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The Safety of using Liposomal Doxorubicin in Combination with Trastuzumab for the Treatment of HER-2 overexpressing Breast Cancer: A Systematic Review Raksheeth Agarwal*, Oliver Emmanuel** *Universitas Indonesia – (+62) 85777808310, raksheeth@hotmail.com ** Universitas Indonesia – (+62) 818635925, oliveremmanuel@hotmail.com
Introduction: Breast cancer occurs in 124.8 and causes 21.9 deaths per 100,000 women every year. HER-2 is a growth receptor, that when overexpressed can cause increased proliferation of cancer cells. Current treatments for breast cancer include Trastuzumab and Doxorubicin, both of which are known to be effective. However, the administration of trastuzumab and doxorubicin are associated with lethal cardiotoxicity, and their combination has been heavily discouraged. Liposomal drug delivery is a recent technological advance that allows a drug to be delivered to its incumbent site and reduces systemic distribution, reducing systemic side effects. The purpose of this study is to evaluate the safety of using liposomal doxorubicin in combination with trastuzumab in patients with HER-2 overexpressing breast cancer. Methods: Search engines PubMed and Google Scholar were used to systematically search for prospective trials that assess the cardiac function in HER-2 overexpressing breast cancer patients undergoing treatment with a combination of liposomal doxorubicin and trastuzumab. Inclusion criterias were used to filter the abstracts and full texts in assessing the eligibility of the trials. The search was limited to trials written in English and published in the last 10 years. Changes in left ventricle ejection fraction (LVEF) were extracted from each study to assess cardiotoxicity in patients. Results: Four clinical trials were selected based on inclusion criteria. LVEF values were measured using either Multi Gated Acquisition (MUGA) scan or echocardiography. In the studies by Cortes, et al. (2009) and Chia, et al. (2006), the decrease of LVEF from baseline to post-treatment was 3% (from 63% to 60%). Martin, et al. (2011) reported a decrease of 3.6 % (from 63.5% to 59.9%), and Stickeler, et al. (2009), of 3.4 % (from 66.1% to 62.7%). These values were compared to a trial conducted by Slamon, et al. (2001) which used non liposomal doxorubicin in combination with trastuzumab.
Discussion: The fall in median LVEF values from baseline to post-treatment was negligible and asymptomatic in all four studies. The treatment gave good response in all four trials. All studies showed reduced cardiotoxicity as compared to a previous study by Slamon, et al. (2001), which had 27% of its patients experiencing life threatening cardiotoxicity. This review gives hope for future research in the application of liposomal technology in other chemotherapeutic drugs. Conclusion: Liposomal doxorubicin with trastuzumab is an effective treatment for HER-2 positive breast cancer patients with reduced cardiotoxicity that are consistent with reduced systemic distribution.
East Asian Medical Students’ Conference Asian Medical Students’ Association, Indonesia
Scientific Paper
The Safety of Using Liposomal Doxorubicin in Combination with Trastuzumab for the Treatment of HER-2 Overexpressing Breast Cancer: A Systematic Review
By: Raksheeth Agarwal (Universitas Indonesia) Oliver Emmanuel (Universitas Indonesia)
The Safety of Using Liposomal Doxorubicin in Combination with Trastuzumab for the Treatment of HER-2 Overexpressing Breast Cancer: A Systematic Review Raksheeth Agarwal*, Oliver Emmanuel** *Universitas Indonesia – (+62) 85777808310, raksheeth@hotmail.com ** Universitas Indonesia – (+62) 818635925, oliveremmanuel@hotmail.com
1. Introduction Breast cancer is the most frequent form of cancer in women and is the second most frequent cancer associated with death in patients. About 124.8 per 100,000 women are diagnosed with breast cancer per year, and the number of deaths caused by breast cancer is 21.9 per 100,000 women per year. About 12.3% of women will be diagnosed with breast cancer throughout their lives. Fortunately, about 89.4% of women survive 5 years or more after being diagnosed with breast cancer. (Surveillance, Epidemiology... n.d.). Common drugs used to treat Breast Cancer include doxorubicin, and trastuzumab. A more aggressive variant of this disease is called HER-2 overexpressing breast cancer. HER-2 membrane bound protein is a growth receptor that regulates the growth and proliferation of healthy breast cells. HER-2 positive breast cancer means that there is overexpression of this growth factor receptor in the cancer cells. The prognosis of HER-2 positive breast cancer is much worse than in HER-2 negative breast cancer due to the excessive copies of the growth receptors increasing the proliferation of cancer cells. (HER2 Status and Breast Cancer, n.d.) In a study conducted by the MD Anderson Cancer Center, the five year recurrence-free survival rate was 77.1% in those suffering HER-2 positive tumors in early stages and 93.7% in those with negative HER-2 expression (Gonzales, et al. 2005) Doxorubicin is a part of a group of cancer chemotherapy drugs known as anthracyclines. It is widely regarded as one of the most effective and potent antineoplastic drugs, limited only by its potential toxicity to non-cancerous cells. The most widely known systemic side effect of doxorubicin administration is its associated cardiotoxicity. Doxorubicin has been classically used for the treatment of various cancers, one of them being Breast Cancer. The known cytotoxic mechanisms of doxorubicin include intercalation of DNA, inhibition of Topoisomerase II, and generation of free radicals (Katzung & Trevor, 2013). Doxorubicin is able to diffuse passively across the cell membrane and associate itself with cytoplasmic proteasomes. The drug-proteasome complex is then translocated
to the nucleus (Kiyomiya, et al., 2001). The doxorubicin molecule has higher affinity to nuclear DNA than to proteasomes, allowing it to dissociate to the genetic material. The intercalation into DNA and inhibition of Topoisomerase II directly stop the DNA replication process, and hence stops cell division in interphase. The generation of free radicals causes damage to macromolecules, including DNA (Tacar, et al., 2013) Trastuzumab is a humanised monoclonal antibody specific to the extracellular portion of HER-2 and has been known to prolong the lifespan of patients with metastastic breast cancer and to reduce the risk of death by 33% (Romond, et al., 2005) Although the mechanisms underlying trastuzumab's mode of action on cancer cells is not well known, several proposed concepts have shown to be well corroborated (Valabrega, et al., 2007). Trastuzumab is known to stop the proteolytic cleavage in HER-2 that occurs when it is overexpressed, which will lead to the cleaved portion entering the serum. According to Molina et al, the decrease of serum HER-2 fragments is consistent to an increased progression free survival which implies that the prevention of this cleavage might be the mode of action of trastuzumab (Molina, et al., 2001). Overexpression of HER2 in breast cancer is frequently associated with increased angiogenesis. One study done on mice treated with trastuzumab showed a more controlled angiogenesis in an experimental human HER-2 overexpressing breast tumor model, indicating another possible mechanism of trastuzumab (Valabrega, et al., 2007) Doxorubicin and trastuzumab are breast cancer treatments often associated with systemic side effects, especially cardiotoxicity. As reported in a study by Cardinale, et al., about 34% patients undergoing treatment with trastuzumab encountered cardiotoxicity complications (Cardinale, et al., 2010) Another study yielded that the risk of occurence of cardiotoxicity is 4% in treatment with trastuzumab alone and 27% in combination with anthracycline and cyclophosphamide. The pathogenesis of transtuzumab induced cardiotoxicity is still under investigation (Keefe, 2002). Other side effects associated with the administration of trastuzumab include asthenia, fever, pain and nausea (Vogel, et al., 2002) As for doxorubicin, administration of free form doxorubicin is not well targeted, and hence has systemic effects like nausea, alopecia, gastrointestinal problems, and neurological problems such as hallucinations. However the most dangerous outcome of doxorubicin, as mentioned above, is its associated cardiomyopathy (Tacar, et al., 2013). The incidence of cardiomyopathy with doxorubicin is dose dependent, but it is approximately 11% in general. The prognosis in patients with doxorubicin cardiomyopathy is poor, with a mortality rate of about 50% in one year. Proposed mechanisms for cardiomyopathy include generation of free radicals, down regulations of genes coding for contractile proteins, and apoptosis of cardiomyocytes (Chatterjee, et al., 2010) If both trastuzumab and doxorubicin are used together, they can be lethal, as they are both known to cause cardiomyopathy. Neuregulins are a group of growth factors that can induce cardiomyocyte
repair and proliferation. Exposure to trastuzumab is thought to suppress the protective effect of neuregulins. Hence, the risk of cardiotoxicity caused by doxorubicin is amplified when used with trastuzumab, as there the protective system is suppressed (Rayson, et al., 2008). A widely cited clinical trial by Slamon, et al. first used this combination of drugs. Their result showed that a significant proportion of the patient population developed major cardiotoxixity (27%), with 16% patients experiencing Congestive Heart Failure (Slamon, et al., 2001). Due to its systemic distribution, it is not always practical to administer free form doxorubicin in cancer patients. Instead, advances in technology have allowed the use of liposomes to target the drug to a specific tissue. A liposome is a type of nanoparticle. It is a closed spherical vesicle consisting of at least one phospholipid bilayer (Allen, et al., 2004). These vesicles can be used as vehicles for various drugs. Immunotargeting is used to target liposomes to specific tissues. Antibodies for certain surface biomarkers of the targeted tissues are added to the liposome. Once the antibodies have attached themselves to the antigen, the drug is released form the liposome. This allows reduced systemic distribution of the drug, and the drug is instead concentrated to the targeted tissue (Ferrari, 2005) A study by Schmeeda, et al. (2009) investigated the effect of HER-2 targeted Pegylated Liposomal Doxorubicin (HT-PLD) on binding rate with HER-2 expressing cells. The study found that adding anti HER-2 antibodies to PLDs improved their binding capacity to HER-2 expressing cells by more than 10 times in vitro. Liposomal doxorubicin now manufactured worldwide since its recent approval by the FDA. Liposomes are generally rapidly cleared from the body’s bloodstream when administered intravenously by the action of the body’s reticulo-endothelial system. Thus, they have a short biological half-life. Methods of increasing the circulation time of liposomes have been developed. One of the most commonly used methods is surface modification of the liposomes by adding PEG molecules (Polyethylene Glycol). The added PEG molecules tend to shield the liposome from interactions with other macromolecules such as blood opsonins, and allow it to circumvent the reticulo-endothelial system of our body (De Rose, et al., 2012 & Deshpande, et al., 2013). This greatly increases the time period for which the liposome can circulate in the body. With the development of liposomal doxorubicin, there is hope that this drug can be used with trastuzumab for effective treatment of breast cancer. This combination is still in clinical trial phase, and shows good hope for the future of chemotherapy. This review aims to examine some clinical trials that have used this combination.
Study Purpose
The objective of this systematic review is to assess the cardiotoxicity associated with using trastuzumab in combination with liposomal doxorubicin to conclude whether it is a viable option for Breast Cancer Treatment. As stated before, the combination can cause lethal cardiotoxicity if doxorubicin is used in its free form. However, with recent advancements in medical nanotechnology which allow liposomal drug formulations and targeted drug delivery, this combination can be a potent treatment for cancer. This review examines a few clinical trials which have tested the combination to assess whether it is viable, by analyzing the cardiac status of the subjects. 2. Research Methodology
2.1. Search Strategies A comprehensive literature search was conducted in October 2015 using two main search engines, PubMed and Google Scholar. The combinations of terms used for the search included “Liposomal Doxorubicin”, “Trastuzumab”, “HER-2 Overexpressing”, and “Breast Cancer”. Limits were applied and only studies published in the last 10 years (2005-2015), and written in English were included. Studies outside of the ten year range were excluded to avoid external factors such as healthcare level and advancements in hospitalization.
2.2. Inclusion and Exclusion Criteria Inclusion Criteria:
Clinical Trials with Human Subjects
Subjects with HER-2 positive Breast Cancer
Subjects within the age range of 18-80
Studies published in the last 10 years
Studies using Trastuzumab in combination with Liposomal Doxorubicin for treatment of Subjects
Studies evaluating the cardiotoxicity in test subjects
Exclusion Criteria:
Studies not using the liposomal formulation of Doxorubicin
Studies that use one drug after the other, and not both concurrently
Studies not assessing treatment efficacy along with safety of the treatment regimen.
2.3. Data Extraction The following data was extracted from the studies: 1. Baseline Left Ventricle Effusion Rates (LVEF)*
2. LVEF values after 6 cycles of Treatment 3. Treatment Efficacy (Overall Survival and Overall Response Rate) 4. Patient Characteristics *LVEF is the fraction of the end-diastolic blood volume that is being pumped out by the left ventricle. An LVEF value of 55% or higher is considered normal. Low LVEF values indicate cardio-pathologies such as dilation cardiomyopathy and Myocardial Infarction (Guyton & Hall, 2006)
2.4. Quality Assessment The quality of included studies was assessed by a quality assessment tool (Quality Assessment Tool…, March 2014) developed by The National Heart, Lung, and Blood Institute (NHLBI) and Research Triangle Institute International Jointly. It includes 14 points of criteria that need to be assessed. All of the points referred to the internal validity of the tests, and hence the reliability of the results of each of the four included studies was assessed based on their methodology. All of the criteria were scored with either yes, no, Cannot Determine (CD), or Not Applicable (NA). A “yes” was given one point, whereas a “no” was given a score of 0. No standard for a good, moderate, or poor study was given. Hence, a study obtaining a score of 11/14 or higher was defined as a good quality study, meanwhile studies receiving a score of 7/14 or less were defined as poor studies. A score between 7 and 11 out of 14 was defined as moderate. Two reviewers independently analyzed the four included studies based on the quality assessment criteria. If the ratings differed, the articles were discussed until a common consensus was reached. 3. Results
3.1. Research Findings The initial search that was conducted yielded a total of 43 trials. After reading the titles, 29 results were excluded as they did not fulfill the inclusion criteria, and a further 4 trials were excluded after reading the abstract. From the resulting 10 texts, 5 did not have a full available article, and 1 did not assess the overall response rate (hence it did not assess treatment efficacy). Thus, a total of 4 resulting clinical trials were used. This information can be seen in the flow chart below: Figure 1: Flow chart of the Search Strategy
The four clinical trials selected in this systematic review are conducted by Cortes, et al. (2009), Martin, et al. (2011), Chia, et al (2006), and Stickeler, et al (2009).
3.2. Quality of the Included Studies From the result of this quality assessment, all 4 studies were defined as good quality studies, and can be seen in the table below: Table 1: Results of Quality assessment for the four studies. Chia, Cortes, Stickeler, Criteria et al et al et al 1. Was the research question or objective in this paper Yes Yes Yes clearly stated? 2. Was the study population clearly specified and Yes Yes Yes defined? 3. Was the participation rate of eligible persons at least Yes Yes Yes 50%? 4. Were all the subjects selected or recruited from the same or similar populations (including the same time period)? Were inclusion and exclusion criteria for being Yes Yes Yes in the study prespecified and applied uniformly to all participants? 5. Was a sample size justification, power description, or Yes Yes No variance and effect estimates provided? 6. For the analyses in this paper, were the exposure(s) of Yes Yes Yes
Martin, et al Yes Yes Yes
Yes
Yes Yes
Table 1: Results of Quality assessment for the four studies. Chia, Cortes, Stickeler, Criteria et al et al et al interest measured prior to the outcome(s) being measured? 7. Was the timeframe sufficient so that one could reasonably expect to see an association between exposure Yes Yes Yes and outcome if it existed? 8. For exposures that can vary in amount or level, did the study examine different levels of the exposure as related No No No to the outcome (e.g., categories of exposure, or exposure measured as continuous variable)? 9. Were the exposure measures (independent variables) clearly defined, valid, reliable, and implemented Yes Yes Yes consistently across all study participants? 10. Was the exposure(s) assessed more than once over Yes Yes Yes time? 11. Were the outcome measures (dependent variables) clearly defined, valid, reliable, and implemented Yes Yes Yes consistently across all study participants? 12. Were the outcome assessors blinded to the exposure No No No status of participants? 13. Was loss to follow-up after baseline 20% or less? Yes Yes Yes 14. Were key potential confounding variables measured and adjusted statistically for their impact on the Yes Yes Yes relationship between exposure(s) and outcome(s)? Score 12/14 12/14 11/14
Martin, et al
Yes
No
Yes Yes Yes No Yes Yes 12/14
3.3. Study Designs and Characteristics The following table summarizes the study designs of the studies mentioned above Table 2: The summary of Experimental Designs of the four studies Study Cortes, et al
Patient Criteria
Treatment Plan
Cardiac Monitoring
Age Range: 26-78 (Median: 53)
Liposomal Doxorubicin:
LVEF was measured using
Illness: HER-2 Overexpressing
1 hour intravenous
echocardiography or by
Metastatic or Locally Advanced
infusion, every 3 weeks,
MUGA scan (Multi Gated
Breast Cancer
for 6 cycles
Acquisition Scan). A drop
Other Criteria: Baseline LVEF ≥
Trastuzumab: Initial
in LVEF by ≥10% resulting
50%, No history of Myocardial
loading dose of 4mg/kg
in a final LVEF <50%,
Infarction. Prior administration of
on day 1, followed by 2
LVEF <40%, or any
anthracyclines, taxanes, or
mg/kg Intravenous
absolute drop ≥20% was
trastuzumab was not permitted
Infusion over 30
considered a cardiac event.
Table 2: The summary of Experimental Designs of the four studies Study
Patient Criteria Number of Patients: 69
Treatment Plan
Cardiac Monitoring
minutes, once a week, for 52 weeks.
Martin, et al
Age Range: 37-78 (Median: 57)
Liposomal Doxorubicin: 2
Illness: HER-2 Overexpressing
50mg/m once every 4
echocardiography or
Metastatic Breast Cancer
weeks, for 6 cycles.
MUGA scan (Multi Gated
Other Criteria: Adequate cardiac
Trastuzumab: Initial
Acquisition Scan). Cardiac
function, Baseline LVEF ≥ 50%.
loading dose of 4mg/kg
Toxicity Criteria: absolute
Patients with prior chemo therapy
on day 1, followed by 2
LVEF decrease from
were not allowed. Prior adjuvant
mg/kg Intravenous
baseline ≥15% or a
therapy was allowed if completed
Infusion, once a week,
decrease <10% with an
6 months before testing.
for 24 weeks.
absolute baseline value
Number of Patients: 48 Chia, et al
Stickeler, et al
LVEF was measured using
≤45%
Age Range: 29-73 (Median: 57)
Liposomal Doxorubicin:
LVEF was measured using
Illness: HER-2 Overexpressing
50mg/m2 intravenously,
serial MUGA scans.
Metastatic Breast Cancer
over 1 hour once every 4 Cardiac toxicity criteria: A
Other Criteria: Baseline LVEF ≥
weeks, for 6 cycles.
patient with symptomatic
55%, Prior use of Trastuzumab
Trastuzumab: Initial
cardiotoxicity (Ex:
was not allowed. Life expectancy
loading dose of 4mg/kg
orthopnea, S3 gallop,
> 6 Months
on day 1, followed by 2
tachycardia), or a ≥ 15%
Number of Patients:30
mg/kg Intravenous
decline from baseline in
Infusion, once a week,
LVEF regardless of final
for 24 weeks.
(absolute) value
Liposomal Doxorubicin:
LVEF was measured using
Age Range: 37-68 (Median: 63)
2
Illness: HER-2 Overexpressing
40mg/m intravenously,
Simpson’s method
Metastatic Breast Cancer
once every 4 weeks, for
(Echocardiography).
Other Criteria: No prior history of
9 cycles.
Cardiac Toxicity was
cardiac defects, Baseline LVEF ≥
Trastuzumab: 2 mg/kg
defined by the incidence of
50%, No prior heavy
Intravenous Infusion,
a cardiac symptom (Ex:
chemotherapy
once a week, until end
Tachycardia), or a decrease
Number of Patients: 16
of Liposomal
in LVEF <44% or ≥ 10
Doxorubicin treatment
units below the normal value of 50%
3.4.1. Study Outcome: Safety of the Treatment
Next, the results related to cardiac functions from the four studies are presented. This includes median baseline LVEF values, Median LVEF values after 6 cycles of Liposomal Doxorubicin, cardiac events, and any other important notes from the authors. Table 3: Summary of changes in cardiac function of test subjects Study Cortes, et al
Median Baseline
Median LVEF
LVEF (%)
after 6 cycles (%)
63%
60%
Cardiac Events A total of 12 patients (17%) experienced predefined cardiac events (an absolute decline in LVEF ≥10% resulting in final LVEF <50%, LVEF <40%, or any absolute decline in LVEF ≥20%). 8 out of the 12 patients recovered fully. No symptomatic events were observed.
Martin, et al
63.5%
59.9%
A total of 8 (16.7%) patients experienced predefined cardiac events. 7 of the 8 patinets recovered fully. None of the patients experienced symptomatic cardiac events.
Chia, et al
63%
60%
Three patients experienced an absolute decline in LVEF of ≥ 15%. 2 of the 3 patients recovered completely. None of the patients showed clinical symptoms of cardiac failure
Stckeler, et al
66.1% (Mean)
62.7% (Mean)
Three patients experienced severe to moderate LVEF changes. However, none of the patients were symptomatic
3.4.2. Study Outcome: Efficacy of Treatment Next, the efficacy of the combination in the four studies will be presented. The parameters evaluated for this are median values for Overall Survival (months), and Overall Response Rates (Complete Response plus Partial Response). Response rates are measured by the number of patients that respond to the treatment as a percentage of the total number of test subjects that are evaluated. Each of the four studies used appropriate imaging tests for tumor measurements to assess the response of the solid tumor to the treatment. The studies used the RECIST (Response Evaluation Criteria in Solid Tumor) criteria developed by collaboration between The National Cancer Institute of the United States, the European Organisation for Research and Treatment of Cancer (EORTC), and the National Cancer Institute of Canada Clinical Trials Group (Therasse, 2000). These criteria are used by most clinical trials including solid tumors worldwide. Imaging as response assessment was done at regular intervals in all four studies. The efficacy of treatment in the four studies is summarized in Table 4 below. Whether the response was complete or partial was determined using the criteria of RECIST. Table 4: The efficacy of treatment In the 4 included studies Study
Overall
Partial
Complete
Overall Response
Survival
Response
Response
Rate
Cortes, et al
61.4 Months
44.4%
53.7%
98.1%
Martin, et al
34.2 Months
56.25%
12.5%
68.75%
Chia, et al
1-year
-
-
52%
estimated OS:
76.9% Stickeler, et al
16.23 Months
33.3%
50%
83.3%
4. Discussion
4.1. Analysis of Results This systematic review shows that when trastuzumab is used together with liposomal doxorubicin, the treatment is safe and effective. This can be seen when the results of each of the studies are compared to the initial testing by dr. Slamon (2001). In dr. Slamonâ&#x20AC;&#x2122;s clinical trial, patients received trastuzumab with non-liposomal doxorubicin. In this clinical trial, 27% of the patients experienced severe cardiotoxicity that was life threatning. In all of the studies, none of the patients showed clinical symptoms of cardiac toxicities or heart failure. None of the patients in the studies of this review experienced severe or serious cardiac morbidities, indicating that cardiac functioning was well maintained and that the combination of drug was safe. This is further supported by the data of the baseline LVEF and LVEF after 6 cycles in the test subjects. The baseline LVEF values in all the test subjects over the four clinical trials were normal. The median LVEF of the test subjects in the four trials did not decrease by much. As seen from figure 2, the decrease in median LVEF values from baseline to after 6 cycles of treatment remained largely conserved, with only negligible decreases. In the studies by Cortes, et al. (2009) and Chia, et al. (2006), this decrease was by 3 % (from 63% to 60%). In the study by Martin, et al. (2011), this decrease was by 3.6 % (from 63.5% to 59.9%). In the study by Stickeler, et al. (2009), this decrease was by 3.4 % (from 66.1% to 62.7%). This portrays that the LVEF values did not fall significantly, and the patientsâ&#x20AC;&#x2122; cardiac function was well maintained. Even though the cardiac functions of the patients receiving this combination of drugs was maintained well, there were some asymptomatic drops in LVEF that characterized the events as cardiotoxicity according to pre-defined criteria by the authors. The incidence for this was 17% in the study by Cortes, et al., 16.7% in the study by Martin, et al., 10% in the study by Chia, et al., and 19% in the study by Stickeler et al. Nevertheless, we see that in most of these patients, the LVEF recovered to normal. We see that the patients in the study by Chia, et al. showed excellent cardiac tolerability to the treatment, with only 10% experiencing pre-defined cardiotoxicity. This may be because the cut off baseline LVEF values in this study was higher (55%), as compared to 50% in the other 3 studies (Table 2). This suggests that the patients in the study by Chia, et al. might have had a healthier cardiac function at the start of the study than the patients in the other three studies. This in turn suggests that initial cardiac function may play a role in predicting possible cardiotoxicity during treatment.
The treatment also had extremely high efficacy in all four trials. It must be considered that HER-2 positive Metastatic Breast Cancer has extremely poor prognosis, as seen from the data in the introduction (Gonzales, et al., 2009). The overall response rates of the illness to the combination of drugs was 98.1%, 68.75%, 52%, and 83.3% in studies by Cortes, et al., Martin, et al., Chia, et al., and Stickeler, et al. respectively. The median overall survival rate is also reported to be significantly high in the four studies. Cortes, et al. reported the median OS to be as high as 61.4 months, whereas Martin, et al., and Stickeler, et al. reported it to be 34.2 months and 16.23 months respectively. Chia, et al. reported that the survival rate after 1 year is 76.9%. The cancer was extremely responsive to the combination of drugs used, and the survival rate was also quite high, considering the poor prognosis of advanced breast cancer. The overall response rate of each of the studies is stated by their respective authors to be within range of other studies with similar designs. Chia, et al (2006) mentioned that their overall response rate (52%) was on the lower side of this range, but it was compensated by their higher median Progression Free Survival rate (12 months). Also, we see an extremely high overall response rate in the study by Cortes, et al., but the reason for this is not known. In summation, these results show us that when doxorubixin is used in its newly developed liposomal formulation along with trastuzumab, the combination yields great results. This combination was once vastly discouraged due to the obvious severe cardiotoxicity (Rayson, et al., 2008). However, recent clinical trials (such as the ones discussed in this review) show us that there is promise for the use of this combination in treatment for advanced breast cancer. In the introduction, we discussed that the systemic side effects of liposomal drugs should be lower due to reduced systemic distribution (Deshpande, et al., 2013 & Ferrari, 2005). The data received from the four clinical trials supports this point.
4.2. Limitations of the Study There are several limitations in this systematic review. Firstly, only 4 studies were included in the review. This was because not many clinical trials have been published on the administration of a combination of liposomal doxorubicin and trastuzumab for the treatment of advanced breast cancer. The liposomal formulation of doxorubicin is a relatively new technology, and hence its concerted use with trastuzumab is yet to be tested completely. Secondly, our resources were extremely limited, as we had access to only free publications. This is the reason why we could not access the clinical trials in Cochrane Library.
4.3. Future Research The review evaluates four trials and shows that the concerted use of trastuzumab with liposomal doxorubicin was extremely effective and safe in the treatment of advanced breast cancer. Future
research must be done in determining the effectiveness and increased safety of using liposomal formulations of other chemotherapeutic drugs. So far, one of the only chemotherapy drugs that have a commercially available liposomal formulation is doxorubicin. Hence, it would be beneficial to develop more drugs with liposomal formulations to reduce systemic side effects. Liposome technology for targeted drug delivery is the future of pharmaceuticals. In addition, we believe that future studies should be conducted using the design used by Cortes, et al. in their study, in order to find the determining factors to obtain the high overall response rate. This could improve the efficacy of the treatment in the future. 5. Conclusion From the obtained results from the systematic review, it can be concluded that a combination of trastuzumab with liposomal doxorubicin is a safe and effective treatment regimen for advanced stage breast cancer. This conclusion shows great potential for future research in the treatment of breast cancer, as well as for the development of new liposomal formulations of various drugs with known adverse systemic side effects.
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Kiyomiya, K. I., Matsuo, S., & Kurebe, M. (2001). Mechanism of specific nuclear transport of adriamycin the mode of nuclear translocation of adriamycin-proteasome complex. Cancer research, 61(6), 2467-2471. Martín, M., Sánchez-Rovira, P., Muñoz, M., Mel, J. R., Margeli, M., Ramos, M., ... & Carrasco, E. (2011). Pegylated liposomal doxorubicin in combination with cyclophosphamide and trastuzumab in HER2-positive metastatic breast cancer patients: efficacy and cardiac safety from the GEICAM/2004–05 study. Annals of oncology, 22(12), 2591-2596. Molina, M. A., Codony-Servat, J., Albanell, J., Rojo, F., Arribas, J., & Baselga, J. (2001). Trastuzumab (herceptin), a humanized anti-Her2 receptor monoclonal antibody, inhibits basal and activated Her2 ectodomain cleavage in breast cancer cells. Cancer research, 61(12), 47444749. Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. (2014 March). Retrieved October 19, 2015, from http://www.nhlbi.nih.gov/health-pro/guidelines/in-develop/cardiovascular-riskreduction/tools/cohort
Rayson, D., Richel, D., Chia, S., Jackisch, C., Van der Vegt, S., & Suter, T. (2008). Anthracyclineâ&#x20AC;&#x201C; trastuzumab regimens for HER2/neu-overexpressing breast cancer: current experience and future strategies. Annals of Oncology,19(9), 1530-1539. Romond, E. H., Perez, E. A., Bryant, J., Suman, V. J., Geyer Jr, C. E., Davidson, N. E., ... & Wolmark, N. (2005). Trastuzumab plus adjuvant chemotherapy for operable HER2-positive breast cancer. New England Journal of Medicine, 353(16), 1673-1684. Shmeeda, H., Tzemach, D., Mak, L., & Gabizon, A. (2009). Her2-targeted pegylated liposomal doxorubicin: retention of target-specific binding and cytotoxicity after in vivo passage. Journal of Controlled Release, 136(2), 155-160. Slamon, D. J., Leyland-Jones, B., Shak, S., Fuchs, H., Paton, V., Bajamonde, A., ... & Norton, L. (2001). Use of chemotherapy plus a monoclonal antibody against HER2 for metastatic breast cancer that overexpresses HER2. New England Journal of Medicine, 344(11), 783-792. Stickeler, E., Klar, M., Watermann, D., Geibel, A., FĂśldi, M., Hasenburg, A., & Gitsch, G. (2009). Pegylated liposomal doxorubicin and trastuzumab as 1st and 2nd line therapy in her2/neu positive metastatic breast cancer: a multicenter phase II trial. Breast cancer research and treatment, 117(3), 591-598. Surveillance, Epidemiology, and End Results ProgramTurning Cancer Data Into Discovery. (n.d.). Retrieved October 15, 2015. Tacar, O., Sriamornsak, P., & Dass, C. R. (2013). Doxorubicin: an update on anticancer molecular action, toxicity and novel drug delivery systems. Journal of Pharmacy and Pharmacology, 65(2), 157-170. Therasse, P., Arbuck, S. G., Eisenhauer, E. A., Wanders, J., Kaplan, R. S., Rubinstein, L., ... & Gwyther, S. G. (2000). New guidelines to evaluate the response to treatment in solid tumors. Journal of the National Cancer Institute,92(3), 205-216. Trevor, A., & Katzung, B. (2013). Cancer Chemotherapy. In Katzung & Trevor's pharmacology: Examination & board review (10th ed., p. 471). New York: McGraw-Hill Medical. Valabrega, G., Montemurro, F., & Aglietta, M. (2007). Trastuzumab: mechanism of action, resistance and future perspectives in HER2-overexpressing breast cancer. Annals of oncology. Vogel, C. L., Cobleigh, M. A., Tripathy, D., Gutheil, J. C., Harris, L. N., Fehrenbacher, L., ... & Press, M. (2002). Efficacy and safety of trastuzumab as a single agent in first-line treatment of HER2-overexpressing metastatic breast cancer. Journal of Clinical Oncology, 20(3), 719-726.
The efficacy of transcranial magnetic stimulation on improving motoric functional impairment of post ischemic stroke patients. Iin Tammasse1, Khumaira1, Nadya Sumolang1 1
Hasanuddin University, South Sulawesi, Indonesia
Background: Stroke is the 1st leading cause of death in Indonesia (15,4%). Advances have occurred in the prevention and treatment of stroke during the past decade. One of the current methods to treat post stroke disability is TMS. Transcranial magnetic stimulation (TMS) is a noninvasive method by which weak electrical currents are induced in the brain by a rapidly changing magnetic field. The magnetic field passes through the skull, inducing mild electric currents in the brain, which excite and depolarize neurons in the brain Aims and objective: This study is a cohort observational study to assess the efficacy of TMS intervention on improving motoric function of post-stroke patients. In particular, we measured the patientsâ&#x20AC;&#x2122; motoric impairment using the European Stroke Scale and compare the result before and after receiving TMS intervention. Key Findings: There was an average elevation of 15,48 from pre to post ESS score. (CI=95%)(p<0,05). The mean of pre- score was 70,19 and the mean of post-score was 85,68 with respectively standard deviation of 18,264 and 13,372 Methodology used: The study population consisted 124 post-ischemic stroke patients, who were undergoing TMS intervention in a clinic in Indonesia and followed up during January 2015 to September 2015. Inclusion criteria for this study are patients with post non-hemorrhagic stroke that has motoric functional impairment. The primary outcome measures the therapeutic efficacy of TMS intervention, using the European Stroke Scale (ESS). Paired T-test was used to assess the statistical significance of the sample. Scope of research and areas for future research: we can conclude that TMS is a technology that can be used to treat patients with post-ischaemic stroke motoric impairment and prevent further disability in the future. TMS intervention has been proven to be effective to improve patientsâ&#x20AC;&#x2122; clinical condition. We also see that there is a possibility of TMS to be used as solution for other motoric related disorder.
Authors : Iin Tammasse, Khumaira, Nadya Sumolang
Hasanuddin University, South Sulawesi, Indonesia iinfadhilahf@gmail.com +82188833395
THE EFFICACY OF TRANSCRANIAL MAGNETIC STIMULATION ON IMPROVING MOTORIC FUNCTIONAL IMPAIRMENT OF POST ISCHEMIC STROKE PATIENTS
IIN TAMMASSE1, KHUMAIRA1, NADYA SUMOLANG1
Faculty of Medicine Hasanuddin University
1
ASIAN MEDICAL STUDENTS’ ASSOCIATION INDONESIA (AMSAUNHAS) 2015
25
2 Introduction Stroke is the 1st leading cause of death in Indonesia (15,4%). In 2007, prevalence of Stroke was 8.2 per 1000 population on 33 provinces in Indonesia (Indonesia Basic Health Research 2007). Stroke accounted for 99/100 000 agegenderstandardized death rate and 685/100 000 agegenderstandardized disabilityadjusted life years lost (Karyana et al. 2014, Kusuma et al. 2009). Thus, further investigation into treatments to decrease the number of post stroke disability are critical to undertake. Stroke is defined by the World Health Organization as a clinical syndrome consisting of rapidly developing clinical signs of focal (or global in case of coma) disturbance of cerebral function lasting more than 24 hours or leading to death with no apparent cause other than a vascular origin (Hatano, 1976). Classification based on the TOAST system identifies the mechanism that leads to five categories: (1) Largeartery atherosclerosis, (2) Cardioembolism (3) Smallartery occlusion (lacune) (4) Acute stroke of other determined etiology (5) Stroke of undetermined etiology (Harold et al. 1993) Approximately two thirds of stroke survivors have residual neurological deficits that impair function and approximately 50% are left with disabilities making them dependent on others for activities of daily living (Greshan GE et al. 1975). Previous studies have found that among the more common are physical impairments in upper limb use and in functional walking. Upper limb dysfunction remains an important hurdle for many stroke survivors. Only 5% of adult stroke survivors regain full function of the upper limb and 20% regain no functional use. In addition, the other common concern for poststroke patients is whether they would regain independent walking (Duncan P et al, 1198). Advances have occurred in the prevention and treatment of stroke during the past decade. One of the current methods to treat post stroke disability is TMS. Transcranial magnetic stimulation (TMS) is a noninvasive method by which weak electrical currents are induced in the brain by a rapidly changing magnetic field. The magnetic field passes through the skull, inducing mild electric currents in the brain, which excite and depolarize neurons in the brain (Almaraz et al. 2010). TMS has shown promising results in improving gait, a major cause of disability, and may provide a therapeutic alternative. As it is a relatively new form of treatment, there are less data on the side effect or longterm efficacy. Some studies had addressed the efficacy of TMS for the treatment of motoric impairment of poststroke patients (Table 1). This study attempts to assess the efficacy of TMS intervention on improving motoric function of poststroke patients. In particular, we measured the patients’ motoric impairment using the European Stroke Scale and compare the result before and after receiving TMS intervention. Table 1: TMS studies as a treatment for stroke patient Table 1: TMS studies as a treatment for
26
3 Table 1: TMS studies as a treatment for stroke patient
Author
Study Design
Population
Intervention
s
Duratio
Outcome
n
(Lee et al.
Casecontrol
29 patients
rTMS was
2014)
study
with
applied to the
found to be
subacute
hand motor
significantly
stroke
cortex for 10
associated
minutes with
with a
10 Hz
response to
frequency
rTMS
11 patients
2 weeks Patients were
(Cassidy et
Crossover ,
A. active 6 Hz 5 weeks Significant
al. 2015)
double blind
priming
withintreat
trial
tactive 1 Hz
ment
rTMS, B.
differences
active 1 Hz
from
priming t
baseline in
active 1 Hz
ipsilesional
rTMS, and C.
cortical
sham 6 Hz
silent period
priming
(CSP)
tactive 1 Hz
duration and
rTMS
shortinterva l intracortical inhibition.
(Nowak et
Crossover
15 adult
1Hz rTMS
During
al. 2008)
investigation
right
for 10 minutes 4
Improved the kinematics
hand–domi applied to the
weeks4 of finger and
nant 15
vertex
months
grasp
patients
(control
after
movements
27
4
with a first
stimulation)
stroke
in the
subcortical
&contralesion
affected
ischemic
al M1
hand
(Trompetto
Casecontrol
21
Stimulation of 5 days
Subgroup
et al. 2000)
study
patients
the motor
A1: the hand
affected by
cortex was
motor score
stroke (12
performed
was 0; Only
male, 9
with a
two patients
female;
Magstim 200
of group B
aged
stimulator
showed
39±90
plegic hand
years)
muscles at T1;only one of the patients of group C had some degree of hand movement at (T1)
(Weidusch
Randomized,
10
1Hz
9
Better
at et al.
controlled,
rghthande
repetitive
months
clinical
2010)
blinded study
d patients
transcranial
improvemen
magnetic
t.
stimulation over righthemisph eric Broca Materials and Method A cohort observational study was conducted from January 2015 to September 2015 on 124
28
5 patients who were undergoing TMS intervention
Study population The study population consisted 124 postischemic stroke patients, who were undergoing TMS intervention in a clinic in Indonesia and followed up during January 2015 to September 2015. Inclusion criteria for this study are patients with post nonhemorrhagic stroke that has motoric functional impairment. All patients had to received MRI scan before undergoing TMS intervention. Finally, all patients that passed the inclusion criteria were taken as total sample.
Clinical outcome The primary outcome measures the therapeutic efficacy of TMS intervention, using the European Stroke Scale (ESS). The European Stroke scale can be used as an instrument for matching of treatment groups as well as for evaluation of the patients’ level of impairment. The scale consists of 14 items selected on the basis of their specificity and their prognostic value. The 14 items are level of consciousness, comprehension, speech, visual field, gaze, facial movement, maintenance of arm position, arm raising, wrist extension, finger strength, maintenance of leg position, leg flexing, foot dorsiflexion, and gait (L. Hantson et al. 1994). All patients were evaluated by one consultant neurologist who runs a neurology clinic. Outcome data were retrieved from the Electronic Patient Records. Statistical analysis Paired Ttest was used to assess the statistical significance of the sample. P<0.05 was considered statistically significant. We compared the calculated value with the table value. If the result show no difference between the preTMS intervention and postTMS intervention. Thus, the null hypothesis is accepted.
29
6 Results Clinical characteristic of the study population The clinical characteristics of the study population are shown in Table 1. The mean age was 56.65 years old. Seventy seven subjects (62.1%) were males and forty seven of subjects (37.9%) were females. There were 124 subjects who suffered motoric functional impairment due to stroke attack.
Characteristic Age Sex Male Female
Total Number (%)
Mean +/ SD 56.65 +/ 11.489
77 (62.1) 47 (37.9)
Significant motoric improvement postTMS intervention A parametric paired ttest analysis was performed as describe in the method to compare pre and post the ESS score. The mean of pre score was 70,19 and the mean of postscore was 85,68 with respectively standard deviation of 18,264 and 13,372. Thus, there was an average improvement score of 15,48 using ESS score (0100) with a standard deviation of 11,03. (p<0,05) Ttest resulted in a t value of 15,63 and with two tail critical value of 1,98 with a confidence interval of 95%. Thus, there is a significant overall improvement as a result of TMS intervention. The graph below indicates an association in comparison of pre and post score of ESS. There is a clear improvement in ESS score . 90 80 70 60
ESS Score
50 40 30 20 10 0 Pre
Figure
Post
A.
Significant elevation of ESS Score of stroke patients with post TMS Intervention. There was an average elevation of 15,48 from pre to post ESS score. (CI=95%)(p<0,05)
30
7
Discussion Our result showed that the improvement of motoric impairment was significantly correlated using European Stroke Scale. This study indicated that there is improvement on motor functions such as facial movement, hand movement and gait. Multiple reports previously done in TMS and stroke have confirmed the positive link between TMS and hand movement ,as Nowak et al.(2008) has found application of rTMS to the contralesional M1 improved the kinematics of finger and grasp movements in the affected hand. Previous studies have shown several methods to improve patients’ motoric function using different scale. Konecny et al. (2011) studied there were changes in facial movement, evaluated with the houseBrackmann Grading System (hBDS) after given orofacial therapy. The study was focused merely on patients’ with facial paresis. Meanwhile our study addressed motoric impairment in general, including but not limited to facial paresis. Berger et al. (2006) measured the horizontal eyeinhead and headontrunk deviation. The measurements were done at the bedside of patients with acute left or rightsided stroke. It concluded that a marked spontaneous horizontal deviation of the eye and the head observed ~ 1.5 days poststroke is not a symptom associated with acute cerebral lesion per se, nor is a general symptom of right hemisphere lesion, but rather is a specific sign of a spatial neglect. Our study has clearly demonstrated that TMS improve patients’ situation with an average European Stroke Scale elevation of 15.48 and the result is considered significant. The observation of this study is consistent with a former study done by Khedr et al.(2005) showing 10 consecutive days of rTMS employed as an addon intervention to normal physical and drug therapies improves immediate clinical outcome in early stroke patients, assessed using Scandinavian Stroke Scale (SSS), NIH Stroke Scale (NIHSS), Barthel Index Scale (BI). Conclusion From this study, we can conclude that TMS is a technology that can be used to treat patients with postischaemic stroke motoric impairment and prevent further disability in the future. TMS intervention has been proven to be effective to improve patients’ clinical condition. We suggested for deeper investigation and analysis to be conducted on TMS regarding the treatment of other subtypes of stroke. We also see that there is a possibility of TMS to be used as solution for other motoric related disorder.
31
8 Reference Almaraz, C., Dilli, E., Dodick, D. (2010). The Effect of Prophylactic Medications on TMS for Migraine Aurahead. 1787 16301634. Adams,Harold P., Bendixen ,B. H. , Kappelle L. J., Biller J., Love B.B., Gordon,D.L., Marsh E.E. (1993). Classification of Subtype of Acute Ischemic Stroke. Definitions for Use in a Multicenter Clinical
Trial
Berger M., Pross RD., Ilg UJ, Karnath HO. (2006). Deviation of eyes and head in acute cerebral stroke. BioMed Central. Duncan P, Richards L, Wallace D, et al.(1998) A randomized, controlled pilot study of a homebased exercise pro¬gram for individuals with mild and moderate stroke. Stroke; 29: 20552060. Gresham, GE, Fitzpatrick, TE, Wolf PA. (1975) Residual capacity in survivors of stroke: the Framingham study. New England Journal of Medicine. 293:954956. Hatano, S. (1976). Experience from a multicentre stroke register: a preliminary report. Bulletin of the World Health Organisation. 54(5):541–553. Karyana, M., Siswanto, Yudiarto, F., Machfoed, M., Ong, A., Darwin, A. (2014). Indonesia Stroke Registry Neurology. 82(10). Khedr,EM., AbdelFadeil, MR., Farghali A., Qaid, M. (2010) Role of 1 and 3 Hz repetitive transcranial magnetic stimulation on motor function recovery after acute ischemic stroke. Acta Neurol Scand. 121(1):307. Konecny P., Elfmark M.,Urbanek K. (2011). Facial paresis after stroke and its impact on patients’ facial movement and mental status . Journal of Rehabilitation Medicine Kusuma, Y., Venketasubramanian, N., Kiemas, LS., Misbah, J. (2009). Burden of Stroke in Indonesia. Int J Stroke. 4(5):37980. doi: 10.1111/j.17474949.2009.00326.x. L. Hantson, W. De Weerdt, J. De Keyser, H. C. Diener, C. Franke, R. Palm, M. Van Orshoven, H. Schoonderwalt, N. De Klippel & K. Herroelen. (1994). The European Stroke Scale. Stroke. 25:22152219. Macko, RF, Ivey, FM, Forrester, LW, et al. (2005) Treadmill ex¬ercise rehabilitation improves ambulatory function and cardiovascular fitness in patients with chronic stroke: a randomized, controlled trial. Stroke ; 36:22062211. Nowak D., Grefkes C., Dafotakis M., Eickhoff S., Kust J., Karbe H., Fink G. (2008). Effects of low frequency repetitive transcraniam magnetic stimulation of the contralesional primary motor cortex on movement kinematics and neural activity in sub cortical.American Medical Association. Potempa K, Braun LT, Tinknell T, Popovich J. (1996). Ben¬efits of aerobic exercise after stroke. Sports Med. 21:337346.
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9 The European Stroke Scale
Overview : The European Stroke Scale can be used to assess a patient who has recently had a stroke involving the distribution of a middle cerebral artery. This can be used to measure therapeutic efficacy and to match patients for comparison.
Parameters: (1) level of consciousness (2) comprehension: The patient is asked to follow these commands: (a) stick out tongue, (b) put a finger from the (unaffected) side on the nose, (c) close the eyelids. The examiner must not demonstrate the action. (3) speech: The examiner makes general conversation with the patient. (4) visual field: The examiner stands at arm's length and compares the patient's field of vision by advancing a moving finger from the periphery inwards. The patient is asked to fixate on the examiner's pupil. The test is done first with one eye open and the other closed, then the opposite. (5) gaze: The examiner steadies the patient's head and asks the patient to follow the examiner's finger. The examiner observes the resting eye position and subsequently the full range of movements by moving the finger from the left to the right, then vice versa. (6) facial movement: The patient's face is examined while talking and smiling, with any asymmetries noted. Only the muscles in the lower half of the face are assessed. (7) arm in outstretched position: The patient is asked to close the eyes. The patient's arms are actively lifted into a 45째 position relative to the horizontal plane, with both hands in mid position facing each other. The patient is asked to maintain this position for 5 seconds after the examiner withdraws support. Only the affected side is evaluated. (8) arm raising: The patient's arm is rested next to the leg with the hand in mid-position. The patient is asked to raise the arm outstretched to 90째 (vertical). (9) extension of wrist: The patient is tested with the forearm supported. The hand is unsupported but relaxed in pronation. The patient is asked to extend the hand. (10)fingers: The patient is asked to form a pinch grip with the thumb and forefinger and to resist a weak pull. The examiner assesses the strength of the pinch grip by pulling on the pinched fingers using one finger. (11)leg maintained in position: The examiner actively lifts the patient's affected leg into position, with the thigh perpendicular to the bed and the lower leg parallel to the bed. The patient is asked to close the eyes and to maintain the leg in position for 5 seconds without support. (12) leg flexing: The patient is supine with the leg outstretched. The patient is asked to flex the hip and knee. (13) dorsiflexion of foot: The patient's leg is outstretched, with the patient asked to dorsiflex the foot. (14) Gait Parameter level of consciousness
Finding alert, keenly responsive drowsy but can be aroused by minor stimulation to obey, answer or respond requires repeated stimulation to attend, or is lethargic or obtunded, requiring strong or painful
Points 10 8 6
33
10
comprehension
speech
visual field gaze
facial movement
arm (ability to maintain outstretched position)
stimulation to make movements cannot be roused by any stimulation, does react purposefully to painful stimuli cannot be roused by any stimulation, does react with decerebration to painful stimuli cannot be roused by any stimulation, does not react to painful stimuli patient performs 3 commands patient performs 1 or 2 commands patient does not perform any command normal speech slight word-finding difficulty, conversation is possible severe word-finding difficulties, conversation is difficult only yes or no mute normal deficit normal median eye position, deviation to one side impossible lateral eye position, return to midline possible lateral eye position, return to midline impossible normal paresis paralysis arm maintains position for 5 seconds arm maintains position for 5 seconds but affected hand pronates arm drifts before 5 seconds pass and maintains
arm (raising)
extension of the wrist
fingers
leg (maintain position)
leg (flexing)
lower position arm can't maintain position but attempts to oppose gravity arm falls normal straight arm, movement not full flexed arm trace movements no movement normal (full isolated movement, no decrease in strength) full isolated movement, reduced strength movement not isolated and/or full trace movements no movement equal strength reduced strength on affected side pinch grip impossible on affected side leg maintains position for 5 seconds leg drifts to intermediate position by the end of 5 seconds leg drifts to bed within 5 seconds but not immediately leg falls to bed immediately normal movement against resistance, reduced strength movement against gravity trace movements
4 2 0 8 4 0 8 6 4 2 0 8 0 8 4 2 0 8 4 0 4 3 2
1 0 4 3 2 1 0 8 6 4 2 0 8 4 0 4 2 1 0 4 3 2 1
34
dorsiflexion of foot
gait
no movement normal (leg outstretched, full movement, no decrease in strength) leg outstretched, full movement, reduced strength leg outstretched, movement not full or knee flexed or foot in supination trace movements no movement normal gait has abnormal aspect and/or distance limited and/or speed limited patient can walk with aid patient can walk with physical assistance of one or more persons patient cannot walk but can stand supported patient cannot walk nor stand
0 8 6 4 2 0 10 8 6 4 2 0
European stroke score = SUM(points for all 14 parameters) Interpretation: • minimum score: 0 • maximum score: 100 • A completely normal person would have a score of 100. • The maximally affected person has a score of 0. References: Hantson L, De Weerdt W, et al. The European Stroke Scale. Stroke. 1994; 25: 2215-2219.
35
36
THE 3D BIOPRINTING TISSUE ENGINEERING : REVOLUTIONARY SOLUTION FOR HEART TRANSPLANTATION ORGAN DONOR SHORTAGE BY USING HUMAN INDUCED PLURIPOTENS STEM CELLS (iPSCs) AS RECELLULERIZATION MATERIAL ON PIG HEART Khrisna Rangga P 1, Deddy Dwi S, Isma Dewi M, Hasna Okta A AMSA Brawijaya University
Background/Introduction: Heart transplant is the only definitive treatment for end-stage heart disease in the last 50 years. Despite the advances development in transplant technology, the main obstacle for heart transplantations is the availability of donor organ. With more than 100,000 hearts has been transplanted in the last decade, it still ranked 1 in donor shortage compared with other donor organ. There is an emerge development in 3D biopriting tissue enginering that will allow us to construct whole heart to end the heart donor sortage. The most robust and efficient way to construct 3D object is by utilizing decellulerization and recellulerization technique. Research Purpose: To develope the idea of using human induced pluripotent stem cells (ICPs) as recellularization material on pig heart scaffold. Methods: Method in this study is conducted by the method of literature review based on issues, both through up to date digital and non-digital information such as journals and medical books by using two approaches, exposition methods and analytic methods. Findings, Discussion and Conclusion: The best way to construct 3D organ is by using decellularization and recellularization technique. The major obstacle untill this day is the availibilty of native human heart as organ scaffold through decellularization. Fortunately, decellularized pig heart shown no differences from native human heart to become organ scaffold. Human ICPs is the best material for recellularization on pig heart scaffold because its renewable and free of prolonged pharmaceutical treatment. The recellularized heart scaffold exhibited myocardium and vessel-like structures, contracted spontaneously with a rate of 40â&#x20AC;&#x201C;50 beats per min, exhibited intracellular Ca2Ăž transients (CaiT) and responded as
expected to various drug interventions. In addition, we found that heart extracellular matrix (ECM) could promote proliferation, specific cell differentiation and myofilament formation of cardiomyocytes (CMs) from the repopulated human cardiovascular progenitors (MCPs). Scope Of Research and Areas for Future Research: Therefore, this study established a novel strategy in biomolecular medicine and tissue enginering of human heart, which could be beneficial to study heart development, and future preclinical and clinical applications.
Keywords: 3D Bioprinting, Heart transplantation, Decellularization and Recellularization, Human Induced Pluripotent Stem Cells, Scaffold
Contact Person : Khrisna Rangga P Phone : +628970331167
THE 3D BIOPRINTING TISSUE ENGINEERING : REVOLUTIONARY SOLUTION FOR HEART TRANSPLANTATION ORGAN DONOR SHORTAGE BY USING HUMAN INDUCED PLURIPOTENS STEM CELLS (iPSCs) AS RECELLULERIZATION MATERIAL ON PIG HEART by: Khrisna Rangga Permana
batch 2010
Deddy Dwi Septian
batch 2010
Isma Dewi Masithah
batch 2012
Hasna Okta Asyrofi
batch 2014
This paper is under guidance: Prof. Dr. dr. M. Rasjad Indra, MS
FACULTY OF MEDICINE BRAWIJAYA UNIVERSITY AMSA BRAWIJAYA MALANG 2015
INTRODUCTION Three-dimensional (3D) bioprinting is a revolutionary tissue engineering method in which objects are made by fusing or depositing materials such as non-organic materials or even living cells in layers to produce a 3D object (Schubert, 2014). Medical applications for 3D printing are expanding rapidly and are expected to revolutionize healthcare. Medical uses for 3D printing, both actual and potential, can be organized into several broad categories, including tissue and organ fabrication, creation of customized prosthetics and anatomical models, pharmaceutical research regarding drug dosage forms, and organ transplantation. The application of 3D printing in medicine can provide many benefits including the customization and personalization of medical drugs and equipment, time and cost-effectiveness and increased productivity for mass production. The potential of 3D printing in medicine is limitless and yet still unexplorable (Mertz et al., 2013). Organ shortage is the greatest challenge facing the field of organ transplantation today and it becomes an ever-present obstacle for transplant medicine. Heart transplantation is the highest shortage compared to waiting list among the donor organs. More than 100,000 hearts were transplanted for last decades and its number raises for last 5 consecutive years. While the number of organs is in shortage, the cost of a transplanted organ is also high. The cost for organ transplants ranges anywhere from 250,000 dollars to over 1 million dollars (Stehlik et al., 2012). Another reason for extreme costs is contributed to the amount of time and care that must go into the transplant organ. While the cost is high, healthcare and government cover much of these costs, which make it to be a huge national financial burden. Moreover, 3D bioprinting tissue enginering of whole functional organs is seen as the main hope to resolve these issues that will be a major advancement in the field over the next generation. The potential benefits of bio-printing organs are vast; the demand for transplant organs significantly outweighs the number of available organs. By increasing the number of available organs, this demand could be met. Additionally, a patientâ&#x20AC;&#x2122;s body can reject donated organs. 3D printed organs can be based on a patientâ&#x20AC;&#x2122;s own cells, which can be cultured and could potentially reduce the risk of rejection during transplantation. This would not only improve patient outcomes, but also reduce the financial burden on healthcare and government' services providing care (Mertz et al., 2013).
1
The major obstacle for heart engineering requires a resource of heart cells, such as CMs (cardiomyocytes), SMCs (smooth muscle cells), Ecs (endothelial cells ), CFs (cardiac fibroblasts) and a 3D heart scaffold that allows the seeded cells to attach, assemble, synchronize, and form 3D structures. Currently, a variety of synthetic matrices and natural-derived biomatrices have been developed and widely utilized for tissue engineering (Jakab et al., 2015). However, such matrices normally have a uniform composition and are lack of 3D architecture as well as microniches in the native heart. This issue has prevented 3D bioprinting technology to move any further (Lin, 2012). Recently, decellularization and recellularization of whole organs, such as lung, liver, kidney and heart, has been utilized to obtain intact organ specific scaffolds for potential whole-organ regeneration. For more than a decade, research has shown that pig is the most feasible for animal organ donor (Lin et al., 2014). Their heart bear all the crucial component of the extracelluler matrix, but unlikely to carry human disease and also itâ&#x20AC;&#x2122;s rarely weakened by illness or resuscitation efforts. Many researches says that pig heart is also much likely to human heart anatomically and physiologically (Rodriguez et al., 2013). Therefore we have an idea to construct heart through decellularization and recellularization methods using pig heart to end heart donor shortage. As a consequence, 3D bioprinting tissue engineering and decellularization and recellularization methods using pig heart have potential to become subtite as transplantation organ donor and a revolutionary breakthrough to end heart transplantation organ donor shortage. But, there is still no further research or literature review of the 3D bioprinting tissue engineering by using decellularization and recellularization methods using pig heart to end heart transplantation organ donor shortage. So, in this paper, we will discuss about that with the hope of this paper will be the basis for further knowledge and experimental research and facilitating health care in the future through technology advancement.
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RESEARCH METHODOLOGY This scientific paper is based on literature review through biomolecular medicine and tissue enginering that describe how pig heart for decellulerization and recellulerization will be a subtite for human heart in heart transplant process without causing any side effect or immune rejection. Data collection methods in this study conducted by the method of literature (literature review) based on issues, both through digital and non-digital information from literature such as journals and medical books. The method of data analysis literature conducted through two approaches, namely: 1. Method of exposition, that the presented data and facts that may ultimately sought correlations between these data. 2. Analytic methods, namely through the analysis of data or information by giving the argument through logical thinking and were then taken to a conclusion
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RESULTS AND DISCUSSION 3D Bioprinting Tissue Engineering Era in Medicine Technology Three-dimensional (3D) bioprinting is a revolutionary tissue engineering method in which objects are made by fusing or depositing materials such as non-organic materials or even living cells in layers to produce a 3D object. The ability to design and fabricate complex, 3D biomedical devices is critical in tissue engineering. Applications for 3D biomedical devices are restoration of 3D anatomic defects, the reconstruction of complex organs with intricate 3D microarchitecture (e.g. liver, lymphoid organs), and scaffolds for stem cell differentiation (Badylak et al., 2011). An example of a need is anatomic defects in the bone and soft tissue organs complex caused by cancer, trauma, and congenital defects. Proper restoration of these defects requires functional nerves, vessels, muscles, ligaments, cartilage, bone, lymph nodes and glands (Almond et al., 2012). In recent years, various approaches based on tissue engineering principles have been explored to regenerate other functional tissues that are relevant to organ tissue regeneration. In tissue engineering, scaffolds are critical to provide structure for cell infiltration and proliferation, space for extracellular matrix generation and remodeling, biochemical cues to direct cell behavior, and physical connections for injured tissue. When making scaffolds, design of the architecture on the macro, micro, and nano level is important for structural, nutrient transport, and cell-matrix interaction conditions. Solid free form fabrication (SFF) has allowed for the design and fabrication of complex 3D structures which can be patient specific. The integration of computer aided design, advanced imaging techniques (i.e. magnetic resonance imaging and computer tomography), and rapid prototyping has advanced fabrication of objects with both macro and microarchitecture control (Crapo et al., 2011). Medical applications for 3D printing are expanding rapidly and are expected to revolutionize healthcare. Medical uses for 3D printing, both actual and potential, can be organized into several broad categories, including tissue and organ fabrication, creation of customized prosthetics and anatomical models, pharmaceutical research regarding drug dosage forms, and organ transplantation. The application of 3D printing in medicine can provide many benefits including the customization and personalization of medical drugs and equipment, time and cost-effectiveness and increased productivity for mass production. The potential of 3D printing in medicine is limitless and yet still unexplorable (Almond et al., 2012).
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Heart Transplantation Shortage More than 50 years, heart transplantation has been established as definitive treatment for end-stage heart disease. Survival of donor recipient has improved, with current reports stating a 5- year survival of more than 80%. In general, the indication for a heart transplant include patients who have deteriorating cardiac function and a prognosis of 1 year to live. Unfortunately, despite the advances development in technology, the main obstacle for heart transplantations is the availability of donor organ. To adress this problem, in 1999, the United Network for Organ Sharing (UNOS) implemented a major change in the way donor heart were allocated by assigning higher priority to sicker status 1 patients who were less likely to survive a prolonged wait period (Stehlik et al., 2012). More than 100,000 hearts has been transplanted over the last decades, heart transplantation still ranked 1st in donor shortage compared to waiting list among other donor organ. Therefore heart donor shortage is the greatest challenge facing the field of heart transplantation (Mulloy et al., 2013). Not only facing organ shortage, heart transplantation also have another obstacle with financial limitation. With the total cost ranging from $250,000 to over $ 1 million, thereâ&#x20AC;&#x2122;s also limitation for the recipient with financial issue. Huge amount of money that must be spent for heart transplant mostly caused by time and care that goes to transplant organ. The only way a patient from a low-income familly will get heart transplant is by using national health insurance, which will cause a huge national burden for the government (Mulloy et al., 2013). Pig Heart Comparison with Human Heart Over the last decades, the pig has been chosen as a feasible animal organ donor for the human species, namely regarding heart transplantation. This has led to the development of transgenic pigs with the goal of avoiding the rejection caused by transplantation. As an alternative to primates, other animal species have been considered with the goal of obtaining organs for xenotransplantation. Among these, the pig seems to be the organ donor of choice for our species, because it is easy to breed, it has large litters, and is easily maintained in aseptic conditions. In addition, several studies have shown that the pig can be genetically modified, and also that the risk of porcine zoonoses affecting humans is much lower than in the case of primates. Another advantage is that the size of the organs of the pig corresponds to those of human adults. The acquisition of hemodynamic parameters is fundamental in cardiovascular research (Rodriguez, 2013).
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Swine show high resemblance to humans in regard to their hemodynamic parameters. However, direct interspecies and intraspecies comparisons should be made prudently. The same pattern of increased innervation is also present in the Purkinje fiber network. The Purkinje system of swine is characterized by fast electrical coupling. Purkinje fibers are connected to the ventricular myocardium at Purkinjeâ&#x20AC;&#x201C; ventricular junctions. In humans, dogs, and rabbits, these junctions have been identified only subendocardially, whereas they usually lie transmurally in sheep and pigs. At the microscopic level, the swine conduction system appears to possess more connective than elastic tissue, compared with that in humans (Maher, 2013). The porcine heart responds similarly to the human heart after infraction and presents arrhythmogenity with reperfusion, contrary to the canine heart with its multiple preexisting collateral anastomoses. For human cases where the infraction has developed gradually, allowing time for the formation of collateral circulation, dogs might serve as an appropriate animal model. Swine could mimic such a situation after gradual occlusion of a coronary artery by using balloon angioplasty and the administration of an atherogenic diet. When compared with sheep, swine resemble humans more closely regarding the healing characteristics of the myocardium, given that in ruminants, healing is characterized by the formation of collagenous scars. Therefore, pig heart assembles much similarities compared to another species with human heart and it has potential to be used as basic research especially for tissue replacement for organ transplantation (Ng, 2011). Decellularization and Recellularization to Construct a Whole-Heart The most robust and effective decellularization protocols include a combination of physical, chemical, and enzymatic approaches. Decellularized tissues and organs have been successfully used in a variety of tissue engineering/regenerative medicine applications, and the decellularization methods used vary as widely as the tissues and organs of interest. The efficiency of cell removal from a tissue is dependent on the origin of the tissue and the specific physical, chemical, and enzymatic methods that are used. Each of these treatments affect the biochemical composition, tissue ultrastructure, and mechanical behavior of the remaining extracellular matrix (ECM) scaffold, which in turn, affect the host response to the material. Herein, the most commonly used decellularization methods are described, and consideration give to the effects of these methods upon the biologic scaffold material (Ott et al., 2008).
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A decellularization protocol generally begins with lysis of the cell membrane using physical treatments or ionic solutions, followed by separation of cellular components from the ECM using enzymatic treatments, solubilization of cytoplasmic and nuclear cellular components using detergents, and finally removal of cellular debris from the tissue. These steps can be coupled with mechanical agitation to increase their effectiveness. Following decellularization, all residual chemicals must be removed to avoid an adverse host tissue response to the chemical. The mechanisms of physical, enzymatic, and chemical decellularization for a whole organ are reviewed in Table 1. The latest breakthrough for human heart construction is using induced pluripotent stem cells (iPSCs) for recellulerization (Maher, 2013). Compared with CMs directly isolated from patients under heart transplantation with end-stage heart diseases, human iPSCderived CMs are renewable and free of prolonged pharmaceutical treatment. Thus, human iPSCs and the decellularized whole-heart ECMs (DC-ECMs) theoretically provide a novel platform for making personalized heart tissues. A previous study reported the repopulation of decellularized hearts using human undifferentiated embryonic stem (ES) cells. However, contractility and electrical activity were not detected in those engineered heart tissues (Moralez, 2011). (Table 1. Mechanisms of physical, enzymatic, and chemical decellularization for a whole organ) (Figure 1. Post decellulerization pig heart) (Figure 2. Decellulerization of rat heart step by step) The newest report of engineered human heart by repopulating whole decellulerized mouse heart with human iPS cell-derived multipotential cardiovascular progenitors (MCPs). The seeded MCPs differentiated in situ into CMs, smooth muscle cells (SMCs) and endothelial cells (ECs) with high efficiency, which reconstructed the decellularized mouse hearts. The recellularized DC-ECMs (RC-DC-ECMs) exhibited myocardium and vessel-like structures, contracted spontaneously with a rate of 40â&#x20AC;&#x201C;50 beats per min, exhibited intracellular Ca2Ăž transients (CaiT) and responded as expected to various drug interventions. In addition, we found that heart ECM could promote proliferation, specific cell differentiation and myofilament formation of CMs from the repopulated human MCPs. Therefore, this study established a novel strategy of human heart tissue engineering, which could be beneficial to study heart development, and future preclinical applications (Vacanti, 2012).
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(Figure 3. Recellulerization process using human iPS-cell derived derived multipotential cardiovascular progenitors (MCPs)) 3D Bioprinting Tissue Enginering to Tackle Organ Donor Shortage In the last 25 years, tissue enginering and regenerative medicine have captured a large attention from the public and stimulated imagination of physicians, scientists and enginers to push the frontier of this field. The emergence of stem cell science was heralded by the description of embrynoic stem cells first in mice and then in humans. Coupled with the clonal creation of â&#x20AC;&#x153;Dollyâ&#x20AC;? the sheep it underscored a new understanding of the developmental biology and wound repair that could be applied to creating tissue and organs. Regenerative medicine utilizing tissue manufacturing has been a creative topic of study, offering promise for resolving the gap between insufficient organ supply and transplantation needs (Wikiel et al., 2014). Development of clinically functional bio-printed organs that can be transplanted and then physiologically integrate with the recipient patient requires advancements in three related technologies. First we need better understanding of cell biology and development of biotechnology to secure adequate populations of clinically functional cells. Then advancements in bio-printing processes are needed that allow creation of 3D conformations of cells and biomaterials that more closely mimic the natural organ function. Finally we need to be able to integrate the bio-synthesized organ to function and perform in vivo, i.e., in the patient (Moreno et al., 2012). As we look toward the future, the prospect of using a patientâ&#x20AC;&#x2122;s own cells to develop living models of their active biochemistry as well as functional, life-lasting cellular implants offers potentially revolutionary changes to research and healthcare. Stem cell biologists are uncovering exciting new ways to induce pluripotency (Yang et al., 2014). The major obstacle for heart engineering requires a resource of heart cells, such as CMs (cardiomyocytes), SMCs (smooth muscle cells), ECs (endothelial cells), CFs (cardiac fibroblasts) and a 3D heart scaffold that allows the seeded cells to attach, assemble, synchronize, and form 3D structures. Currently, a variety of synthetic matrices and natural-derived biomatrices have been developed and widely utilized for tissue engineering. However, such matrices normally have a uniform composition and are lack of 3D architecture as well as microniches in the native heart. This issue has prevented 3D bioprinting technology to move any further (Lund et al., 2013).
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Decellularization and Recellularization Technique Tissue enginering holds a great potential to end the heart donor crisis. There is one potential method which currently developed is decellurization and recellulerization of whole-organ. Decellulerization is a protocol to efficiently remove all cellular and nuclear material while minimizing any adverse effect on the composition, biological activity, and mechanical integrity of the remaining ECM in the simple words decellulerization is any processing step intended to remove cells will alter the native three-dimensional architecture of the ECM. Component of ECM are generally conserved among species and are tolerated well even by xenogonic recipient (Long et al., 2014). Biologic scaffolds derived from decellularized tissues and organs have been successfully used in both pre-clinical animal studies and in human clinical applications. Removal of cells from a tissue or an organ leaves the complex mixture of structural and functional proteins that constitute the extracellular matrix (ECM). The tissues from which the ECM is harvested, the species of origin, the decellularization methods and the methods of terminal sterilization for these biologic scaffolds vary widely. Each of these variables affects the composition and ultrastructure of the ECM and accordingly, affects the host tissue response to the ECM scaffold following implantation (Clarke et al., 2014). The objective of this manuscript is to provide an overview of the various methods that have been used to decellularize tissues, and the potential effects of the various decellularization protocols on the biochemical composition, ultrastructure, and mechanical behavior of the ECM scaffold materials. The growing list of biologic scaffolds used for tissue engineering and regenerative medicine applications makes the continued development of decellularization protocols a clinically relevant and important effort. 3D
Bioprinting
Tissue
Engineering
combined
with
Decellularization
and
Recellularization to Construct a Whole-Heart The most usable technique in tissue enginering that being used to construct whole-organ is decellularization and recellularization. The easiest way to explain this technique is like refilling our own water bottle when itâ&#x20AC;&#x2122;s empty. When the water bottle is empty is like our end-stage heart disease thereâ&#x20AC;&#x2122;s something wrong inside it, but the bottle is still fine like our heart scaffold, all we need to do is refill it with healty stem cell using recellularization tecnique to obtain a health whole-heart organ (Mertz et al., 2013).
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Naturally occurring extracellular matrix (ECM) has been shown to promote constructive remodelling as opposed to scar tissue formation in a variety of body systems, including but not limited to the lower urinary tract, esophagus, myocardium, arteries and veins, tendons and ligaments. Most studies have used ECM that was not chemically crosslinked or otherwise altered by processing and that was isolated from porcine small intestinal submucosa or urinary bladder matrix (UBM). The single or multilayered sheet forms of these materials have practical limitations with regard to their shape, threedimensional form, and clinical utility. A particulate form of ECM is of interest for injection into tissues and for the development of 3D scaffolds (Clarke et al., 2014). When we get whole heart with end-stage disease we need to remove all cellular and nuclear material while minimizing any adverse effect on the composition, biological activity, and mechanical integrity of the remaining ECM by using decellulerization technique (Song et al., 2012). The most robust and effective decellularization protocols include a combination of physical, chemical, and enzymatic approaches. A decellularization protocol generally begins with lysis of the cell membrane using physical treatments or ionic solutions, followed by separation of cellular components from the ECM using enzymatic treatments, solubilization of cytoplasmic and nuclear cellular components using detergents, and finally removal of cellular debris from the tissue. These steps can be coupled with mechanical agitation to increase their effectiveness. Following decellularization, all residual chemicals must be removed to avoid an adverse host tissue response to the chemical (Gilbert et al., 2013). After we get a heart scaffold contain ECM from decellularization technique, all we need to do is fill it with stem cells that will grow and fill the scaffold. The latest breakthrough for human heart construction is using induced pluripotent stem cells (iPSCs) for recellulerization. Compared with CMs directly isolated from patients under heart transplantation with end-stage heart diseases, human iPSC-derived CMs are renewable and free of prolonged pharmaceutical treatment. Thus, human iPSCs and the decellularized whole-heart ECMs (DC-ECMs) theoretically provide a novel platform for making personalized heart tissues. A previous study reported the repopulation of decellularized hearts using human undifferentiated embryonic stem (ES) cells. However, contractility and electrical activity were not detected in those engineered heart tissues (Guethoff et al., 2013). The newest report of engineered human heart by repopulating whole decellulerized mouse heart with human iPS cell-derived multipotential cardiovascular progenitors (MCPs) (Heidenrich et al.,2013).
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The seeded MCPs differentiated in situ into cardiomyocytes (CMs), smooth muscle cells (SMCs) and endothelial cells (ECs) with high efficiency, which reconstructed the decellularized mouse hearts (Ramlinger et al., 2012). The recellularized DC-ECMs (RCDC-ECMs) exhibited myocardium and vessel-like structures, contracted spontaneously with a rate of 40â&#x20AC;&#x201C;50 beats per min, exhibited intracellular Ca2Ăž transients (CaiT) and responded as expected to various drug interventions. In addition, we found that heart ECM could promote proliferation, specific cell differentiation and myofilament formation of CMs from the repopulated human MCPs (Lu et al., 2013). Therefore, this study established a novel strategy of human heart tissue engineering, which could be beneficial to study heart development, and future preclinical applications. But, there is still no further experimental research to prove this theory clinically. We therefore also propose that repurposing to develope the idea of using human induced pluripotent stem cells (ICPs) as recellularization material on pig heart scaffold. We hope it emerges development in 3D biopriting tissue enginering that will allow us to construct whole heart to end the heart donor sortage.
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CONCLUSION 1. Three-dimensional (3D) bioprinting is a revolutionary tissue engineering method in which objects are made by fusing or depositing materials such as non-organic materials or even living cells in layers to produce a 3D object. Medical applications for 3D printing are expanding rapidly and are expected to revolutionize healthcare. Moreover, 3D bioprinting tissue enginering of whole functional organs is seen as the main hope to resolve donor organ issues. 2. The best way to construct 3D organ is by using decellularization and recellularization technique. The major obstacle untill this day is the availibilty of native human heart as organ scaffold through decellularization. Fortunately, decellularized pig heart shown no differences from native human heart to become organ scaffold. Human ICPs is the best material for recellularization on pig heart scaffold because its renewable and free of prolonged pharmaceutical treatment. Moreover, 3D bioprinting tissue enginering of whole functional organs is seen as the main hope to resolve donor organ issues. ACKNOWLEDGMENT AND FUTURE RESEARCH RECOMMENDATION We thank to Prof. Dr. dr. M. Rasjad Indra, MS for his guidance to finish this paper into a great literature review. Therefore, this study established a novel strategy in biomolecular medicine and tissue enginering of human heart, which could be beneficial to study heart development, and future preclinical and clinical applications. We hope this paper will be the basis for further knowledge and experimental research and facilitating health care in the future through technology advancement.
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APPENDIX Table 1 Commonly used decellularization methods and chaotropic agents Method
Mode of action
Effects on ECM
Physical Snap Freezing Mechanical force Mechanical agitation
Intracellular ice crystals disrupt
ECM can be disrupted or fractured
cell membrane
during rapid freezing
Pressure can burst cells and tissue
Mechanical force can cause damage to
removal eliminates cells
ECM
Can cause cell lysis, but more
Aggressive agitation or sonication can
commonly used to facilitate
disrupt ECM as the cellular material is
chemical exposure and
removed
cellular material removal Chemical Alkaline; acid
Solubilizes cytoplasmic
Removes GAGs (glycosaminoglycans)
components of cells; disrupts nucleic acids Non-ionic detergents
Disrupts lipid–lipid and lipid–
Mixed results; efficiency dependent on
Triton X-100
protein interactions, while leaving
tissue, removes GAGs
protein–protein interactions intact Ionic detergents
Solubilize cytoplasmic and
Removes nuclear remnants and
Sodium dodecyl
nuclear cellular membranes; tend
cytoplasmic proteins; tends to disrupt
sulfate (SDS)
to denature
native tissue structure, remove GAGs
proteins
and damage collagen.
Sodium deoxycholate More disruptive to tissue structure than SDS Triton X-200 Yielded efficient cell removal when used with zwitterionic detergents Zwitterionic detergents CHAPS
Exhibit properties of non-ionic
Efficient cell removal with ECM
and ionic
disruption similar to that of Triton X-
17
Detergents
100
Organic solvent that disrupts
Yielded cell removal and mild ECM
proteinâ&#x20AC;&#x201C;protein interactions
disruptionwith Triton X-200
Sulfobetaine-10 and 16 (SB-10,SB-16) Tri(n-butyl)phosphate Variable cell removal; loss of collagen Cell lysis by osmotic shock
content, although effect on mechanical properties was Minimal
Hypotonic and hypertonic solutions
Chelating agents that bind
Efficient for cell lysis, but does not
divalent metallic ions, thereby
effectively remove the cellular remnants
disrupting cell adhesion to ECM EDTA, EGTA
No isolated exposure, typically used with enzymatic methods (e.g., trypsin)
Enzymatic Trypsin
Cleaves peptide bonds on the C-
Prolonged exposure can disrupt ECM
side of
structure,
Arg and Lys
removes laminin, fibronectin, elastin, and GAGs
Endonucleases
Catalyze the hydrolysis of the
Difficult to remove from the tissue and
interior
could
bonds of ribonucleotide and
invoke an immune response
deoxyribonucleotide chains Exonucleases
Catalyze the hydrolysis of the terminal bonds of ribonucleotide and deoxyribonucleotide chains
18
Figure 1. Post- decellulerization pig heart
Figure 2. Each step of decellularization process: before decellularization (1); after deionized water perfusion (2); after PBS perfusion (3); after enzymatic perfusion (4); after 1% SDS solution perfusion (5); after 3% Triton X-100 solution perfusion (6); after acidic perfusion (7); perfusion of DC-ECMs with trypan blue solution to visualize the intact coronary vasculature (8).
19
Figure 3. A scheme showing the working strategy to recellularize the decellularized mouse hearts with human iPSC-derived MCPs. Human iPSC-derived EBs were differentiated until day 6 and then dissociated into single cells (Stage 1). Dissociated cells (10 million) were seeded into a decellularized mouse heart and perfused (Stage 2). The seeded MCPs in situ differentiated into cardiac lineage cells and reconstructed DC-ECMs.
20
The application of 3D printing technology and stem cell culture for organ and disease modelling Edwin Ti Ramadan, Muhammad Akbar, Lawrence James Giovanni Limesa Faculty of Medicine, Universitas Indonesia
Abstract The need to do clinical trials and drug testing has been an issue since the beginning of the medical era. There are various approaches such as using other organisms and then humans. Unlike what is expected, this method is only 37% useful according to McGill university. Thus, in this technology era, a model of organ which represents real life condition is wished to be able to fulfil a better representation and to produce more meaningful results. One of the methods which can facilitate this development is by printing wanted model three dimensionally. This systematic review is made through literature searches, synthesis, and conclusion. From this review, we can see that printing organs three dimensionally by using stem cells for organ modelling opens new doors for many improvements in medical and research fields. Keywords: 3D organ printing, Stem cells, Disease modelling Authors: Edwin Ti Ramadan, Faculty of Medicine, Universitas Indonesia +628129013121 edwin.ti@hotmail.com Muhammad Akbar, Faculty of Medicine, Universitas Indonesia +6285319476817 akbar.muhammad1710@gmail.com Lawrence James Giovanni Limesa, Faculty of Medicine, Universitas Indonesia +6281322255596 magical_lawrence@hotmail.com
The Application of 3D Printing Technology and Stem Cell Culture for Organ and Disease Modelling
Edwin Ti Ramadan, Muhammad Akbar, Lawrence James Giovanni Limesa Faculty of Medicine Universitas Indonesia PCC EAMSC 2016
I.
Introduction In this modern age, various innovations and drugs have been tried and used to
treat various diseases inflicting humans. However, data collected from clinical trials in the United States of America by McGill University stated that out of 177 stage III clinical trials performed in the United States, only 37% were successful despite the fact that a total of 20.135 subjects were used. These data suggest that a significant number of research efforts ended with meaningless results due to limitations from said experiments and clinical trials. (The Globe and Mail, 2015) One of various new methods currently being incorporated in biomedical research is in vitro disease modelling, which is a development from stem cell techniques. However, the current method still has a lot of limitations as in vitro studies do not wholly represent mechanisms in which diseases develop. This causes lack of data about the pharmacokinetics and pharmacodynamics of drugs being tested for said disease. (Unternaehrer and Daley, 2011) One latest innovation in in vitro disease modelling is 3D organ printing. It is a technology which incorporates biocompatible material, stem cells, and other supporting materials to replicate organs in three dimensional forms. This technology has already been applied in regenerative medicine such as organ transplantation as the resulting printed organ has similar anatomical and physiological properties as a real organ. (Murphy and Atala, 2014) Therefore, the authors of this paper made a literature review by combining theories of disease modelling. This review aims to propose to researchers the idea of applying 3D organ printing technology to aid in increasing effectiveness in drug research and treatment. II.
Methodology The review is done by gathering data from various literary sources, both
printed (medical journal articles and medical textbooks) and electronic (websites and online journal articles). Some of the key words used in searching for literature are “3D organ printing”, “Stem cells”, and “Disease modelling”. The various literature used in this review are cited from sources that are trusted and have their validity tested. After data from literature are gathered, read, and studied comprehensively,
they are processed by arranging them in a systematic manner. Data analysis is done by descriptive argumentative analysis to observe the possibility of 3D organ printing for disease modeling as a new drug-testing technique. After data analysis, the authors then underwent a synthesis by relating the research problem, aim, and discussion. Finally, a conclusion is made with suggestions as a form of statement. III.
Results
Stem Cell Stem cells are cells that have outstanding potential to develop into other types of cells with much more specific functions. They are present in a wide variety of tissues, may it be during early life or growth, and naturally serves to repair tissues. Generally, stem cells have two properties that distinguish them from other cells: renewal and differentiation. Initially undifferentiated cells, stem cells can renew themselves through cell division when they are inactive after a long time. When active, these cells can differentiate to other specific cells, forming new tissue, under certain physiological conditions. (National Institutes of Health, U.S. Department of Health and Human Services, 2015) Overall, stem cells differentiate into other cells by means of epigenetic mechanisms. Stem cells have varying degrees of differentiation potential and thus are classified based on these degrees. Cells which can differentiate to all embryonic and extra-embryonic cells are said to be totipotent, while those that differentiate to only embryonic cells are said to be pluripotent. Some cells may differentiate into multiple types of cells but will not differentiate into cells with no relation to its tissue of origin; these are said to be multipotent cells. Examples of these type of cells are hematopoetic stem cells and mesenchymal stem cells. There are also stem cells which only differentiate into only a specific type of cell, such as the spermatogonium stem cell; these are unipotent cells. (De Los Angeles, Ferrari, Xi, Fujiwara, Benvenisty, Deng and Daley, 2015) Out of these stem cells, pluripotent and multipotent cells are the types of stem cells that are commonly used for research and treatment. Hematopoetic stem cells from the bone marrow are widely used for transplants for diseases such as leukemia, while mesenchymal stem cells have wide applications for replicating bone tissue, adipose tissue, cartilage, tendons, muscle, or even regenerating certain tissues such as
vascular tissues through cytokine secretion. Mesenchymal stem cells are usually found in a variety of adult tissue such as bone marrow, adipose tissue, or umbilical cords. Mesenchymal cells also has low risk of forming tumors compared to pluripotent cells and has a low risk of being rejected due to being capable of immune suppression. Despite that, mesenchymal cells from adult sources are rather difficult to extract and cultivate due to its very limited lifespan. (Jung, Bauer, and Norta, 2012) Pluripotent cells naturally can be found in the form of embryonic stem cells. Being pluripotent, it has very wide uses and can virtually replicate every type of adult tissue. However, these type of stem cells also have a high chance of forming tumors and cancer, and thus differentiating these cells in vitro will prove a challenge for scientists. Additionally, embryonic stem cells have a higher chance of rejection, though still quite low, when introduced to the body, being foreign material. (Jung, Bauer, and Norta, 2012) Embryonic stem cell usage has also become an ethical issue in
several
countries such as the United States and also is banned in European countries and Indonesia itself. (Jung, Bauer, and Norta, 2012; Lo and Parham, 2009; Nielen, de Vries, and Geijsen, 2013; Utomo, 2012) Scientists have succeeded in developing a new type of pluripotent stem cell. These cells are derived from adult somatic cells, commonly from fibroblasts, by encoding specific transcription factors to induce pluripotency. These stem cells are called induced pluripotent stem cell (iPSC). (De Los Angeles, Ferrari, Xi, Fujiwara, Benvenisty, Deng and Daley, 2015; Yamanaka, 2009) These cells remedy all ethical issues related to embryonic stem cells, other than in European countries due to a certain law existing. (Nielen, de Vries, and Geijsen, 2013) It also has a lower chance of rejection when introduced to the patient as usually the cells are extracted from the patient him or herself. However, technology to produce such cells is still relatively new. (Yamanaka, 2009) 3D organ Modelling 3D printing is a method by which a digital file is used to produce a three dimensional, graspable object. This process has been developed before the 21st century and continued developed since. The result of 3D printing is so sophisticated that it can show details in high resolution providing many advantages for many fields. Companies willing to produce highly detailed product can rely on this technology for their business. This technology can also be used in many other fields such as architecture, arts, medicine, etc.
Similar to a picture produced by a camera, 3D printed products have resolution. The resolution of the product indicates how detailed the result is. The higher the resolution, the more detailed the result. 3D printed objects so far can have a precision of less than 0.01 mm and 0.02 mm in horizontal and vertical direction, respectively (Markert, Weber, & Lueth, 2007). Producing an artificial organ is also another method by which patient with disease can be treated more accurately and efficiently. The structural changes on the organs which are the focus can be found with the resolution offered by 3D printing technology. Another function of the 3D printing is producing printed organs which helps surgeons in preparing the surgery beforehand. Similar method has actually been implemented and reduce the risk of failure in surgery since the preparation for the real surgery can be done in the form of a virtual surgery with virtual reality (Brian Gee Chacko, 2008). There are various things to consider when it comes to 3D printing such as the material, the printer, and the source from which the product will be printed. In choosing materials, there are three basic requirements which need to be fulfilled, which are service, fabrication, and economic requirements (Karana, Hekkert, & Kandachar, 2008). This means that the material must be suitable for the purpose of the product, it must be able to be shaped coherently, and cost-friendly. After choosing the suitable material, the printer takes care of the process. The types of 3D printing are Fused Deposition Modeling (FDM), Stereolithography (SLA), and Selective Laser Sintering (SLS) (“Domain Group 3D Printing Workshop Notes,” 2013). As for the source of the printing, it must be from a digital source. This source can be made or gained. It can be gained by using a 3D scanner but in case of medicine, the projection is gained from CT scans, MRI and x-rays (Ventola, 2014). As mentioned before (“Domain Group 3D Printing Workshop Notes,” 2013), there are several types of printer which prints differently. Although the final product may be similar from one to another but the process which the machines go through may vary. In FDM, which is one of the common technology used, the process is done by creating the bottom most layer first. After this layer is laid out, the next layer is laid on the first, after the first layer is dry -- ready to be laid on. This process goes on, third layer on the second, fourth on the third, and so on until the product is done. This process is also known as additive principle. The SLA works on similar method as the FDM by using additive process. In SLA process, a bath of the material has been
prepared. A laser is shot to the material and the material solidifies and then the platform on which the printed layer goes down as far as the thickness of a layer, normally 0.05 to 0.15 mm. Then the next layer of the material can be solidified. In this method a specific material needs to be used. One example of the material is a liquid curable photopolymer “resin”. Last method mentioned, the SLS also used the additive printing principle. In SLS, the laser used is highly powered such as carbon dioxide laser to fuse smaller particles of a material into a big lump of it. The method is similar to SLA but in SLS the basic material is in the form of powder-like substances instead of liquid form resin. Disease Modelling Disease Modelling is the treatment of stem cells to form tissue and organ which is inflicted with a specific disease by engineering their genetic structure so that the stem cells express the phenotype of the wanted disease, or taking a sample of tissue which has been inflicted by the disease and convert them to stem cell samples to obtain tissue with the disease. Disease modelling is used in research to observe the pharmacokinetic and pharmacodynamics effects of a drug towards a specific disease. The discovery of this technique has increased the effectiveness of pharmacological research. (Unternaehrer and Daley, 2011) Since the start of iPS cell production for the use of disease modelling, areas of research for disease modelling using iPS cells have been steadily expanding. Researchers observed that to increase the success of disease modelling, there needs to be a selection of iPS cells based on genetic or epigenetic factors, as well as the clinical manisfestations of the disease, the pathological characteristics of the disease and the patient’s tissue availability. Because the differentiation of iPS cells are used for disease modelling, derivates of iPS cells used for disease modelling can be used to observe cellular function and perform screening for diseases through various ways. This is aimed to study diseases more comprehensively and aid in deciding the most optimal medication for the patient. (Unternaehrer and Daley, 2011) The preparation of iPS cells for disease modelling from the patient’s tissue inflicted by the disease follows several steps. First, the inflicted cells of the patient are extracted and cultured in a medium containing Oct4, Soc2, Kif4 and c-Myc. Thus, iPS cells with the disease can be obtained from the resulting culture. In the situation
where the researcher wants to modify the cellâ&#x20AC;&#x2122;s condition genetically, the researcher can do so after these first few steps. After that, cell differentiation can be directed using specific mediums which determine which tissue will be produced depending on the medium. Then, the tissue that will be used for disease modelling is then obtained. The genetic structure of cells expressing the phenotype of a certain disease can be identified using Southern blot or sequencing to identify the genetic base sequence. Disease modelling can also be studied to identify specific biomarkers for certain diseases, and used for studying the progress and molecular mechanisms of diseases. For the interest of treatment, disease modelling can be used to test the potency of molecules such as proteins, chemicals, or microRNAs which potentially have therapeutic effects which then can be further verified in animal or human models. (Unternaehrer and Daley, 2011)
IV.
Discussion
Procedure To Make 3D Organ printing For Disease Modelling Disease Modelling with Stem Cell The preparation of stem cells used for disease modelling as a material for 3D organ printing needs several considerations. These considerations depend on the type of tissue inflicted by the disease. The following are techniques of stem cell preparation for several diseases with specific tissues. a. Model for neurological conditions and neurodegeneration Treatment of cells will vary according to the type of neurological condition. This is because the condition of each type of disease is different from one another. The following are examples of disease modelling in several neurological diseases. (Siller R, Greenhough S, Park I, J. Sullivan G,2013) A model has been made for amythropic lateral sclerosis (ALS) by reprogramming dermal fibroblasts. Differentiation of iPS cells to motor neurons can occur by using sonic hedgehog agonist and retinoic acid. A proportion of 20% iPS cells will become motor neurons with HB9 marker.
Then, the cells are then left to develop until it has the appropriate function and anatomy with the disease in the culture. (Siller R, Greenhough S, Park I, J. Sullivan G,2013) Spinal muscular atrophy (SMA) is caused by an autosomal recessive mutationin the survival motor neurone 1 (SMN1) gene. The decrease in SMN1 expression can cause lower motor neurone loss. By changing the structure of the SMN1 gene in iPS cells. Using this method, a cell with SMA can be obtained and thus be used as drug screening testâ&#x20AC;&#x2122;s object. (Siller R, Greenhough S, Park I, J. Sullivan G,2013) Another neurological disease, familial dysauronomia (FD), disease modelling could also be done by programming fibroblast of iPS cell. This disease is inherited through autosomal recessive pattern which is caused by defect in splicing the gene IKBKAP. This defect will cause disturbances in differentiation on the central nervous system (neural crest), peripheral neural system, hematopoietic cells, endothelial cells, and endodermal cells. The lowest ratio is found in endodermal cells, hematopoietic cells, and neural crest precursors. (Siller R, Greenhough S, Park I, J. Sullivan G,2013) b. Model for hematopoietic disease Hematopoietic condition shows a second class interesting disease for experts of disease modelling. Beta-thalassemia, a disease caused by synthesis defect of beta globin which results progressive anemia thus requiring blood transfusion and iron chelation therapy, can be made a disease model by programming fibroblast cells from fibroblast, amnion cells, or chorionic villi cells. Through observations iPS cells can be found differentiating into colony of hematopoietic cells and haemoglobinized erythroid. However, in vitro disease modelling shows a limited clinical manisfestations. (Peixoto D, Dingli D, Pacheco J.,2011) c. Model for cardiovascular conditions Cardiovascular disease ranks third on disease which can be disease modelled since it has protocols to guide the differentiation into cardiomyocytes. One example on cardiovascular disease which can be made disease model is Long QT syndrome type
I, a condition which causes cardiac arrhythmia, and can be controlled by drugs. The method to create this disease is by fibroblast cells of the skin which is a derivate of iPS cells which got missense mutation on KCNQ1 (190Q), components of potassium channel. Those cells are then differentiated into cardiomyocytes which are able to show ECG abnormalities which is the length of QT interval. This model can be used for studying the molecular effects from the disease and drug trials to keep the QT interval normal in patients with the disease. (Narsinh K, Narsinh K, Wu J.,2011)
d. Model for metabolic disorders Metabolic disease which came from the liver has been able to be disease modelled by reprogramming patientâ&#x20AC;&#x2122;s fibroblast followed with a directed differentiation using a chemical medium such as polyvinyl alcohol, activing A, FGF2, bone morphogenetic protein 4, and phosphoinositide 3-kinase (PI3K) inhibitor in order to obtain derivate such as endrodermal cells, followed with Activin-A and B27 for hepatic progenitor and hepatocyte growth factor (HGF)/Oncostatin-M for derivate with hepatocytes components. This process will produce hepatocytes which show glycogen storage and low density lipoprotein, albumin secretion, drug metabolism and glucagon response. (Maury Y, Gauthier M, Peschanski M, Martinat C.,2011) e. Model for other organs Several forms of lungs disease include emphysema (alfa-1 antitrypsin deficient), cystic fibrosis (homozygous delta F580 in FGTR) and scleroderma (unknown genetic component) have been able to be disease modelled from iPS cells through reprogramming of dermal fibroblast or liver fibroblast from patients using lentiviral vector with 4 factors. iPS cells is then differentiated into definitive endoderm (from lung and liver epithelial derivate) with culture containing BMP4, Activin A, and FGF2. (Snoeck H., 2014) 3D organ printing There are several steps in applying 3D organ printing which are as follow (Murphy S, Atala A., 2014) :
1. The first thing to do is imaging, done to get any information on 3 dimension of the targeted organ to be printed. This process can be obtained through X-ray, CT-Scan, and MRI. 2. Following the imaging process is the design approach. There are 3 methods which can be done: biomimicry, cell-assembly, and mini-tissue. Biomimicry is a process to produce a biocompatible material following the shape which is compatible with the printed organ. Cell-assembly is a technique which prints the shape of the organ following the embryonic process of the organ by controlling the substances used by cells for communication in embryonal stages. Last, mini-tissue is a technique which forms small tissues which are part of an organ and then combined to produce the organ. 3. Next, material selection. Some choice of materials used are synthetic polymer, natural polymer, and ECM. 4. Fourth, the preparation of bio-engineered stem cell and shaped by diseased modelling 5. Bioprinting comes next. There are 3 methods in bioprinting. First, thermal inkjet printer is heated by electricity to produce droplet. Second, microextrusion printer with the pneumatic pattern or mechanical pattern producing a continuous patter of the material and/or cell. Last, laser-assisted printers with focus on absorbing substrate to increase pressure to join the materials into substrate collector. 6. Last step is the maturation of the produced organ.
Functions Organ modelling provides many applications in treating diseases through several methods.
It can be used to provide a tissue-specific model to study them
further thus providing a better understanding on both how the diseased and normal function of a certain tissue. (Schmeichel & Bissell, 2003) Another medical use of such modelling is in the field of surgery. Physicians can train on such model to develop their skill of surgery; this reduces the risk of failure during the practice of the skill. The same modelling also provides a better imaging for the surgeons before performing any surgery which will increase the success rate of the surgery. (AlAli, Griffin, & Butler, 2015)
Advantages There are various advantages when 3D printing is used (Ventola, 2014) : -
3D printing provides possibility for a personalized medication
-
Medication is done more efficiently which means better cost-efficiency to some extent 3D printed objects can be manufactured at low cost even with traditional manufacturing methods in large-scale production. This is due to the cost of the first and last product stays the same. (Schubert, van Langeveld, & Donoso, 2013) This constant cost gives an advantage for companies with low volume of production
-
Time friendly. The process by which a printed product is produced takes several hours only, which is fast.(Mertz, 2013)
Disadvantages Although 3D printing is relatively fast, takes several hours (Mertz, 2013), it is still not fast enough to serve a helpful use to emergency cases since many cases require even a more rapid attention. Another weakness of this technology is the accessibility due to the price, should every patient pays an extra cost, this might burden the poor. (â&#x20AC;&#x153;3D printing raises ethical issues in medicine,â&#x20AC;? 2015). V.
Conclusion The application of 3D printing and stem cell for organ modelling will
bring various advances toward the field of medical research as well as clinical practice in studying diseases as well as pharmacokinetics more comprehensibly than current existing methods. However, this technique still has some limitations of its own. Despite that, this application of technology opens new chances to dig deeper toward the unexplored territory of medical research, and thus researchers should try to apply such technology in the future.
References: 3D printing raises ethical issues in medicine. (2015, February 11). [item]. Retrieved October 20, 2015, from http://www.abc.net.au/science/articles/2015/02/11/4161675.htm AlAli, A. B., Griffin, M. F., & Butler, P. E. (2015). Three-Dimensional Printing Surgical Applications. Eplasty, 15. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4539849 Brian Gee Chacko, H. S. (2008). Virtual Surgery on Geometric Model of Real Human Organ Data. Technorama. De Los Angeles, A., Ferrari, F., Xi, R., Fujiwara, Y., Benvenisty, N., Deng, H., Daley, G.Q. (2015). Hallmarks of pluripotency. Nature, 525(7570), 469–478. http://doi.org/10.1038/nature15515 Domain Group 3D Printing Workshop Notes. (2013). Ministry for Education and Employment. Retrieved from https://www.google.co.id/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad= rja&uact=8&ved=0CBwQFjAAahUKEwjEr825g8XIAhURjo4KHV6lDhg&url= https%3A%2F%2Feducation.gov.mt%2Fen%2Fresources%2FNews%2FDocume nts%2FYouth%2520Guarantee%2F3D%2520Printing.pdf&usg=AFQjCNG8eHg kgLy7TKjehUuU6zva2t4eFg&sig2=gopYUrbwcb3Fg8qu3clvpQ Jung, Y., Bauer, G., & Nolta, J. A. (2012). Concise Review: Induced Pluripotent Stem Cell-Derived Mesenchymal Stem Cells: Progress Toward Safe Clinical Products. STEM CELLS, 30(1), 42–47. http://doi.org/10.1002/stem.727 Karana, E., Hekkert, P., & Kandachar, P. (2008). Material considerations in product design: A survey on crucial material aspects used by product designers. Materials & Design, 29(6), 1081–1089. Lo, B., & Parham, L. (2009). Ethical Issues in Stem Cell Research. Endocrine Reviews, 30(3), 204–213. http://doi.org/10.1210/er.2008-0031 Maury, Y., Gauthier, M., Peschanski, M., & Martinat, C. (2012). Human pluripotent stem cells for disease modelling and drug screening. Bioessays, 34(1), 61–71. Mertz, L. (2013). Dream it, design it, print it in 3-D: what can 3-D printing do for you? IEEE Pulse, 4(6), 15–21. http://doi.org/10.1109/MPUL.2013.2279616 Murphy, S., & Atala, A. (2014). 3D bioprinting of tissues and organs. Nat Biotechnol, 32(8), 773–785.
Narsinh, K., Narsinh, K. H., & Wu, J. C. (2011). Derivation of human induced pluripotent stem cells for cardiovascular disease modeling. Circulation Research, 108(9), 1146– 1156. National Institutes of Health, U.S. Department of Health and Human Services. (2015). Stem Cell Basics: Introduction. Retrieved October 15, 2015, from http://stemcells.nih.gov/info/basics/pages/basics1.aspx Nielen, M. G., de Vries, S. A., & Geijsen, N. (2013). European stem cell research in legal shackles. The EMBO Journal, 32(24), 3107–3111. Peixoto, D., Dingli, D., & Pacheco, J. M. (2011). Modelling hematopoiesis in health and disease. Mathematical and Computer Modelling, 53(7), 1546–1557. Schmeichel, K. L., & Bissell, M. J. (2003). Modeling tissue-specific signaling and organ function in three dimensions. Journal of Cell Science, 116(Pt 12), 2377–2388. http://doi.org/10.1242/jcs.00503 Schubert, C., van Langeveld, M. C., & Donoso, L. A. (2013). Innovations in 3D printing: a 3D overview from optics to organs. British Journal of Ophthalmology. http://doi.org/10.1136/bjophthalmol-2013-304446 Siller, R., Greenhough, S., Park, I.-H., & Sullivan, G. J. (2013). Modelling human disease with pluripotent stem cells. Current Gene Therapy, 13(2), 99. Snoeck, H.-W. (2015). Modeling human lung development and disease using pluripotent stem cells. Development (Cambridge, England), 142(1), 13–16. http://doi.org/10.1242/dev.115469 The Globe and Mail. (n.d.). Data on failed drug experiments rarely made public, McGill study finds. Retrieved October 21, 2015, from http://www.theglobeandmail.com/life/health-and-fitness/health/data-on-failed-drugexperiments-rarely-made-public/article23442593 Unternaehrer, J., & Daley, G. (2011). Induced pluripotent stem cells for modelling human diseases. Philosophical Transactions of the Royal Society B: Biological Sciences, 366(1575), 2274–2285. Utomo, T. S. (2012). STEM CELL RESEARCH DEVELOPMENT AND ITS PROTECTION IN INDONESIA. Mimbar Hukum, 24(3). Ventola, C. L. (2014). Medical Applications for 3D Printing: Current and Projected Uses. Pharmacy and Therapeutics, 39(10), 704–711. Yamanaka, S. (2009). A Fresh Look at iPS Cells. Cell, 137(1), 13–17. http://doi.org/10.1016/j.cell.2009.03.034
Artificial blood HBOC-201 versus packed red blood cells (pRBC) for adult patients: a systematic review Ficky Huang, Koe Stella Asadinia Faculty of Medicine, Universitas Indonesia
Introduction. More than two-thirds of the world struggle with inadequacy of blood supplies. Other than inavailability and practical reasons, safety of blood transfusion has long been an issue particularly in exposure to risks of blood-borne pathogens and immune reaction. Hence, a search of blood substitute has been conducted. HBOC-201 is regarded as an ideal option as it has advantages in long shelf life and temperature stability range beneficial for stockpiling. HBOC-201 also has equivalent haemoglobin concentration to whole blood. It has been investigated in Phase III clinical trials. However, due to bankcrupty filed by Biopure Corporation (producer and developer of HBOC-201), a randomized clinical trial was delayed in publisihing their results until recently in 2014. Meanwhile, in 2008, a meta-analysis was published condemning HBOC-201. The meta-analysis indirectly halted development of HBOC since then. Therefore, this review was conducted to assess adverse effects and efficacy of HBOC-201 versus packed red blood cells (pRBC) in adult patients. The review is expected to be able to present novel overview of HBOC-201. Methods A comprehensive literature search based on determined search strategy was conducted on six search engines: Clinical Key, BMJ, Google Scholar, EBSCO, PubMed and ScienceDirect. The studies were limited on articles presenting original report of randomized controlled trials on humans assessing efficacy and safety of HBOC-201 compared to RBC transfusion. Results 2 randomized clinical trials were included. One trial compared HBOC-201 treatment group and RBC treatment group. One other trial compared HBOC-201 treatment group and a control group treated by both HBOC-201 and RBC. Results of efficacy and adverse effects of these two studies were compared. Discussion Both trials showed HBOC-201 as second to RBC in terms of efficacy and safety evaluation. One trial did present HBOC-201 as successful blood substitute in eliminating the need for blood transfusion while still second to RBC. Safety evaluation outcomes of both studied were
unfavorable in HBOC-201 group as they showed higher incidence of adverse events but no significant difference in serious adverse events. Two most significant of adverse events incidence in HBOC-201 subjects were jaundice and hypertension respectively. Conclusion HBOC-201 has lower efficacy and higher incidence of adverse events than RBC. However, in conditions of inavalailability of RBC or else, HBOC-201 could be used as a blood substitute as it has statistically and clinically succeded in avoiding the need for blood transfusion and no significant difference in causing serious adverse events with RBC. Key words: artificial blood, HBOC-201, red blood cells, RBC, randomized controlled trials, RCT, adverse events, efficacy.
Authors: Ficky Huang Phone : +6287893193597 fickyhng21@gmail.com Koe Stella Asadinia Phone : +6281282411321 koestella@live.com
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ABSTRACT
Introduction More than two-thirds of the world struggle with inadequacy of blood supplies. Other than inavailability and practical reasons, safety of blood transfusion has long been an issue particularly in exposure to risks of blood-borne pathogens and immune reaction. Hence, a search of blood substitute has been conducted. HBOC-201 is regarded as an ideal option as it has advantages in long shelf life and temperature stability range beneficial for stockpiling. HBOC-201 also has equivalent haemoglobin concentration to whole blood. It has been investigated in Phase III clinical trials. However, due to bankcrupty filed by Biopure Corporation (producer and developer of HBOC-201), a randomized clinical trial was delayed in publisihing their results until recently in 2014. Meanwhile, in 2008, a meta-analysis was published condemning HBOC-201. The meta-analysis indirectly halted development of HBOC since then. Therefore, this review was conducted to assess adverse effects and efficacy of HBOC-201 versus packed red blood cells (pRBC) in adult patients. The review is expected to be able to present novel overview of HBOC-201. Methods A comprehensive literature search based on determined search strategy was conducted on six search engines: Clinical Key, BMJ, Google Scholar, EBSCO, PubMed and ScienceDirect. The studies were limited on articles presenting original report of randomized controlled trials on humans assessing efficacy and safety of HBOC-201 compared to RBC transfusion. Results 2 randomized clinical trials were included. One trial compared HBOC-201 treatment group and RBC treatment group. One other trial compared HBOC-201 treatment group and a control group treated by both HBOC-201 and RBC. Results of efficacy and adverse effects of these two studies were compared. Discussion Both trials showed HBOC-201 as second to RBC in terms of efficacy and safety evaluation. One trial did present HBOC-201 as successful blood substitute in eliminating the need for blood transfusion while still second to RBC. Safety evaluation outcomes of both studied were unfavorable in HBOC-201 group as they showed higher incidence of adverse events but no significant difference in serious adverse events. Two most significant of adverse events incidence in HBOC-201 subjects were jaundice and hypertension respectively. Conclusion
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HBOC-201 has lower efficacy and higher incidence of adverse events than RBC. However, in conditions of inavalailability of RBC or else, HBOC-201 could be used as a blood substitute as it has statistically and clinically succeded in avoiding the need for blood transfusion and no significant difference in causing serious adverse events with RBC. Key words: artificial blood, HBOC-201, red blood cells, RBC, randomized controlled trials, RCT, adverse events, efficacy.
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Acknowledgement We would like to express our sincerest gratitude to Radhian Amandito, S.Ked for his patience and guidance from the beginning until the end of writing this review. We appreciate the insights and feedbacks which enable us to keep the review on track. We also thank Mochamad Iskandarsyah Agung Ramadhan for his valuable advices.
Depok, 21 October 2015 Authors
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Table of Contents
Cover
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i
Abstract..........................................................................................................................
ii
Acknowledgement ......................................................................................................... iv Table of Contents ..........................................................................................................
v
List of Figures................................................................................................................ vii List of Tables ................................................................................................................. viii 1. Introduction ......................................................................................................
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1.1 Background ................................................................................................. 1.1.1 Description of the condition ........................................................... 1.1.2 Description of the intervention ....................................................... 1.1.3 How the intervention might work .................................................. 1.1.4 Why it is important to conduct the review ..................................... 1.2 Objectives ....................................................................................................
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2. Methods.............................................................................................................
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2.1 Search strategy ............................................................................................ 2.2 Study selection ............................................................................................ 2.2.1 Inclusion criteria ............................................................................. 2.2.2 Exclusion criteria............................................................................ 2.3 Quality assessment ...................................................................................... 2.4 Data extraction ............................................................................................
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3. Results ...............................................................................................................
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3.1 3.2 3.3 3.4
Research findings ........................................................................................ Quality of included studies .......................................................................... Randomized controlled trials comparing HBOC-201 with a control group Outcome measures ......................................................................................
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4. Discussion ......................................................................................................... 10 4.1 Outcome measures ...................................................................................... 10 4.2 Limitations .................................................................................................. 11
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4.3 Future research ............................................................................................ 11 5. Conclusion ........................................................................................................ 11 Appendix A â&#x20AC;&#x201C; Jadad scale for randomized controlled trials ........................................... 13 References ....................................................................................................................... 14
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List of Figures
Figure 1. Search strategy flow chart ..............................................................................
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List of Tables
Table 1. Quality assessment using Jadad scale ..............................................................
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Table 2. Comparison between two studiesâ&#x20AC;&#x2DC; characteristics ............................................
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1. Introduction 1.1 Background 1.1.1
Description of the condition
Blood supplies through blood donor up until now have not succeeded in meeting the demand. Only one-third of the world has adequate blood supplies while the rest struggles with blood shortages (Klein et al., 2007). 80% of potentially survivable war victims in Iraq war died due to hemorrhage (Kelly et al., 2008). Availability of blood supply is determined by compatibility of donor and recipient blood type, shelflife of collected and processed blood, and readiness of blood supply to be transfused at all times. Other than inadequacy of blood supply, several issues regarding safety of blood were also raised (Busch, 2001; Van Hemelrijck et al, 2014; Njoku et al., 2015). Allogeneic blood transfusion still poses risks in carrying blood-borne pathogens. Inaccurate cross-matching also carries the risk of antigen binding and agglutination due to recipient‘s immunological reaction. This particular issue became the leading direct cause of deaths as result of blood transfusion (Ross et al., 1996). These have led scientists to researching blood substitute in attempt to provide beneficial alternative regarding availability and safety. These make blood substitute as the ―Holy Grail‖ in trauma medicine as the ideal blood substitute might be able to eliminate risks carried by blood and solve all kinds of blood shortage problems, especially in settings of trauma (Chen et al., 2009). Haemoglobin-based oxygen carriers (HBOC) as blood substitute is expected to replace packed red blood cells transfusion (pRBC) when blood supplies are not possible to be cross-matched, blood supplies are contaminated or possibility of adverse events are higher with blood transfusion, unavailability of blood, frequency of blood transfusion needs to be reduced due to certain chronic diseases such as sickle cell anemia, and there is an urgent need for organ preservation and resuscitation before transplation (Njoku et al., 2015) 1.1.2
Description of the intervention
Mackenzie (2013) stated HBOC-201 (Hemopure®) as the best option of blood substitute based on its advantages in stockpiling as it has three-year shelflife and suitable range of temperature stability (2-30oC) and its equivalent haemoglobin concentration to whole blood. Blood transfusion using HBOC-201 has been investigated in Phase III clinical
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trials. It has already been approved for clinical use on humans in South Africa (Jahr et al., 2008). HBOC-201 has product charasteristics as the following: pure cell-free, glutaraldehyde cross-linked, polymerized Hb in a modified and lactated Ringerâ&#x20AC;&#x2DC;s solution with pH 7.6 to 7.9, isosmotic, and has a circulatory half-life within range of 19 to 24 hours. HBOC-201 does not require crossmatching and reconstitution. HBOC-201 is administered directly into central or peripheral vein. One unit of HBOC-201 is 250 mL with haemoglobin concentration of 13 g/dL (Van Hemelrijck et al., 2014). 1.1.3
How the intervention might work
As HBOC-201 lacks antigens of packed red blood cells (pRBC) membrane, HBOC-201 is expected to pose no transfusion errors due to uncrossmatched blood use (Zou et al., 2008). Other than universal compatibility, free-cell property of HBOC-201 is also expected to benefit over pRBC in optimization of acute anemia management, enhancement of oxygen delivery in tissues beyond stenosis in arteries, and increased accessibility than red blood cells (Weiskopf, 2011). 1.1.4
Why it is important to conduct the review
Previously, Natanson et al. published a meta-analysis examining clinical trials involving HBOC-201 in 2008, condemning HBOC by stating that HBOCs have increased risk of mortality due to the scavenging effect on HBOC by nitric oxide (NO). Even though these findings have been disputed by various arguments, such as unclear and unproven clinical implications, development of HBOC was practically stopped (Lewis et al., 2014). Biopure, producers of HBOC-201, declared bankcruptcy one year later in 2009 and purchased by OPK Biotech, LLC one month later. However, there has been recent publication by Van Hemelrijck et al. in 2014 presenting the result of unpublished HBOC201 study conducted in 1988-1999. The publication of study report was delayed due to bankcruptcy filed by HemopureÂŽ developer and producer, Biopure Corporation (Van Hemelrijck., 2014). A novel systematic review has to be conducted in attempt to give a more objective and comprehensive evaluation of randomized pRBC-controlled trials with HBOC-201. 1.2 Objectives To assess adverse effects and efficacy of HBOC-201 versus packed red blood cells (pRBC) in adult patients.
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2. Methods 2.1 Search strategy A comprehensive literature search was conducted in October 2015 using six electronical databases, Clinical Key, BMJ, Google Scholar, EBSCO, PubMed and Science Direct. The term used to search in these databases are ‗HBOC-201‘, ‗adult‘ , ‘red blood cells‘, ‗randomized controlled trials‘, ‗adverse effect‘, and ‗efficacy‘. Only randomized controlled trials on adults were included. Relevant reference lists in included articles were also searched. Articles presenting ongoing trials, study on animal and comparison between HBOC-201 and blood subtitutes were excluded. Meta-analysis and systematic reviews were also excluded to avoid subjectivity and bias in conducting this review. 2.2 Study selection 2.2.1
Inclusion Criteria
Studies were included in this review if they are RCTs. 2.2.2
Exclusion Criteria
Studies were excluded if they were: (1) ongoing trials, (2) studies on animals and (3) comparison between HBOC-201 and other blood substitutes. 2.3 Quality assessment Qualities of included studies were assessed using Jadad scaling. Criteria were scored based on randomization (0, 1, 2), blinding (0, 1, 2), and an account of all patients (0, 1). Randomization score adds one point if the report clearly stated the trial as randomized and adds another point if the appropriate method of randomization is mentioned. Inappropriate method of randomization results in one-point deduction. Blinding adds one point if the report clearly stated the trial as double-blind and adds another point if the appropriate method of blinding is mentioned. Inappropriate method of blinding deducts one point. An account of all patients adds one point if the fate of all patients is stated clearly. If there is no data, the point will be zero. A minimum score of a study is zero while the maximum is five. Studies with four or five points Jadad score are considered as high quality studies whereas studies with less or same as three points Jadad score are regarded as poor quality studies.
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2.4 Data extraction Data obtained from included studies match the following: 1. Characteristics of study participants including sample size and control group, procedures undergone by patients 2. Type of compared interventions 3. Outcome measures: efficacy, significant adverse effects, and mortality 4. Time at which measurement by follow-up was conducted 5. Result of studies: data significance and conclusions
3. Results 3.1 Research findings We found 173 articles of interest in the initial search. Fourty-nine were excluded because they involve studies on animals. Twenty articles presenting ongoing trials were also excluded. Fourty-two did not meet the inclusion criteria because they mainly discuss another blood substitutes. Fifty-seven were not included because they did not discuss both adverse effects and efficacy of HBOC-201 and pRBC. After filter doubles we found eight articles as suitable articles in this review. But after reading the full text, four were not included becase they were either meta-analysis or systematic review and two were excluded because their articles were not randomized controlled trials, resulting in a total of two studies. 3.2 Quality of included studies Two final studies included were assessed using Jadad scale for reported randomized controlled trials. Three main criterias were assessed: randomization, blinding, and an account of all patients (withdrawal and patients). Study A (Van Hemelrijck et al., 2014) clearly states ―randomized‖ and mentions the method of randomization using envelopes, hence, was added two points. Study B (Jahr et al., 2008) states ―randomized‖ but does not mention the method, hence, was added one point. Both studies are single-blind due to ethical, practical and safety issues; therefore have zero point on blinding criteria. Both studies mention withdrawals and dropouts with clear rationale; therefore each was added one point. Total score of study A is three points and total score of study B is two points.
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Based on this scaling, both studies are considered as poor quality studies because both have scores of less or same as three points.
Table 1. Quality assessment using Jadad scale RCT
Randomization
Blinding
An account of all patients
Study A
++
0
+
+
0
+
Van Hemelrijck et al. (2014) Study B Jahr et al. (2008)
3.3 Randomized controlled trials comparing HBOC-201 with a control group Two studies compared adverse effects and efficacy bwtween HBOC-201 with pRBC. Study A conducted by Van Hemelrijck et al. in 1998-1999 evaluated safety and efficacy of HBOC-201 in pRBC controlled trial in noncardiac surgery patients. Study B conducted by Jahr et al. (2008) evaluated efficacy and safety of HBOC-201 as a blood transfusion alternative in a multicenter phase III trial in elective orthopedic surgery. 3.3.1
Study A (Van Hemelrijck et al., 2014): noncardiac surgery patients
Van Hemelrijck et al (2014) presented unpublished results of multicenter, single-blind, randomized, and comparative study of HBOC-201 versus allogeneic RBC transfusion conducted in 1998-1999. The purpose of the study was to evaluate safety and efficacy of HBOC-201 as a blood substitute for pRBC. During 24 hours before surgery, investigators estimated each patientâ&#x20AC;&#x2DC;s discharge haemoglobin (Hb). Before randomly assigned, patients have to undergo first transfusion decision. Requirement for transfusion is set when patientâ&#x20AC;&#x2DC;s total Hb level was lower by minimum of 2 g/dL than the estimated discharge Hb or less than 6 g /dL. When the total Hb was >10 g/dL, transfusion must not be done. However, transfusion was allowed when one or more of these criteria were present: heart rate more than 100 beats/minute, systolic blood pressure less than 90 mmHg, metabolic acidosis occurs (minimum base excess of -4), acute blood loss (more than 7mL/kg within two hours), urine output less than 0.5 mL/kg/hour for more than two hours, and limited activity as a result of dizziness or
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lethargic. HBOC-201 infusion rate depended on each investigator‘s decision. Patients with criteria of transfusion reached after post-op day three were not allowed to be enrolled. After the first transfusion decision was made, patients were enrolled. They went through randomization into either one of two treatment groups (HBOC-201 or pRBC). Clinical trial material (CTM) was set for the two groups as a total of six transfusions within six days. If patients needed further transfusion, pRBC as non-CTM would be given. First HBOC-201 infusion was set on 2 units or equal to 60 g Hb in 1 unit of pRBC. Due to patient safety, principal investigators were free to switch subjects in HBOC-201 to pRBC group and were not required to reveal their reasons. Measurements were collected right before first CTM administration. Follow-up period started right after treatment period until the final evaluation (3 to 4 weeks post-op). 3.3.2
Study B (Jahr et al., 2008): orthopedic surgery patients
Jahr et al. (2008) conducted a randomized, single-blind, parallel-group multicenter and packed red blood cell (pRBC)-controlled study to evaluate the ability of HBOC-201 to safely reduce and/or eliminate perioperative transfusion in patients undergoing orthopedic surgery. Firstly, patients were randomized to PRBC or HBOC-201 and received the first transfusion based on investigator‘s assessment and a total blood Hb <10,5 g/dL. Also another transfusion decision can be made if the patients having at least one of these following clinical signs : systolic blood pressure (SBP) <90 mm Hg, heart rate ≥100 beats per minute, electrocardiogram (ECG) evidence of myocardial ischemia , metabolic acidosis (base deficit—4 or worse) , oliguria with urine output <0.5 mL/kg/h for at least 2 hours , acute blood loss >7 mL/kg within 2 hours or less, restricted patient activity (e.g., walking) due to weakness or dizziness. When the treatment was initiated, the later transfusion was permitted for up to 6 days using the same criteria. A loading dose of 65 g Hb (two units of 32,5 g, a 500 mL infused volume considered equivalent in total of Hb to one unit of pRBC) was transfused to patients randomized to HBOC-201, followed by up to an additional 260 g HBOC-201. After total tranfussion with 325 g HBOC-201 were transfused or after 6 days, pRBC will be used in order to fulfill oxygen carrying capacity need. However, patients could be crossed-over to
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91
19981999
2008
Jahr et al.
Year
Van Hemelrijck et al.
Study
RCT
RCT
Design
Orthopedic surgery patients.
Non-cardiac surgery patients except patients with major acute neurological disorders, uncontrolled hypertension, hematological disorders and cardiac-related complications.
Participants
350
Sample Size 83
338
Control Group 77
Sample groups received 2 units of HBOC-201 as initial treatment with up to 8 units additional HBOC201. Control group received up to 2,500 mL of pRBC in addition to HBOC-201.
Intervention Group Two groups received maximum 7 units of HBOC201 (n=83) or pRBC (n=77). With exception, HBOC patients could be switched to RBCs for safety reason.
Table 2. Comparison between two studiesâ&#x20AC;&#x2DC; characteristics
Patients were evaluated before and after infusions on days 2 through 6, 24 hours, and 48 hours of final administration of HBOC-201 and pRBC. The adverse effects and death were also recorded.
Absolute hematology markers were evaluated by post-operative day 1,2,4,7,10, discharge and follow up. The markers were also evalueated before and after each infusion. The primary efficacy, arterial blood pressure after first infusion and adverse effects of HBOC-201 and pRBC were also recorded and analyzed.
Outcome Measures
There were no significant differences in mortality and electrolyte and acid-base paramaters. The adverse effect was slightly higher than controls.
There were no major differences in mortality and serious adverse effect incidence between sample and control group.
Main Findings
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treatment with pRBC based on investigator‘s assessment of clinical needs. And patients were evaluated before and after transfusion from days 2 till 6, 24 hours, and 48 hours after final transfusion and 6 weeks post-operatively. 3.4 Outcome measures 3.4.1
Efficacy
Primary efficacy of HBOC-201 in Van Hemelrijck et al. (2014) was assessed by the proportion of HBOC-201 patients who did not receive any pRBC during the time of study. And then patients were evaluated in every pre- and post infusion to check the total Hb and plasma Hb. Another efficacy criterion was assessed by comparing non-CTM avoidance of both gourps (HBOC-201 subjects and pRBC subjects). Jahr et al. (2008) compared the efficacy of HBOC-201 treatment to a control group with treatment of HBOC-201 and pRBCs. One group received only HBOC-201 and another group received HBOC-201 and then RBCs. Addition of pRBC for HBOC-201 subjects were based on clinical need. Patients from two groups were evaluated before and after infusions on days 2 through 6, 24 hours, and 48 hours after the final administration of HBOC-201 or pRBC, and 6 weeks postoperatively. The endpoint of primary efficacy was set as elimination of the need for blood transfusion in ≥ 35% randomized patients. 3.4.2
Serious Adverse Events (SAEs) and Adverse Events (AEs)
Two studies included in this review were scored basis of ‗yes‘ (+) and ‗no‘ (-) to assess mortality, SAEs and AEs in patients. Van Hemelrijck et al. (2014) assessed the body system total of AEs using Coding Symbols for a Thesaurus of Adverse Reaction Term (COSTRAT) which consists assessment of digestive system (constipation, diarrhea, dysphagia, jaundice, nausea, nausea and vomiting and vomiting), body as whole (abdominal pain, asthenia, fever and pain), cardiovascular system (atrial fibrillation, hemorrhage, hypertension and tachycardia), metabolic and nutrition disorders (edema, healing abnormal and hypokalemia), hemic and lymphatic system, nervous system (confusion and insomnia), respiratory system (dyspnea), skin and appendeges (pruritus and rash) and urogenital system (hematuria and oliguria). SAEs assessed consist of acidosis, GI hemorrhage, hypoxia, pneumonia, lung edema, myocardial infarct and also cerebrovascular accident (CVA).
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Jahr et al. (2008) assessed AEs and SAEs according to Medical Dictionary for Regulatory Activities. AEs were reported as increase of blood pressure or hypertension. Meanwhile SAEs were reported as strokes or cerebrovascular injuries. Evaluation of AEs and SAEs was conducted by study investigators and Safety Endpoint Evaluation Committee (SEEC) physician reviewers on independent review of patientsâ&#x20AC;&#x2DC; medical record. The evaluations then were defined by two clinicians through blinded review. In case of disparate scores, the number of clinicians was added.
4. Discussion 4.1 Outcome measures In terms of efficacy evaluation, both studies show success of HBOC-201 in avoiding blood transfusion although it is still lower than RBC itself. Van Hemelrijck et al. (2014) presented two criterias in evaluating efficacy of HBOC-201. First, the primary end point was taken from patients in HBOC-201 group who did not receive RBC transfusion during the study. HBOC-201 was concluded as successful in eliminating the need for blood transfusion in patients, either clinically or statistically. A secondary criterion for efficacy evaluation was observed in terms of comparing HBOC and RBC treatment. Average of 3.2 (SD = 5.9) RBC units were injected to HBOC patients compared to 4.4 (SD = 4.1) units in RBC patients. 83 HBOC patients and 77 RBC subjects had overall rates of nonCTM avoidance: 43% and 74% severally. Jahr et al. (2008) presented the result of efficacy evaluation in HBOC patients. HBOC-201 turned out having a 50% avoidance of blood transfusion within six weeks of follow-up assessment. In terms of safety evaluation, HBOC-201 had unfavorable outcomes in both studies. There were several indicators in study conducted by Van Hemelrijck et al. (2014) including causality adverse events (AEs), arterial blood pressure (BP) after first infusion, serious adverse events (SAEs), selected clinical chemistry parameters, and hematology markers pre and postinfusion. Hematology markers were also observed by treatment period. With COSTART basis, all-cause AEs in HBOC patients are higher than RBC patients. However, in cardiovascular system, the AEs were distributed evenly with exception of hypertension, which was higher in HBOC subjects and transient to increase in arterial BP. Incidence of jaundice in HBOC subjects was the most significant AE compared to RBC subjects. It was also proven to be dose-dependent to HBOC-201. The event was suspected to be the result of HBOC-201 processing to bilirubin by human
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physiology. While significant higher AEs consist of jaundice and hypertension respectively, difference of SAEs in both groups were not statistically significant. COSTART also showed no significant differences in any SAE incidence in both groups. Safety evaluation of HBOC-201 in Jahr et al. (2008) was also not favorable either in blinded review by SEEC or report of AEs and SAEs by investigators. These outcomes were most probably due to the already high need for additional oxygen-carrying features which highly unlikely can be met by sole treatment of HBOC-201. 4.2 Limitations There are several limitations in the RCTs which affect this review significantly. First, both studies included are regarded as poor quality studies which made data incuded in this review not wholly reliable. Method of randomization was mentioned in only one study. Both studies were also single-blind due to several issues preventing the study to be double-blind. Nonetheless, the low scores of included studies based on Jadad scaling do not provide strong evidence as materials of this review. Secondly, several judgments of outcome measures in each study, which were made subjectively, made the data prone to subjectivity. Lastly, scarcity of appropriate study, particularly RCT regarding HBOC-201, makes a hardship to apply results in wider population. 4.3 Future research A study of adverse effects and efficacy of HBOC-201 in trauma settings would be more applicable to potential use of HBOC-201 in the future as it is highly likely to be blood substitute in settings of war, mass casualty, and other settings of blood shortage in inaccessible area or high demand situation for blood supplies. Future studies of adverse effects and efficacy comparison between HBOC-201 with another blood substitutes could also be conducted to help better allocation of further research and investigation in attempt to finding the right blood substitute.
5. Conclusion This systematic review concludes that in terms of efficacy, HBOC-201 has lower efficacy than pRBC transfusion. In terms of adverse effects, HBOC-201 generally has higher incidence of adverse events than pRBC transfusion. These make the use of HBOC-201 could be conducted if there is no RBC available or in another particular situation and
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condition because of two reasons. First, HBOC-201 itself did not show significant difference in causing serious adverse events than RBC. Second, HBOC-201 also succeded statistically and clinically in avoiding the need for blood transfusion, although it still second to RBC itself.
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Appendix A - Jadad scale for randomized controlled trials
Jadad, A. R., Moore, R. A., Carroll, D., et al. (1996). Assessing the quality of reports of randomized controlled trials: is binding necessary? Control Clin Trials, 17, 1-12.
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Tumor Related-outcomes in Spinal Cord Injury Therapy Using Induced Pluripotent Stem Cells Nadya Johanna, Phebe Anggita Gultom, Robby Hertanto Faculty of Medicine, Universitas Indonesia Background Spinal cord injury (SCI) is a traumatic disturbance affecting motor, sensory, and autonomic function which impairs overall patient’s condition, including physical, psychological, and social contentment. The severity of SCI is graded by American Spinal Injury Association Impairment Scale (AIS), a five-point ordinal scale from A to E. SCI grade A represents total absence of motor and sensory functions, while SCI grade B to E describe partial injury in motor and/or sensory functions until they become fully recovered in SCI E. During the 1st year post-injury study, 10-20% patients with AIS A could regain their abilities and converted to AIS B-D. Nonetheless, even if the AIS grade improved, there is only a slight correlation with the daily functional activities such as ambulation. At present, none of available SCI treatments could yield satisfactory improvement in patients’ life quality. Regenerative medicine has been reviewed as one of the most potential treatments of SCI, especially the induced pluripotent stem cells (iPSCs). iPSCs are taken from somatic cells and are induced by some altered genes: Oct4, Sox2, Klf4, and c-Myc. The advancement of research in iPSCs usage to treat some complex diseases, including SCI, shows some promising results in some in vivo nonhuman primate trials. However, due to some tumor formations in these studies, the development of iPSC-based treatment is still undergoing extensive evaluations. Objectives To assess the possibility of tumor formation caused by iPSCs derived cells therapy for SCI. Search Methods We searched PubMed and Science Direct to 20th October 2015. We used snowball method to identify additional studies. Selection Criteria We included all in vivo studies, human and non-human, involving iPSCs derived cells for SCI therapy with tumor-related outcomes. Only English studies are included. Results We included 4 studies which mentioned tumor-related outcomes on SCI therapy using iPSCs derived cells. Three studies concluded no tumor-related outcomes; however, one study showed tumor-related outcomes. All studies shown positive result towards improved SCI condition, except the one study which shown declining result after the tumor formation. Discussion Tumor-related outcomes might be caused by the unintroduced c-Myc reprogramming factor. This factor caused desensitization of several apoptotic responses usually present in the cell. Conclusions iPSCs could be used and deemed safe to promote recovery for SCI. We concluded that tumor formation could be prevented by introducing c-Myc to regulate the cell’s growth and apoptosis.
Keywords Induced Pluripotent Stem Cells; iPSCs; Spinal Cord Injury; SCI; Tumor.
Contact Person Nadya Johanna University of Indonesia e-mail: nadya.johanna@gmail.com
Tumor Related-outcomes in Spinal Cord Injury Therapy Using Induced Pluripotent Stem Cells Nadya Johanna Phebe Anggita Gultom Robby Hertanto Faculty of Medicine, Universitas Indonesia
Tumor Related-outcomes in Spinal Cord Injury Therapy Using Induced Pluripotent Stem Cells Nadya Johanna, Phebe Anggita Gultom, Robby Hertanto Faculty of Medicine, Universitas Indonesia e-mail: nadya.johanna@gmail.com Introduction Spinal Cord Injury SCI is a traumatic disturbance affecting motor, sensory, and autonomic function due to devastating assault to the central nervous system. SCI extensively impairs overall patientâ&#x20AC;&#x2122;s condition, including physical, psychological, and social contentment (Fehlings, Singh, Tetreault, Kalsi-Ryan & Nouri, 2014). SCI prognosis is predominantly determined by whether an injury is clinically complete or incomplete (Burns, Marino, Flanders & Flett, 2012). Complete injury refers to complete absence of sensory and motor function in the two lowest sacral segments: S4 & S5. On the other hand, if there is conservation of any sensory and/or motor function below the neurological level of injury including S4 & S5 sacral segments, the injury is classified as an incomplete injury. Furthermore, injury severity is ultimately graded using the American Spinal Injury Association Impairment Scale (AIS), an A-to-E ordinal scale. An AIS A represents a complete motor and sensory injury, while AIS grade B to E represent incomplete motor and/or sensory injury. AIS grade E is given to a person who has regained all his/her sensory and motor function in some tested aspects (Kirshblum et al., 2011). Eventhough approximately 10-20% of complete SCI injury (AIS A) converts to incomplete injury (AIS B-D) during the 1st year post-injury, the degree of motor recovery in these cases is very limited or even absent. 20% to 75% individuals with incomplete SCI will eventually regain some degree of walking ability by the first year post-injury (Burns, Marino, Flanders & Flett, 2012). Nonetheless, even if there is conversion of AIS grade occurs, there is only slight relation with functional activities such as ambulation (van Middendorp et al., 2009). The current objectives of SCI treatments are to prevent further spinal injury, sustain blood flow, console spinal cord compression, and maintain secure vertebral stabilization in order to allow mobilization and recovery, none of which provides adequate improvement in patientâ&#x20AC;&#x2122;s life quality (Ozdemir, Attar & Kuzu, 2012). Induced Pluripotent Stem Cells Scientist nowadays are focusing on development of pluripotent stem cells, induced adult cells, since its promising capabilities to have unlimited self-renewal and reproduction. Pluripotency characteristic is made by groups of complex signaling and gene which responsible only for pluripotent cells. One of the well-studied sources of pluripotent stem cells is embryonic stem cells (ESCs) which is taken from inner cells mass. However, the study of ESCs gets disrupted as researchers found some problems related to implantation of ESCs and the use of ESCs. Immunological reason and ethical issue are the major reasons why research on ESCs cannot be more developed. Lately, in 2006, the pluripotent cells induced by ectopic factors were recorded and it is called as induced pluripotent stem cells (iPSCs). iPSCs are taken from somatic cells and are induced by some altered gene, Oct4, Sox2, Klf4, and c-Myc. iPSCs have similar morphological and characteristics with ESCs. Likewise the ESCs, iPSCs are sensitive to growth factors and they can develop into three germ layers (ectoderm, mesoderm, and endoderm). Moreover, when iPSCs are injected into tetraploid
blastocyst, they can form into whole organism. Lastly, iPSCs can be derived from various somatic cell types and they are all free from ethical issue. Recently, the advanced researches on iPSCs concluded that iPSCs may give many advantages for development of regenerative medicine (Chun et al., 2011). Firstly, iPSCs has powerful ability on toxicology studies, therefore it can increase the efficiency of novel treatment on human and decrease the costs spent. Secondly, iPSCs is known to have ability in adapting with the transplanted cells, therefore there will not be any immunological reaction as rejection to iPSCs. Additionally, iPSCs can also be used to correct defect gene that cause several diseases. Although iPSCs seem to give promising perspective in the future, some problems related to the effect in the use of iPSCs are still questioned. One of the most debatable effects of iPSCs is oncogenicity or tumorigenicity characteristic that is induced by the appearance of iPSCs. A systematic review written by Kramer, et al in 2013 showed that iPSCs could induce the formation of cancer or tumor on certain area in the body. In the contrary, scientists are still trying to develop these programmed cells to cure almost all diseases like cancers, spinal cord injuries, degenerative diseases, and many mores. The development of induced pluripotent stem cells have been running in a controversial situation where this on-going research should be continued or terminated regarding its ability to cure diseases, ethical-passed, and its controversial finding about tumorigenicity or oncogenicity characteristic. Assessment in iPSCs should be done to prevent any dangerous effects when iPSCs is used to human Objectives To assess the possibility of tumor formation caused by iPSCs derived cells therapy for SCI. Methods We included all in vivo studies, human and non-human, involving iPSCs derived cells for SCI therapy with tumor-related outcomes. Only English studies are included. Keywords used are [Induced Pluripotent Stem Cells] AND [Spinal Cord Injury] AND [Tumor OR Cancer OR Carcinogen OR Carcinogenic OR Carcinogenicity OR Oncogene OR Oncogenic OR Oncogenicity] AND [Therapy] AND NOT [Mesenchymal]. PubMed and Science Direct are examined without restriction on date. Additional studies are obtained using snowballing method from reference search during abstract and title examination. Inclusion criteria 1. In vivo studies involving iPSC-derived cells for spinal cord injury therapy. 2. Tumor-related outcomes (tumor, excessive proliferation, or clusters of proliferating cells) mentioned in the study. Exclusion criteria 1. Other language than English. 2. Only the abstract is found or accessible. 3. Review articles.
Identification
Figure 1. Number of records identified. Results Summary of Results We found 1 study reporting tumor-related outcomes (Nori et al., 2015) and 3 studies reporting no tumor-related outcomes (Kobayashi et al., 2012; Nori et al., 2011; Saadai et al., 2013). Studies Reporting Tumor Incidence First Author and Reference Year -
Nori, et al (2015)
-
Method
Neural differentiation of human iPSCs and lentiviral transduction of nanosphere using hiPSCs clone 253G1 Adult female NOD-SCID mice were induced with contusive SCI at the Th10 level using IH impactor Bioluminescence imaging is used to confirm the survival of grafted cells. Monitoring is done for 103 days after transplantation Evaluation of motor function by using BMS, Rotarod apparatus, and DigiGait system RNA-isolation and PT-PCR and analysis Statistical analysis
Result
Conclusion
Tumor
The grafted 253G1NSs survived, differentiate into three neural lineage and promoted functional recovery accompanied by synapses formation after 47 days of transplation. Longterm observation for 103 days showed deteroriated motor function accompanied with tumor formation
Studies Reporting No Tumor Incidence First Author Method and Reference Year Saadai, et al NCSCs were produced from hiPSCs (2013) derived from skin fibroblast in vitro The cells were mixed with hydrogel solution with ratio 2:1 (volume to volume) The mixture were spread into scaffold and were incubated for 1 hour LIVE/DEAD assay was performed to see the viability of NCSCs in engineered scaffold in vitro Stem cell-hydrogel-scaffold was cultured in medium of neural induction for 2 weeks. Its purpose is to see the capability of iPSC-NCSCs together with hydrogel and scaffold Two-mated ewe were obtained to have laparotomy and hysterotomy 75 days after gestation to create fetal MMC defect MMC lesion was made via surgery by exposing spinal cord and opening dura of the lambs 100 days after gestation, second surgery was done. The ewes were given iPSCNCSC seeded scaffold. It was implanted into its spinal cord. Identification of human nuclear mitotic apparatus protein (NuMA) and mature axonal neurofilament subunit was done by microscopy and immunohistochemical staining in spinal cord Kobayashi, et al All intervention and animal care (2012) procedure were performed based on the Laboratory Animal Welfare Act hiPSCs used is clone 201B7 About 10 adult female common marmosets were induced with contusive using modified NYU (New York University) dropdevice Behavioral tests were done from the first injury up until about 12 weeks after SCI Upper extremities motors function were tested using bar grip strength Coordination between the fore and hind limb was evaluated by cage climbing test MRI was performed to evaluate effect of hiPSC-NS/PCs on the injured spinal cord. Immunostaining examination for neurofilamen-200 and kinase II was done to evaluate impact of grafted hiPSC-NS/PCs for
Result
Conclusion
No tumor
Engraftment of human stem cells on fetal model underwent MMC is successfully done. iPSCS-NCSCs has potential capability to treat spinal cord injury. No tumor observed from the research
No tumor
Pre-evaluated hiPSCNS/PCs is potential agent to treat SCI clinically
Nori, et al (2011)
-
growth of axonal. Iba1 staining to evaluate activity of microglial, GFAP staining to see formation of glial scar The clone of hiPSCs used is 201B7 and lentivirus was induced into the neurosphere Adult female NOD-SCID mice was induced with contusive SCI at Th10 level using IH impactor The epicenter lesion of each mice were received transplantation from hiPSCs-NSs nine days after the injury Rotatord apparatus, DigiGait system, and BMS were used to analyze behavior of the mice. Paraformaldehyde is used to analyse histologically
No tumor
Significant functional recovery in hiPSCNS-grafted mice compared to the control. hiPSCs are known to increase activity of stem/progenitor cells and it can improve function post-SCI, hiPSCs are also potential and promising source for treatment of disease
Discussion Conflicting results of tumor-related outcomes in the studies included raises safety concern outside of its positive therapeutic effect. All of the studies assessed long term safety of the grafted iPSC derived cells for a minimum of 84 days and maximum of 136 days. Three studies which reported no tumorrelated outcomes used four reprogramming factors: OCT4, SOX2, KLF4, and c-Myc. However, the study which reported tumor-related outcomes used only three reprogramming factors: OCT4, SOX2, and KLF4. All of the studies showed positive result towards the recovery from spinal cord injury, except one study with tumor-related outcomes which showed a decline after positive motoric result on day 103 (Nori et al.,2015). c-Myc The difference of introduced reprogramming factors may contribute to the tumor-related outcomes in one of the studies (Nori et al., 2015). Reprogramming factor c-Myc is a transcription factor that regulates cell survival and apoptosis during all cell phases by sensitizing to apoptotic triggers. This factor is required for efficient response to apoptotic stimuli, such as transcription and translation inhibitors, hypoxia, glucose deprival, heat shock, chemotoxins, DNA damage, and cancer chemotherapeutics. Apoptosis responses by c-Myc could be caused p53-dependent or p53independent. Althrough c-Myc represses growth arrest genes, it works together to activate many of the same target genes. Apoptosis caused by p53-dependent was regulated by c-Myc interaction with DNA Binding Protein Miz-1, directly blocking p21(Cip1)’s promoter induction by p53. This inhibition influences the normal outcome of p53 outcomes response in favor of cell death. Expression of c-Myc also shown to impair the ability of TNF-α to activate NF-κB and JnK. (Hoffman & Liebermann, 2008; Prendergast, 1999) Conclusion All studies showed that iPSCs could be used to promote recovery for SCI with only one study shown tumor-related outcomes. However, the tumor is introduced when c-Myc gene is not introduced as programming factor (Nori et al., 2015). The previous study (Nori et al., 2011) stated that no tumor, excessive proliferation, or clusters of proliferating cells observed. We concluded that tumor formation could be prevented by introducing c-Myc to regulate the cell’s growth and apoptosis.
Reference Burns, A., Marino, R., Flanders, A., & Flett, H. (2012). Clinical diagnosis and prognosis following spinal cord injury. Handbook Of Clinical Neurology 109(1), 47-62. Chun, SY., Byun, K, Lee, B. (2011). Induced pluripotent stem cells and personalized medicine: current progress and future perspective. Anatomy & Cell Biology 44(1), 1-11. Fehlings, M., Singh, A., Tetreault, L., Kalsi-Ryan, S., & Nouri, A. (2014). Global prevalence and incidence of traumatic spinal cord injury. Clinical Epidemiology, 309. Hoffman, B., Liebermann, DA. Apoptotic signaling by c-MYC (2008). Oncogene 27(1), 6462-6472. Kirshblum, S., Burns, S., Biering-Sorensen, F., Donovan, W., Graves, D., & Jha, A. et al. (2011). International standards for neurological classification of spinal cord injury (Revised 2011). The Journal Of Spinal Cord Medicine 34(6), 535-546. Kobayashi, Y., et al. (2012). Pre-evaluated safe human iPSC-derived neural stem scells promote functional recovery after spinal cord injury in common marmoset without tumorigenicity. PLOS ONE 7(12), 1-12. Kramer, AS., Harvey, AR., Plant, GW., Hodgetts, SI. (2013). Systematic review of induced pluripotent stem cell technology as a potential clinical therapy for spinal cord injury. Cell Transplant 22(4), 517-617. Medvedev, SP., Shevchenko, AI., & Zakian, SI. (2010). Induced pluripotent stem cells: problems and advantages when applying them in regenerative medicine. Acta Naturale 2(5), 18-27. Nori, S., et al. (2011). Grafted human-induced pluripotent stem-cell-derived neurospheres promote motor functional recovery after spinal cord injury in mice. PNAS 108(40), 16825-16830 Nori, S., et al. (2015). Long-term safety issues of iPSC-based cell therapy in a spinal cord injury model: oncogenic transformation with epithelial-mesenchymal transition. Stem Cells Reports 4(1), 360-373. Ozdemir, M., Attar, A., & Kuzu, I. (2012). Regenerative Treatment in Spinal Cord Injury. Curr Stem Cell Res Ther 7(5), 364. Prendergast, GC. (1999). Mechanisms of apoptosis by c-Myc. Oncogene 18(19), 2967-2987. van Middendorp JJ, Hosman AJF, Pouw MH et al. (2009). ASIA impairment scale conversion in traumatic SCI: is it related with the ability to walk? A descriptive comparison with functional ambulation outcome measures in 273 patients. Spinal Cord 47(1), 555â&#x20AC;&#x201C;560. Saadai, P., et al. (2013). Human induced pluripotent stem cell-derived neural crest stem cells integrate into the injured spinal cord in the fetal lamb model of myelomeningocele. Journal of Pediatric Surgery 48(1), 158-163
A systematic review of stem cell-based neural regeneration as post-ischemic stroke therapy for the development of stem cell banking in Indonesia Gabriele J. Kembuan1, Kevin J. Wijanarko1, Yusuf Azmi1 1
Faculty of Medicine, Universitas Airlangga, Indonesia
Introduction: The increasingly widespread use of human stem cells to treat conditions that had no solution before, shows that the stem cell approach to medicine may be the key for developing medical science in the future. One of the most common, yet difficult, conditions plaguing many nations including Indonesia is the loss of function in patient after an ischemic stroke event. It turns out that stem cell is now a viable approach in treating this morbidity, and the authors aim to elaborate on both the theoretical basis of stem cell use, as well as explaining the translation from bench to bedside by explaining about the available clinical trials to date. The advantages and increasing prominence of umbilical cord blood derived stem cells will also be discussed. Methods: We systematically reviewed journals from databases such as PubMed, Cochrane, and ScienceDirect, as well as government documents, to determine the viability and the best approach to stem cell that is most suitable to the conditions in Indonesia. Key Findings: We found that stem cell therapies are gaining increasing prominence and are undergoing several clinical trials. We summarized from many studies that stem cells have various properties that yield it viable as a treatment approach in stroke and CNS repair in general, and that umbilical cord blood stem cells hold advantages in differentiation and HLA antigenicity compared to other adult stem cells. We also found that the majority of clinical trials on stroke yield satisfying results, and that the field of stem cell medication is rapidly expanding, with a focus on umbilical cord stem cells. We suggest umbilical cord blood banking as a form of feasible futuristic medicine approach by the Indonesian government. Scope of research and areas for future research: Our study is a systematic review feasibility study on translational medicine, health policy, and regenerative medicine. We suggest future research on implementation, feasibility, and further clinical trials. Correspondence: Gabriele J. Kembuan [email] k_gabriele@outlook.com [phone] +6289688884209
A systematic review of stem cell-based neural regeneration as post-ischemic stroke therapy for the development of stem cell banking in Indonesia
Gabriele J. Kembuan Kevin J. Wijanarko Yusuf Azmi
Faculty of Medicine, Universitas Airlangga, Indonesia AMSA-Universitas Airlangga Asian Medical Students Association Indonesia
A systematic review of stem cell-based neural regeneration as post-ischemic stroke therapy for the development of stem cell banking in Indonesia Gabriele J. Kembuan 1, Kevin J. Wijanarko 1, Yusuf Azmi 1 1
Faculty of Medicine, Universitas Airlangga, Indonesia AMSA Universitas Airlangga, AMSA-Indonesia
Introduction The increasingly widespread use of human stem cells to treat conditions that had no solution before, shows that the stem cell approach to medicine may be key for developing medical science in the future. Use of stem cells in patients undergoing many diseases is now also complemented by the promise of regenerative therapy present in both bone marrow and cord blood. One of the most common, yet difficult, conditions plaguing many nations including Indonesia is the loss of function in patient after an ischemic stroke event. It turns out that stem cell is now a viable approach in treating this morbidity, and the authors aim to elaborate on both the theoretical basis of stem cell use, as well as explaining the translation from bench to bedside by explaining about the available clinical trials to date. The advantages and increasing prominence of umbilical cord blood derived stem cells will also be discussed.
Purpose The authors aim to give possible suggestions on the possible futuristic approach in translating basic science research to clinical medicine, that is also relevant to the needs of Indonesian populace. The authors also aim to give suggestions on stem cell banking as an important futuristic medical approach in Indonesia.
Research and Methodology This study is based on journals found via specific keyword searches in databases such as PubMed, Cochrane, and Sciencedirect, as well as official Republic of Indonesia documents for epidemiological data. For clinical trials, the authors screen for eligible trials in clinical trials registry and followed up the trials via comprehensive searches in the companyâ&#x20AC;&#x2122;s archives. The information is then synthesized and summarized and finally suggestions are made based on the conclusions.
Result and Discussion Stem Cell as Therapy Stem cells are cells found in virtualy all multicellular organisms featuring an ability to divide and differentiate into another type of cell. Stem cells can be further classified as totipotent, pluripotent, multipotent, or unipotent â&#x20AC;&#x201C; depending on the type of tissue(s) that the cell can differentiate into.[1-3] Although commonly found during embryonic development, stem cells can be found and harvested post-natal, including from an adultâ&#x20AC;&#x2122;s organs. Based on its source, stem cells can be classified into of embryonic origin (ES, embryonic stem cell) or of adult origin â&#x20AC;&#x201C; if harvested post-natally. Adult stem cells can be further classified by its tissue of origin, such as neural, hepatic, umbilical cord blood, etc.[4] Embryonic stem cells are totipotent stem cells harvested from the morula or pluripotent cells taken from the inner cell mass within a pre-implantation blastula. Embryonic stem cells are very versatile due to its near-zero level of differentiation, and through modifications of multiple transcriptional factors, including OCT and NANONG, ES cells can theoretically give rise to every type of tissue in the adult organism. But due to the adverse effects of cell harvesting on the embryo, usage of ES gives rise to multiple ethical problems, and are very restricted in use, mostly only for research purposes. For the creation of a viable countrywide source of stem cells, ES cells are generally avoided due to ethical considerations. Adult stem cells, however pose almost no ethical controversy, and are generally preferred for widespread medical use.[6-8] The human umbilical cord blood is a rich source of stem cell and has been studied as a source of adult stem cell. Cord blood harvested for stem cells can originate from the recipient or from a donor and are screened, frozen and stored for future use.[4-5] Comparison of Umbilical Cord Blood derived stem cell and other adult stem cells The choice of stem cell type for treatment relies largely on technology available within the country of note and the nature of the disease being treated. The most widely used stem cell treatments for haematological malignancies such as leukemia and bone marrow failure use bone marrow-derived haematological stem cells. Stem cell treatments from cord blood may be a viable alternative, due to better tolerance for HLA mismatch and therefore easier donor-recipient matchup, with only a match of at least 4 HLAs needed for immune tolerance (compared to a match of 6 HLAs using bone marrow cells). Umbilical cord blood transplants also show lower incidence of graft versus host disease (GvHD). Therefore, this also consequently
shortens the time from donor-searching to actual transplant. If an umbilical cord blood bank is available, and assuming the patient is 10 years old or younger (lifetime of umbilical cord blood storage), the patientâ&#x20AC;&#x2122;s own cells can be used, allowing quick treatment. This is especially important in bone marrow suppressed individuals of rare HLA types and ethnic minorities, due to difficult donor-recipient matchup and the less constrained HLA matchup of human cord blood transplant being of large importance. Another important advantage in using umbilical cord blood is its relatively undifferentiated state compared to bone marrow haematological stem cells.[4-5, 9] Of other types of diseases that are still being clinically evaluated, depending on tissue type to be regenerated, human cord blood stem cells may or may not be a viable alternative. Mesenchymal stem cells (taken from the bone marrow or umbilical cord blood) can be differentiated into many different cell types with smaller diffculty, such as myocytes and neuronal cells. For more specialized adult stem cells found within organs, harvesting an adequate amount of cells can be problematic, such as in the brain, where neuronal stem cells are not as abundant or easily obtained. Regarding the regeneration of neurons or non-neuronal (glial) cells for treatments of diseases such as Lou Gehrigâ&#x20AC;&#x2122;s disease and ischemic stroke, BM mesenchymal cells are the focus of many studies and recent advances in the ability of producing multiple cell types from three germ layers from cord blood potentially drives its clinical importance forward.[4-5] A 2012 study outlines the 3 different types of stem cells found within umbilical cord blood, which are haematological stem cells, mesenchymal stem cells (similar to bone marrow derived MSC), and SSEA-4 expressing stem cells, which are similar to embryonic stem cells. UCB stem cells also express OCT4, SOX2 and NANOG, which are markers of pluripotent cells. Of particular interest in the regeneration of neural tissue, UCB MSCs are the most viable option.[4] These cells have the inherent ability of differentiating into mesodermal cell types (osteogenic, adipogenic and chondrogenic lineages) as well as cells of non-mesodermal origin, including neuron.[10-11] MSCs isolated from umbilical cord blood shows high morphological similarities with bone marrow derived MSCs.[12-14] Although the isolation of MSCs from umbilical cord blood poses a problem due to their low number, compared to the bone marrow, cord blood-derived MSCs have higher proliferation capabilities than bone marrow MSCs and have been successfully differentiated into osteogenic, chondrogenic, neural and hepatic lineages.[15-16] Culturing Stem Cells Neural Lineages
Culture of UCBs into neural stem cells (NSC) involves procedures to separate mononuclear cells from whole blood, and further processed by depleting CD34+ cells (CD34 being a marker for haematological stem cells) and CD45. This procedure effectively selects non-haematological stem cells, which can be further differentiated into neural/non-neural stem cells, expressing markers of OCT4 and SOX2. Purified non-haematological stem cells can then be further differentiated into NSCs through a 3-step induction. Cells are first cultured using a media infused with epidermal growth factor (EGF) and bFGF for 10 days, then moved to another medium with a lower concentration of EGF, brain derived neurotrophic factor (BDNF) and retinoic acid for 7 days. The last step involves maturation using EGF, BDNF, and neural growth factor (NGF) for 7 days.[9,17] Further conditioning of mature NSCs can be conducted through specific culture methods. NSCs can be co-cultured with rat astrocytes, oligodendrocytes, microglia, or neurons. Co-culture with astrocytes promotes differentiation of NSCs into neuronal cells, with a small proportion of differentiation into astrocytes. In contrast, differentiation when co-cultured with microglia provides an almost equal proportion of neurons and astrocyte differentiation. Co-culture with rat neurons promote the differentiation of NSC into oligodendroglia-like cells. These different differentiation procedures can be used accordingly to adjust cellular composition result.[18]
Diseases in Indonesia In the last decades, Indonesia has faced the problem of triple burden diseases. On one hand, infectious diseases are still a problem which is characterized by frequent outbreaks of certain infectious diseases, reappearance of some infectious diseases (re-emerging diseases), as well as the emergence of new infectious diseases (new-emerging diseases) such as HIV / AIDS, Avian Influenza, and the Swine Flu. On the other hand, noncommunicable diseases show an increasing trend over time. According to Riset Kesehatan Dasar (Riskesdas) in 2007 and Survei Kesehatan Rumah Tangga (SKRT) in 1995 and 2001, for 12 years (1995-2007) there had been an epidemiological transition in which the mortality due non-communicable diseases increased while the mortality due to infectious disease decreased.[18] Data from Riskesdas in 2013 shows the number of hypertensive disease ranks top in the category of non-communicable diseases with the prevalence of 28.5%, followed by arthritis (24.7%), stroke (12.1%), asthma (4.5%), COPD (3.7%), diabetes mellitus (2.1%), and heart disease (1.5%).[19] While in terms of mortality, stroke is considered as a noncommunicable diseases that cause most deaths. According to Sample Registration Survey in
2014 by Badan Penelitian dan Pengembangan Kesehatan (Balitbangkes), stroke led to the most fatality rate with a percentage of 21.1 %, followed by heart disease (12.9 %), and diabetes mellitus (6.7%).[20] The prevalence of stroke increases with age, tends to occur in people with low education and are more prevalent in urban areas than in rural areas.[21] A stroke, sometimes called a brain attack, occurs when a clot blocks the blood supply to the brain (ischaemic) or when a blood vessel in the brain bursts (haemorrhagic).[22] The vast majority of stroke is ischaemic stroke that accounts for approximately 80% of strokes. Vessel rupture into brain parenchyma (10%) and into the subarachnoid space (10%) comprises the remainder. Mortality of cerebral infarcts is 5-10% during hospitalization, 1020% by 30 days, and 20-30% by a year. Moreover, the dependency is 50% among survivors.[23,24]
Ischemic Stroke Treatment Ischemic stroke and post-stroke neural regeneration therapy Traditional clinical management of ischemic stroke includes thrombolytic therapy, percutaneous intravascular interventions, behavioral rehabilitation strategies, and medication such as aspirin. The wide application of thrombolytic therapy is limited by a narrow time window (within 3â&#x20AC;&#x201C;4.5â&#x20AC;&#x2030;h after acute stroke onset) and possibility of a serious hemorrhagic complication.[25] There are several events involved in neural cell death in brain of stroke patients.[25-27] Initially, increased apoptosis, triggered by calcium influx, impaired mitochondria, and energy depletion and followed by glutamate excitotoxicity as a result of oxygen and glucose depletion, play a pivotal role in cell death. The release of nitric oxide, oxygen free radicals, and other reactive oxygen species cause further damage to neurons. In addition, the abolishment of blood-brain barrier by the release of matrix metalloproteinases (MMPs) and other proteases from endothelial cells allows the infiltration of immune cells. Cytokines released by immune cells lead to an inflammatory reaction and increased brain injury.[28, 29]
Mechanism of repair or replacement in ischemic stroke Donor stem cells as post-ischemic stroke therapy must not only survive in the CNS setting, but must also be capable of improving the pathophysiological condition, possibly by modulating local inflammatory and immune reactions, and by antagonizing toxic phenomenon. It has been previously documented that human neural stem cells (hNSC) have high integration capacity and prospective therapeutic efficacy in preclinical rodent models of neurological disease.[30] Whether implanted
intravenously or intrathecally, NSCs shows amelioration of the pathophysiological and neurological traits in experimental model of autoimmune encephalomyelitis, both in rodents and non-human primates.[31] Several mechanisms have been explored to account for the beneficial effect of MSCs (mesenchymal stem cells) on experimental stroke model. MSCs might exert their effects via a series of secreted trophic factors that directly or indirectly promote ischemic brain tissue repair. MSCs are stimulated to secrete various neurotrophic factors, including cytokines, chemokines, and extracellular matrix protein by damaged surrounding environment. Secretion of trophic factors by MSCs might play critical roles in neuroprotection, angiogenesis, synaptogenesis, endogenous neurogenesis, and inflammatory and immune response.[32,33] Several studies found that numerous neurotrophic factors such as SDF-1, VEGF, GDNF, BDNF, NGF, IGF, EGF, and bFGF were significantly increased in ischemic animal brain after MSCs treatment
[34][35]
The neuroprotection mediated by these neurotrophic factors,
including antiapoptosis, increasing neuron survival, antioxidation, antiglutamate excitotoxicity, and anti-inflammatory activity probably account for beneficial effects of MSCs on ischemic brain injury. Moreover, MSCs have also been described to favor angiogenesis and synaptogenesis.[36-38] In another study, enhanced proliferation, migration, and differentiation of endogenous neural stem/progenitor cells have also been demonstrated in the SVZ and the subgranular zone of the hippocampus when Flk-1+ hBMSCs was intracerebrally injected into ischemic brain in rats. It is speculated that enhanced endogenous neurogenesis might be attributed to increased angiogenesis and subsequent improved CBF.[39-41] Inflammatory and immune response modulation by MSCs are mechanisms underlying neuronal protection in ischemic stroke. After Ad-MSCs were intravenously injected into a rat model of stroke, mRNA expressions of IL-18, TLR-4, and plasminogen activator inhibitor (PAI)-1 in the infarcted brain area, indexes of inflammation, were significantly reduced.[42-43] MSCs administration into MCAO rats could cause amplification of activated CD11+ microglia and reactive GFAP+ astrocytes in the peri-infarct area are far greater and more long lasting than those seen after stroke alone.[44-45] Recently, MSCs have been demonstrated to decrease MCP-1 expression and subsequent infiltration of CD68+ cells in the ischemic brain.[46] Homing of transplanted cells to areas of tissue damage is extremely important towards the success of stem-cell therapy. Many research reports have concluded that MSC can home to areas of tissue injury: MSC appear to be able to â&#x20AC;&#x153;senseâ&#x20AC;? hypoxia and migrate to ischemic areas.[47] Human MSC mRNA analysis have
shown several cytokines or chemokines that could be involved in MSC homing, including CCR1, CCR2, CCR4, CCR7, CCR9, and CXCR5 and CXCR6.[48-49]
Clinical application of stem cell therapy Several clinical trials on stem cell focused for ischemic stroke treatment utilize mesenchymal stem cells, mostly originated from patientsâ&#x20AC;&#x2122; bone marrow. The authors found eleven clinical trials to date that perform research on stem-cell therapy feasibility in ischemic stroke treatment. Out of these, five trials are already completed and have published results in sufficient detail for further elaboration in this review, as detailed in Table 2. Three other studies (Aldagen, Johnson and Johnson, and Stemedica) have not concluded whether stem cell therapy provides significant benefit to their subjects; however, these studies have confirmed that stem cell therapy posed no immediate risks or additional morbidities to their subjects so far.[50] Table 1. Current and finished clinical trials utilizing stem cell for ischemic stroke therapy No
1
Clinical Trial
Stem Cell Source UCB
Marrow
derived
derived
ReNeuron Ltd., PISCES
Others
v fetal
Stem Cell Result
Route of
Ischemic
Administration
Stroke
Neural
Non-
Blood
Intrace
Unkn
Stem
Neural
(IV/I
rebral
own
Cell
Stem Cell
A)
v
v
Stage
Stable
Trial 2
Aldagen NCT01273337
v
v
IA
Post-Acute
3
Athersys Inc
v
v
IV
Acute
4
China Medical University
v blood
v
v
Chronic
Hospital 5
Johnson and Johnson RnD
v
v
IV
Acute
NCT01273467 6
SanBio NCT01287936
v
v
7
Stemedica NCT01296413
v
v
8
Bundang CHA Hospital
v
v IV
v
Chronic Chronic
v
Unspecified
NCT01884155 9
Honmou et al
10
Jiang et al
11
Bhasin et al
v v v
v
IV
Chronic
v
IA
Chronic
v
IA
Chronic
ReNeuron, Inc. is currently holding the Phase II trial of their PISCES study, utilizing allogeneic,
fetal
brain-derived
neural
stem
cells
immortalized
with
cmycER
ReN001/CTX0E03. After a twelve-month follow up, the study managed to conclude that the median NIHSS of their subjects increased from 7 to 4, and an MRI analysis showed signs of increased short term connectivity between putamen and sensory control organs. However, this study utilizes fetal stem cells instead of adult stem cells, and does not have any control subjects.[50] In a study by China Medical University Hospital, MSC stem cells are implanted intracerebrally and conferred a significant increase in the median NIHSS score post-12 month follow up, compared to control group with the same size.[51] In the study by Honmou et al., autologous MSCs, expanded in autologous serum, were delivered intravenously 36–133 days after stroke. There were no cell infusion-related side effects such as tumours, abnormal cell growths, neurological deterioration, or venous thromboembolism. As a result, the median daily rate of NIHSS change increased during the first week after infusion, and mean lesion volume as assessed by MRI was reduced by >20% at 1 week after cell infusion.[52] Table 2. Results of clinical trials in stem cell therapy for ischemic stroke Clinical
Study details
Treatment Outcome
trial
NIH Stroke Scale
ReNeuron
Fetal brain derived NSC
Ltd.,
Baseline Score
12-month follow up
(median)
score (median)
7
4
MRI / Radiology Parameter
Success Rate
Increased short
7/11
immortalized with cmycER
term connectivity
Sample
PISCES
ReN001/CTX0E03
between putamen
Trial
Allogeneic genetically modified,
and sensory
clonal
control regions
China
Peripheral blood, CD34+ ,
Control: 9.3 ±
Control: 8.7 ± 1.9
Positive MEP
Control:
Medical
Intracerebral implantation, in
0.5
Intervention: 5.5 ±
response
0/15
University
combination with conventional
Intervention:
1.8
Hospital
treatment
9.6 ± 0.5
SanBio
Adult mesenchymal stem cells
Statistically
NCT0128
transiently modified with Notch
significant
7936
plasmid, SB623. MRI Guided
improvement in
stereotactic injection
median score
Intervention : 9/15
Honmou
Autologous MSCs, expanded in
Median daily
Median daily rate of
Reduction of
et al
autologous serum, delivered
rate of
improvement: 0.36
lesion volume by
intravenously 36–133 days after
improvement:
points
more than 20%
stroke
0.04 points
Bhasin et
50–60 million bone marrow-derived
Statistically
al
MSCs infused intravenously into
significant
patients with diagnosed stroke from 3
improvement in
months to 2 years of index event
median Barthel score
In a clinical trial by Jiang et al., four patients with stroke (three with ischemic and one with hemorrhagic stroke) in the middle cerebral artery territory were recruited. One single dose of 2 × 107 UCMSCs was infused into the MCA. No side effects such as stroke, death, fever, and rash were observed during the 6-month follow up. Improved modified Rankin scale was observed in two of the ischemic patients. However, the efficacy and safety of the approach cannot be determined due to the small number of enrolled patients and lack of control.[53] Meanwhile, a recent study by Bhasin et al. studied 50–60 million bone marrowderived MSCs infused intravenously into patients with diagnosed stroke from 3 months to 2 years of index event. There were no mortality or cell-related adverse reactions in stem celltreated patients. Modified Barthel Index (mBI) showed statistical significant improvement in the stem cell group. An increased neural plasticity was observed after stem cell infusion indicating neural plasticity. The authors concluded that stem cells act as “scaffolds” for neural transplantation and may aid in repair mechanisms in stroke.[54] Another study by SanBio, inc. also showed a statistically significant improvement in NIHSS score of subjects, after treatment with SB623 stem cells that are mesenchymal in origin with a modified Notch plasmid. [55] Out of these eleven studies, an overwhelming amount shows promise in furthering the translation of stem cell treatment from bench to bedside. All of the completed studies show that stem-cell therapy can confer beneficial results in the intervened subjects, both in terms of behavioral improvement (NIHSS and Barthel Stroke Scale), and through MRI imaging. Although more, larger studies are needed, the authors believe that stem-cell mediated therapy for ischemic stroke is viable for use and development and may hold the key for bettering stroke treatment in the future.
Umbilical cord stem cell banking in the future of medicine More studies are needed to clarify details about technical considerations in using stem-cell derived therapy in post-ischemic stroke treatment, such as determining which source of cells is preferred in the uses of regenerative therapy. Moreover, implications related
12/12
to banking cord blood in both private and public settings, must be considered and studied. But the authors believe that the current outlook on the issue is an optimistic one. The use of bone marrow derived-cells, or other autologous stem cells, in treating diseases, are clinically less preferred than those of umbilical cord blood derived cells. The extraction of marrow stem cells is invasive, and the quality of these stem cells decreases with age. For non-autologous stem cell use, the use of umbilical stem cell is much more preferred, mostly because of better tolerance for HLA mismatch and therefore easier donor-recipient matchup, with only a match of at least 4 HLAs needed for immune tolerance (compared to a match of 6 HLAs using bone marrow cells), and lower incidence of graft versus host disease (GvHD). Therefore, this also consequently shortens the time from donor-searching to actual transplant. Another important advantage in using umbilical cord blood is its relatively undifferentiated state compared to bone marrow haematological stem cells.[55-57] Existing cord blood banking establishments usually focus on HLA diversity, for purposes of hematopoietic stem cell transplantation (HSCT). However, the use of stem cell in other regenerative applications may rely on units with properties that may not be ideal for HSCT. Specific cell types, such as MSCs, may need to be expanded first and then stored, or developed from cryopreserved unprocessed units of umbilical cord blood. The selection of regenerative units, including those for CNS therapy, however, must also be limited to the more common HLA haplotypes, to preserve the rare haplotypes for HSCT use.[55] This also requires more study to assure that immune rejection does not occur at significant levels. Greater understanding about specific biomarkers that characterize regenerative therapy units may also help further distinguish stored cord blood for regenerative use and those best suited for HSCT. MSCs isolated from umbilical cord blood show high morphological similarities with bone marrow derived MSCs.[56] Although the isolation of MSCs from umbilical cord blood poses a problem due to their low number, compared to the bone marrow, cord blood derived MSCs have higher proliferation capabilities than bone marrow MSCs.
Picture 1. The growth of umbilical cord stem cell therapy, 1997-2009
Many clinical trials for CNS regenerative therapy uses patientsâ&#x20AC;&#x2122; own marrow cells in developing NSCs. However, the derivation of MSCs and NSCs from umbilical cord blood was already identified in the early 2000s and the derived cells are similar to the marrowderived cells, except for the surface expression of molecules such as intercellular adhesion molecule 1 (ICAM-1) or CD54. The biological importance of this increased expression remains under active study.[57,58] UCB derived cells can also be induced toward neuron-like morphology when cultured in neuron inducing medium, which is confirmed by expression of cytoskeletal proteins found in neurons and astrocytes-like beta-tubulin III and glial fibrillary acidic protein.[59] Moreover, USB derived MSCs may have broader applicability in regenerative therapy than MSCs derived from adult tissues, such as marrow or adipose tissue, because of a loss of differentiating potential that is associated with aging.[60] Taken together, UCB derived MSCs represent a promising candidate for stem-cell based regenerative therapy for a broad range of damaged tissues. CBUs
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Cum.
44
70
105
136
181
229
256
292
406
452
537
462
508
691
848
1,467
1,740
2,336
2,671
3,393
3,522
3,749
21,387
1.05%
0.73%
0.66%
0.62%
0.81%
0.76%
0.91%
0.91%
0.84%
0.78%
0.70%
3.98%
available x1000 CBUs provided Percentage
Table 3. Increasing scope of umbilical cord banking, 1999-2009
It is indeed more difficult to expand MSCs from UCB than it is with marrow-derived cells. Despite this challenge, successful production of clinical grade MSCs from cord blood or placental tissues has been accomplished by private or public cell banking facilities; and considerable preclinical research activity has occurred using UCB-derived MSCs to facilitate tissue repair in animal studies.[61] Cell banking facilities also play an even greater role in stem cell therapy, since the need for non-autologous stem cells is increasing rapidly. In the study by Bart, it is shown that during the last 12 years, amount of non-autologous stem cell donation has more than quadrupled, making it an important niche for UCB derived cells to shine, thanks to their low antigenicity and wide availability. The same study concluded that the amount of cord blood units available has increased more than twelve-fold in 2009, compared to 1999. This shows that worldwide, UCB derived stem cells is gaining more prominence and it may be key towards future medicine.[61]
Conclusion Post-ischaemic stroke therapy is an important niche that needs to be addressed by the Indonesian government in the future. The increasing research on stem cells has extended the idea from bench to clinical setting, and so far most of the trials conducted show promise in its utilization in the future. Umbilical cord blood stem cell is a very viable source of stem cell, especially in terms of non-autologous stem cell draft, and it confers advantages both towards the host and during further processing in laboratories. The industry for UCB-derived stem cells is currently expanding rapidly, and stem cell banking might be a viable idea to develop in future Indonesian medicine.
Future Suggestions ď&#x201A;ˇ
More research needs to be done on the use of stem cells, both in laboratories and in more clinical trials.
ď&#x201A;ˇ
Feasibility studies can be performed to analyze in detail the possibility of a stem cell banking institution in Indonesia in the future.
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Eyes are windows to the world: The use of pupillometry to diagnose autonomic disorder in elderly. Gerry Wino*, Theodora Kristoforus, Robert
AMSA-Unika Atma Jaya, Faculty of Medicine Universitas Katolik Indonesia Atma Jaya Abstract
Background and introduction: The pupil response is controlled by the parasympathetic and sympathetic system of the autonomic nervous system. The neurotransmitter controls the movement of pupils as it receives light stimulation. Individuals with impaired autonomic system will present abnormal pupil response. This is the fundamental of pupillometry to be used as an early diagnostic tool for people, especially the rising elderly population, with autonomic disorder. However, the limitation of publication of the topic and research conducted poses questions about the validity, reliability and efficacy of the method. The purpose of this study is to evaluate the use of pupilometer and its probability as a device to diagnose patients with autonomic disorder. Methodology: The method pursued in this study is literature review. Scholarly publications between the year 2005 to 2015 from Proquest, Springerlink and Google Scholar are used. The scope of the research varies from around the world. The keywords included are “pupillary response”, “pupillometry” and “autonomic nervous system” or “autonomic disorder”. Result: Pupillometry has a potential to be an early detection method of various disorders, especially autonomic disorders in elderly. Studies show that there is a significant difference in pupil diameter due to stimuli carried out in pupillometry. Patients with diabetes, dementia and sympathetic and parasympathetic disorder have smaller pupil diameter compared to healthy controls. Validity is proven from the result of test and re-test as well as constant finding in tests of the pupil diameter. It is simple to be carried out and requires only infrared camera to record the movement and can be easily replicated, relatively economical and requires less training. Pupil dysfunction also occurs earlier compared to a more general manifestation of autonomic disorder. Conclusion: The significant difference in pupil response between healthy controls and patients with autonomic disorder allows pupillometry to be considered as a diagnostic device in these cases. Besides the convenience, it answers the need to provide massive and easy detection among the rising population in countries with logistic and geographical limitation. However, further studies should be conducted since the exact algorithm of diagnosis and findings according to lesions are not able to be used as guideline.
Keywords: pupillometry, autonomic disorder, elderly population
Contact details of director: Gerry Wino Correspondence author AMSA-Unika Atma Jaya +6282155563317 gerrygoei@gmail.com
Eyes are windows to the world: The use of pupillometry to diagnose autonomic disorder in elderly
AMSA UNIKA ATMA JAYA Authors: Gerry Wino Theodora Kristoforus Robert
Faculty of Medicine Universitas Katolik Indonesia Atma Jaya Jakarta 14440 Indonesia Eyes are windows to the world: The use of pupillometry to identify autonomic disorder in elderly.
129
Introduction The eye is the window to the world. Through our eyes, we can see the things around us and perceive sensory stimulation. However, the eye is not merely a sensory organ that helps us receive visual stimulation. Anatomically, the eye consists of the conjunctiva, cornea, iris, pupil, lens, retina, blood vessels and optic nerve. Pupil is the part of the eye that is responsible in controlling the amount of light that comes in through the eye to the retina. Light adaptation is a considered as an important function for too much light can blind the eye, while too dim will result in the inability to see.(Sherwood, 2007) The pupil responds to light in two ways: dilate or constrict. In a bright area, the pupil will constrict to limit the amount of light. In contrary, pupil dilation will occur in dim area. Both the dilation (mydriasis) and constriction (miosis) of the pupil happens without awareness. Pupillary response is controlled by the autonomic nervous system. (Fion Bremner, 2009) Success in public health programs, better education and advancement in medicine has led to higher life expectancy. WHO released the list of countries with the highest life expectancy by gender groups. (“WHO | World Health Statistics 2014,” n.d.) For men, Iceland leads with the average life expectancy of 81.2, followed by Switzerland (80.7), Australia (80.5) and next are Israel, Singapore and New Zealand (80.2). Respectively, Japanese women have a life expectancy of 87, followed by Spain, Switzerland and Singapore (85.1) and Italy (85). Indonesia expects to reach 71.1 years old in average life expectancy and is predicted to reach 28.8 million elderly population (11.34% of the population) by the year 2020 (“Komisi Nasional Lanjut Usia - Komnas Lansia - Lampu Kuning Ledakan Kaum Renta,” n.d.), positioning itself as one of the countries with the highest elderly population in the world. (“Artikel | BKKBN,” n.d.) Autonomic nervous degradation occurs in the elderly population. The etiology might be from “natural cause” where the ability to repair the body could not up with the rate of degradation. Pathologically, autonomic nervous system disorder can result from underlying diseases such as diabetes.(“Diabetic Neuropathies: The Nerve Damage of Diabetes keep | National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK),” n.d.) Diseases such as Alzheimer’s, Parkison’s and dementia with Lewy bodies cause defects to the autonomic nervous system.(Allan et al., 2006) Autonomic nervous system covers a wide range of organ from the heart, gut motility, micturition, homeostasis.(Muppidi et al., 2013) This is the reason why autonomic disorder could be progressive and might impose serious problems to the patient.(cite) Early detection of a progressive disease could give better prognosis to the patient. The challenge is to provide early detection plan to help in diagnosing a patient with autonomic disorder that is both valid and reliable. Since pupil movements are controlled by the parasympathetic (constrict) and sympathetic (dilate) nervous system (Nowak, Żarowska, Szul-Pietrzak, & Misiuk-Hojło, 2014), any disorder
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regarding the autonomic nervous system could manifest as a defect of pupillary response.(Bremner, 2006) Pupillometry is gaining recognition in research of migraine (Connell & Baxendale, n.d.), psychiatry (Graur & Siegle, 2013) and autonomic disorder (Bremner, 2009). Methods to measure pupillary response varies from using pharmacology-induced pupillary test using tropicamide (Turana et al., 2014) to using pupillometer (Bremner, 2009). Since pupillometer only needs infra-red light and camera to function (Martínez-Ricarte et al., 2013), the method can be simply replicated to ensure wide coverage. Trusted ophthalmology research lab has begun to use their own version of novel pupillometer.(Bremner, 2009) However, the debate about the efficacy, validity and reliability of pupil movement as a biomarker of autonomic disorder is not resolved. The purpose of this study is to evaluate the use of pupillometer and its probability as a device to diagnose patients with autonomic disorder. Research Methodology In this literature review, we used the scholarly search engine Proquest, Springerlink and Google Scholar. The keywords used are “pupillary response”, “pupillometry” and “autonomic nervous system” or “autonomic disorder”. Using Proquest, we found 82 scholarly journals published from 1984-2014. From those numbers, 63 were published between the year 2005 and 2015. From Springerlink, 3 publications meets the purpose of the study. In the end, 5 studies suit the purpose of the research and is included. Results The basic principle of pupillometry is to measure the dynamic diameter of the pupil when given stimuli. (Nowak, 2014) Pupillometer mainly consist of a single camera with a frame grabber that is used to record the changing of diameter, optical path and infrared illumination (Figure 1). Measurements can be done monocular and binocular, although binocular measuring of the left and right eye using a single camera is recommended. Normal pupillograph are shown in Figure 2. Variability in pupil response helps locate the lesion of the disorder.(Muppidi et al., 2013) Autonomic disorder affecting the brain stem or peripheral autonomic ganglia could be associated with pupillary dysfunction. Conditions such as diabetes with or without cardiac autonomic neuropathy (CAD) results significant pupillary response difference within healthy patients and healthy control.(Ferrari et al., 2010)The ratio of pupil in darkness differs significantly between the healthy control, diabetic patients without CAD and diabetic patients with CAD. Healthy controls have shorter latency period from flash exposure to the start of constriction and greater iris-pupil ratio in the frame of largest constriction. The duration of constriction is not significantly different. Autoimmune autonomic gangliopathy (AAG) patients are also reported to show signs of parasympathetic deficit in the pupillary response test.(Muppidi et al., 2013)
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Sympathetic disorder, such as Horner syndrome, would manifest as dark miosis.(Figure 3) This is due to the inability of the pupil to dilate in a dark situation. Patients with parasympathetic disorder due to pre-ganglionic lesions would have large unresponsive pupils as a result of paresis of both ciliary and sphincter muscles. Lesions of the ciliary ganglion or short posterior ciliary nerves will result in accommodation disorder, with the levator muscles and extraocular muscles spared.(Bremner, 2009) Pupillometry is also a safe procedure. (Herbst 2010) During the experimental research to validate the result of pupillometer in healthy adults with no prior ophthalmologic disorder, ten participants from age 24 to 30 underwent pupillometry testing and re-testing using a novel pupilometer and no side effects during and after the test was reported. In the same study, no significant result between the test and re-test was found. However, there is a difference between the area under curve (ACU) between the test and re-test results. Discussion The results show how pupillometry is accurate as a measuring tool of dynamic pupil response. It also serves as a good diagnostic device for patients with suspected or confirmed autonomic disorder. Even when varius versions of pupillometer is used and in the absent of re-test, the pupillary diameter remains constant.(Muppidi et al., 2013) However, basic pupillary diameter should be adjusted according to age(Herbst, Sander, Milea, Lund-Andersen, & Kawasaki, 2011) Furthermore, pupillary dysfuntion manifest earlier before a more generalized autonomic disorder is present. Hence, pupillometry can be a simple, valid and reliable early detection device for autonomic disorder. (Ferrari et al., 2010) The parasympathetic nervous system innervates the iris sphincter muscle starting from the preganglionic neurons located in the ipsilateral Edinger-Westphal nucleus in the upper midbrain. It then joins the oculomotor nerve through the subarachnoid spaces and then terminate in the ciliary ganglion that lies in front or the superior orbital fissure in the orbital cavity. The sympathetic innervation of the dilator muscle of the eye runs from a polysynaptic pathway that originates in the ipsilateral hypothalamus. Throughout the brain stem and upper spinal cord, it runs uncrossed to then end in the cilio spinal center of Budge and Waller. From the thoracic level T1, the pre-ganglionic sympathetic fibers emerge and join the cervical sympathetic chain before terminating in superior cervical ganglion. Post-ganglionic fibers ascend along with the internal carotid artery to the superior orbital fissure through the middle cranial fossa. (Bremner, 2009) The receptors found in the parasympathetic are muscarinic receptors, while sympathetic receptors in the eye are made up of norepinephrine receptors.(Kara et al., 2013) This is complex as the muscles receive two stimulation at once (Figure 4). In the same time as parasympathetic cholinergic fiber stimulates the iris muscles to contract, it also receives beta-adrenergic innervations. The adrenergic sympathetic system innervates the dilator muscle, which results in limited contraction of the muscle.
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Hence, the pupil constricts. Alpha-adrenergic receptors are responsible for dilator muscle movements. Inhibition and relaxation of the muscle is controlled by muscarinic and possibly, beta-adrenergic receptors. (Monaco et al., 2012) The imbalance between the two causes pupillary response disorder. In small pupils, the failure to dilate can be caused by either hyperactivity parasympathetic activity, hypoactivity of the sympathetic system or both.(Maguire, Craig, Craighead, & Chan, 2007) In resting phase, pupil size is under sympathetic control. Constriction results from reduced sympathetic outflow. Thus, parasympathetic control is reflected the in pupilâ&#x20AC;&#x2122;s constriction phase. However, both are active during the recovery phase where the stimuli from the pupillometry is absent.(Ferrari et al., 2010) In the elderly population, there is a decrease of neurons in the norepinephrine locus coeruleus (LC). This structure plays in vital role in pupillary control as it creates tonic inhibition through the parasymphatetic Edinger-Westphal nucleus. (Hou et al., 2006) Damage in this area automatically results in small pupil diameter in pupillometry. As the elderly population are more prone to developing diabetes (Kirkman et al., 2012), the risk of developing autonomy disorder also increases. Diabetes is characterized by the high glycemic index in the blood. Prolonged exposure to high blood glucose can be damaging to the nerves, a condition known as diabetic neuropathy.(NIH) This condition has various clinical manifestations such as sensory, motoric and autonomic symptoms. Dementia is a neurodegenerative disorder that could be found in the elderly. This covers a wide range of cognitive impairment which progressive rostrocaudally. After affecting the cortex, it will reach the brain stem. The cranial nerve nuclei are spared, while the autonomic parasympathetic outflow is disturbed. This means that the Edinger-Westphal nucleus is affected.(Engelhardt & Laks, 2008) In the pupillometry, patients who suffers from dementia are mostly likely to present small pupil diameter due to the parasympathetic dysfunction. With the efficacy of the pupillometer to be implemented in areas with geographic and equipment limitation, and the reliability of the results compared to other methods (Ferrari et al., 2010), pupillometer might be a way to detect disorders, especially autonomic disorder in elderly. Furthermore, the method is simple and does not require a long time to train professional.(Herbst et al., 2011) Conclusion The eye is not merely a visual organ. The ability to perceive light stimulation in the form of pupil diameter movement can predict disorders that manifest in the abnormal dilation or constriction. Pupil response test has been used in multidisciplinary medical research ranging from neurology, psychiatry to endocrine metabolic disorder.
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Pupillometer is relatively simple, economist, portable and can be easily replicated using novel tools. The validity of the result when pupillary resting diameter is adjusted to age is reliable and remains constant from test to test. These advantages makes it a probable candidate as testing tool for autonomic disorder especially in the rising elderly population in Asian countries that mostly consist of developing nations and are made up of islands with limitation on equipment and logistics. Further studies about this topic are needed for pupillometry as a diagnostic tool for autonomic disorder needs more evidence. To this date, some findings are still contradicting or supporting other similar research. There is no systematic or meta-analysis of the study, thus findings with clear statistical significance is still needed. This is to provide more concrete proof of pupil reponse as a biomarker for autonomic disorder. The number of research is also limited as seen by the number of publication in the last 10 years. As the method holds potential in advancement of technology in medicine, more research into this topic is needed to provide exact diagnostic algorithm and map of lesions regarding the autonomic nervous system according to the clinical findings in pupillometry.
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References Allan, L. M., Ballard, C. G., Allen, J., Murray, A., Davidson, A. W., McKeith, I. G., & Kenny, R. A. (2006). Autonomic dysfunction in dementia. Journal of Neurology, Neurosurgery & Psychiatry, 78(7), 671–677. http://doi.org/10.1136/jnnp.2006.102343 Artikel | BKKBN. (n.d.). Retrieved October 20, 2015, from http://www.bkkbn.go.id/ViewArtikel.aspx?ArtikelID=111 Bremner, F. (2006). Pupil findings in a consecutive series of 150 patients with generalised autonomic neuropathy. Journal of Neurology, Neurosurgery & Psychiatry, 77(10), 1163–1168. http://doi.org/10.1136/jnnp.2006.092833 Bremner, F. (2009). Pupil evaluation as a test for autonomic disorders. Clinical Autonomic Research, 19(2), 88–101. http://doi.org/10.1007/s10286-009-0515-2 Connell, J., & Baxendale, J. (n.d.). Eyes play a focal role in research two unique techniques help characterize pharmacodynamic drug effects in healthy subjects. Retrieved from http://www.appliedclinicaltrialsonline.com/eyes-play-focal-role-research Diabetic Neuropathies: The Nerve Damage of Diabetes | National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). (n.d.). Retrieved October 20, 2015, from http://www.niddk.nih.gov/health-information/health-topics/Diabetes/diabetic-neuropathiesnerve-damage-diabetes/Pages/diabetic-neuropathies-nerve-damage.aspx Engelhardt, E., & Laks, J. (2008). Alzheimer disease neuropathology: understanding autonomic dysfunction, 2(3), 183–191. Ferrari, G. L., Marques, J. L., Gandhi, R. A., Heller, S. R., Schneider, F. K., Tesfaye, S., & Gamba, H. R. (2010). Using dynamic pupillometry as a simple screening tool to detect autonomic neuropathy in patients with diabetes: a pilot study. BioMedical Engineering OnLine, 9(1), 26. http://doi.org/10.1186/1475-925X-9-26 Graur, S., & Siegle, G. (2013). Pupillary motility: bringing neuroscience to the psychiatry clinic of the future. Current Neurology and Neuroscience Reports, 13(8). http://doi.org/10.1007/s11910013-0365-0 Herbst, K., Sander, B., Milea, D., Lund-Andersen, H., & Kawasaki, A. (2011). Test–retest repeatability of the pupil light response to blue and red light stimuli in normal human eyes using a novel pupillometer. Frontiers in Neurology, 2. http://doi.org/10.3389/fneur.2011.00010 Hou, R. H., Samuels, E. R., Raisi, M., Langley, R. W., Szabadi, E., & Bradshaw, C. M. (2006). Why patients with Alzheimer’s disease may show increased sensitivity to tropicamide eye drops: role of locus coeruleus. Psychopharmacology, 184(1), 95–106. http://doi.org/10.1007/s00213005-0227-9
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Kara, K., Karaman, D., Erdem, zeyir, Congologlu, M., Durukan, I., & Ilhan, A. (2013). Investigation of autonomic nervous system functions by pupillometry in children with attention deficit hyperactivity disorder. Bulletin of Clinical Psychopharmacology, 1. http://doi.org/10.5455/bcp.20121130085850 Kirkman, M. S., Briscoe, V. J., Clark, N., Florez, H., Haas, L. B., Halter, J. B., … Swift, C. S. (2012). Diabetes in older adults. Diabetes Care, 35(12), 2650–2664. http://doi.org/10.2337/dc121801 Komisi Nasional Lanjut Usia - Komnas Lansia - Lampu Kuning Ledakan Kaum Renta. (n.d.). Retrieved October 20, 2015, from http://www.komnaslansia.go.id/modules.php?name=News&file=article&sid=26 Maguire, A. M., Craig, M., Craighead, A., & Chan, A. (2007). Autonomic nerve testing predicts the development of complications: a 12-year old follow-up study, 30(1), 77. Martínez-Ricarte, F., Castro, A., Poca, M. A., Sahuquillo, J., Expósito, L., Arribas, M., & Aparicio, J. (2013). Infrared pupillometry. Basic principles and their application in the non-invasive monitoring of neurocritical patients. Neurología (English Edition), 28(1), 41–51. http://doi.org/10.1016/j.nrleng.2010.07.001 Monaco, A., Cattaneo, R., Mesin, L., Ciarrocchi, I., Sgolastra, F., & Pietropaoli, D. (2012). Dysregulation of the autonomous nervous system in patients with temporomandibular disorder: a pupillometric study. PLoS ONE, 7(9), e45424. http://doi.org/10.1371/journal.pone.0045424 Muppidi, S., Adams-Huet, B., Tajzoy, E., Scribner, M., Blazek, P., Spaeth, E. B., … Vernino, S. (2013). Dynamic pupillometry as an autonomic testing tool. Clinical Autonomic Research, 23(6), 297–303. http://doi.org/10.1007/s10286-013-0209-7 Nowak, W., Żarowska, A., Szul-Pietrzak, E., & Misiuk-Hojło, M. (2014). System and measurement method for binocular pupillometry to study pupil size variability. BioMedical Engineering OnLine, 13(1), 69. http://doi.org/10.1186/1475-925X-13-69 Sherwood, L. (2007). Human physiology: from cells to systems. Australia; United States: Thomson/Brooks/Cole. Turana, Y., Ranakusuma, T. A. S., Purba, J. S., Amir, N., Ahmad, S. A., Machfoed, M. H., … Waspadji, S. (2014). Enhancing diagnostic accuracy of aMCI in the elderly: combination of olfactory test, pupillary response test, BDNF plasma level, and APOE genotype. International Journal of Alzheimer’s Disease, 2014, 1–9. http://doi.org/10.1155/2014/912586 WHO | World Health Statistics 2014. (n.d.). Retrieved October 20, 2015, from http://www.who.int/mediacentre/news/releases/2014/world-health-statistics-2014/en/
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Appendix
Figure 1. Pupillometer consists of the pupil stimulator and the camera to record the response. source: Ferrari, G. L., Marques, J. L., Gandhi, R. A., Heller, S. R., Schneider, F. K., Tesfaye, S., & Gamba, H. R. (2010). Using dynamic pupillometry as a simple screening tool to detect autonomic neuropathy in patients with diabetes: a pilot study. BioMedical Engineering OnLine, 9(1), 26. http://doi.org/10.1186/1475-925X-9-26
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Figure 2. Normal pupillograph. source: Muppidi, S., Adams-Huet, B., Tajzoy, E., Scribner, M., Blazek, P., Spaeth, E. B., â&#x20AC;Ś Vernino, S. (2013). Dynamic pupillometry as an autonomic testing tool. Clinical Autonomic Research, 23(6), 297â&#x20AC;&#x201C;303. http://doi.org/10.1007/s10286-013-0209-7
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Figure 3. Horner syndrome resulted in (a) right sympathetic deficit and (b) bilateral sympathetic deficit in a patient with dopamine hydroxylase deficiency. source: Bremner, F. (2006). Pupil findings in a consecutive series of 150 patients with generalised autonomic neuropathy. Journal of Neurology, Neurosurgery & Psychiatry, 77(10), 1163â&#x20AC;&#x201C; 1168. http://doi.org/10.1136/jnnp.2006.092833
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Figure 4. Innervation of the spinchter muscle and dilator muscle by the parasympathetic and sympathetic nervous system. source: Muppidi, S., Adams-Huet, B., Tajzoy, E., Scribner, M., Blazek, P., Spaeth, E. B., â&#x20AC;Ś Vernino, S. (2013). Dynamic pupillometry as an autonomic testing tool. Clinical Autonomic Research, 23(6), 297â&#x20AC;&#x201C;303. http://doi.org/10.1007/s10286-013-0209-7
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The Future of Health Care Nafisa Naaz Nisha, Priscilla Christina Natan, Savannah Quila Thirza Brawijaya University
Background Today, it is widely understood that the health care system suffers from low quality and high medical error rates. Measures of the quality of care as a return on expenses and the incidence medical errors depict a severely underperforming system despite the expansion of medical knowledge and the use of increasingly sophisticated technology. As an example in Indonesia, we always have to wait for a long time to get a medical service such as blood test. Our healthcare system has to dramatically improved by establishing a high-efficiency system performing largescale repetitive tasks such as screening tests, inoculations, and generic health care. We suggests that an important step toward relieving this medical problem is to create our own personal health care device. And since the device has multifunction, easy to use, mobile, and doesnâ&#x20AC;&#x2122;t cost a lot, we sure that it will adversely affect the ability of health care organizations to provide either individual or prevention/population services. Objective Medical technologies benefit the lives of people in many ways. Through the use of such technologies, people can live healthier, more productive and independent lives. Many individuals who previously may have been chronically ill, disabled, or suffering chronic pain can now look forward to leading normal or close-to- normal lives. Improving quality of life is one of the main benefits of integrating new innovations into medicine. Medical technologies like minimally-invasive surgeries, better monitoring systems, and more comfortable scanning equipment are allowing patients to spend less time in recovery and more time enjoying a healthy life.
Contact details of Directors of Authors Name
: Nafisa Naaz Nisha
Name
: Priscilla Christina Natan
: fiza.nisha@gmail.com
: priscillanatan@gmail.com
Phone number
: 082245384242
Phone number
: 0838 4945 7354
Name
: Savannah Quila Thirza
: thirzaquilas@gmail.com
Phone number
: 082143802858
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A systematic review of stem cell-based neural regeneration as post-ischemic stroke therapy for the development of stem cell banking in Indonesia Gabriele J. Kembuan1, Kevin J. Wijanarko1, Yusuf Azmi1 1
Faculty of Medicine, Universitas Airlangga, Indonesia
Introduction: The increasingly widespread use of human stem cells to treat conditions that had no solution before, shows that the stem cell approach to medicine may be the key for developing medical science in the future. One of the most common, yet difficult, conditions plaguing many nations including Indonesia is the loss of function in patient after an ischemic stroke event. It turns out that stem cell is now a viable approach in treating this morbidity, and the authors aim to elaborate on both the theoretical basis of stem cell use, as well as explaining the translation from bench to bedside by explaining about the available clinical trials to date. The advantages and increasing prominence of umbilical cord blood derived stem cells will also be discussed. Methods: We systematically reviewed journals from databases such as PubMed, Cochrane, and ScienceDirect, as well as government documents, to determine the viability and the best approach to stem cell that is most suitable to the conditions in Indonesia. Key Findings: We found that stem cell therapies are gaining increasing prominence and are undergoing several clinical trials. We summarized from many studies that stem cells have various properties that yield it viable as a treatment approach in stroke and CNS repair in general, and that umbilical cord blood stem cells hold advantages in differentiation and HLA antigenicity compared to other adult stem cells. We also found that the majority of clinical trials on stroke yield satisfying results, and that the field of stem cell medication is rapidly expanding, with a focus on umbilical cord stem cells. We suggest umbilical cord blood banking as a form of feasible futuristic medicine approach by the Indonesian government. Scope of research and areas for future research: Our study is a systematic review feasibility study on translational medicine, health policy, and regenerative medicine. We suggest future research on implementation, feasibility, and further clinical trials. Correspondence; [email] k_gabriele@outlook.com [phone] +6289688884209
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The efficacy of transcranial magnetic stimulation on improving motoric functional impairment of post ischemic stroke patients. Iin Tammasse1, Khumaira1, Nadya Sumolang1 1
Hasanuddin University, South Sulawesi, Indonesia
Background: Stroke is the 1st leading cause of death in Indonesia (15,4%). Advances have occurred in the prevention and treatment of stroke during the past decade. One of the current methods to treat post stroke disability is TMS. Transcranial magnetic stimulation (TMS) is a noninvasive method by which weak electrical currents are induced in the brain by a rapidly changing magnetic field. The magnetic field passes through the skull, inducing mild electric currents in the brain, which excite and depolarize neurons in the brain Aims and objective: This study is a cohort observational study to assess the efficacy of TMS intervention on improving motoric function of post-stroke patients. In particular, we measured the patientsâ&#x20AC;&#x2122; motoric impairment using the European Stroke Scale and compare the result before and after receiving TMS intervention. Key Findings: There was an average elevation of 15,48 from pre to post ESS score. (CI=95%)(p<0,05). The mean of pre- score was 70,19 and the mean of post-score was 85,68 with respectively standard deviation of 18,264 and 13,372 Methodology used: The study population consisted 124 post-ischemic stroke patients, who were undergoing TMS intervention in a clinic in Indonesia and followed up during January 2015 to September 2015. Inclusion criteria for this study are patients with post non-hemorrhagic stroke that has motoric functional impairment. The primary outcome measures the therapeutic efficacy of TMS intervention, using the European Stroke Scale (ESS). Paired T-test was used to assess the statistical significance of the sample. Scope of research and areas for future research: we can conclude that TMS is a technology that can be used to treat patients with post-ischaemic stroke motoric impairment and prevent further disability in the future. TMS intervention has been proven to be effective to improve patientsâ&#x20AC;&#x2122; clinical condition. We also see that there is a possibility of TMS to be used as solution for other motoric related disorder.
Authors : Iin Tammasse, Khumaira, Nadya Sumolang
Hasanuddin University, South Sulawesi, Indonesia iinfadhilahf@gmail.com +82188833395
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“CASPASE 1 INHIBITOR : THE PROMISING CELL SUICIDE INHIBITOR FOR THE HIV THERAPY” Ficky, Audrey Clarissa, Nathania Sutandi Asian Medical Students’ Association - Faculty of Medicine University of Indonesia HIV/AIDS has been the substantial health problem globally. In 2011, the number of people suffering from HIV infection has reached 34 million worldwide where it increases with an alarming rate, roughly around 2.7 million of new cases each year. In HIV progression to AIDS, the hallmark of this process is massive loss of CD 4+ T cells, in which the process called pyroptosis plays an important role. The underlying mechanism of pryoptosis is the activation of caspase 1 with inflammasome pathway that leads to a vicious cycle of CD 4+ T cells deaths. Antiretroviral therapy (ART) as the prime treatment for HIV/AIDS patient has shown to be beneficial in delaying the progression of HIV to AIDS. However, it does not prevent the progressive loss of CD 4+ T cells resulting in the resistancy of the drug. Mutation of HIV antiviral has become one of the major problems in the treatment currently. Hence, we introduce caspase 1 inhibitor as a new HIV therapy that works by inhibiting the inflammatory response, thus decreasing CD4+ T cells death and slowing the progression of HIV to AIDS. One of the most promising inhibitor is VX-765 in which IL-1β production can be hindered leading to the extension of the patient life span. In making this poster, we did a literature review on several medical journals and our findings show that caspase 1 inhibitor is a promising key therapy in the future HIV treatment. Keywords : HIV/AIDS, CD4+ T cell, cell to cell transmission, pyroptosis, caspase-1 inhibitor Author 1. Ficky Email : fickyhng21@gmail.com Mobile phone : 087893193597 Indonesia 2. Audrey Clarissa Email : audreyclarissa@hotmail.com Mobile phone : 081210381784 Indonesia
3. Nathania Sutandi Email : nia_sutandi@hotmail.com Mobile phone : 082168888807 Indonesia
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Mini Health Technology Assessment of Urban and Rural Health Care in Indonesia Angela Franzeska1*, Fabianto Santoso2*, Ferdy Iskandar3*, Yenna Tasia3, Kamajaya Mulyana4 1
Asian Medical Students’ Association – Universitas Airlangga, Surabaya, Indonesia 2
3 4
Asian Medical Students’ Association – Universitas Indonesia, Jakarta, Indonesia
Asian Medical Students’ Association – Universitas Katolik Atma Jaya, Jakarta, Indonesia
Asian Medical Students’ Association – Maranatha Christian University, Bandung, Indonesia
*Contributed equally
Background: Health Technology Assessment (HTA) is a program to evaluate the use of technology in healthcare. HTA proposed by World Health Organization (WHO) will affect the government’s decision-making in the development of healthcare technology. The use of technology should be assessed from its cost-effectiveness to its potential ethical problems. HTA Unit – a division who organizes HTA in government in Indonesia – has emerged in ministry of health in 2003 and focused in drugs and vaccines problems. However, HTA in Indonesia has not been formally effective until today. Objectives: To evaluate the usage, supply, and demand of the health technology and the spread of health technology in urban and rural areas. Methods: This study is a cross-sectional study using questionnaire to gather quantitative and qualitative data. The respondents of this study are medical doctors in Indonesia, and the selection of the respondents is done consecutively. We divide respondents’ area into urban and rural areas, and health practitioners as field executors (general practitioners or GP and specialists) and head of healthcare facilities. Results: The total samples are 48 health practitioners and 14 head of healthcare facilities. Statistical analysis shows that the two settings (urban and rural) are not significantly different (p=0.478), while descriptive analysis shows that the inadequacy of health technology is higher in rural than that in urban areas (70% vs 52.63%). The relationship between the field of health practitioners (GP and specialist) and the adequacy of health technology is not significant. More GP than specialists complain about the inadequacy of health technology in giving the health service to the patients. About 92.8% head of health facility said that technology is needed to support the health service, while only 35.71% agreed that their health facilities still have inadequate health technology.
Conclusion: The use of health technology in Indonesia is still inadequate. The spread of health technology is not equal in urban and rural areas. The lack of health technology in rural areas, especially for GP, affect in diagnosing and giving therapy to patients. The poor spread of technology in healthcare also make gap between health research and health clinical practice. Key Words: health technology assessment, urban, rural, Indonesia Scope of research and areas for future research: This mini HTA can be followed up by conducting the research equally distributed in all provinces in Indonesia with the help of medical students all over Indonesia. Contact information: Angela Franzeska Phone number: +6287888800097 Email: enjifranzeska@gmail.com
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The Future Is Mobile Andi Tiara S.Adam, Andi Yaumil Chaeriyah, AndiAsyuraAlikha Faculty of Medicine, Hasanuddin University Makassar, Indonesia Abstract When people talk about the future of healthcare, most people will immediately picture super robots posing as surgical machines or advanced diagnostic tools that only exist in big hospitals. But to us who live in developing countries, our biggest dream is to have healthcare that can be accessed by anyone even in the most rural areas. What we fail to notice is that the answer is already here. The smartphone! Most people consider their smartphone as the most important piece of technology that they own. It can be seen through the number of smartphone users that keep onskyrocketing. Viewing the statistics, 1.91 billion people worldwide, including 55.4 million of Indonesia's population, are smartphone users. This shows that the smartphone has shifted from being a luxury item, to becoming a basic need and even a form of addiction for some people that compulsively check their phone every once a while. This form of addiction sends a negative message to the society that your smartphone is something that must be avoided, when the whole idea is notabout the choice between using it ornot, rather the choice to use it right. The way to use it right is by imbuing it with a positive matter like a healthcare application. There are approximately 97.000 mobile health applications that can help you reduce your risk of developing any noncommunicable disease by 80% and also help you fight through one. These applications can do the simplest actions like movement and activity tracking, to the more sophisticated actions like blood pressure and glucose monitoring, and noncommunicable disease management. In conclusion, we would like to promote the smartphone as the best solution for health issues, as it brings healthcare directly to usand it leads usto ourgoal, healthcare for all. Source: 1. "Smartphone Users and Penetration Worldwide".Emarketer, December 2014. 2. "Internet, Smartphone, and Social Media Usage Statistics".Rapidvalue, December 2014.
3. "Mobile HealthAppMarketplace toTake Off, Expected to Reach $26B by2017". Emarketer, March 2013. 4. Harris, Randall E. "Epidemiology ofChronic Disease Global Perspectives". Jones & Bartlett Learning, 2013. Contact details Andi Tiara S.Adam tiarasdm@gmail.com +6281354818969
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The Time Has No Limit But Your Body Surely Does Falensia Dwita Lestari, Nurizki Meutiarani, Richard Winardi Universitas Hasanuddin, Indonesia ABSTRACT Background Technology is not a new concept. Humans have been innovating ways to make life easier from the beginning. Recently, these changes have been coming faster and faster. Technology itself is not a bad thing; actually, it has helped better millions of lives by providing faster and more easily accessible information for education, job performance, and entertainment. However, it is becoming more of an impact and prevalent in the lives of its users. This leads to higher rates of technology addiction and can lead to numerous social, physical, and psychological problems. Technology often fulfills our natural human needs for stimulation, interaction, and changes in environment with great efficiency. Overusing the technology can lead to technology addiction. Vision Watch Data 2014 showed that nearly one-third of adults (30%) spend at least nine hours on digital devices each day. These are symptoms commonly associated with overexposure of digital devices such as eye strain, neck/shoulder/back pain, headache, blurred vision, dry eyes. This type of addiction unfortunately can lead to several bad impacts. Also, self- luminous devices, such as computers, tablets and cell phones can emit short wave length (blue) light, which maximally suppresses melatonin and cause detrimental to sleep quantity and quality. In order to prevent the negative impact of technology the user must use it wisely. Objective: Through this public poster, we would like to spread the message and increase society awareness regarding the bad impact of overusing technology and in the end we can get the benefit from technology without sacrificing our own body. Slogan: Get Your Body Undercontrolled Before Technology Take The Control Contact Details of Directors of Authors: Falensia Dwita Lestari falensia.dwita@yahoo.com +6211220345956
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Ectogenesis Henry Timothy, Fenska Seipalla Faculty of Medicine Universitas Airlangga, Indonesia Abstract According to World Health Organization in 2014, pregnancy and live births bring 800 women die in the world every day. The number might be reduced by ectogenesis technology. The technology allows you to grow a fetus outside the body in an artificial womb. It provides 24/7 mechanical life-support in a sterilized environment to ensure pathogens such as bacterias or viruses can not pass through the fetus. The placenta machine controls the supply of nutrients and oxygen. Fetus development like weight and circulatory system are also controlled by this machine. Custom-built amniotic fluid sacs will take the role of removing waste. For women who are unable to carry babies naturally because of uterus damage and menopause, ectogenesis gives a new hope for them. This technology also helps people who are willing to have children but cannot give labor and have to use surrogate mothers. Women would not feel any pain and they don’t have to worry about the labor time. However, as great as this sound, there are still many concerns with ectogenesis. It could be contradicted with women reproductive rights. Without the baby growing inside the mother, she would have less of a connection with the baby. Some say, it’s against the natural morality of human being. In addition, ectogenesis can provide great opportunity to increase our knowledge about fetus development and “Taking Gestation to The Next Level”.
Contact Details Directors of Authors; Henry Timothy Htimothy95@gmail.com +6285242854004
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One Cell Can Make a Difference Budi Santoso, Muhammad Reynald Aditya Faculty of Medicine, Universitas Indonesia, Indonesia
Abstract Stem cells are cells with remarkable potential to develop into many specialized cells. Studies in stem cells started in 1960s, but not until twenty years later scientists discovered ways to derive embryonic stem cells. Since then, research on stem cells has progressed rapidly and making breakthrough in medical world. There are many uses of stem cells, but perhaps the most important potential usage is as cellbased therapies. Nowadays, damaged tissues or organs are repaired by replace them with donated organs or tissues but the donor supply cannot suffice the demand for replacement. Stem cells offer the possibility of a source of replacement cells and tissues that can be renewed for treating diseases such as macular degeneration, stroke, burns, heart disease, diabetes, through its ability to differentiate into specific cell types and to divide by mitosis. Therefore, this poster is made to raise awareness among healthcare providers and society about the benefit of stem cell therapy. It illustrates that with stem cell therapy we can do amazing things, one of them is repair of damaged cell due to myocardial infarction. So, people can acknowledge that there is always hope for the better healthcare with the advance of technology and research in medical. Authors
Budi Santoso tjungbudisantoso@gmail.com +6282161317635
Muhammad Reynald Aditya rendi95@gmail.com +6285216841870
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Personalized medicine: your gene talks to us Koe Stella Asadinia1, Michelle Valeria1, Edelyne Chelsea1 1
Faculty of Medicine, Universitas Indonesia
Abstract Genome sequencing has taken medicine to a whole new level: personalized medicine.1 “Personalized medicine: your gene talks to us” represents the simplest form of understanding genomic-based medicine as a future of medical care. Each genome of an individual provides a blueprint of one’s life. Genome science has already begun to revolutionize the field of medicine in diagnosis, prevention, course of treatment in most human diseases ranging from Alzheimer’s, Parkinson’s, diabetes, to the most highlighted one: cancer.1-5 By determining an individual’s drug response and risk effects based on her or his unique genome, a tailored “perfect-fit” medical care could be conducted.2 In terms of therapy, personalized medicine enables enhancement of treatment outcome and minimization of undesired effects.2 Initial public understanding of personalized medicine concept will prepare society to anticipate further issues regarding the application itself. While scientifically being a medical breakthrough, personalized medicine is not without its challenges. Benefits of genomics are considered luxurious and far from means of public health.3 Several ideas have been proposed in terms of reaching higher scale of genomic application. One of them is the use of public health genomics which still does not provide comprehensive solution as it will be limited to screening attempt.4 A number of countries had tried to assess many aspects revolving around the practice of personalized medicine and showed potential misuse and disruptions along with great advantages it will bring.1,3-5 However, these challenges do not stop the rapid development of personalized medicine itself, making it the possible future of medical care but still with numerous considerations in matters of ethics and legal.5
References 1. Limaye N. Pharmacogenomics, theranostics and personalized medicine – the complexities of clinical trials: challenges in the developing world. Applied & Translational Genomics 2013;2:17-21 2. Badalian-Very G. Personalized medicine in hematology – a landmark from bench to bed. Computational and Structural Biotechnology Journal 2014;10:70-7
3. Annas GJ. Personalized medicine or public health? Bioethics, human rights, and choice. Rev Port Saúde Pública 2014; 32(2):158-63 4. Evans JP, Berg JS, Olshan AF, Magnuson T, Rimer BK. We screen newborns, don’t we?: realizing the promise of public health genomics. Genet Med. 2013;15:332-4 5. Cordeiro JV. Ethical and legal challenges of personalized medicine: paradigmatic examples of research, prevention, diagnosis and treatment. Rev Port Saúde Pública 2014;32(2):164-80
Authors Koe Stella Asadinia koestella@live.com +6281282411321 Michelle Valeria michellevaleri@hotmail.com +628114232323
Edelyne Chelsea edelyne.chelsea@gmail.com +6287771988320
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Pure Water Leads to Healthier Life Prisca Gisella, Lara Aristya, Ivan Pradhana Universitas Indonesia People in Indonesia lack of access to safe-drinking water, causing the number of the population whose water intake relied on the surface water reaches 18% of the households.1 The biggest concern related to high water contamination risk and poor water access is water borne diseases, such as cholera, diarrhea, and dysentery. Eighty eight percent of the diarrhea mortality is attributed to lack of safe drinking water, well sanitation, and hygiene practices.2 Diarrhea is the major cause of child mortality in Indonesia. Although diarrhea canâ&#x20AC;&#x2122;t be solved with only providing households with safe drinking water, we have to consider other factors (clean living environment and hygienic behavior).3 The Drinkable Book uses papers to purify water. The paper can deactivate pathogenic bacteria (Escherichia coli and Enterococcus faecalis) by percolation through a paper sheet containing silver nanoparticles. The nanoparticles are deposited by the in situ reduction of silver nitrate on the cellulose fibers of an absorbent blotting paper sheet.5 Rather than removing the bacteria from the effluent by filtration, the main purpose is achieving inactivation of bacteria by 99,9%.5 Moreover, each paper gives education (tips and ideas) about safe water habit.6 The Drinkable Book, with the catchphrase of â&#x20AC;&#x153;Healthier by Every Pageâ&#x20AC;?, targets areas suffering from poverty and poor sanitation, specifically in Indonesia. The distribution can be accomplished by allocating the books, initially directed from the central government, channeled to the local government of the designated areas. The obstacles that might be encountered reside on the inadequate infrastructure throughout the distribution process, also the populations with limited education and close-minded perception towards unfamiliar concepts specifically new technology. However, the solutions to the possible obstacles comprise of enhancing the infrastructures within the targeted areas and giving the appropriate education regarding to the importance of clean water and proper sanitation. Contact Details of Directors of Author 1. Name : Prisca Gisella Email : prscgsll@gmail.com Phone number :+6281381204094 2. Name : Lara Aristya Email : laracipapa@hotmail.com Phone number : +6281806367766 3. Name : Ivan Pradhana Email : pradhanaivan@yahoo.com Phone number : +6281310230414
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DOCDOC FIND YOUR DOCTOR APPLICATION : FIND THE BEST DOCTORS IN SECONDS Ade Saputri Universitas Gadjah Mada, Indonesia Doctors: Simple, Fast, Within Your Reach Background & Objective Patient satisfaction is a variable that remains severely overlooked in developing countries, despite it being one of the most sought out outcomes in the developed world. Other than being an end goal within itself, failure to achieve patient satisfaction has been shown to lead to lesser patient cooperation, decreasing pursuit of follow-up care, and even word-of-mouth based dissuasion from seeking healthcare. However, today's technology has provided us with new solutions to bridge the gap between doctors and patients. The rising popularity of the internet and smartphones is illustrated by the fact that internet users in Asia have now reached number of 1.563.200 as of June 30th 2015 based on Internet World Stats by Miniwatts Marketing Group. These conditions have given rise to high potential applications such as Docdoc's Find a Doctor application which allows patients to locate and contact doctors with ease and comfort. Furthermore, it allows patients to create reviews and ratings towards doctors. Andaleeb's research published by the Oxford University Press, revealed that the service orientation of doctors was the most influential factor in patient satisfaction. Examples of negative doctor-patient interactions that affect this include longer waiting times and innefective communication. Therefore, the application will increase the accessibility of doctors as well as aid them in tailoring themselves to fit the needs of the patients. Through public posters, we hope to raise awareness towards the existence of the application. A larger member base not only increases the accessibility of the application, but also increases the quality of service the site provides. Thus, it increases the overall effectiveness of the country's healthcare system.
References 1.
Docdoc. 2014. Find A Doctor Application. www.docdoc.com, Copyright © 2014 DocDoc Pte Ltd. Access on 18 Oct, 2015.
2.
Lee, Alicia V. et al. “What Can We Learn from Patient Dissatisfaction? Analysis of Dissatisfying Events at an Academic Medical Center.” Journal of hospital medicine : an
official publication of the Society of Hospital Medicine5.9 (2010): 514â&#x20AC;&#x201C;520. PMC.Web. 21 Oct. 2015. 3.
Andaleeb, Syed Saad, NazleeSiddiqui, and ShahjahanKhandakar. "Patient satisfaction with health services in Bangladesh." Health policy and planning22.4 (2007): 263-273.
4.
Internet World Stats. 2015. Internet User In The World Distribution By World Region-2015 Q2. www.internetworldstats.com, Copyright Š 2015, Miniwatts Marketing Group. Access on 21 Oct , 2015.
Contact of Director of Authors Ade Saputri adesaptr@gmail.com +628747245096
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Portable USG Alvin Saputra1 AMSA Universitas Airlangga, Indonesia1 In 2013, everyday about 800 women died due to complications of pregnancy and child birth. Almost all of these deaths occurred in low-resource settings, and most could have been prevented. The number of women dying during pregnancy and childbirth has decreased by 45% from an estimated 523.000 in 1990 to 289.000 in 2013. The progress is notable, but it is possible to increase the maternal mortality again. Most of the pregnant women are lazy to check up. Even just for a consultation or ultrasound. It is not just because of laziness, but it could be because many of the business of modern women. Whereas antenatal care is essential to prevent bad things happen to both mother and child. In addition to pay attention to nutrition, fetal conditions also need to be in maintanance, so can be done with ultrasound. Through ultrasound, many things can be seen starting from the condition of the fetus, the extent to which the development and growth of fetal organs, and also the gender of the fetus. Abnormalities that occur in the fetus can also be seen on ultrasound. We think about a solution to keep the two of them safe and easy to use. We have an idea about making ultrasound portable that can use everywhere and everytime. This portable ultrasound is used with wifi. So it can connect to gadget with wifi access. Mother can do the ultrasound without going to the hospital. But they need to consult to the doctor for the theraphy and education. It can safe more time because of the flexibility. Our main goal is to make mother and child keep their health and safe with 3C (Call, Care, and Check).
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Slide to be Healthy Andi Tiara S. Adam, Andi Yaumil Chaeriyah, Andi Asyura Alikha Faculty of Medicine, Hasanuddin University â&#x20AC;&#x201C; Makassar, Indonesia Smartphones are now spreading faster than any technology in human history. In Indonesia, recent studies show that smartphone users increase 8.6% every month. More astonishingly, according to global statistics, there are 1.91 billion people that own a smartphone, and it is expected to double in number two years from now. The most appealing fact is, smartphones are also capable to provide a reliable and inexpensive way to reach people no matter where they are. With the massive coverage that this technology has to offer, it becomes thebest solution for prevention and management of urgent global health issues. Avoiding the risk of having diseases, and fighting the disease in order to pursue a healthier life is very challenging. But now, there are more than 97.000 smartphone applications related to health ready to accompany its user to fight the battle together. Every application has a different use, from the simplest ones like movement and activity trackers, to the more sophisticated ones like blood glucose monitoring, blood pressure monitoring, and noncommunicable diseases management. It is an effective solution indeed. But unfortunately,the majority of people do not fully utilize their smartphone. According to a survey by Nielsen Company, todayâ&#x20AC;&#x2122;s smartphones are mainly used for simple purposes like texting, playing games, checking the weather, and so on. Therefore, we would like to enhance the knowledge of the society about the actual capability of their phone, that it can now be a tool to reach their healthy life, not just a device to text or play games. With the understanding of the society, we hope that they can use their smartphone smartly. Be healthy, be mobile. Contact details Asyura Alikha asyuraalikha@gmail.com +6282188891313
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Anti Bleeding Gel Albab Youndra Darmawan, Carla Octavani, Dini Nurmalah, Tiafanni Azzahrah Trisakti University, Jakarta, Indonesia
Catchphrase : Our Blood Our Lives Gel is made up of plant-derived analogue of something called as the extracellular matrix (ECM)â&#x20AC;&#x201D;a mesh of protein and sugar that sits around cells and tells them what to do and how to behave. The ECM varies from organ to organ. The gel is broken down into small pieces, a kind of Lego blocks, and when it's placed on a wound, it rebuilds itself into the pattern of the existing ECM. If you apply the gel on skin, it will have the properties of skin. If you put it next to the liver, it will take on the properties of the liver. Vetigel works by using a plant-based hemophilic polymer made from polysaccharides that grabsinto the blood and form a mesh that seals over the wound, without any need to apply pressure.VetiGel is different in that it is formed from plant cell wall polymers that, according to the company, form a mesh when exposed to blood or tissue. The mesh quickly collects fibrin, a protein that is the key to blood clotting. Since it is a plant-based polymer, the mesh can be left in the wound to be absorbed by the body as it heals. Thus, this gel is expected to be able to help community in the future by stoping bleeding and preventing from massive loss of blood which may cause death, a fatal condition. It also aims to reduce the mortality of population.
Reference 1.
http://www.ibtimes.co.uk/vetigel-plant-based-gel-that-stops-traumaticbleeding-wounds-15-seconds-1476464 International Business Times UK. Retrieved 30 December 2014
2.
Matt Safford
http://www.smithsonianmag.com/innovation/plant-based-
gel-stops-bleeding-seconds-180953488/?no-ist Smithsonian. Retrieved 30 December 2014
3.
http://www.fastcoexist.com/3034403/a-gel-that-can-stop-bleeding-in-under-10-seconds-gets-cl oser-to-human-use Co.Exist. Retrieved 30 December 2014
4.
http://downtownbrooklyn.com/posts/learn/nyu-company-named-a-coolest- college-startup Downtownbrooklyn.com. Retrieved 30 December 2014.
5.
http://www.nydailynews.com/life-style/health/nyu-student-creates-cureexcess-bleeding-article-1.1286843 NY Daily News. Retrieved 30 December 2014
6.
http://www.bloomberg.com/video/vetigel-the-band-aid-of-the-future-stops-bleeding-instantlyPaIvLxjcS66F5IWO1SsKtA.html Bloomberg. Retrieved 30 December 2014
Director authors : Dini Nurmalah Dini_nurmalah@yahoo.co.id +6285817266690
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CNT: The Promising Breakthrough Erika Indrajaya, Quinta Febryani H, Robert Universitas Katolik Atma Jaya, Jakarta Indonesia Nanosensor is a new emerging technology in the medical sector, which will give clinicians the hope they have been waiting for to be able to help their patients in a more promising way. While it is still being developed, it has shown some tremendous abilities that are sparking the interest of a lot of people. It is claimed that nanosensor technology is able to monitor the condition of its surrounding tissue where it is put. It can detect if there is an inflammation or the presence of a certain microorganisms in the body. The best part of the discovery of this technology is its ability to be used for early diagnosis in the medical field.
This is the advanced technology that clinicians have
been waiting for, since until now, based on the statistics from 2012 there are 8.2 million cancer deaths worldwide and almost half of the colorectal cancer and cervical cancer cases are diagnosed at late stages, when treatment is more difficult and it will most likely to increase the mortality rate. Through this poster, we would like to introduce one of the many nanosensor technology discoveries that can be implemented in the medical field, that is Carbon Nano Tube (CNT). This tube is made out of carbon atoms shaped cylindrically with the amazing ability to catch micro sized molecules. And the world believes that this can be used to catch proteins that the cancer cell produced which cannot be detected in the past due to the lack of improvements from the former technique. With this promising encounter of atom sized technology, comes a huge prospect to develop this technology to a new level. This is, the promising breakthrough.
Contact details of authors: 1.
Erika Indrajaya +62 81 271 001379 indrajayaerika@gmail.com
2.
Quinta Febryani H +62 81 949 633654 quinta.fh@hotmail.com
3.
Robert +62 87 868 588388 robert_shen09@yahoo.com
REFERENCES 1. Kowalczyk, J. (2013). Tracing emerging irreversibilities and development pathways in the field of nanosensor technologies. 2. McIntosh, J. (2015). Nanosensors: the future of diagnostic medicine?. Retrieved 18 October 2015, from http://www.medicalnewstoday.com/articles/299663.php?page=2 3. cdc.gov,. (2015). CDC - Cancers Diagnosed at Late Stages Despite Available Screening Tests. Retrieved 18 October 2015, from http://www.cdc.gov/cancer/dcpc/research/articles/tests.htm
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Printable Organs Felix Hindarto, Kirti Anindita Suharsono & Alvian Gunawan Faculty Medicine of Atma Jaya Indonesia Three-dimensional printing is creating a 3D structure. It was first developed in the early 1990s at MIT by using a regular ink-jet print head. In a recent medical field, this method is used for creating living tissues and replacing the damaged ones, for example bone, skin, and other tissues. This whole process of 3D printing is made in vitro. The scaffold is made to match the extracellular matrix. Multi-potent stromal cells (MSC) then injected into the scaffold before implantation so that the duplicate tissue can “survive” in the body. The traditional tissue engineering strategy is to isolate stem cells from small tissue samples, mix them with growth factors, multiply them in the laboratory, and seed the cells onto scaffolds that direct cell proliferation and differentiation into functioning tissues. In 2009, 154,324 patients in the U.S. were waiting for an organ and only 27,996 of them (18%) received an organ transplant, and 8,863 (25 per day) died while on the waiting list. If this problem can be solved, fulfilling the demands can also reduce this mortality number efficiently. Printing complex organs have not been developed completely. Complex organs have a specific metabolic mechanisms in which cannot function properly without vascularization. Three-dimensional printing lets us produce custom-made medical products and equipment cheaply by decreasing the use of unnecessary resources. Doctors and patients can have a positive impact in terms of the time required for surgery. Patients will have more recovery time, and success of the surgery or implant as the progenitor cells are taken from the patients themselves so the transplant rejection can be minimized. “Fast” in 3D printing means that a product can be made within several hours with high resolution, accuracy, reliability, and repeatability of 3D printing technologies. So, no more waiting in line to save lives! Contact Name: Felix Hindarto, e-mail: hindarto_felix@yahoo.com, Phone: +6287851662272
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Bionic Arm : Live Your Life to The Fullest Ferdy Bahasuan Universitas Kristen KridaWacana Indonesia
Abstract: Over a billion people, about 15% of the worldâ&#x20AC;&#x2122;s population in 2014 are disabled, which have many form of disabilities. That keeps increasing because of population aging. People with disabilities are more likely to be unemployed than non-disabled people and that makes disability people have worse living conditions like insufficient food, poor housing than non disabled people. WHO has done things for disabled people, they promotes strategies to ensure that people with disabilities are knowledgeable about ther own health conditions and protect the rights and dignity of persons with disabilities but that doesnâ&#x20AC;&#x2122;t mean that they could live their life independently. Because of that we need to do something that could help disabled people. Bionic arm is one of many ways to help them, bionic arm can help people with arm disabilities. People that have arm disabilities will be able to do things like non-disabled people do and have a better life. Bionic arm is a way to make a better future for people that have arm disabilities. Many people still think that disabled people just a hindrance and disabled people will feel insecure, so with bionic arm, it will raise their confidence. When you think that your life can't get any better, it can. Live Your life to the fullest.
Directors of Authors : Ferdy Bahasuan ferdy.fkukrida.14@gmail.com +6285924186879
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Dr. Google, Better or Worse? â&#x20AC;&#x153;It Will Not Feel the Warm of Your Body, the Pain of Your Sore, and the Empathy You Needâ&#x20AC;? Giordano Bandi Lolok1), Syaiful Islam2), M. Shulfie Asadul J.3) 1)
Medical Faculty of Hasanuddin University, Makassar, Indonesia
Abstract Background : Google is a search engine that began operating in 1997. Over time, Google became the most popular search engine on the world wide web to obtain information, including health information, such as various types of disease and its treatment. Therefore, in this time, many internet users resolve their health problems by using Google, or what we call Dr. Google services, but it is still debatable among the world community. This is because Dr. Google has a positive and negative impact on a person who would use this as a primary health service. Dr. Google is able to cure diseases because they are able to provide quick and instant access of medical information that would not be provided back where internet did not exist. Full of doubts, Dr. Google raises controversy because the information obtained is not entirely trustworthy and is not supported by a doctor's diagnosis, therefore patients do not know the dose and duration of drug therapy, and can lead to complications. On the 26 cases, Google gives the correct diagnosis in 15 cases, while in 11 other cases, Google approach the correct diagnosis, but is not specific enough to be considered correct (Hangwa & Jennifer, 2006:1143). Therefore, as an internet users, we must use these services appropriately. Users of Dr. Google should know what the symptoms and signs of their illness before searching information. If they do not know or doubt, it is better to consult a doctor immediately to avoid misdiagnostic. In addition, users are also expected to find sources of information on the trusted site. Objective : Through this poster, we present the advantages and disadvantages of Dr. Google, in order to increase awareness and to avoid misdiagnostic towards the user that is using Dr Google. Contact Details : Directors ofAuthors Giordano Bandi Lolok giordanomath997@gmail.com +6282271857479 Syaiful Islam syaiful14333@gmail.com M. Shulfie Asadul J asaduljailie25@gmail.com
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Emergency Video Call: Improved Emergency Medical Services by Means of Smartphone Features Khairu Zein, Ristra R Universitas Airlangga
Emergency comprises various conditions: road crashes, kidnapping, force majeure, drowning, choking, heart attack, or even dog bite, with the penultimate being the leading cause of death in the world. Notably, there are only 3-6 minutes of time to save heart attack victims until their brain is dead by complete deprivation of oxygen supply from the blood circulation. Nevertheless, the long duration of ambulance’s arrival questions the effectiveness of emergency call system. Also, basic life support must be immediately given to the victim. Extremely few people understand the procedure of basic life support, while teaching the procedure through phone is practically difficult. These adversities inhibit the improvement of accidental casualties. About 52.2 million people in Indonesia are already using smartphones that have at least camera, internet, and location services. Smartphones enable people to communicate not only by means of audio, but also visual. Although these advantages improve many ways of people dealing with their lives, there is little attention given to the problems of emergency services aforementioned. Therefore, we elaborate an idea of integrating video call technology into government’s emergency hotline institution. This gives a whole new system, namely emergency video calls. Our slogan is “Forget 911: video call the emergency patient,” and we aim to help create faster and better life support, so there will be more people saved from permanent disability or even death. People in road crash, swimming accident, or even hiker who is stuck in the middle of a forest can ask for ambulance and provide enough information just by the camera’s view. And while they are waiting for the ambulance, they are guided by medical services to perform basic life support. The face-to-face communication helps victim feel calm, accompanied, and safe. Because each second, each attempt of giving life support, means so much to the victims. Slogan / Catchphrase; Forget 911: video call the emergency doctor Author information 1. Khairu Zein kz_durandal@ymail.com 0811556551 2. Ristra Ramadhani ristrar@gmail.com 085785928807 or 081334225885
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Just a Click Away Kusuma Putri, Clara Regina, Michelle Malekhi
Universitas Pelita Harapan, Indonesia Abstract Background: Indonesia is a very rich country, where culture and believes are still a major part of their lives. Even though this could be a positive thing, sometimes it does not. Some of the cultures and believes have their methods of medical cares, which have been done for generations and are thought to be effective. For instance, the management of broken bone is usually by massaging it. Therefore, rather than taking chances of being wrong, it would be safer to consult it with your doctor, which just a click away. Technology is evolving from time to time and grows in our lives in every aspect, including medical care. Now people could contact their doctor to ask question without having to go to the hospital. There are several sites now that provides online consultation for their patients. This method is called telemedicine. Patients who want to ask small questions could just contact the medical expertise via online chatting or video call. Telemedicine allows the specialists to contact patients who are located in distant or remote area. According to a report from Pew Research Centerâ&#x20AC;&#x2122;s Internet & American Life Project, one from three American adults have used the Web to figure out a medical issue and 38% believed they could handle their ailments in the privacy and comfort of their own homes. Our poster aim to encourage people to utilize the technology provided instead of dealing with problems to go to the hospital. Objectives: To encourage people to make use of online consultation Slogan: Use your time and energy efficiently Contact detail of Directors of Authors: Kusuma Putri kusumaput@gmail.com 081908338463
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A Snapshot of Digital Healthcare University of Gadjah Mada, Indonesia Marcellus, Gloria Evita Thalia, Tegar Wardhana Catchphrase : Healthcare Reinvented! Objectives : Introduce to the public how a futuristic healthcare concept can be beneficial for both doctor and patient , which can be achieved by maximizing the use of a smartphone. Background : 129,8 million people visit the emergency department each year whereas 40 % could have gone to a lower acuity of care . Aside from the fact that people tend to overuse the emergency room (ER), the time taken to visit a general practitioner is also ineffective. The average time taken to register at the hospital is 50 minutes , and wating in the doctorâ&#x20AC;&#x2122;s office takes 20 minutes . After their first visit, some patients do not want to return to the doctor for a follow-up examination, this way doctors have a hard time on monitoring the patientâ&#x20AC;&#x2122;s health status. These problems can be reduced by the use of a smartphone. 80 % of web users look for health information online and more than 30 % look up specific symptoms online. Most clinicians also use a smartphone as a part of their practice. Which shows that smartphones are very common amongst us nowadays. Smartphones have a lot of applications that can be utilized to make the healthcare service more effective for both the patient and doctor. Directors of Authors : 1) Marcellus
1) Gloria Evita Thalia
1) Tegar Wardhana
2) +6287840788803
2) +6287876748999
2) +6281325131509
3) marcelluskorompis
3) gloriagloriaa97@g
3) tegar.ardhiwardana
@gmail.com
mail.com
@gmail.com
References: 1. http://mobihealthnews.com/47675/rock-health-80-percent-of-internet-connected-adults-usedigital-health-tools/ 2. http://mobihealthnews.com/15905/each-month-16-9m-access-health-info-via-mobiles/
3. http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2011_ed_web_tables.pdf 4. http://www.beckershospitalreview.com/capacity-management/study-71-of-ed-visitsunnecessary-avoidable.html 5. http://hse.eng.wayne.edu/Research/VA-registrationYu-Yang.pdf 6. http://m.huffpost.com/us/entry/7597902 7. http://www.mobihealthnews.com/27865/fda-clears-android-based-continuous-ecg-monitor/ 8. http://www.medgadget.com/2012/07/lifewatch-v-android-based-healthcare-smartphonepacked-with-medical-sensors.html 9. http://www.master-of-health-administration.com/3-great-android-app-for-hospital-staff/ 10. http://www.epocrates.com/oldsite/statistics/2013%20Epocrates%20Mobile%20Trends%20R eport_FINAL.pdf
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Fight Cancer with Something Inside Aqdam Fauqo Al’Adli, Fah ri Somantri, Immanuella Yosephine Sirait, Laksmita Dwana, Pinka Nurashri Setyati, Pretika Prameswari, Taufik Supriyana Trisaputra, Telaga Biroe University of Trisakti, Faculty of Medicine, Jakarta Indonesia
Background: According to American Cancer Society: Cancer is a group of diseases characterized by the uncontrolled growth and spread of abnormal cells. If the spread is not controlled, it can result in death. Cancer is caused by external factors such as tobacco, infectious organisms, and an unhealthy diet.It is also caused by internal factors, such as inherited genetic mutations, hormones, and immune conditions. There are more than fourteen million cases of new cancer diagnosed in 2012 and the number has been gradually increasing since then. It proves us that cancer is still one of the biggest challenge to overcome with in medical world, with no specific treatment to fully cure and recover the patient up until today. Amongst those newly discovered treatment for cancer, T-Cell Imunotherapy is one of them. The said therapy can be divided into two approaches first is the use of gene-modified Tcell receptors (TCRs) or use of or use of chimeric antigen receptors (CARs). Each one of the approaches has it own benefit. These differences are associated with the design of the two approaches that results in the mechanism of work, thus bringing different effect in the growth of the cells. CARs are recombinant receptors for antigens that retarget and eventually reprogram T-cell function. TCRs are the physiological recognition system of T cells and has two chains, a and b, that are necessary and sufficient for T cells to recognize their targets, including cancer cells. Through our slogan in this poster ‘Fight Cancer with Something Inside’ we would like to introduce the public with the new treatment of cancer that the components are already inside our body. Altough it is not fully developed yet, hopefully it will pique the interest of medical student to conduct future research. REFERENCE 1. American Cancer Society. Cancer Facts & Figures 2015.Atlanta: America Cancer Society;2015 2.
Curay J C, Kiem H P, Baltimore D,O’Reilly M, Brentjens R J,Cooper L, Forman S, et al. T-Cell Immunotherapy: Looking Forward. The American Society of Gene & Cell Therapy; 22(9) :2014
3. Bot A, Brewer J E. Eshhar Z,Frankel S R,Hickman E,Jungbluth A A,et al. Journal for ImmunoTherapy of Cancer (2015) 3:31
Contact Person: Aqdam Fauqo Alâ&#x20AC;&#x2122;Adli: Aqdam_fauqo@yahoo.co.id Fahri Somantri: Fhr.somantri@gmail.com +628211643940 Immanuella Yosephine Sirait: Ella_news@hotmail.com +6282164221418 Laksmita Dwana: aksmitadwana@gmail.com Pinka Nurashri Setyati: Pinkachairul@gmail.com +6281282846953 Pretika Prameswari: Pretika_p@yahoo.com +6281296645486 Taufik Supriyana Trisaputra: taufikste@gmail.com Telaga Biroe telagabiroe@gmail.com +6282218941137
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Foodscanner: No Monster in My Tummy Meilia Dwi Cahyani AMSA Universitas Airlangga, Indonesia
The metabolic syndrome is a combination of several abnormalities, including abdominal obesity, glucose intolerance, hypertension and dyslipidemia that usually share insulin resistance as a common underlying pathophysiological disturbance. The metabolic syndrome is associated with the risk of type 2 diabetes, cardiovascular disease, and all-cause mortality on the daily caloric intake and nutrient composition. According to the data from the World Health Organization (WHO) in 2011, the rate of obesity in the world has more than doubled since 1980. In fact, nearly 43 million children under five are overweight in 2010 and the prevalence was significantly higher in female than male especially for central obesity. It is a fact that is very worrying because from the higher rate of this obesity you can suffer from many disease especially type 2 diabetes with insulin resistance. Diabetes patients always have to maintain their glucose intake every time they are eating something and sometimes if the resistance is too severe so they have to inject insulin everyday before eating something. As the future thinking goes on, we think about something that can prevent all of that problem from the early phase before the diseases come to us. We have an idea to make a Food Scanner application that can scan all of the nutrition fact from the food that we will eat. We can know about the glycemic index, protein level, lipid concentration, vitamins and their mineral. So, for diabetic patient this tool can help them manage their disease because they can know how many the glucose intake before they will eat so they can control their blood glucose near the normal line. Our main goal is to make people know what they are going to eat clearly so they can choose the best healthy meal to maintain their health. So, scan the monster in your food now, because you are what you eat. Contact Person; Meilia Dwi Cahyani meilenidwi@gmail.com +6281249466762