Translating cell-based regenerative medicines from research to successful products: challenges and solutions

The Tissue Engineering & Regenerative Medicine International Society-Europe (TERMIS-EU) Industry Committee as well as its TERMIS-Americas (AM) counterpart intend to address the specific challenges and needs facing the industry in translating academic research into commercial products. Over the last 3 years, the TERMIS-EU Industry Committee has worked with commercial bodies to deliver programs that encourage academics to liaise with industry in proactive collaborations. The TERMIS-EU 2013 Industry Symposium aimed to build on this commercial agenda by focusing on two topics: Operations Management (How to move a process into the good manufacturing practice [GMP] environment) and Clinical Translation (Moving a GMP process into robust trials). These topics were introduced by providing the synergistic business perspective of partnering between the multiple regenerative medicine stakeholders, throughout the life cycle of product development. Seven industry leaders were invited to share their experience, expertise, and strategies. Due to the complex nature of regenerative medicine products, partnering for their successful commercial development seems inevitable to overcome all obstacles by sharing experiences and expertise of all stakeholders. When ideally implemented, the "innovation quotient" of a virtual team resulting from the combination of internal and external project teams can be maximized through maximizing the three main dimensions: core competences, technology portfolio, and alliance management.

Regulating cell-based regenerative medicine: the challenges ahead

Those working in the regenerative medicine field currently face numerous regulatory and related challenges. This Perspective captures some of the key ideas of a UK-based working group drawn from academic, clinical and industrial communities and also identifies some key steps that should be taken in the UK and elsewhere to address these challenges.

A comparative approach to understanding tissue-specific expression of uncoupling protein 1 expression in adipose tissue

The thermoregulatory function of brown adipose tissue (BAT) is due to the tissue-specific expression of uncoupling protein 1 (UCP1) which is thought to have evolved in early mammals. We report that a CpG island close to the UCP1 transcription start site is highly conserved in all 29 vertebrates examined apart from the mouse and xenopus. Using methylation sensitive restriction digest and bisulfite mapping we show that the CpG island in both the bovine and human is largely un-methylated and is not related to differences in UCP1 expression between white and BAT. Tissue-specific expression of UCP1 has been proposed to be regulated by a conserved 5′ distal enhancer which has been reported to be absent in marsupials. We demonstrate that the enhancer, is also absent in five eutherians as well as marsupials, monotremes, amphibians, and fish, is present in pigs despite UCP1 having become a pseudogene, and that absence of the enhancer element does not relate to BAT-specific UCP1 expression. We identify an additional putative 5′ regulatory unit which is conserved in 14 eutherian species but absent in other eutherians and vertebrates, but again unrelated to UCP1 expression. We conclude that despite clear evidence of conservation of regulatory elements in the UCP1 5′ untranslated region, this does not appear to be related to species or tissues-specific expression of UCP1.

Evidence based mental healthcare and service innovation: review of concepts and challenges

Health provision systems in the developed western nations are currently facing major financial challenges. In order to meet these challenges, a number of new approaches used to assist the provision of health have been introduced, including the practice of health professionals. These approaches utilize specific methods of data capture and summarization such as: evidence based medicine (EBM) and practice guidelines. Evidence is generated from systematic clinical research as well as reported clinical experience and individually case based empirical evidence. All types of research though (quantitative or qualitative) have limitations. Similarly all types of evidence have advantages and disadvantages and can be complimentary to each other. Evidencebased individual decision (EBID) making is the commonest evidence-based medicine as practiced by the individual clinician in making decisions about the care of the individual patient. It involves integrating individual clinical expertise with the best available external clinical evidence from systematic research. However this sort of evidence-based medicine, focuses excessively on the individual (potentially at the expense of others) in a system with limited budgets. Evidence-based guidelines (EBG) also support the practice of evidence-based medicine but at the organizational or institutional level. The main aim is to identify which interventions, over a range of patients, work best and which is cost-effective in order to guide service development and provision at a strategic level. Doing this effectively is a scientific and statistical skill in itself and the quality of guidelines is based primarily on the quality research evidence. It is important to note that lack of systematic evidence to support an intervention does not automatically mean that an intervention must instantly be abandoned. It is also important that guidelines are understood for what they are, i.e. not rules, or complete statements of knowledge. EBM will never have enough suitable evidence for all and every aspects of health provision in every locality. Innovation signifies a substantial positive change compared to gradual or incremental changes. Innovation using inductive reasoning has to play a major role within health care system and it is applicable to all three level of service provision: clinical practice, policy and organisation structure. The aim of this paper is to examine critically the above concepts and their complimentary role in supporting provision of health care systems which are suitable for the requirements of the population, affordable, deliverable, flexible and adaptable to social changes.

Differentiation of frontotemporal dementia from dementia with Lewy bodies using FP-CIT SPECT

INTRODUCTION

There is increasing evidence that imaging with [123I]FP-CIT SPECT is helpful in differentiating dementia with Lewy bodies (DLB) from Alzheimer's disease (AD) but it is not known how well the scan performs in differentiating DLB from frontotemporal dementia (FTD).

METHOD

We compared the striatal dopamine transporter (DAT) binding in FTD (n=12), DLB (n=10) and AD (n=9) by visually rating the caudate and putamen on [123I]FP-CIT SPECT scans.

RESULTS

The majority (9/10) of DLB cases had an abnormal scan and a significant reduction of uptake of DAT binding in the putamen and the caudate. A third (4/12) of the FTD cases also had an abnormal scan and a significant reduction in uptake in the putamen and the caudate. In contrast, only one out of nine AD cases had an abnormal scan. Significant differences were found when comparisons were made between the groups for visual analysis of the entire scan (p=0.001) and the four regions of interest (p=0.001 - 0.013). In contrast to the AD group (specificity of scan 89%), the specificity of [123I]FP-CIT SPECT scans was reduced in the FTD group to 67%. Three quarters of the study population had at least one extrapyramidal motor sign (EPMS), with bradykinesia being the most common EPMS in both FTD (83%) and DLB (70%).

CONCLUSIONS

This study highlights to clinicians that a positive (abnormal) [123I]FP-CIT SPECT scan, even in a patient with an EPMS, does not exclude the diagnosis of FTD and emphasises the importance of a comprehensive clinical evaluation and a detailed cognitive assessment.

The role of dopaminergic imaging in patients with symptoms of dopaminergic system neurodegeneration

Diagnosis of neurological and psychiatric conditions associated with disturbances of dopaminergic functioning can be challenging, especially in the early stages, and may be assisted with biomarkers such as dopamine system imaging. Distinguishing between Alzheimer's disease and dementia with Lewy bodies is a major diagnostic challenge. Clinical diagnosis of Parkinson's disease is straightforward with classic presentation, but accurate distinction among Parkinsonian variants may be difficult; non-Parkinson's disease conditions are commonly misdiagnosed as Parkinson's disease, and ~20% of patients with Parkinson's disease are not clinically diagnosed despite coming to medical attention. Early and accurate diagnosis is desirable to improve management. Imaging of the dopamine transporter using single-photon emission computed tomography may be of particular utility in this regard. Abnormal imaging indicates underlying nigrostriatal neurodegeneration, supportive of a diagnosis of Parkinson's disease, atypical parkinsonism or dementia with Lewy bodies, and identifies patient groups in whom dopaminergic therapy may be beneficial. Normal imaging supports diagnosis of a condition not involving nigrostriatal neurodegeneration such as Alzheimer's disease, essential tremor or drug-induced parkinsonism and hence a different therapeutic approach. In patients in whom there was diagnostic uncertainty between degenerative parkinsonism and non-degenerative tremor disorders, baseline imaging with the dopamine transporter ligand [(123)I]ioflupane (DaTscan™) has shown 78% sensitivity and 97% specificity with reference to clinical diagnosis at 3 years, versus 93% and 46%, respectively, for baseline clinical diagnosis. In a Phase III trial of [(123)I]ioflupane in patients with initial clinical diagnosis of probable or possible dementia with Lewy bodies or non-Lewy body dementia, mean specificity for excluding non-Lewy body dementia (predominantly Alzheimer's disease) was 90.4%. Using clinical diagnosis as a reference against which to assess sensitivity and specificity of dopamine transporter imaging is a limitation, but definitive diagnosis via pathological confirmation is generally not feasible. In a series of patients with post-mortem brain examination, imaging using [(123)I]ioflupane has demonstrated higher sensitivity (88%) and specificity (100%) for differentiating dementia with Lewy bodies from non-Lewy body dementia than clinical diagnosis (75% and 42%, respectively). Dopaminergic system imaging may be particularly valuable in patients with clinically inconclusive parkinsonism or a clinical diagnosis of possible dementia with Lewy bodies; it is not helpful in differentiating between Parkinson's disease and atypical parkinsonism, although postsynaptic dopaminergic imaging may be of utility. Other potential uses of dopamine transporter imaging include identification of patients with premotor Parkinson's disease, monitoring disease progression in testing novel therapeutics, and as an inclusion criterion for entry into clinical trials.

Numerical analysis of a unique mode of locomotion: vertical climbing by Pacific lamprey

Pacific lampreys are capable of climbing vertical wetted surfaces through a two-phase (bending and stretching) locomotion mode using the oral disc for adherence. We investigate the physical mechanism and performance of this process by using a continuous beam model. Two mechanisms, one akin to the jumping process and the other related to the fast stretching of the body, have been identified. This locomotion mode may inspire biomimetic designs of anguilliform swimming devices capable of overcoming steep obstacles. By using a genetic algorithm simulation we identify the combination of kinematic parameters corresponding to optimal efficiency (defined as the gravitational potential energy gained in each climbing step divided by the energy spent to activate the motion). These parameters are similar to laboratory observations of lamprey motion, suggesting that this type of locomotion has been optimized for maximum efficiency through evolution.

Snail shape and growth rates: Evidence for plastic shell allometry in Littorina littorea

The periwinkle Littorina littorea exhibits morphological variation among southern New England populations that appear to be genetically continuous. In dense populations, individuals have relatively elongate shells in comparison to individuals in sparse populations, which have rounder, globose shells. We experimentally demonstrate that this shell variation is a function of snail growth rate. Rapidly growing snails develop thin, globose shells that accommodate more body mass than thicker, more elongate shells. The implications of these results are discussed in relation to interpreting morphological variation in extant gastropods and in the molluscan fossil record.