So, I got my hands up. I'm not a physician. So, this is not going to have any clinical trial, any horrible morphology slides. So, we know cutting remarks, except the first cutting remark that I want to make, which is mesenchymal stem cells in your body are not stem cells, and we as a profession have to stop, stop. Please, I'm begging you, begging you. It's hard for me to do that. Begging you to stop using this term stem cells because it's not what we deliver, and I'm going to try to convince you of that. So, there's three take-home lessons that I'm going to talk about. MSCs are not stem cells. MSCs can control pain, and I'm going to show you the mechanism. I'm going to show you the mechanism. And third, MSCs are removed from active sites very rapidly. How can you get long-term clinical benefit from MSCs if they're gone, if they're gone? I'm going to show you the mechanism by which they do that, and it changes the focus of how you think about these cells. These are my disclosures. The other disclosure is that I'm a paid consultant for lipogen, so I'll say lots of nice things about lipogens if you twist my arm, but you'll see them during the lab course, so I'm not going to focus on them. So, the focus of everything, everything I'm going to say has to do with the innate capacity of tissues to fix themselves, and the absolute model for all of this is your blood system. Every single second, 15 million blood cells drop dead and are perfectly replaced. Couple hundred million blood cells just drop dead in your body and were perfectly replaced, and it's because you have this hemopoietic stem cell sitting in your bone marrow, which generates all your circulating blood cells, some that live for 20 minutes and some that live for 50 years from memory T-cells. Also in your bone marrow is a cell which I call the mesenchymal stem cell, and I drew this slide as a hypothesis slide in the late 1980s, and in the late 1980s, we were taught that there was only one stem cell in your adult body, and that's your hemopoietic stem cell, so this is already heresy. I put a stem cell at the top of the slide and said that we could induce it into pathways, lineage pathways to make bone or cartilage or tendon or fat or any of these mesenchymal tissues, so this is already my esteemed colleagues in the orthopedic audience. You could read their lips, and the words they were saying were BS, and rightfully so because it was against all that dogma. I'm going to tell you and show you that every single tissue of your body, without exception, has its own intrinsic tissue-specific stem cell, and that's what you manage as physicians, and this is the manager of those stem cells, the MSC. If you want cartilage, if you want a tissue-engineered cartilage in culture, the MSC from marrow, from fat, from liver, from any tissue is fabulous because we know how to make cells dance on a Petri dish, and so you can get lineage progression into these pathways. We know how to do that. I'm not going to discuss it. I'm going to talk about regenerative medicine, and that's the MSC at the top of the scale, so one of the shocking things for somebody who works on marrow is to realize that every tissue that's listed on the left-hand side of the slide, there's a published paper saying you can get MSCs out of those tissues. How disheartening is that to know that the special cell that we found in bone marrow is found in every single tissue listed on the slide. What's missing from this figure? The fact that all of those tissues have vasculature, and that's the take-home message, and that's the message that I'm going to give you. So when Brian Cole took his blood pressure medication this morning, this red cell, this pericyte, is the one that controlled the response to that blood pressure medication. It squeezes the vessel to give you high blood pressure and relaxes to give you lower blood pressure. This is a capillary that is in heart. These, every cell you see in these scanning EMs is a pericyte. Every cell that you see in these scanning EMs is a pericyte. Every cell you see in these scanning EMs is a pericyte. Every cell, are you getting bored yet? Are you sick of this? But what you noticed is that all those pericytes had different morphologies because they're in different tissues. So they have their grabbing or wrapping around the blood vessel, but they have their backs to a different microenvironment. And so therefore, even within the same tissue, an arterial and a venial, those cells are different. So although MSCs are derived from these cells, you could expect that the MSCs from fat and the MSCs from marrow and the MSCs from skin are different. And here's the key take-home lesson, which is in every single tissue of your body, there is a stem cell, this yellow ball. The yellow ball is sitting next to an MSC pericyte. And both of those cells are in contact with the endothelial cells, with the blood vessels. This is liver, neural stem cells, kidney stem cells, heart stem cells. All of them are sitting next to an MSC pericyte. And that cell is making molecules that are special to the stem cell. So it's the cohort to the tissue-specific stem cell. That's where it is normally, and that's where it goes when that tissue is injured. Very important. Tissue injured, pericyte comes off the blood vessel, as you saw in Adam's video, and goes to the site of injury and becomes activated. So watch me for a second, if you could. Blood vessel, pericyte, blood vessel breaks or gets injured, pericyte comes off and it differentiates, changes, changes its molecules and becomes an MSC. From the front of the MSC, it makes a curtain of molecules that stop your over-aggressive immune system from interrogating the injured tissue, which has new antigens. This is your first line of defense against autoimmune reactions from setting up. From the back of the MSC, it makes a different class of molecules, which actually set up a microenvironment for the regeneration of that injured tissue, not the repair. Repair is scar. Our quick fix for every tissue is scar it. You take two pieces of tissue, you want them, every surgeon knows it, you bring them together and you say, oh, there's gonna be a beautiful scar there because it's gonna hold those two tissues together. You squirt some MSCs on that newly joined two tissues, no scar, open heart patients, no zipper. Perfect alignment of those tissues. So everything I just said, everything has nothing whatsoever to do with stem anything. So I got a delicate ego, of course, I want everyone to continue using the MSC nomenclature. So I call them medicinal signaling cells. I did this in 2010. I've been begging this industry for a number of years. So they're not stem cells. So if you put mesenchymal stem cells into this website search engine, clinicaltrials.gov, 891 listed clinical trials. This is a map of the United States. I'm politically very active. I hate red states, but in this graph, I love red states. They have the highest number of MSC clinical trials. Here are all the clinical conditions. What are these conditions? This is an eye test for Brian Cole. What are these clinical conditions have in common? They all have an immunomodulatory and a regenerative component. The kidney transplant trial, which is published 2010 in JAMA, has data which shows that MSCs can be used as chaperones for allokidney transplants. No immunosuppression is necessary. And there's a 500 patient clinical trial going on in China at the moment. So MSCs dock at broken blood vessels. They have an immunomodulatory and regenerative component, and they are the regulators of the tissue's innate capacity to regenerate. Remember, that's where they hang out anyway, and I'll show you data for that. So what's missed by everybody in the field is that the MSCs are sensory. They go to a tissue, or they're born in a tissue, they survey that tissue, and they have a built-in response profile. So here's a perfect paper. Blue MSC on the left, if you give it an inflammatory microenvironment, it makes anti-inflammatory molecules. If on the right side, you give it a bacterial signal, it makes inflammatory molecules. It wants you to bring in the cells of the hemopoietic system to eat those bacteria and clean up that wound. So same cell, two different microenvironments, built-in profiles of how to deal with those microenvironments. This is my good friend, Dr. Chang, who's at the Cleveland Clinic. He's just a brilliant pain specialist. he snuck this abstract into this 2015 pain meeting. The experiment is as follows. He takes rodents, and he tolerizes them on opioids. You and I can take opioids for 10 to 16 weeks, and then we become tolerant to the opioids, so we increase the dose. That's the problem we're facing in this country. He does that to rodents, tolerizes them, comes to my lab, steals some marrow, human marrow MSCs, puts it in these animals, and the animals lose tolerance, lose tolerance. The better experiment is he takes the animals, puts the—now, human MSCs, how can you put human MSCs in an immunoresponsive rodent? We make MSCs that have powerful curtains. They're not immunoprivileged. They're immunoevasive, so that curtain allows them to evade the immune system, works fine in rodents. He puts MSCs in rodents. He cannot tolerize them. He's published all this data in an article that's been peer-reviewed, and it's the basis that got me thinking about pain management and how MSCs do it. And here's the most fabulous article, which shows you the power of the MSCs. So you take an animal, and you give it trigeminal nerve pain so that if you touch this rodent on the cheek, it goes through the roof. If you give it morphine, you can slap its cheek all you want. If you give it MSCs, you can slap its cheek all you want. They have molecules which are antagonists to opioids. They knock the opioids off the receptor. So if you give the animal morphine and give them the peripheral antagonists, and you touch the cheek of that animal, it's through the roof. If you give the animal MSCs, and you give them this antagonist that kicks molecules off of peripheral opioid receptors, and you touch its cheek, through the roof. That works for the first three weeks of the treatment. At week five, if you give them the peripheral antagonist, it doesn't work. Now actually, it's at your brainstem. It's a central, actually, activity. Now there's antagonists for central opioid receptors. MSCs somehow stimulate the secretion of molecules that sit on central opioid receptors. So MSCs make molecules that sit on opioid receptors. So if you put MSCs in my horrible osteoarthritic knees three to five days later, if I'm a responder, those molecules are sitting on my opioid receptors. There's nothing good happening to my cartilage, but my pain has gone away. And eventually, it stays away because my central opioid receptors get occupied. So MSCs are effective for central or peripheral nervous system. They make molecules that sit on opioid receptors, as indicated by the antagonist experiments. And the pain management involves their producing molecules that occupy opioid receptors. So how do we get long-term therapeutic effects? By five weeks, by three weeks, those MSCs are long gone from those rodents. You can't find them. Here's the paper that answers that question. This is another fabulous study. They put human MSCs, which have labels inside, into mice. 24 to 72 hours later, the MSCs are gone. What has happened is that there's a monocyte which has eaten the MSC, has eaten the MSC. How do I know that? The labeled molecules are in the monocytes, and they're in a special class of monocytes. They're called LY6C low. We can sort those out of bloodstream, not a problem. If that monocyte has eaten an MSC, it changes its cell surface receptors. It becomes CD206, CD163 positive. In that case, that monocyte now, if it bumps into a T cell, changes the T cell to a regulatory T cell. Regulatory T cells can cross the blood-brain barrier. Regulatory T cells regulate the local immune microenvironment. For the young people, I created this cartoon, which is the only thing you'll remember for my whole lecture, is that a red LY6C low monocyte eats an MSC. It becomes instructed by that. Is that exosomes? Just an MSC is just a big exosome. The little exosomes are pieces of MSCs and are thereby instructed in the same way. Now when that instructed monocyte breathes on a T cell, that T cell becomes a regulatory T cell. The regulatory T cell can stick around for years. It sticks around for months. This is how long after the MSCs are gone, you can get an immunomodulatory effect. And again, this is the comment that MSCs are not only local sentinels for invasive pathogens, but they can be added from the outside and provide guards for those kinds of activities. So MSCs are involved in the innate regenerative capabilities of every tissue of your body. So this is the original hypothesis slide. This slide is wrong. There's no stroma in marrow. If you have stroma, if you have connective tissue in your marrow, you have a disease. MSCs come from pericytes. It just changes the way you think about the management of all of the orthopedic tissues that I know because they're all hugely vascularized. If you take a cc of fat and you compare it with a cc of marrow, you can get 300 to 500-fold more MSCs from fat than from the same volume of marrow. Let me state, if you take a bone marrow aspirate of 10 mLs from a 50-year-old, I'll tell you exactly how many MSCs are in there. Count them, five. So bone marrow aspirate, as you pointed out, is not an MSC preparation. There's other active agents in there. And Lisa Fortier's paper is a perfect example of how many hundreds of things are in a bone marrow aspirate. Who knows who's the active agent? So remember MSCs? They're medicinal signaling cells. They're not stem cells. This is a poster that we did for Nature. You can download it for free from this particular website. And this is the picture of marrow that is in every textbook. And when we come to medical school, we see this picture. So let me tell you that the bottom left-hand corner is wrong. That doesn't happen in the body. In marrow, there's a mesenchymal cell, which is already in the osteoblast lineage. It is an osteoblast progenitor cell. In brain, there's a neural stem cell, and it's sitting next to a mesenchymal stem cell. And in this picture, you see the blood vessel with the pericyte. That's where the MSC came from when we took a bone marrow aspirate. And this is the key portion of that poster. And here's... Sorry, can you go back one? Here's the key. On the left-hand side, you have a quiescent hemopoietic stem cell. It's sitting next to a bone marrow, a MSC pericyte that's making special molecules. The yellow ball on the right side is an active hemopoietic stem cell. And it's sitting next to a pericyte, MSC pericyte. If you look carefully, you see the cell surface signatures of those two pericytes are different. They're making different molecules. We can sort those two different pericytes out. In a bone marrow aspirate, when you isolate MSCs, you have five to seven different MSCs with different molecular signatures. One is an osteoblast progenitor cell. So all these different colonies that you see, they're from different places, and you see the colonies are different sizes because the cells have different chemistries. So an MSC, there's not one MSC preparation that anybody has which is pure. And there was just an article in Nature that says the MSC story is a mess. The only thing a mess is the people who wrote that article. Because the MSC story is evolving, and clinically, all of those clinical trials, eventually within the next 18 to 20 months, you'll see three of those trials will provide products that come to market because their phase three trials are going to be finished, and I think they'll be successful. So I think managing cells is what an orthopedic surgeon does anyway. Bone marrow is one of the things that has been done to add zip to your regenerative reconstruction of bone. It's been discussed since the days of Aristotle. So again, now we're trying to figure out how it works and how to use it therapeutically. This is my favorite quote. We're finally, for cell-based therapy, at the end of the beginning, and you're going to see products come to market, and they will be approved by the FDA, and they will come to market under reasonable circumstances. This is a course that we teach every year. You can come to Cleveland in May. We have weather that's much better than this. And all of my, all the research in my lab is supported by your tax dollars, and there's clearly a large group of researchers at the Skeletal Research Center who are responsible for the data. I'm just the front man. Thanks.

mesenchymal stem cells

regenerative medicine

medicinal signaling cells

pain control mechanism

long-term clinical benefits

innate regenerative capabilities