Okay, well, that was wonderful. Now my turn to talk about PRP, and as we're going through, sorry, get this moving here. As we're going through the talk on PRP and thinking about how really to speak on PRP after over 10,000 articles, and I think that when we look at it, we can see evidence from these articles that look somewhat like the scale, but I think really what we should do is really not talk anymore about what PRP is, but what really PRP could do for us and our patients. And if this is a biologics course, and I know that we want to optimize our ability to use biologics and to think that way, so for those of you who are looking for a list currently of 2018 of the indications that you can get reasonable level one data on, I think this is our list as of 2018, and I will certainly go into these in more detail. That of course leaves a long list of things that has been attempted to use PRP to cure lots of different things that just we really have seen very little evidence. And I guess the question is now, did we do those studies right? Did we use the correct type of PRP for this? Because we just started using PRP without really knowing what we were doing, and I think we've learned a hard lesson about PRP in the end, and that is there's not one type of PRP and we certainly can't use one type of PRP for all indications, and we're really going to have to study this. We're going to have to study this from the basic science all the way possibly through animal trials into clinical trials, and if we do so, we'll likely have a better chance of finding something that will work. Maybe it was because we made a mistake at the beginning. I think the benefit of using this technology is autologous blood, and we have tons of things in our blood biologically that can help us, but we chose a small fraction at the very beginning and that put us into a little bit of a biologic box. This is really all we get, but I think you're going to see the future things really change about PRP. You're going to see a new dimension of using more than just a small fragment within the blood for autologous blood therapies, and I think that's really where PRP is headed in the future. So let's talk about tendinopathy and maybe some different approaches to this, and I agree with lateral epicondylitis. That is one indication where there is some of the best proof that PRP works. I clearly think Alan Mishra's article on this randomized trial on lateral epicondylitis is the best that the literature has to offer, and the three largest randomized control trials all show that it's better than corticosteroid and dry needling. That's not the question. It's not the question if it's statistically significant. It definitely is statistically significant. The question is, how much does it work? How well does it work? How well does it work in comparison to just injecting whole blood? Well, look at the data. It works. The teleteninopathy, one randomized trial. There's some other ones that are coming due now. Does it work? Yeah, but kind of. So the question is, are we going in the right direction with tendinopathy? So we're taking a different approach to this to really attempt to find an answer because it just doesn't seem like it's optimized. So what we've done is we've taken this from a surgical model, and we've harvested stem cells from tendons and from tendinopathy tendons, so normal and tendinopathy, to look at what these progenitor cells or these renewable cells can actually accomplish from these different tissues. And we see that this tendon, we'll call it stem cell behavior just for easy semantics here, and we see that when we subject these two different cells from tendinopathy and from normal, that they still maintain their potential to have trilineage potential. There's very few differences in between these two types of progenitor cells. You look at their colony-forming units, it's about the same. Their proliferation in culture, all about the same. And then something interesting happened. We said, well, our body's not a culture dish, so let's put these in more physiologic conditions. So we did a custom apparatus here that puts physiologic load mimicking what these tendon cells would be like in a tendon. And we saw some fascinating changes. First of all, we saw that the normal cells are able to realign with stress, as in the human body, as we've seen that the tendon fibers align with stress. And the tendinopathy stem cells could not, or had much more difficulty aligning with stress. If you see it in a graphic form, it looks like this, where a much smaller percentage of the tendinopathy cells were able to realign themselves and to be receptive to external cues, such as force. I think one of the most telling things, though, that was different is the RNA and the products that were produced from these two different cells. And if you looked at the tendinopathy cells, they have lost their ability to produce extracellular matrix of tendon. And here we have tenomodulin, and you see that it's just not even detectable in tendon stem cells when you put them in the correct environment. Fascinating. So of course, the next thing was, OK, if we can now have a model that shows why tendinopathy is not able to regenerate and to heal, what can we do biologically to stimulate it? And so of course, the easy picking was to go through the current formulations of PRP, and we saw that it just didn't have that capacity. And this data is ongoing, so we don't have the final data yet. But as of now, PRP, maybe like its clinical correlate, is not showing outstanding results in being able to turn these cells around. Now there is some interesting early data that, for some reason, BMAC is. And we need to look into this further. This is just an early look, and I'm not going to show you any data because it's too early. But I want to show you that this is probably will be our ability to then find, from the basic science perspective, a better way that we can stimulate these abnormal cells. Interesting, when you read the literature, there are certain growth factors, such as BMP 12, 13, and 14, which have been shown to improve the cell's ability to turn into tendon cells. And when you use the tendinopathy stem cells, they did not help that. So the BMP has not been shown to improve it. We have a backup plan, too, because now that we have these two progenitor cell populations isolated, we're looking at the genetic status of these as well. And so what we're doing is we're getting the genetic data, and we're seeing the relative genes that are turned on in the tendinopathy versus off, et cetera, in the normal. So then we can use the CRISPR model. This is, for those in genetic fields of study, is a very promising way to turn genes on and off. And so if we can find the recipe, then we may have other options on how to turn these tendinopathy cells around into producing extracellular matrix. Many of the previous speakers have spoken about inflammation and how that if there's anything that certain versions of PRP can do, it is to decrease inflammation. And the very appropriate questions are that, well, that's great, but how do we really understand which one of our patients actually have inflammation? And one of the ways we could do it is just with their exam of having a bogginess. There may be ones that have a little bit of effusion after exercise, and maybe it's just the way they feel the day after exercise, the morning stiffness and the residual symptoms after exercise. It's pretty clearly telling us that maybe that first day of medical school that we all went to, that osteoarthritis is a non-inflammatory arthritis, is wrong at least in a certain cohort of the population with arthritis. So the question is, how do we figure them out? We've done studies with the synovial fluid, and if you take the synovial fluid from these two different osteoarthritis patients, they're different, with a marked increase in the levels of inflammatory mediators in the folks that have a reactive knee. So then if you take a special look at the literature with PRP, and you divide down the studies that take into consideration the leukocyte-rich versus the leukocyte-poor, and then you can see that there is a trend. I'll see how Tom Vegsnes can also create other arguments, such as the opposite of this, and they certainly did from this one Iranian study with 160 patients. The overwhelming prevailing thought is that anti-inflammatory preparations of PRP can be of benefit, and it may not work in every patient, as we've all been talking about, but maybe the ones with an inflammatory component. This is the leukocyte-rich versus leukocyte-poor type of scenario here. The two main different types of PRP, and you can see that taking out the neutrophils, that's the leukocyte-poor, right, can decrease the inflammatory capacity, and that's been shown in multiple studies. And there is some evidence to suggest that if the leukocyte-poor is actually anti-inflammatory, but that's a little bit controversial. As we expand from the small fraction of PRP, we can reach out to the other parts of blood to get other proteins that are of benefit, such as the potential of alpha-2 macroglobulin, otherwise known as A2M. And what we know biologically is potently anti-inflammatory. It's a scavenging type of molecule. So that can be increased within PRP preparations. And if you look at the basic science, as the amount of A2M increases, so does its anti-inflammatory capacity. Missing from this is the clinical evidence to suggest that this is the case, right? So stay tuned, but at least reasonable basic science evidence. Here's one that's really tricky, right? So this is the IL-1 receptor antagonist and all the different ways that can be increased within the PRP. And I've looked at lots and lots of data, and it's interesting that the biologic equation here at the bottom is a tough one, because many of the methods that are used to increase receptor antagonists also increase the IL-1 beta levels, and we have a net neutral amount of true anti-inflammatory scavenging from these particular type of preparations. The other thing the FDA has been worried about in these compounds is the small amounts of RA or IL-1 RA that are present. So if there are some new formulations in the future that can increase this amount and change the equation from a net zero, these may be very reasonable choices for anti-inflammatory treatment. I think Arne Kaplan is going to discuss this a little bit. I'm not going to say much, because this is going to be part of what he says. But you can make an argument that PRP has its role with the mesenchymal signaling type of cells and the cellular therapy. They can go hand-in-hand because of the growth factors that are contained within PRP. And I'll let him explain this further to you in a few minutes. I'm also not going to really talk about muscle. Dr. Kristen Oliver is going to be talking later on tonight about the methods with which to, at least the best evidence with which to treat muscle injuries. And so I could just tell you, and I'll leave it at this, there's not very good evidence to suggest that PRP works. And so looking in other ways to address muscle injury may be very reasonable. And she'll explain more about that. And I'm just going to pass forward all this here, because if I could get this thing to go faster, I would. And into the summary is that PRP efficiency and efficacy is going up in comparison to previously because we're now studying certain formulations for certain indication. And this whole note that PRP is one thing and it's in its own column of PRP versus something else can no longer be entertained and is no longer really acceptable in the peer review literature. This will be a tough go. This will be a tough go because we've got to start from the beginning at first getting basic science, then possible animal, and then clinical trials. If we want to look at our best current as of now, we probably have the tendinopathy of leukocyte-rich, the osteoarthritis leukocyte-poor. This whole muscle repair is so early on, I hate to even put a slide in that because it's too early and lacking clinical evidence. We all get asked all the time, studying biologics and PRP now for many years, what do we really do in our clinics? What system can I really choose so I can give the best PRP results? And we see this is really difficult because the more we learn, the more we learn that there is different indications and different formulations. So it's really tough to have one system. But if you had a setup where you could be flexible and then be able to synthesize multiple different formulations of PRP, that would probably be the best thing that you can get now as of 2018. So thank you very much for that. And then we will go now to Arne Kaplan. And when Brian and I and Rachel first started putting this program together, there was one thing we wanted to start with. And that is who should give the, quote, stem cell introductory talk. And all of us, of course, unanimously said, well, it should be the person who number one described at that time as enkemal stem cell. But probably also would be the one that would refute a stem cell talk altogether by calling it something else other than the stem cell. So this will be a very great new look at what we think MSCs truly are. And no one better to do that than Arne Kaplan. So thank you for joining us. Thank you.

platelet-rich plasma

PRP

medicine

tendinopathy

stem cells