Cell-based therapies for amyotrophic lateral sclerosis/motor neuron disease

Optimal Therapeutic Strategy of Bone Marrow-Originated Autologous Mesenchymal Stromal/Stem Cells for ALS

Amyotrophic lateral sclerosis (ALS) is characterized by selective and progressive neurodegenerative changes in motor neural networks. Given the system complexity, including anatomically distributed sites of degeneration from the motor cortex to the spinal cord and chronic pro-inflammatory conditions, a cell-based therapeutic strategy could be an alternative approach to treating ALS. Lessons from previous mesenchymal stromal/stem cell (MSC) trials in ALS realized the importance of 3 aspects in current and future MSC therapy, including the preparation of MSCs, administration routes and methods, and recipient-related factors. This review briefly describes the current status and future prerequisites for an optimal strategy using bone-marrow-originated MSCs to treat ALS. We suggest mandatory factors in the optimized therapeutic strategy focused on advanced therapy medicinal products produced according to Good Manufacturing Practice, an optimal administration method, the selection of proper patients, and the importance of biomarkers.

[Promising approaches to the pathogenetic therapy of amyotrophic lateral sclerosis]

Amyotrophic lateral sclerosis is a severe incurable disease of the nervous system. Currently only methods of palliative care for the patients with this disease are available. Few medications for the pathogenetic therapy are registered in some countries, i.e. riluzole, edaravon, sodium phenylbutyrate/taurursodiol as well as tofersen (conditionally). Their efficacy is relatively low. The main directions in the development of pathogenetic therapy of ALS include gene therapy, use of stem cells, immunomodulators, agents affecting gut microbiota. A search is also underway for low-molecular compounds with neuroprotective and antioxidant properties. Perspective direction is prevention of ALS. This will be possible when biomarkers for identification of patients in pre-manifest/prodromal stage are detected.

Efficacy and safety of Lenzumestrocel (Neuronata-R® inj.) in patients with amyotrophic lateral sclerosis (ALSUMMIT study): study protocol for a multicentre, randomized, double-blind, parallel-group, sham procedure-controlled, phase III trial

BACKGROUND

A single cycle (two repeated treatments) with intrathecal autologous bone marrow-derived mesenchymal stem cells (BM-MSCs, 26-day interval) showed safety and provided therapeutic benefit lasting 6 months in patients with ALS but did not demonstrate long-term efficacy. This phase III clinical trial (ALSUMMIT) protocol was developed to evaluate the long-term efficacy and safety of the combined protocol of single-cycle intrathecal therapy and three additional booster injections of BM-MSC (Lenzumestrocel) treatment in patients with ALS.

METHODS

ALSUMMIT is a multicentre, randomized, double-blind, parallel-group, sham procedure-controlled, phase III trial for ALS. The 115 subjects will be randomized (1:2:2) into three groups: (1) study Group 1 (single-cycle, two repeated injections with 26-day interval), (2) study Group 2 (single-cycle + three additional booster injections at 4, 7, and 10 months), and (3) the control group. Participants who have an intermediate rate of disease progression will be included in this trial to reduce clinical heterogeneity. The primary endpoint will be evaluated by combined assessment of function and survival (CAFS), also known as joint rank scores (JRS), at 6 months (study Group 1 vs. control) and 12 months (study Group 2 vs. control) after the first Lenzumestrocel or placebo administration. Safety assessment will be performed throughout the study period. Additionally, after the 56-week main study, a long-term follow-up observational study will be conducted to evaluate the long-term efficacy and safety up to 36 months.

DISCUSSION

Lenzumestrocel is the orphan cell therapy product for ALS conditionally approved by the South Korea Ministry of Food and Drug Safety (MFDS). This ALSUMMIT protocol was developed for the adoption of enrichment enrolment, add-on design, and consideration of ethical issues for the placebo group.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04745299 . Registered on Feb 9, 2021. Clinical Research Information Service (CRIS) KCT0005954 . Registered on Mar 4, 2021.

[From the social pediatric center to the medical center for adults with disabilities-transition in adults with complex disabilities]

The successful medical treatment of patients with complex disabilities requires care by multidisciplinary teams in social paediatric centers (German: SPZ) and medical centers for adults with disabilities (German: MZEB). These complement general outpatient medical care, which would be overwhelmed without this support. The quality of this care is crucial for the participation of patients and the prognosis of the disease. At the age of 18, this system requires a transition from the SPZ to the MZEB, which has not yet been satisfactorily regulated. The task and structural prerequisites for this are described. An inadequate or absent transition entails the risk of additional worsening of the course of the disease.

Murine glial progenitor cells transplantation and synthetic PreImplantation Factor (sPIF) reduces inflammation and early motor impairment in ALS mice

Amyotrophic lateral sclerosis (ALS) is a progressive motor neuronal disorder characterized by neuronal degeneration and currently no effective cure is available to stop or delay the disease from progression. Transplantation of murine glial-restricted precursors (mGRPs) is an attractive strategy to modulate ALS development and advancements such as the use of immune modulators could potentially extend graft survival and function. Using a well-established ALS transgenic mouse model (SOD1^G93A), we tested mGRPs in combination with the immune modulators synthetic PreImplantation Factor (sPIF), Tacrolimus (Tac), and Costimulatory Blockade (CB). We report that transplantation of mGRPs into the cisterna magna did not result in increased mice survival. The addition of immunomodulatory regimes again did not increase mice lifespan but improved motor functions and sPIF was superior compared to other immune modulators. Immune modulators did not affect mGRPs engraftment significantly but reduced pro-inflammatory cytokine production. Finally, sPIF and CB reduced the number of microglial cells and prevented neuronal number loss. Given the safety profile and a neuroprotective potential of sPIF, we envision its clinical application in near future.

Therapeutic Mesenchymal Stem/Stromal Cells: Value, Challenges and Optimization

Cellular therapy aims to replace damaged resident cells by restoring cellular and molecular environments suitable for tissue repair and regeneration. Among several candidates, mesenchymal stem/stromal cells (MSCs) represent a critical component of stromal niches known to be involved in tissue homeostasis. In vitro, MSCs appear as fibroblast-like plastic adherent cells regardless of the tissue source. The therapeutic value of MSCs is being explored in several conditions, including immunological, inflammatory and degenerative diseases, as well as cancer. An improved understanding of their origin and function would facilitate their clinical use. The stemness of MSCs is still debated and requires further study. Several terms have been used to designate MSCs, although consensual nomenclature has yet to be determined. The presence of distinct markers may facilitate the identification and isolation of specific subpopulations of MSCs. Regarding their therapeutic properties, the mechanisms underlying their immune and trophic effects imply the secretion of various mediators rather than direct cellular contact. These mediators can be packaged in extracellular vesicles, thus paving the way to exploit therapeutic cell-free products derived from MSCs. Of importance, the function of MSCs and their secretome are significantly sensitive to their environment. Several features, such as culture conditions, delivery method, therapeutic dose and the immunobiology of MSCs, may influence their clinical outcomes. In this review, we will summarize recent findings related to MSC properties. We will also discuss the main preclinical and clinical challenges that may influence the therapeutic value of MSCs and discuss some optimization strategies.

A review and update for registered clinical studies of stem cells for non-tumorous and non-hematological diseases

Objective

To provide consultative information on selecting potential indications of stem cells in the treatment of non-tumorous and non-hematopoietic system conditions, we screened the clinical trials on website: http://www.clinicaltrials.gov.

Methods

A literature search was conducted using the National Institute of Health (NIH) website (http://www.clinicaltrials.gov) from May 10th, 2012 to Oct 13th, 2020 with stem cells as an intervention in human trials for non-tumorous and non-hematological conditions. There was no restriction for language, research location, and research race.

Results and conclusion

Search terms initially found a total of 3576 articles. Firstly, 138 terminated or suspended studies were excluded and further 24 repeated studies were excluded. Secondly, 987 tumorous and hematopoietic conditions-related studies were excluded. Lastly, 1218 studies were excluded without stem cell therapy as their primary purpose. A total of 1209 research studies were entered into the analysis and reviewed. The top 4 diseases were about motor system diseases 229 (19.28%). In addition, 206 (17.34%) studies were related to central nervous system (CNS) diseases. 140 (11.78%) were autoimmune diseases or graft-versus-host disease (GVHD) after organ transplantation. 129 (10.86%) were about respiratory system diseases, among them, 44.19% projects were about new coronary pneumonia (NCP). The main cell types used in various diseases are Mesenchymal Stem Cells (MSCs), bone marrow stem cells (BM-SCs), peripheral blood stem cells (PBSCs), hematopoietic stem cells (HSCs), adipose stem cell (ASCs) and precursor cells.

Safety and efficacy of bone marrow derived-mesenchymal stem cells transplantation in patients with amyotrophic lateral sclerosis

Stem cell-based treatments have emerged as potentially effective approaches to delay the progression of amyotrophic lateral sclerosis (ALS). This study was designed as a single-center, prospective, and open-label study without a placebo control group to assess the safety and efficacy of concurrent intrathecal (IT) and intravenous (IV) administration of autologous bone marrow-derived mesenchymal stem cells (BM-MSCs) in patients with ALS. Autologous BM-MSCs were isolated and expanded under standard conditions. Fifteen patients were neurologically examined before BM-MSCs transplantation (1 × 10 ⁶ cells/kg BW) to evaluate the rate of pre-treatment disease progression. To assess the safety and efficacy, patients were examined at 1, 3, and 6 months following the treatment with BM-MSCs. Adverse reactions were assessed, and the clinical outcome was determined by the evaluation of the ALS functional rating scale-revised (ALSFRS-R) and forced vital capacity (FVC). No serious adverse reaction was observed after combined IT and IV administration of BM-MSCs. The mean ALSFRS-R and FVC values remained stable during the first 3 months of the treatment. However, a significant reduction in ALSFRS-R and FVC levels was observed in these patients 6 months after BM-MSCs administration. Our study revealed that the concurrent IT and IV application of BM-MSCs in patients with ALS is a safe procedure. Furthermore, our data indicate a temporary delay in the progression of ALS after a single combined IT and IV administration of BM-MSCs. Further studies are required to explore if the repeated applications of BM-MSCs could prolong survival and delay the progression of ALS.

Local and Remote Effects of Mesenchymal Stem Cell Administration on Skin Wound Regeneration

Wound healing is an important medical problem. We evaluated the efficacy of locally administered mesenchymal stem cells (MSCs) isolated from human umbilical cords on the dynamics of skin wound healing. The study was conducted on the backs of Wistar rats, where two square wounds were created by removing all layers of the skin. Four groups were studied in two series of experiments: (1) a Control_NaCl group (the wounds were injected with 0.9% NaCl solution) and a Control_0 group (intact wounds on the opposite side of the same rat's back); (2) an MSC group (injected MSCs, local effect) and a Control_sc group (intact wounds on the opposite side of the back, remote MSC effect). The area and temperature of the wounds and the microcirculation of the wound edges were measured. Histological and morphometric studies were performed on days 3 and 7 after the wounds were created. The results showed that the injection trauma (Control_NaCl) slowed the regeneration process. In both MSC groups (unlike in either control group), we observed no increase in the area of the wounds; in addition, we observed inhibition of the inflammatory process and improved wound regeneration on days 1-3 in the remote group and days 1-5 in the local (injected) group. The MSC and Control_sc groups demonstrated improved microcirculation and suppression of leukocyte infiltration on day 3. On day 7, all the studied parameters of the wounds of the Control_0 group were the same as those of the wounds that received cell therapy, although in contrast to the results of the Control_ NaCl group, fibroblast proliferation was greater in the MSC and Control_sc groups. The dynamics of the size of the wounds were comparable for both local and remote application of MSCs. Thus, even a one-time application of MSCs was effective during the first 3-5 days after injury due to anti-inflammatory processes, which improved the regeneration process. Remote application of MSC, as opposed to direct injection, is advisable, especially in the case of multiple wounds, since the results were indistinguishable between the groups and injection trauma was shown to slow healing.

A perspective on therapies for amyotrophic lateral sclerosis: can disease progression be curbed?

Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease involving both upper and lower motor neurons, leading to paralysis and eventually death. Symptomatic treatments such as inhibition of salivation, alleviation of muscle cramps, and relief of spasticity and pain still play an important role in enhancing the quality of life. To date, riluzole and edaravone are the only two drugs approved by the Food and Drug Administration for the treatment of ALS in a few countries. While there is adequate consensus on the modest efficacy of riluzole, there are still open questions concerning the efficacy of edaravone in slowing the disease progression. Therefore, identification of novel therapeutic strategies is urgently needed. Impaired autophagic process plays a critical role in ALS pathogenesis. In this review, we focus on therapies modulating autophagy in the context of ALS. Furthermore, stem cell therapies, gene therapies, and newly-developed biomaterials have great potentials in alleviating neurodegeneration, which might halt the disease progression. In this review, we will summarize the current and prospective therapies for ALS.

Behavioral Problems, Quality of Life and Caregiver Burden in Children with Idiopathic Nephrotic Syndrome: Improving Outcomes by Pragmatic Interventions in a Resource-Poor Setting

A cross-sectional questionnaire-based study was conducted on 38 children with idiopathic nephrotic syndrome. The prevalence and pattern of behavioral abnormalities was studied. Except in the conduct domain, the prevalence of behavioral problems was comparable with controls. Severe complications of disease and adverse drug effects were significantly associated with abnormal behavior. The Quality of life (QOL) of these children and their caregivers was assessed. It appeared to be unaffected by illness. Additional findings were high maternal literacy, no disruption of schooling, regular follow-up and good adherence to treatment. Behavioral problems in childhood nephrotic syndrome can be minimized by regular follow-up and supportive interventions to reduce caregiver burden. Such children and their caregivers can do well in terms of QOL, even in a resource-poor setting, with appropriate psycho-social support.

The Potential of Induced Pluripotent Stem Cells to Test Gene Therapy Approaches for Neuromuscular and Motor Neuron Disorders

The reprogramming of somatic cells into induced pluripotent stem cells (iPSCs) represents a major advance for the development of human disease models. The emerging of this technique fostered the concept of "disease in a dish," which consists into the generation of patient-specific models in vitro. Currently, iPSCs are used to study pathological molecular mechanisms caused by genetic mutations and they are considered a reliable model for high-throughput drug screenings. Importantly, precision-medicine approaches to treat monogenic disorders exploit iPSCs potential for the selection and validation of lead candidates. For example, antisense oligonucleotides (ASOs) were tested with promising results in myoblasts or motor neurons differentiated from iPSCs of patients affected by either Duchenne muscular dystrophy or Amyotrophic lateral sclerosis. However, the use of iPSCs needs additional optimization to ensure translational success of the innovative strategies based on gene delivery through adeno associated viral vectors (AAV) for these diseases. Indeed, to establish an efficient transduction of iPSCs with AAV, several aspects should be optimized, including viral vector serotype, viral concentration and timing of transduction. This review will outline the use of iPSCs as a model for the development and testing of gene therapies for neuromuscular and motor neuron disorders. It will then discuss the advantages for the use of this versatile tool for gene therapy, along with the challenges associated with the viral vector transduction of iPSCs.

[Pediatric pain treatment and prevention for hospitalized children]

INTRODUCTION

Prevention and treatment of pain in pediatric patients compared with adults is often not only inadequate but also less often implemented the younger the children are. Children 0 to 17 years are a vulnerable population.

OBJECTIVES

To address the prevention and treatment of acute and chronic pain in children, including pain caused by needles, with recommended analgesic starting doses.

METHODS

This Clinical Update elaborates on the 2019 IASP Global Year Against Pain in the Vulnerable "Factsheet Pain in Children: Management" and reviews best evidence and practice.

RESULTS

Multimodal analgesia may include pharmacology (eg, basic analgesics, opioids, and adjuvant analgesia), regional anesthesia, rehabilitation, psychological approaches, spirituality, and integrative modalities, which act synergistically for more effective acute pediatric pain control with fewer side effects than any single analgesic or modality. For chronic pain, an interdisciplinary rehabilitative approach, including physical therapy, psychological treatment, integrative mind-body techniques, and normalizing life, has been shown most effective. For elective needle procedures, such as blood draws, intravenous access, injections, or vaccination, overwhelming evidence now mandates that a bundle of 4 modalities to eliminate or decrease pain should be offered to every child every time: (1) topical anesthesia, eg, lidocaine 4% cream, (2) comfort positioning, eg, skin-to-skin contact for infants, not restraining children, (3) sucrose or breastfeeding for infants, and (4) age-appropriate distraction. A deferral process (Plan B) may include nitrous gas analgesia and sedation.

CONCLUSION

Failure to implement evidence-based pain prevention and treatment for children in medical facilities is now considered inadmissible and poor standard of care.