is this number significant? No one can say for sure but I would rather have stem cells present than not.
A question one may ask is why not just use whole blood? The problem with that is we will not get enough of the platelets. We have to concentrate the platelets. This is the whole idea behind Platelet Rich Plasma. The bottom line is to try to make full use of the tools nature has given us in blood. This probably gives us the best chance of success when using PRP for a Regenerative Medicine treatment. Thanks Dr. P
The Boston Biolife Meeting
Occasionally I am asked by some docs where I will be doing my next speaking engagement. I have tried to cut down on my international travel schedule. It will be creeping up in the fall with a few trips to Asia. In the meantime, I will try to stay local in the good old USA. This month I am scheduled to give a talk in Philadelphia at the Boston Biolife meeting. I am very much looking forward to this meeting. In looking at the faculty and topics presented it appears to be a well balance meeting presenting many different viewpoints. Probably more than any field, Regenerative Medicine demands an open mind. I can see this thru my own transformation. There were topics that I once considered gospel than I began to question them and finally discovered that what I once considered true was actually not so. Every meeting I attend I usually take back a small nugget of information. I am looking forward to doing so at this meeting. The meeting does not seem to have an ax to grind. They are not pushing one type of technique over another. What they are pushing is science and techniques. They want to present many different opinions. Too often meetings get tilted in their approach to Regenerative Medicine problems. The Boston Biolife approach is to give a solid background in Regenerative Medicine so that the physician can build upon this and better treat his patients. They do this by giving many different points of view. After being given information, the physician can make an informed decision on how to best treat his patients.
I am asked to give a lecture in the field of Regenerative Medicine as it pertains to musculoskeletal skeletal problems. What I will do is call upon my experience of performing many thousands of cases in Regenerative Medicine. I will tell what seems to work for me. More importantly, why it probably works for me. When one understands the “why” than they possess tools to improve upon the situation. To do things as a mechanic means to not understand the “why”. Unless one understands the “why” than improvement is an elusive goal.
I will introduce some our our newer concepts in the field of Regenerative Medicine. One topic that I suspect will garner interest is a procedure called Purekine. Purekine is our method of producing a IRAP product. IRAP stands for anti-interleukin-1 antagonist. This is one on the most potent anti-inflammatory agents known. It is similar to the German process called Regenokine. However, it is derived from the bone marrow.
We will also present some of our clinical data that compares centrifuged vs non-centrifuged bone marrow. This data has never been presented before anywhere in the world.
All in all I look forward to this meeting to present new material and at the same time learn some valuable nuggets of information from the other faculty. We all must realize one thing. Regenerative Medicine is a field that unlike any other there is a good chance that someone at the meeting can make a significant difference and change the course of events in the field of Regenerative Medicine. Thanks Dr. P
