Does Fat (Adipose Tissue) have stem cells?

Well, yes. It turns out that the blood supply of fat, squeezed in between the fat cells, has a thin layer of vascular cells called “pericytes” that, under the right conditions, have the characteristics of stem cells. Dr. Caplan of Case Western Reserve has recently termed these cells “medicinal stromal cells”, I think to avoid any confusion (and regulatory oversight) with stem cells from other sources.  Regardless of what they are called, we have them- some of us in abundance, in the layer of abdominal fat and elsewhere. An Italian company, Lipogems, has developed a simple office procedure for gathering these cells from fat in a form to make them injectable- for example, in a knee joint. There are early anecdotal reports of tremendous pain relief (for osteoarthritis) using this technique, but I know of no formal controlled study as yet.

Please see my previous post about the FDA.  What type of oversight, if any, would the agency have over stromal cells from your own body that could be safely used (one assumes) to treat your arthritis?

doc M

From The FDA


The best way to learn about stem cell controversies is to listen to what the Food & Drug Administration folks have to say; it is very well balanced, and shows the difficulty in assimilating new lines of research into products that should improve health.

doc m

Optimal Candidates for Platelet Rich Plasma (PRP)

All medical therapies have optimal patient “targets”; the old assumption that one size fits all is incorrect, and has led to the new hype about “personalized medicine”. Nevertheless, there are many treatments which work pretty well for most folks- say, within 2 standard deviations from the average- which would comprise about 66% of patients. Forget the exceptions, for now.

The best “average” patient for PRP treatment of osteoarthritis  might look like this: Either under 65  and/OR very fit and active, on few if any medications, non obese, motivated, AND with X-rays that show SOME joint space remaining. Also, the joint in question should not be very stiff and/or crooked. (Note: Many patients have been informed that their X-rays are “bone on bone” when, in fact, this is not the case)

If we reverse these criteria, the failure rate of therapy will markedly increase; that is to say; folks with zero joint space,  stiff and crooked, overweight and with multiple medical issues might be better served by surgical intervention rather than commit time and resources to injection therapy. There are exceptions. These occur when a person is either unable or unwilling to undergo surgery, sometimes at a point when independence or employment is threatened. In fact, some of m y most notable successes have been in these outlier circumstances.

Therefore, each recommendation has to be individualized.  I am happy to review X-rays for those who have questions. Simply call 703 569 6700 to arrange this electronically.




Stem Cells; Failure leading to success?

For diseases and conditions for which there is no acceptable treatment- like paraplegia and stroke, for example, the FDA is lenient in allowing companies to try new approaches.

Two such studies that I am aware of have, unfortunately, failed. Stem Cells, Inc is now winding down its business after many years of effort in trying to provided neurological return to patients with paralysis.  Such studies attempt to deliver stem cells to the site of spinal cord disruption in the hope that they will “reconnect” nerve endings.  One must realize that some return can seem to occur even without stem cells,,so the noise is such a trial is significant, especially when the number of patients is very, very small (less than 10). So, after a bit of early optimism there is no evidence that the therapy really helps…

Another failed trial was run for hemiplegic stroke by the Cytomedix, Inc, using a particular market for stem cells called ALDH and injecting these cells into the carotid artery. 50 patient treated in “blind” fashion failed to show a difference.

BUT, recently, a team from Stanford shows that the efforts keep on  coming; this approach, for stroke patients, injected the stem cells directly into to the brain (through a small hole in the skull). Early results look amazing, but we have all been here before. If and when another group repeats the study, it may be that the route of administration is critical; also it may be that the stem cells simply work by secreting growth factors that allow brain cells to repair themselves. (I would bet on this one).

If that proves to be the case, we will gradually learn that neural tissue, like cartilage, far from being unable to regenerate, can sometimes regenerate if the triggers for cell growth are present.


Wouldn’t that be nice?

The FDA and Stem Cell therapy

The legitimate interest in stem cells and the promise of new therapies sometimes takes a back seat to overhype, false claims, and outright quackery- or at least a very conscientious effort to separate folks from their money. Enter the Food and Drug Administration (, whose main job it is to protect the public. A scheduled meeting at the FDA has now been delayed, but sometime this year a “conversation” will be held between many participants and stakeholders in the field. I suspect that “guidelines” will eventually be determined, and the public should take note; this is a conversation that should be held. A good resource for information is :, no need to repeat it all here. We should all advocate safety,  proper product labelling, and a post treatment effort to determine efficacy.  This gets a bit sticky when the putative stem cell product is autologous (comes from YOU) and there is no drug company involved; but certainly we should at least know IF there are stem cells in the product. Not so easy. In cases where bone marrow aspirate is used, the injections may, in fact, have few if any stem cells …the abundance of such cells is low, and declines with age. Other sources of stem cells should have lot by lot quality control, using appropriate biomarkers, and cell counts.  Without better science, the task of separating a real therapeutic advance from a placebo effect becomes daunting.

Credit and Money in Science

Please read my previous post on Gene Editing first.

Then have a look at a recent article by Eric Lander about the history of the CRISPER/CAS “invention” or “discovery”, take your pick, which attempts to track the numerous findings that has been required to develop this new tool.  Editas is apparently the first of several companies to make it to Wall St. with an IPO soon, looking to raise 120M. There will be more.

It will be very interesting to see what the patent office does with the competing claims for “ownership”. Already there are negative comments about the Lander piece, mainly because he does not disclose his own commercial interest in one of these companies. Also, he was a bit sparse on giving credit to the two women best known for spearheading this effort, but he certainly did include them- so that is a bit of a softer call.

But as for conflict of interest, it is here in science & medicine just as it pervades so many other aspects of civilization. So when we read about gene editing in years to come- certain to make headlines- be aware- be aware of what we really know for sure and what other people just want you to believe is true.

Reprogramming Cells 2016

The hottest topic in biology this past year has been new methods of slicing and dicing DNA. The new tools, called CRISPER/CAS, are simply enzymes (proteins) borrowed and then modified from bacteria- the bacteria use them as a rudimentary immune system. While DNA clipping tools have been around since the 1970s, the new tools are guided by a strand of RNA to be directed specifically- and programmably- to the site of interest. Since DNA contains billions of sites, this is rather important. If you want to debug a computer program, you had better get to the right line of code. Same thing.

In spite of recent success with a muscle disease in mice, actually doing this in a human is a ways off.  First of all, there is the question of slicing and dicing the DNA ONLY in the right place. Secondly, it is a lot easier to cut something out (like in the mouse model) than it is to insert a a corrective sequence. And thirdly, getting the tools to the DNA requires use of a virus as a vector, and these tools can be quite bulky.  Improvements will need to be made in all of these areas before a human trial is possible, and the disease will have to be chosen carefully- I assume, pick something relatively easy first.  One step at a time.

None of these caveats detract from the excitement that we can now guide an enzyme to the correct site of its work. Look for Nobels in this area real soon, Dr. Doudna and Charpentier,  now both competitors in different biotech companies, and then Dr. Zhang’s group from MIT, all squabbling over the intellectual property rights.

As regards arthritis and cartilage loss, one possible approach with such technology would be to disable the enzymes which degrade cartilage…

Cartilage Repair without surgery

It is time to weigh in on the repair capabilities of PRP (platelet rich plasma) for isolated cartilage (chondral) lesions.  In patients under 20 years old, I now have sufficient experience in 5 patients with lesions of either the knee or the ankle, to say that a sufficient course of PRP can definitely result in clinical and radiographic healing. These patients now have over one year followup and have no symptoms. The dose of PRP may be important, for in my clinic we are counting the number of platelets; 5 B seems to be a threshold for excellent response in Osteoarthritis, and this same protocol was used for the osteochondritic cases noted above. Other than PRP, no other treatment (such as non weight bearing) was performed. Perhaps important, it was thought in all cases that the lesions were of less than one year since presentation.

Amniotic Stem Cells; the first 6

Our first 6 injections of ASCs have been for osteoarthritis of the knee, and each has been combined with a course of Platelet Rich Plasma. So far, no complications and no adverse reactions at all. The cells have come from 2 different tissue banks, and both have arrived on time in boxes packed with dry ice; upon defrosting, the cells  must be used that day.

The tissue banks are clear that they do not advertise “stem cells”, only amniotic cells with stem cell like markers.  This is to avoid any conflict with regulatory agencies as the companies involved do not characterize the cells at all; they simply harvest amniotic fluid from scheduled C sections, they test the fluid for a variety of diseases in order to insure safety.  For this reason, the ASCs are a tissue bank product and not treated like a drug.

At issue as we move forward will be the number of cells per package and establishing an optimal dose. In terms of efficacy, stay tuned to this web site for clinical information as it occurs. The first group of patients was selected specifically to give us feedback of whether the ASCs plus PRP are better than PRP alone. In about 6 months we should have some early information.


Amniotic Stem Cells

Amniotic Stem Cells


For over a decade the concept of using stem cells for the therapy of various diseases has been in the public discourse and has been the subject of many investigations. There are now journals and professional societies worldwide devoted to this topic, along with a proliferation of international meetings, newspaper articles, named buildings and even taxpayer-funded initiatives, as in California. No wonder that local “stem cell” clinics are springing up nationwide to take advantage of the public’s enthusiasm for new medical approaches.


The question remains: does it work? Let’s examine why the jury is still out on this question, and what the present opportunities may include, and let’s do so without the hype and the overblown promises so common in our culture.


Firstly, there are several ways of getting at the pristine DNA inside a cell. What we want to accomplish is to use good DNA to replicate cells that are making abnormal DNA. This could be a function of disease, like cancer or inflammation, or it could be a function of aging. All of these processes are related.


Young DNA has fewer “mistakes” in its sequence; it is a bit like getting a computer code without the bugs. Stem cells have the ability both to reproduce themselves AND to differentiate into other cells- like heart cells, skin cells, cartilage cells. Cells with a variable degree of “stemness” can be obtained from embryos, from bone marrow, from fat and from ordinary cells like skin cells if they are treated with a “cocktail” of growth factors that convert them into stem cells. These are called “induced” stem cells. It is arguable which cells have the “best” DNA for the purpose we are looking for; one concern of the regulatory agencies is that all of these cells could have the potential of growing abnormally- although so far we have no evidence of this.


Working with stem cells is a bit like working with radioactivity- one has to know what one is doing.


FDA approved trials are now progressing with a variety of stem cell products for ailments that have no effective treatments with conventional methods. For example, bone marrow stem cells have been used for stroke (safe, but no improvement), Parkinsons (ongoing), meniscus tears (no response), paraplegia (perhaps some improvement in a few patients). Each study must be read carefully to convince yourself that the investigators really have stem cells, and that they are alive, and that they are put in the right place. In some cases, the stem cells may work by becoming part of the patient (engrafting) and in other cases they may work by secreting various growth factors that many other cells grow. Nature continues to be complex at all levels.


Using stem cells from another person- allografts- is attractive because- as long as immune or rejection problems do not occur- it does not require taking tissue samples from the patient, such as bone marrow or fat. Furthermore, a high density of stem cells can be assured and this can be monitored at the tissue bank for quality purposes. Amniotic fluid is one such source of cells that can be prepared under strict guidelines for safety. These cells are “immunoprivileged”; similar to other allo products, like cartilage. They do not elicit an immune response and do not need to be tissue typed to the recipient (unlike blood). Also, as these cells are derived from elective C-sections, they are young and their DNA is young. We have learned that the use of juvenile tissues, such as Denovo NT cartilage repair, is favorable.


Since PRP (platelet rich plasma) contains the growth factors that activate stem cells, it makes sense to consider the combination of amniotic stem cells and PRP.

Keep in mind that there is no present evidence- pro or con- that could help us determine the usefulness of this therapy. Therefore, at this point each patient must act as their own “control”.


Many patients have joint problems for which there is just no good solution with older methods. I am therefore offering the amniotic stem cell product to carefully selected patients who are fully informed, and for whom PRP alone has not resulted in an adequate response. In this way we will learn together if the stem cell component and the growth factor component synergize to product a good result.