The final talk in this session is Lisa Fortier on perinatal tissues, both now and, of course, in the future. Great. Thank you. And thank you for including me. My biggest disclosure is I'm not an MD. I'm a DVM equine sports medicine surgeon, but still proud to be here. These are my disclosures. Where's that coming from? That's interesting. I don't know what happened to that. So I wanted to start with the commonalities of all these perinatal tissues. There's many, many more than what are in the title. We have cord blood and wort and jelly and lots of other things. The commonalities amongst all of these is that we should not be able to consider them as stem cell therapies. For sure, they have a few stem cells in them, but not enough to effectuate change in the way that we're applying them. The manuscript that's supposed to be showing in the upper right-hand side is how we all get misled. And we get misled, frankly, by reps a lot, where it is XX derived MSCs. So that means they're like these cells that I'm showing you here. They're cultured cells from umbilical cord blood, amnion, or other things. So people say, oh, there are stem cells in this product. Well, there are, but you have to culture them to get enough to effectuate change. So again, the way that we're using these products, they cannot be considered as stem cell therapies. That's the example of the manuscript. So this would be very, very common. This is just one of many. And I don't mean to pick on the authors, but umbilical cord derived MSCs. So this is how, again, people are like, oh, there's all these umbilical cord is a stem cell therapy, and that's just not true. We now know, too, that the symptomatic relief for many of these perinatal derived tissue is likely through immunomodulatory and inflammatory properties. And I'll talk about that a little bit more. And it has been spoken many times, they cannot be used without proper authority guidance. These are the first three studies that showed that there are no MSCs of any sort, no stem cells of any sort in any of these amnion products. In fact, there's no live cells in the products that we tested. So not just stem cells. There's not even anything that's alive. Again, misled by some of the companies where we commonly think green is good, red is dead, but they use a different stain that stains all nuclei. So just a little bit misleading, but I'm not going to go into these. And there probably are more manuscripts, but these are the first three that said absolutely no stem cells or even live cells in any of these amnion products that were tested or cord blood. This is Matthew Farrow. He was the first recipient of a cord blood transplant. So if I'm saying there aren't stem cells in cord blood, then how did this work? And for sure there are stem cells, but remember for a stem cell transplant recipient, they need at least 40 mils of cord blood for a transplant. And when we're using cord blood, it's on the order of one mil. So very, very different. And there are lots of cells. There are hematopoietic stem cells, monocytes, leukocytes, because it is blood. But again, I just want to keep emphasizing that cord blood is not a source of stem cells in the way that we show it. Evidence in animal models using umbilical cord blood outside of transplantation for Fanconi anemia and other anemias, that's what Matthew Farrow had, is for reperfusion and organ recovery. Actual use of cord blood itself, not cord blood derived, whatever, MSC, HSC, actual use of cord blood in regenerative orthopedic medicine is zero. I couldn't, I personally couldn't find a single study in the manuscript, even a case report, of using cord blood to treat anything in regenerative medicine. There is a more interesting way to think about umbilical cord blood, and that's umbilical cord blood PRP. So we know that the umbilical cord blood itself has five times more platelets than peripheral blood. And again, coming back to this immunomodulatory, anti-inflammatory property, this really nice manuscript from Frontiers in Immunology showed this NKG2D ligand, and what that does then is suppress the activity of natural killer and T cells. So this idea of adoptive immunotherapy where you increase the anti-inflammatory cells or decrease the inflammatory cells in a patient. I would also like to emphasize that umbilical cord blood is not a growth factor therapy. So this is really important when you read the literature. What is relative to plasma or synovial fluid? If you're just augmenting back to what is there in nature, at least I struggle to think of that as a growth factor therapy. So I provide, this graph is made from lots and lots of different manuscripts, so that's why I call it a rough comparison. But you can see that umbilical cord blood in VEGF, FGF, and IL-1RA is no different than plasma. Very interestingly, amnion product, and I found this in three different manuscripts. Amnion, desiccated, dehydrated, lyophilized amnion has FGF at about 10,000 picograms per mil, which is way more than plasma, and quite high concentrations of IL-1RA. But for any of you that know me, I really love bone marrow concentrate, and still bone marrow concentrate has at least twice as much IL-1RA even compared to amnion. And then I have leuko-rich there as well. The problem with all these, and the reason I call it a very rough comparison, is that all of these products have tons and tons of proteins in them, thousands, tens of thousands of proteins. So we measure these in the laboratory using an ELISA test, but we don't, that's really not the best way to do it because we're gonna get cross-reaction with a lot of different proteins. So these aren't diagnostic tests, they're all to be in a relative comparison. So above all, do no harm. Scott Rodio and his colleagues first started with this manuscript reviewing the really significant morbidity associated with the Escherichia coli infection in patients, and they published that in Arthroscopy. And then in JAMA, this was also published. So these were patients that were outside of musculoskeletal. So if you really want to use these cord blood products, then I would beg you to use something from a credited tissue bank source, and I list two here. You know, Scott Bruder would say, just don't use them, but if you really want to, at least try to be safe. These patients really suffered severely from, and a couple of them lost their life. So above all, do no harm. Amazingly, amniotic membrane has more evidence. I enjoyed putting this talk together, and thank you for addressing this issue with me because I really learned a lot. There's more evidence to amniotic membrane, and it continues to emerge than I thought. There's one in phase three, and several in phase two clinical trials right now. There's several that show symptomatic relief for knee osteoarthritis, and one that shows enhanced cartilage repair with an amnion product. So how are these working? Remember, there's so many proteins. We're not gonna ever really figure out, oh, it's that one protein, but at least we can try to figure out the broad mechanism of action. So it's multimodal, but again, it's not the cells. These amnion products, even like the sheets that are cryopreserved, the thick sheets, they don't have any live cells in them either, so that none of these amnion products should be considered as cell sources. These first two studies that I list here show injection of amnion in a post-traumatic osteoarthritis, destabilization of the medial meniscus in rats, and this is primarily histologic outcomes, but that's our first evidence that injection of amnion into rats with a DMM can prevent the development of post-traumatic osteoarthritis. And then this next group went a little bit further, and they did a MIA, just a different type of osteoarthritis model, and they showed decreased pain and, interestingly, increase in IL-10 in the synovial fluid. And you can see here the second bar, the ASA at 25 microliters, which is the lower dose than ASA, that's their amnion, the lower dose actually increased IL-10 to a greater extent in the synovial fluid than the high dose. And we know this is a really great review of IL-10 and IL-4 and the role of it in articular cartilage. We can see that IL-10 has been known for a long time to be chondroprotective through many mechanisms, anti-inflammatory and analgesic or antinosusceptive. So this is a really big deal that we can see an increase in IL-10. What is causing the increase in IL-10? No idea, but at least we're getting an idea that we're looking at immunomodulation. Karl Flannery, and really, this is, to me, other than Scott Rodeo, this is the who's who of many of the investigators in osteoarthritis, and they did another DMM study in rats, and they also showed not only an increase in IL-10, but a decrease in MMP-13, so decrease in catabolism, decrease in the chondrocytes themselves, and then they had this macrophage. We're all excited about this M1, M2 macrophage business, and they have a really cool culture system where they induce macrophages to be M1, pro-inflammatory, and then they can treat them with different things. And they showed that when they treated these M1 macrophages with their amnion product, they had a decrease in TNF and IL-1 beta. Karl Flannery also, recently, I did this study in conjunction with him, and this is, again, his M1, M2 in the laboratory, so now we're getting from IL-10, so we see immunomodulation, we see decrease in MMP-13, decrease in IL-1, so anti-catabolism. And this one from Karl Flannery then shows in the product itself, there's a very high concentration of TMP3, so tissue inhibitor of matrix metalloproteinases, chondroprotective, and the high concentration of IL-1 that I showed you as well. Interestingly, in this study, he also compared this to leuko-low and leuko-high PRP, and both the TMP3 and IL-1 RA were greater than leuko-low or leuko-high PRP. He also showed in this pro-inflammatory M1 model, when you put the, his, it's the bioventus amnion, that we see a decrease in TNF-alpha, MMP-13, and ADAMTS-5. So again, chondroprotection and anti-catabolic. Most of these were the same or superior to leuko-low, which suggests, as you've heard all morning, that leuko-low PRP is probably best for osteoarthritis, and they were all superior to leuko-high. So leuko-high was not good in this in vitro system. So what are we looking at now? If you look at this very oversimplification of the M1, M2 pathway, the monocytes, when they wanna go down to a classically-activated M1 pro-inflammatory macrophage, we see the effects through amnion are becoming to show that we can see a decrease in IL-1 and decrease in TNF. And down the road, not a direct effect, but down the road, this'll lead to a decrease in ADAMTS and MMP-13, so decrease in pain, inflammation, and catabolism. On the other side, if you see the IL-10 is a potent stimulator of monocytes to go into the regenerative M2 macrophages, and then down the road, we'll see increase in TMP3 and IL-1RA. These aren't direct pathways, of course, but just trying to stay with the red is bad, green is good sort of philosophy. And so in the end, what we see is a symptomatic relief, and the chondroprotection outweighs pain and OA when you're using some of these amnion products. These are early times. This isn't shown in human models. This is rat DMM and in vitro, but at least we're starting to understand some of the mechanisms. So symptomatic relief and chondroprotection are through IL-10, TMP3, IL-1RA, and FGF2, and that should outweigh pain and OAs by decreasing IL-1, decreasing TNF, ADAMTS, and MMP-13. That's all I have, thank you. Thank you.

perinatal tissues

stem cell therapies

immunomodulatory properties

anti-inflammatory properties

amniotic membrane