Human embryonic stem cells: Derivation, culture, and differentiation: A …

The ectoderm derivatives include external ectoderm, neural crest, and neural tube. These structures give rise to cells of the epidermis, external sense organs, and the peripheral and central nervous system (Gilbert, 2006).

Generating functional neurons from hESC with the aim of treating neurodegenerative diseases is the subject of intensive investigation. Shortly after derivation of the first hESC lines, Reubinoff et al. (2000) described isolation of expandable neural progenitor cells from hESC that had been cultivated for four to seven weeks at a high density in vitro. The authors illustrated that the neuroepithelium contained areas of differentiating hESC colonies, identified by expression of the embryonic polysialylated neural cell adhesion molecule (PSA-NCAM), and had distinct morphological features. These areas were mechanically dissected and expanded as neural aggregates or spheres in serum-free media. Neural induction was achieved by plating the spheres on coverslips coated with poly-D-lysine and laminin, which resulted in emergence of cells expressing the neuronal markers -tubulin and microtubule-associated protein 2 (MAP2). They also identified a subset of the neuronal cells as being glutaminergic and GABAergic neurons, as shown by the expression of glutamate and glutamic acid decarboxylase (GAD).

Reubinoff and coworkers (2001) also optimized the expansion of hESC-derived NPC by addition of B27 supplement, human recombinant epidermal factor EGF and the mitogen bFGF. The expanded NPC were capable of differentiating into all three major neural lineages (neurons, astrocytes, oligodendrocytes) in vitro as well as in vivo. Lineage tracing studies showed that NPC grafted to the ventricles of newborn mice differentiated in a region-specific manner, according to normal developmental patterning signals. For example, neuronal differentiation was specifically detected in the olfactory bulb, where postnatal neurogenesis occurs (Reubinoff et al., 2001).

At about the same time, Zhang et al. (2001) used a different protocol with similar success in generating enriched populations of NPC from hESC. In that study, differentiating EBs were treated with insulin, transferrin, progesterone, heparin, and bFGF. Continuous exposure to bFGF led to formation of monolayers of neural tube-like rosettes that were isolated by dispase enzymatic treatment. Similar to the study by Reubinoff et al. (2001), the generated NPC were capable of generating oligodendrocytes, astrocytes, and mature neurons both in vitro and after transplantation into mice.

These observations confirming the multi-lineage differentiation potential of hESC-derived NPC, and promising indications of survival and integration of these cells in vivo, set the stage for future developments of methods for selective differentiation of different neuronal phenotypes that could potentially be used to treat several central nervous system disorders. Indeed, studies examining the signals and factors that govern the proliferation and cell fate specification of neural progenitors are accumulating rapidly.

Generation of transplantable motor neurons from hESC could have potential for treating victims of spinal cord injuries, or degenerative diseases such as amyotrophic lateral sclerosis. The first functional motor neurons originating from hESC were described by Li et al. (2005). In that study, Li and colleagues used the previously described method (Zhang et al., 2001) to generate NPC cells, which were subsequently induced to become motor neurons by addition of RA to the culture medium. Further maturation to postmitotic motorneurons was induced by the ventralizing morphogenic protein SHH. An interesting aspect of this study was the specific temporal effect of RA on motor neuron induction, in that RA could induce only early, but not late neuroectodermal cells, to differentiate into motorneurons (Li et al., 2005). This occurred through upregulation of expression of HOX genes that are involved in assigning the rostrocaudal positional identity of spinal motor neurons. The functionality of the generated motor neurons was confirmed by electrophysiological experiments and establishment of neuromuscular transmission in motorneuron-myotube co-cultures (Li et al., 2005).

In another study, directed differentiation of motor neurons was achieved by addition of RA/SHH extrinsic cues to cultures of differentiating NPC generated from hESC (Lee et al., 2007). With respect to clinical potential, transplantation of hESC-derived motor neurons in developing chick embryo spinal cord showed that these cells were capable of survival and directed axonal growth over relatively long distances (Lee et al., 2007). Nevertheless, transplantation in adult rats did not result in axonal growth to outside the CNS. It should be mentioned that, although caudal and ventral patterning was achieved by RA and SHH, the initial neural induction of hESC was obtained by co-culture with MS5 mouse stromal cells, which would preclude the use of motorneurons generated by this particular strategy for any type of human transplantation therapy (Lee et al., 2007).

In a later study by Li et al. (2008), neural induction medium containing heparin and cyclic adenosine monophosphate (cAMP) in addition to RA and SHH was successful in generating a nearly homogenous population of ventral spinal progenitor cells, with highly efficient generation of motor neurons.

Promoting remyelination for treatment of neurologic disorders caused by demyelination of motor neurons is another potential application of hESC-derived cells. One of the strategies used to promote remyelination involves transplantation of oligodendrocytes, which produce the myelin sheath of motor neurons and are essential for normal signal conduction. In 2005, Keirstead and his associates demonstrated that transplantation of hESC-derived oligodendrocyte progenitor cells (OPC) produced by glial restriction media, can lead to remyelination of motorneurons, and recovery of motor function after spinal cord injury in rats (Keirstead et al., 2005). Following further assessment of the safety concerns associated with OPC transplantation in animal models (Cloutier et al., 2006), Geron Corporation obtained FDA clearance in January 2009 to begin the first human clinical trials of hESC-derived cells in the United States (see Alper 2009). OPC were generated from the H1 hESC line under current good manufacturing practices without the use of feeder cells, in defined media containing only human recombinant proteins. The Phase I trial is designed to assess the safety of transplantation of OPC in patients with acute thoracic spinal cord injuries and will be carried out at multiple medical centers.

A number of additional studies have reported the production of multiple neuronal subtypes, including cholinergic, serotonergic, GABAergic, and dopaminergic (DA) neurons, from hESC (Erceg et al., 2008; Gerrard et al., 2005; Perrier et al., 2004; Yan et al., 2005). As previously mentioned, protocols used for neural conversion of hESC generally give rise to a mixture of neuronal phenotypes. Previous studies of neural differentiation of mouse ESC have established protocols for growth factor-mediated lineage selection and survival-promoting factors of neuronal cells (Barberi et al., 2003; Lee et al., 2000; Okabe et al., 1996). As a general strategy for obtaining selective neuronal differentiation, factors with effects on the anteroposterior (AP) or the dorsoventral (DV) neuronal patterning in combination with specific neurotrophins are used at specific stages during in vitro ESC differentiation. In a comprehensive study of neural development of mouse ESC, Barberi et al. used a stromal feeder-based differentiation system to generate early ectodermal cells (6 days co-culture) and identified various combinations of factors that govern neural and neuronal subtype specification () (Barberi et al., 2003). It should be noted that these differentiation strategies for mouse ESC cannot be directly applied to hESC without some modifications.

Neural subtype specification from neural progenitors derived from mouse ESC using various combinations of inducing factors. AA, ascorbic acid; bFGF, basic fibroblast growth factor; BDNF, brain-derived neurotrophic factor; CNTF, ciliary neurotrophic factor; EGF, epidermal growth factor; FGF4, fibroblast growth factor 4; FGF8, fibroblast growth factor 8; NT4, neurotrophin-4; PDGF, platelet-derived growth factor; RA, retinoic acid; SHH, sonic hedgehog. {Adapted from Barberi et al. (2003), [100]}.

To date, the majority of studies on neural differentiation of hESC have been focused on generation of dopamine producing neurons of the midbrain subtype, due to their potential application in cell replacement therapy for Parkinsons disease. Established protocols used to generate DA neurons include allowing spontaneous differentiation of hESC, followed by addition of DA inducing molecules, SHH and FGF8, and later neurotrophic factors, or by culturing hESC on feeder cells from animal or human origin that have the ability to direct hESC to become DA neurons.

Kawasaki and coworkers in Japan discovered in 2000 that certain mouse stromal cell lines had a neural and DA promoting effect on mouse ESC (Kawasaki et al., 2000). The authors showed that the activity of the stromal cells was not mimicked by FGF8/SHH, or Wnt signaling, previously known to be key factors in development and patterning of midbrain DA neurons. Thus, this strategy was established as a new approach to generate DA neurons and was termed stromal-derived inducing activity (SDIA).

Our group as well as others have adapted this approach to generate DA neurons from hESC. When the hESC line BG01 was cultured on the mouse stromal cells for three weeks, approximately 87% of colonies contained large numbers of TH+ cells (Zeng et al., 2004). The TH+ neurons generated by SDIA had midbrain characteristics, as determined by expression of Nurr1 and Pitx3 transcription factors that are strongly associated with midbrain DA neurons. The DA neurons were functional in vitro as confirmed by electrophysiological assessments and release of dopamine. However, the survival of TH+ neurons grafted into the striatum of parkinsonian rats was very limited. A parallel study of DA induction of hESC by Perrier and colleagues (2004), combined SDIA with SHH and FGF8 patterning molecules, ascorbic acid, and various neurotrophic factors including BDNF, GDNF, TGF-3, dcAMP and demonstrated that the yield and functional properties of TH+ neurons were highly dependent on exposure to SHH and FGF8.

Other feeder cells that possess DA-inducing activity, and that have been used to generate DA neurons from ESC, include testis-derived sertoli cells (Yue et al., 2006), meningeal cells (Hayashi 2008), and striatal or mesencepahlic astrocytes (Buytaert-Hoefen et al., 2004; Roy et al., 2006). Secreted factors produced by astrocytes have also been reported to promote neurogenesis and induction of DA neurons (Nakayama et al., 2003).

Yan and coworkers (2005) demonstrated neural and DA induction of hESC in the absence of any type of feeder cells by addition of SHH and FGF8 to EB-derived neural rosettes which were manually isolated from mixed cultures. The resulting TH+ neurons comprised 50%60% of the total neuronal population and were electrophysiologically active. Other differentiation paradigms have included addition of an NPC expansion step to this protocol in order to generate a more pure population of DA neurons (Cho et al., 2008).

Although mouse stromal cells that possess SDIA activity are considered as one of the most efficient tools for converting hESC to DA neurons, the use of animal cells would preclude any downstream clinical application due to possible transfer of xenogeneic material. To understand the molecular activity of SDIA, we further assessed the activity of stromal cells and found that stromal cell surface activity promoted hESC survival and was able to enhance overall neurogenesis, whereas soluble secreted factors provided DA lineage-specific instructions (Vazin et al., 2008). We then examined the gene expression profile of potent PA6 stromal cells as compared to that of cell lines lacking the DA-inducing effect (Vazin et al., 2009). Several soluble factors and growth-inducing proteins potentially responsible for the DA phenotype-promoting component of SDIA were identified, based on high levels of expression in potent DA-inducing PA6 cells. Testing of these factors showed that a combination of four factors, stromal cell-derived factor 1, pleiotrophin, insulin-like growth factor 2, and ephrin-B1, termed SPIE was sufficient to induce DA neuronal differentiation from hESC. The combination of these four factors mimicked SDIA activity, providing an approach for differentiating DA neurons from hESC in a culture system that is potentially suitable for clinical applications (Vazin et al., 2009).

Transplantation of DA precursors or neuronal cells is still at the stage where survival and integration needs to be optimized, as the majority of studies focusing on neural transplantation have reported limited or no survival of DA neurons. A few studies have, however, reported more encouraging results. A study by Roy et al. (2006) transplanted hESC-derived DA progenitors induced with immortalized human fetal midbrain astrocytes in the presence of SHH and FGF8, and illustrated that about 21% of the total number of transplanted cells (5 105 cells) were TH+. Long-lasting behavioral recovery was found in animals that received cell implants. The enhanced viability of the TH+ neurons post-transplantation may have been caused by the influence of fetal midbrain astrocytes during development or specification of these neurons.

A more recent study by Chiba and colleagues (2008) has indicated that SDIA-induced DA differentiation of hESC can be improved by addition of the BMP inhibitor noggin. Importantly, the number of TH+ cells found in animals transplanted with hESC treated with noggin was five times more (average of about 500 cells/animal) than the animals that received hESC induced by SDIA alone. The enhanced in vivo viability of TH+ cells was also reflected in animal behavioral recovery.

As previously discussed, the patterning of the neural tube along its DV and AP axis is determined by specific concentrations of morphogens including SHH, BMP, FGF and RA. Other important aspects involved in regional specification of NPC are the temporal effect of these factors, as well as the duration of signaling. There is evidence indicating that NPC progressively lose their differentiation potential and can no longer be regionally specified in response to instructive patterning cues after extended in vitro culturing (Machon et al., 2005; Santa-Olalla et al., 2003).

A recent study by Elkabetz and colleagues (2008) has identified a novel population of hESC-derived neural stem cells with a unique gene expression profile, termed neural rosette cells (R-NSC), which are isolated at an earlier stage of differentiation, as compared to the previously described NPC. Forse1 was used as a marker to isolate these early rosette stage cells, which adopted an anterior forebrain characteristic in the absence of extrinsic patterning factors. In contrast to NSC, the R-NSC could be re-specified toward caudal neuronal fates including motor neurons and midbrain DA neurons by SHH/RA and SHH/FGF8 treatment, respectively. This study also illustrated the in vivo survival and phenotype maintenance of these two rosette stage-derived neuronal phenotypes.

These findings provide evidence that neuronal plasticity of NSC is highly dependent on the developmental stage and restricted to a specific time window. Selective expansion of neural stem cells that retain their ability to differentiate towards specified neurons is of great potential value. Moreover, generation of restricted NSC has clinical relevance, as such cells have been reported to have a tendency to migrate towards the site of injury and rescue degenerating neurons following implantation in animal models (Bjugstad et al., 2008; Ourednik et al., 2002).

Characterization studies of SDIA-mediated neural induction have also suggested that midbrain regional identity can only be established during early stages of ESC differentiation (Parmar and Li, 2007). In addition, it has been suggested that early exposure of FGF8, before the onset of the neural stem cell transcription factor Sox1, is necessary for generation of DA neurons with a midbrain phenotype (Yan et al., 2005). Signaling duration is also known to affect the mechanisms that underlie the patterning role of factors. For example cells are known to respond analogously to varying concentrations of SHH, or to varying duration of exposure to this factor (Dessaud et al., 2007).

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Human embryonic stem cells: Derivation, culture, and differentiation: A ...

Controversy Over the Use of Embryonic Stem Cells in Research Hadron

Written by Margaret Wei

Stem cells have been increasing in popularity in research in recent years due to their pluripotency. Stem cells are at first unspecialized, but have the capacity to develop into specialized cells hence their valued versatility when it comes to research. Stem cell research is used to increase understanding of how diseases occur. Researchers do this by observing how the stem cells differentiate into the specialized cells (bones, heart muscle, nerves, and other organs and tissue) to better determine how diseases and conditions develop.

Origin of Stem Cells

Several different types of stem cells are used in research: embryonic, adult, induced pluripotent, and perinatal. Embryonic stem cells originate from donated fertilized eggs in vitro fertilization clinics but never implanted in a womans uterus. Adult stem cells are derived from tissue, like bone marrow, and can be used to grow different types of specialized cells. Induced pluripotent stem cells are manipulated through genetic reprogramming to transform adult cells to stem cells, and then they can be used to replace dysfunctional cells. Perinatal stem cells come from amniotic fluid and can develop into specialized cells. In laboratories, stem cells can live and grow in special solutions in test tubes or petri dishes

Of the different types of stem cells, embryonic stem cells are the most controversial because their research consists primarily of experimentation on cells that have the potential to become a developed human. These cells are derived from embryos at a developmental stage before implantation would normally occur in the uterus. During this time, fertilization occurs in the oviduct, and over the span of the next few days, the cell divides multiple times as it travels to the uterus. At this point, the embryonic cells are undifferentiated, in other words, they do not look or act like the specialized cells of the adult, and they have the potential to become any specialized adult cell type (Yu, J. and Thomson, J.A.).

The first stage of differentiation occurs after five days, and an outer layer of cells that was supposed to become a part of the placenta separates from the inner cell mass (ICM). Because of the process of implantation, the ICM cells no longer have the potential to develop into any cell type of the body, and they are quickly depleted as they differentiate into limited types of cells. Eventually, the ICM-derived cells are fixed to be embryonic stem cells if the ICM is removed from its normal embryonic environment and cultured under appropriate conditions. These specific conditions allow the cells to proliferate and replicate, while maintaining the developmental potential to form any cell type of the body (Yu, J. and Thomson, J.A.).

The diagram above illustrates the process of obtaining embryonic stem cells.

Interactive resources for schools. (n.d.). Retrieved December 30, 2020, from https://www.abpischools.org.uk/topic/stem-cells/4

Embryonic Stem Cells in Research

Stem cells are currently used in regenerative medicine where healthy cells are generated to replace diseased cells. Scientists use embryonic stem cells to determine how specific cells can be used to regenerate and repair diseased or damaged tissues in people. Further research on stem cell regeneration would be beneficial to those who have Parkinsons disease, Alzheimers disease, heart disease, stroke, burns, cancer, etc. The potential that stem cells have to become new tissue can be used in transplant and regenerative medicine.

To ensure that drugs are safe to be used on people, researchers use stem cells to test drug effectiveness before it gets approved for drug development for cardiac toxicity testing. The stem cells that are to be tested on must be programmed to acquire properties of the type of cells targeted by the drug, but more research needs to be done about how to program cells into specific cells to produce more accurate results from the tests that would show what kind of effect the drug had on the cells (Railton, 2019).

Stem Cell Controversy

Despite the benefit of the pluripotency of embryonic stem cells, controversy arises behind how embryonic stem cells originate. Because embryonic stem cells are extracted from human embryos, many scientists question the ethics of embryonic stem cell research because it is correlated to human testing. Additionally, many disagree with testing on embryonic stem cells because the fertilized embryo has the potential to develop into a human. Concerns arise about what qualities determine humans along with the pervasive debate of what constitutes as the official beginning of human life during embryonic development.

According to certain faiths and religions, human life begins at conception, meaning that an embryo is equal to a person and it has the same rights that must be respected. As a result, the scientific process of extracting the embryonic stem cell from a blastocyst and removing the inner cell mass is amounting to murder (Lo, B., & Parham, L., 2009). This mindset is commonly correlated to the opposition of abortion and with the pro-life movement. However, a number of pro-life leaders support stem cell research using frozen embryos that remain after a woman or couple has completed infertility treatment and that they have decided not to give to another couple.

According to Senator Orrin Hatch, a former U.S. senator and a representative of the conservative party interposed the idea that, I believe that human life begins in the womb, not a Petri dish or refrigerator To me, the morality of the situation dictates that these embryos, which are routinely discarded, be used to improve and save lives. The tragedy would be in not using these embryos to save lives when the alternative is that they would be discarded.

A moderate view that others possess in terms of the morality of the embryo would be that the embryo would develop into a person later in development, well after fertilization. This view believes that a newly fertilized embryo does not constitute the same characteristics as a developed individual. However this does not always mean that they do not fully believe that embryonic stem cells are solely a clump of cells and that it is ethical for research without restriction. This does not mean that they do not agree with embryonic stem cell research, many hold a middle ground in which the embryo deserves to be perceived as a potential human being, but it is acceptable to use for certain types of research given good scientific justification, careful oversight, and informed consent from the embryo donor for research (Lo, B., & Parham, L., 2009).

Solutions to Reduce Controversy

Due to the rising controversy on this topic, The National Institutes of Health created guidelines for human stem cell research in 2009, which stated how they may be used in research. Also, to ensure that ethics are not violated, the guidelines state embryonic stem cells from embryos created by in vitro fertilization can be used only when the embryo is no longer needed.

Additionally, to reduce the controversy surrounding the idea of the potential of embryonic stem cells to develop into a human, scientists began to use pluripotent stem cells as an alternative. Since pluripotent stem cells are genetically reprogrammed to transform adult cells into stem cells, they do not have the same ethical concerns as embryonic stem cells. Therefore, genetically reprogrammed pluripotent stem cells do not have the same ethical concerns as embryonic stem cells in terms of origin.

References

Lo, B., & Parham, L. (2009, May). Ethical issues in stem cell research. Retrieved December 27,

2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2726839/

Orive, G., Hernndez R.M., Gascn A.R., Igartua, M., Luis Pedraz, J. (2003, Mar).

Controversies Over Stem Cell Research. Retrieved December 29, 2020, from https://www.cell.com/trends/biotechnology/fulltext/S0167-7799(03)00003-9

Railton, D. (2019, Feb). Stem cells: Therapy, controversy, and research. (n.d.). Retrieved

December 27, 2020, from https://www.medicalnewstoday.com/articles/200904

Yu, J. and Thomson, J.A. Embryonic Stem Cells. (n.d.). Retrieved December 30, 2020, from

https://stemcells.nih.gov/info/Regenerative_Medicine/2006chapter1.htm

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Controversy Over the Use of Embryonic Stem Cells in Research Hadron

Multiomic atlas with functional stratification and developmental dynamics of zebrafish cis-regulatory elements – Nature.com

The DANIO-CODE DCC

We established a DCC protocol26, which we populated with zebrafish developmental genomic data, including standardized annotation of metadata of diverse, often inconsistently annotated, published datasets (Fig. 1a), by the DANIO-CODE consortium (https://www.birmingham.ac.uk/generic/danio-code/partners/index.aspx). The DCC is accessible from ZFIN and includes datasets, their underlying samples and sequencing protocols using ZFIN and ENCODE nomenclature (www.danio-code.zfin.org). To identify and analyze the developmental dynamics of genomic features, direct comparison across datasets produced by different laboratories and different protocols is required. To this end, we carried out consistent reprocessing starting from the raw sequencing data (Fig. 1a). Raw sequencing data were collected and reprocessed by standardized pipelines of ENCODE for ChIPseq and ATAC-seq27, FANTOM for CAGE-seq28 and producer pipelines for Hi-C, 4C-seq or other data (Methods). These pipelines are available on GitLab (https://gitlab.com/danio-code). The DCC data include 1,438 published datasets contributed by data producers directly or collected by DANIO-CODE data annotators, together with strategically selected datasets for developmental stages from the public domain. In addition, 366 datasets were generated by consortium members to fill gaps and to aid functional annotation and functional element characterization, including 15 CAGE-seq, 18 ChIPseq, 11 ATAC-seq, 2 Hi-C and 320 4C-seq datasets (Fig. 1b and Extended Data Fig. 1a,b). Breakdown of the datasets according to data types and stages of development is presented in Fig. 1b. The source of data collection is in Extended Data Figure 1c and Supplementary Table 1. Quality checks and data comparability analyses were carried out for datasets within a data type obtained from multiple laboratories, particularly affecting RNA-seq (Supplementary Fig. 1b), ChIPseq (Supplementary Fig. 1df), CAGE-seq (Supplementary Fig. 2) and ATAC-seq (Supplementary Fig. 1c) data. The DCC continues to be periodically updated (Extended Data Fig. 1e) and is openly accessible to the community for downloading data and uploading new datasets (Supplementary Videos 1 and 2).

a, Collection and manual annotation processes of datasets with the DANIO-CODE DCC with highlights of key findings. b, Extent of the open repository for developmental multiomic data for zebrafish with assay type (y axis) and developmental stage (x axis). Data first reported in this study are highlighted with black circles. c, Visualization of temporal dynamics of selected transcriptomic and epigenomic features during development at a developmentally active locus. Coloring of tracks represents developmental series from maternal (blue) to zygotically active stages of embryogenesis (red). Symbols and track colors indicate representative stages (Extended Data Fig. 1d). CNS, central nervous system.

The resulting data and reprocessed multiomic datasets represent a comprehensive annotation of the zebrafish genome during normal embryonic development and are available as a public track hub in the UCSC browser and uploadable to the Ensembl genome browser. Figure 1c provides an example developmentally regulated locus covering selected stages visualized by the Washington University Epigenome browser29. The tracks further include annotation of approximately 140,000 predicted ATAC-seq-supported developmental regulatory elements (PADRE) annotated by ChromHMM categories. The bulk sample-based predictions for regulatory elements are complemented with annotations of cell-type specificity of candidate regulatory elements provided by single-cell ATAC-seq30 (Supplementary Videos 35).

As genome-wide transcriptome analyses3,31,32,33 fail to annotate 5 untranslated regions (UTRs) precisely, we used DANIO-CODE expression data to improve current Ensembl models of developmentally active genes. We utilized 139 developmental RNA-seq samples to identify 31,458 genes comprising 55,596 transcripts (Fig. 2a and Supplementary Table 2), among them 167 novel transcripts of uncertain coding potential (TUCP) and 726 long noncoding (lnc) RNA genes not previously annotated by Ensembl and supported by CAGE signals (Extended Data Fig. 2 and Supplementary Table 3). We mapped 5 transcription start sites (TSSs) from 34 CAGE samples in 16 developmental stages (Fig. 2a). We applied promoter-calling criteria to CAGE data (Methods and Supplementary Fig. 2ac), resulting in 22,500 active promoters per CAGE sample on average, corresponding to 16,303 genes (Supplementary Table 4), and adding 4,070 novel promoters to 18,461 previously annotated Ensembl TSSs (GRCz10). To supplement the promoterome with cis-regulatory sites, we curated 581 regulatory motifs representing 814 zebrafish transcription factor (TFs), and predicted binding sites for these motifs across all promoters (Methods).

a, DANIO-CODE transcript 5 ends supported by CAGE TSS during stages of development. b, Distribution of absolute distance of Ensembl TSSs to CAGE-dominant TSSs in the Prim-5 stage. c, Relationship between guide distance to TSSs and ddCt. Inset: number of dCas guides for all 26 tested genes. d, CAGE-defined TSSs increase the accuracy of promoter identification and support dCas inhibition guide reagent designs. Distance between Ensembl TSSs and CAGE-dominant TSSs (top). Genome view with CRISPR guide position and efficacy, Ensembl and RefSeq transcripts, CAGE and RNA-seq expression (bottom).

a, Heat map shows the dynamics of expression levels of reference and alternative promoters across 16 developmental stages represented as images. Expression levels are scaled in the range of 01 for each row. Reference and alternative transcripts using the same and different coding sequence (CDS) starts are denoted. Transcript pairs without full CDS annotation are denoted as ambiguous. b, Distribution of correlation coefficient of expression levels of promoters across 16 developmental stages. c, Enrichment of KEGG pathways on multipromoter genes. The adjusted P value cut-off is 0.05, denoted by a vertical dashed line. The number of genes in KEGG pathways and those overlapping with multipromoter genes is shown inside the bars, d, MARA motif activity plots of three TF motifs across development. Posterior means and standard deviations (depicted as error bars) are based on analysis of the expression levels of all n=27,781 promoters for each sample. Motif logos are depicted as insets. e, Genome browser view of the actin alpha 1a promoter. From the top: ATAC signal, CAGE signal, a single TSR (black), two Ensembl transcripts (dark red) and TFBSs predicted to regulate this TSR (red) are shown. Color intensities of the TFBSs reflect MARA scores of predicted regulatory role of TFs.

Our above definition of promoters at single-nucleotide resolution may offer important guidance for promoter-targeted gene manipulation. For instance, gene promoter targeting for transcription block may be useful in reverse genetic experiments to avoid mutant RNA-mediated genetic compensation, which may mask mutant phenotypes and hinder dissection of gene function34. We compared Ensembls RNA-seq-based TSS with our CAGE-seq-based TSS and found a substantial discrepancy in position (Fig. 2b and Extended Data Fig. 3a), potentially impacting guide RNA design for CRISPRCas targeting. Multiple dCas guide positions were designed and their impact on expression reduction with increased distance between the guide target and dominant CAGE-defined TSS was tested. Efficiency of dCas inhibition was higher when CAGE dominant, compared to Ensembl, start sites were used (Fig. 2c,d and Supplementary Table 5), demonstrating the importance of accurate TSS detection and the improved accuracy of CAGE over the current Ensembl pipeline in promoter detection.

Using these data we identified 1,293 multipromoter genes (Supplementary Table 6), where 1,176 genes had one reference and one alternative promoter and 117 genes had two or more alternative promoters. Correlation of expression levels of reference and alternative promoter pairs indicated both convergent (cyan in Fig. 3a,b) and divergent (brown) dynamics during development. The expression of reference promoters was on average higher than those of alternative promoters (Extended Data Fig. 3b). Among 978 transcript pairs with full-length coding sequence annotation, 373 (38%) of the alternative promoters affected only the 5 UTR (for example, dag1; Extended Data Fig. 3c), whereas the remaining 605 altered the N-terminal protein sequence (for example, bmp6; Extended Data Fig. 3d). We analyzed mouse CAGE-seq28 data from comparable embryonic stages and annotated 1,779 multipromoter genes (Extended Data Fig. 3e and Supplementary Table 7). About one-third (294; 30%) of identified mouse orthologs of zebrafish multipromoter genes (974; 75%) utilized alternative promoters. Orthologs of multipromoter genes were likely (P=2.7105; Fishers exact test) to be expressed in similar stages and highly likely (P=3.241058; Fishers exact test) to have multiple promoters in mouse. Multipromoter genes were enriched in KEGG signaling pathways in zebrafish (Fig. 3c) and mouse (Supplementary Table 8), suggesting vertebrate conservation of alternative promoters in signal transduction-associated genes.

Precision promoter annotation and expression dynamics allow exploitation of this resource to predict TF activity regulating the promoters. We implemented Motif Activity Response Analysis (MARA)35,36 for zebrafish. MARA models promoter expression dynamics in terms of the annotated TF binding sites, to infer which TFs most substantially drive expression changes during development. Figure 3d shows the inferred activity profiles of three TFs with strong effects on genome-wide expression patterns. While Tead3 targets are upregulated from gastrulation onwards, Tgif1 targets are transiently downregulated and NF-Y targets are downregulated from the sphere stage onwards, consistent with the known activities of these TFs37,38,39,40,41 (Extended Data Fig. 4 and Supplementary Table 9). MARA predicts substantially changing regulatory activities for regulatory motifs and assigns candidate regulator TFs to promoters (Fig. 3e). We have integrated our zebrafish annotations into the ISMARA webserver (ismara.unibas.ch) to allow this activity analysis on any RNA-seq data.

Next, we aimed to generate a comprehensive atlas of zebrafish developmental regulatory elements. We defined reproducible ATAC-seq42 peaks as PADREs in four pre-zygotic genome activation (ZGA) and seven post-ZGA stages, which we further classified on the basis of the presence of four histone marks using ChromHMM43,44 in five post-ZGA stages (Fig. 4a, Supplementary Fig. 3 and Extended Data Fig. 5a).

a, Genome browser screenshot showing ChromHMM classification of PADREs, and respective histone post-translational modification signals used to define them. b, UMAP plot of PADREs at the Prim-5 stage. Each point represents one open chromatin region, colored by functional assignment. c, Occurrence probabilities of chromatin marks for ChromHMM states. The states function was manually assigned using The Roadmap Epigenomic annotations as reference. 1_TssA1, 2_TssA2: active TSS; 3_TssFlank1, 4_TssFlank2, TSS flanking region; 5_EnhA1, active enhancer; 6_EnhFlank, enhancer flanking region; 7_EnhWk1, primed enhancer; 8_Pois, poised elements; 9_PcRep, Polycomb-repressed regions; 10_Quies, quiescent state. dg, UMAP plot showing PADREs overlapping with CAGE promoters (d), CTCF motif (e), eRNA enhancers (f) and transgenically validated enhancers (g). The transgenically validated enhancers are predominantly associated with enhancer-associated chromatin states (Supplementary Table 11). h, UMAP plot showing the mean phastCons score for each PADRE (top right) and overlap with human CNEs (top left). The bottom subpanel shows the distribution of phastCons scores of active enhancers throughout development (left, bars represents interquartile range), as well as the distribution of the phastCons score for PADREs separated by function at the Prim-5 stage. Two-sided Wilcoxon rank sum test was used to calculate P values between promoters and enhancers (P=2.21016) and enhancers and Polycomb-associated elements (P=2.21016). Exons and intergenic regions were added as reference (right) i, Position of cell-type-specific elements on the UMAP plot (top). ATAC, H3K27ac and H3K4me1 signals around the peak summit of cell-type-specific PADREs (bottom).

a, Openness profile of selected SOM classes (4: early; 6: post-ZGA constitutive; 14: late class), and their position density on the UMAP plots of different developmental stages (top). Heat map of signal intensity of ATAC, H3K27ac and H3K4me1 at the Dome and the Prim-5 stages, along with their respective profiles (bottom). b, Position of COPEs, DOPEs and DOPEs marked with H3K27ac in adult tissues on the UMAP plot (left). Profiles of ATAC, H3K27ac and H3K4me1 of COPEs, DOPEs, DOPEs marked in adult tissues, and other constitutive elements throughout development (right).

To examine the developmental dynamics of PADREs, we developed a UMAP-based method (Methods and Extended Data Fig. 6ac) that can identify known functional classes and potentially novel subclasses during development. The UMAP plot of PADREs (Fig. 4b and Extended Data Fig. 6d) separated most ChromHMM-derived functional classes, including promoters from enhancers (Fig. 4c). Near-symmetry around the y axis reflects strand directionality and was most prominent among promoters (Fig. 4d). Two prominent clusters, which stretched upward and downward from the right apex and bear no chromatin marks, are enriched for the CTCF motif with well-positioned flanking nucleosomes45 (Fig. 4e and Supplementary Fig. 4). Enhancer predictions were validated with two independent sets: (1) enhancers with bidirectional enhancer RNA signals46 called from nuclear CAGE; and (2) a manually curated catalog of published enhancers functionally validated in transgenic reporter assays (Supplementary Table 10). Both colocalized with enhancer-classified PADREs on the UMAP (Fig. 4f,g and Extended Data Fig. 5c,d), demonstrating the utility of the method. DNA methylation analysis revealed CG-rich, promoter-associated PADREs persistently hypomethylated across stages, and less CG-dense enhancer-associated PADREs gradually hypermethylated during development before becoming hypomethylated in adult somatic tissue. Dynamically methylated PADREs varied in the onset and degree of hyper/hypomethylation: for example, conserved phylotypic enhancers11 commenced hypomethylation at the Prim-5 stage (Extended Data Fig. 5f).

Next, we assessed the evolutionary conservation of PADREs by overlapping with human conserved noncoding elements (CNEs) and calculating the phastCons score for each PADRE (Fig. 4h, top, and Extended Data Fig. 5b). Early-acting enhancers appear less conserved than those activated later (Fig. 4h, bottom left, and Extended Data Fig. 5e). phastCons scores of enhancers were higher on average than those of promoters (Fig. 4h, bottom right). Poised elements were the most conserved, suggesting that Polycomb-bound enhancers are a specific class critical for differentiation and organogenesis17,47, and contributing to the hourglass model of development48.

To assign cell-type specificity to PADREs we integrated them with Prim-5 single-cell ATAC-seq30 data (Extended Data Fig. 7a). The majority of anatomical annotation overlapped with transgenically confirmed enhancers and PADRE functional annotation (Extended Data Fig. 7b and Supplementary Table 11). UMAP (Fig. 4i, right) revealed remarkable differences between cell types, both within the same tissue and across tissues. PADREs active in neural precursors of the developing central nervous system showed a threefold increase of H3K27ac compared to those active in differentiating neurons, confirming previous observations about heterogeneity of cell-type population and chromatin dynamics in the developing central nervous system49,50. In contrast, PADREs active in muscle cells carried levels of H3K27ac and H3K4me1 comparable to neural precursors, but distinct accessibility profiles (Fig. 4i, bottom).

To understand the temporal dynamics of PADREs, we created a set of consensus PADREs (cPADREs), containing ~140,000 regions open in at least two neighboring stages (Supplementary Fig. 3a). We clustered nonpromoter cPADREs by chromatin accessibility into self-organizing maps (SOMs) (Extended Data Fig. 7c). Figure 5a (top) shows UMAP locations of 3 out of 16 SOM clusters, which demonstrate remarkable developmental chromatin changes, containing cPADREs active early and subsequently decommissioned (class 4), active from ZGA onwards (class 6) and late elements (class 14). Their chromatin profiles around ATAC-seq peaks were different, with only the early elements depleted of H3K27ac at their peak (Fig. 5a, bottom). With distinct chromatin and conservation profiles, early and late elements represent two separate classes of enhancers.

Finally, we explored the dynamics of PADREs without observable chromatin marks at any stage of development. 2,109 such regions were constitutively open throughout development (Supplementary Fig. 5a), which we termed constitutive orphan predicted elements (COPEs). They colocalized with constitutive SOM class 6 and 40% of them contained a CTCF motif (Figs. 5b, top, and 4e). In contrast, another nonmarked open chromatin set (11,044; termed dynamic orphan predicted elements; DOPES) was open only in specific developmental stages (Fig. 5b and Supplementary Fig. 5b). They were depleted of promoters, with only 65 (0.6%) overlapping CAGE promoters (Supplementary Table 12). Using data from ref. 24, we found that 2,513 DOPEs contained active chromatin marks later in adult tissues, but were open to the same extent as active enhancers already in the embryo (Supplementary Fig. 5c). As we are unaware of epigenetically orphaned accessible elements in the development, whose chromatin opening precedes or is uncoupled from enhancer-associated histone mark deposition, this may represent a discovery of a previously unknown subtype of primed enhancers.

To reveal any developmental promoter regulatory principles, we exploited the PADRE chromatin features to functionally classify CAGE-seq-defined active RNA polymerase II (Pol II) promoters. First, we characterized these promoters at Dome and Prim-5 stages on the basis of their chromatin accessibility at nucleosome resolution, revealing eight clusters (Fig. 6a, Supplementary Fig. 6a and Supplementary Table 13). We detected similar clusters in human embryonic stem cells (Supplementary Fig. 6b) indicating conservation of promoter chromatin architecture classes. The classes differed mostly in their upstream configuration, including the width of the nucleosome-free region (NFR), the signal strength of the central NFR and the presence of upstream open regions (Fig. 6a), which followed GC content (Supplementary Fig. 6c). The NFRs only differed in their amplitude between medium constitutive and weak open (Supplementary Fig. 6a), with the latter either reflecting reduced promoter activity or promoters active only in a subset of cells. The NFR variations were characterized by histone marker presence and patterns of upstream opposite strand transcription (for example, upstream offset) with distinct distances between the main TSS and flanking nucleosomes (for example, wide and strong open) and TSS profiles (Supplementary Fig. 6d). These classes showed notable differences in histone modification patterns (Fig. 6b), confirmed by the differing UMAP positions of promoter PADREs (Fig. 6c). Apart from weak open, each class produces antisense transcription (PROMPTs)51,52,53, including double NFR, wide and upstream offset classes, which showed CAGE expression from both the main NFR and another upstream region, with sense transcription being stronger than antisense (Fig. 6a). Notably, the architecture classes remain stable over developmental time (Fig. 6d and Supplementary Fig. 6e), suggesting they represent distinct regulation mechanisms acting on the genes rather than stage-dependent promoter activity states. Wide and strong open classes contained the most conserved promoters (Fig. 6e and Supplementary Fig. 6f), and were enriched in transcription regulator genes (Fig. 6g and Supplementary Fig. 6g). However, promoter classes showed distinct dynamic temporal expression (Fig. 6f) with notable enrichment of the double NFR class for maternally expressed genes, in contrast to the predominantly early and late zygotic weak open and medium zygotic classes, respectively. The promoter classes also showed distinct gene ontology (GO) enrichment categories (Fig. 6g). Overall, our approach offers a promoter architecture classification for zebrafish and indicates functional specialization and vertebrate conservation of promoter classes.

a, Heat map of chromatin accessibility profiles aligned to dominant TSS per promoter at the Prim-5 stage. Nucleosome-free regions (red) are superimposed with nucleosome positioning (blue). Stack height reflects number of promoters. Above each heat map, combined histograms of CAGE expression are shown. Black, forward TSSs; red, reverse orientation TSSs (the scale is amplified 10 in relation to forward transcription). Nucleosome positioning is symbolized above alignments and black arrows indicate transcription direction; size indicates relative strength. Promoter configuration classes are color-coded consistently in all panels (including Supplementary Fig. 6) b, Aggregated H3K4me1, H3K4me3 (MNase-digested), H3K27ac ChIPseq signals for classes as in a are aligned to dominant TSS. c, UMAP profiles of promoter classes at the Prim-5 stage. UMAPs are cropped to highlight promoter PADREs. d, Flow diagram indicates the relationship between promoter configuration class at the Dome stage (left edge, Supplementary Fig. 6) and the Prim-5 stage (right edge). Band width represents the number of promoters. e, Violin plot of phastCons vertebrate conservation distribution of promoters. Each class is aligned to a. f, Classification of promoter expression during development with SOMs. On the top right, 55 diagrams contain violin plots with stage-by-stage expression levels. Blue to red spectrum indicates maternal to zygotic expression dynamics of promoter clusters. Surface areas of gray circles indicate the number of promoters per cluster. Stages of development are symbolized below the SOM array. On the left, mustard: positive and green: negative color spectrum in SOMs indicates the enrichment in promoter overlap between promoter expression classes (SOMs) in each chromatin architecture class a. g, Enriched GO categories for each promoter architecture class.

Key genes regulating development are controlled by numerous long-range enhancers, which often overlap with highly conserved noncoding elements (HCNEs) within genomic regulatory blocks (GRBs)15, which also often contain other bystander genes that do not respond to those enhancers. The extent of GRBs coincides with those of topologically associating domains (TADs) around developmental genes54 (Fig. 7a). We exploited DANIO-CODE annotations to characterize chromatin opening and interaction topology in those poorly understood loci, and their regulatory role in TADs.

a, Schematic representation of GRBs. Basic components of a GRB. GRB enhancers (green) regulating the target genes span the entire length of the GRB (middle). Typical density pattern of conserved noncoding elements in a GRB, most of which overlap enhancers (top). Hi-C contact matrix within a GRB (bottom). b, Chromatin opening profiles through developmental stages along TADs. c, Genome browser view of a GRB TAD showing H3K27ac signals in the Dome and the Prim-5 stages, H3K27ac ensembles (black bar), CAGE promoters (black blocs) and nonpromoter PADREs (blue active in the Dome stage, red active in the Prim-5 stage and purple PADREs active in both stages). A zoomed-in genome browser view of an H3K27ac ensemble (top, left). d, Aggregate contact enrichment centered on ensembles at stages as indicated. e, TAD compartment score distribution. Positive scores represent A compartments, while negative ones represent B compartments. The comparison was done using two-sided two-sample unpaired Wilcoxon test. g, Heat maps of H3K27ac signal across GRB TADs containing ensembles through developmental stages. TADs are ordered by their width in descending order and fixed on the TAD center. h, CAGE expression patterns of selected gene classes separated by SOM, with the highest and lowest ratios in ensemble-associated genes. Bar plot on the right shows the proportion of ensemble-associated genes in each class. BGT and GST classes are marked on the heat map i, Gene expression pattern of GRB target and bystander genes. The left side bar shows an ensemble association for each gene. The right side bar shows the target or bystander assignment for each gene. Genes in TADs with and without ensembles are separated by a green line. BST and GST classes are indicated on the side. j, Graph showing mean expression and standard error of GRB target genes associated and not associated with early H3K27ac ensembles. k, A model describing the influence of an H3K27ac ensemble on expression of GRB target genes. If the H3K27ac ensemble is in contact with the target gene, it can be expressed early on.

We distinguished GRB TADs, characterized by a high density of extreme noncoding conservation, from non-GRB TADs. In the regions corresponding to late (Long-pec) embryo TADs, chromatin started opening at the boundaries as early as the Dome stage and remains open thereafter (Fig. 7b and Extended Data Fig. 8a). GRB TADs showed a strong increase in accessibility across the entire TAD, whereas in non-GRB TADs the increase was mild and occurred later (Fig. 7b). TADs started to form early but formed fully only at later developmental stages55,56 (Extended Data Fig. 8b). We found more promoter-proximal enhancers in early stages and more distal enhancers in late stages, (Extended Data Fig. 8c), in line with similar findings by contact analysis55.

When we estimated the activity of enhancer candidates by H3K27ac in TADs, we observed that such elements in late stages are numerous, short and distributed throughout the entire TAD length. In contrast, many fewer PADREs were active early at Dome stage, and they often occurred in clusters with uninterrupted H3K27ac signal connecting them (Extended Data Fig. 8d,e and Fig. 7c). We detected ~1,600 such clusters57, of which ~1,300 fell in TADs and were enriched in GRB TADs (Extended Data Fig. 8f). These clusters were reminiscent of super-enhancers57,58, although more numerous than 231 reported in mouse57 and 411 in zebrafish56. Given their unusual scale and early appearance before lineage determination (when previously reported super-enhancers appear), we distinguished them from super-enhancers and called them H3K27ac ensembles. We hypothesized that they might be associated with the lack of fully formed TADs in the early stages, when enhancers are used proximally to early active promoters. To test this, we investigated the relationship between the chromatin interactions and activity of H3K27ac ensemble-associated genes during early versus late embryogenesis.

We found that promoters were enriched at the boundaries of H3K27ac ensembles (Extended Data Fig. 8g) and that the ensembles contain most candidate enhancer PADREs detected in early stages (Extended Data Fig. 8h). In contrast, the PADREs active only later in development represented long-range enhancers, distributed across the entire TAD (Extended Data Fig. 8d), and not enriched in ensembles (Extended Data Fig. 8h). Moreover, H3K27ac present along the entire length of the ensemble became restricted to individual peaks associated with PADREs by Prim-5 (Fig. 7c, zoomed-in panel).

Consistent with an H3K27ac ensemble role in early gene regulation, we observed increased Hi-C contacts within them at Dome in both GRB and non-GRB TADs. By Prim-5, strong contacts spread throughout the entire TAD (Fig. 7d and Extended Data Fig. 9a). TADs with H3K27ac ensembles present at Dome belonged to the active A compartment at Prim-5 (Fig. 7e), arguing for a role for H3K27ac ensembles in the timely opening of chromatin in their host TADs. Indeed, in GRB TADs, the H3K27ac mark propagated from H3K27ac ensembles to fill the entire TAD in later stages (Fig. 7f).

To examine how H3K27ac ensembles influence gene expression, we classified promoters within TADs by expression dynamics using SOM (Extended Data Fig. 9b). H3K27ac ensemble-associated promoters mostly sequestered into clusters, with the highest expression in early post-ZGA stages (Fig. 7g). We termed the top two H3K27ac ensemble-associated classes as blastula-gastrula transition (BGT) and gastrula-segmentation transition (GST) on the basis of the peak expression time. The two major gene classes in GRB TADs were ubiquitously expressed (GRB bystanders) and late zygotic expressed (likely GRB target genes). However, in GRB TADs with an ensemble, we observed a BGT gene class, not present in GRB TADs without an ensemble, as well as more genes in the GST class. Both classes were enriched in ensemble-associated genes (Fig. 7h). Moreover, there was a clear trend of earlier expression in H3K27ac ensemble-associated GRB target genes, compared to other GRB target genes (Fig. 7i), suggesting that ensembles participated in the activation of early-acting developmental genes, including those later dependent on long-range regulation. Moreover, if the target gene is not in contact with the H3K27ac ensemble, it can only become expressed once long-range interactions are present (Fig. 7j).

Next, we investigated whether our annotation of noncoding elements could be exploited to predict functionally conserved cis-regulatory elements (CREs) among vertebrates. Existing comparative methods rely on direct alignments between species of interest59,60. However, the large evolutionary distance between fish and mammals limits the power of comparison, due to loss of noncoding sequence similarity. We developed a method to predict functional conservation across large evolutionary distances and genomic scales independent of direct sequence alignment, exploiting the fact that functional elements often maintain collinear syntenic positions, while their spacing scales with genome size, particularly in GRB TADs15,54,61,62. We selected 13 high-quality bridging species reference genomes and using stepped pairwise sequence alignment (Extended Data Fig. 10 and Methods), which allowed us to map coordinates between genomes of varying sizes, identified reference points (multispecies anchors; Fig. 8a) between genomes and enabling identification of syntenic regions through interpolation of relative syntenic positions between anchor points.

a, Cross-species comparison of the irx3/5(a) TAD between zebrafish and mouse and a zoom-in on the locus around irx3(a). Connecting lines represent projections of bin centers from zebrafish to mouse. b, Distribution of distances from the bin centers (n=528,830) to their closest anchors in zebrafish (blue), and from their projections to their closest anchors in mouse (red), using the direct and the multispecies projection approach. c, Epigenetic comparison of the irx3/5(a) TAD. H3K27me3 overlap in mapped regions is indicated as colored bars (yellow, mutually enriched; blue, zebrafish specific; red, mouse specific; Methods). Opacity reflects signal amplitude and is proportional to the maximum H3K27me3 signal in both species. d, H3K27me3 overlap profiles for four selected GRB TADs. TAD boundaries are indicated with square brackets. e, H3K27me3 overlap profiles of all GRB TADs. TADs are ordered by their relative amount of shared signal. Bins are ordered by the amount of shared signal: bins with shared signal appear in the middle, bins with zebrafish- and mouse-specific signals are left and right, respectively. A view of the TADs with their genomic bin order is given in Extended Data Fig. 10d,f. Classification of zebrafish ATAC-seq peaks in the irx3a locus into DC, IC and NC on the basis of overlaps with direct anchors, multispecies anchors and mouse DNase-seq peak projections (Methods). g, Distribution of DNase-seq signal in the mouse genome around the projected regions of the zebrafish ATAC-seq peaks (n=140,633). Asterisks above the bars indicate the effect size category based on Cohens d: very small (not indicated), small (*), medium (**), large (***), very large (****). h, Cross-species comparison of ChromHMM functional states. i, Cumulative distribution of shared motifs in mouse DNase-seq peaks overlapping zebrafish ATAC-seq peaks. j, H3K27ac enrichment (signal 80th percentile) within (n=11,083) and outside (n=93,020) of enhancer ensembles (P<2.21016, Fishers exact test). k, Cross-species comparison of H3K27ac profile around an H3K27ac ensemble neighboring the zebrafish aktip gene.

We then compared zebrafish and mouse GRB TADs, which differ in size approximately twofold (Extended Data Fig. 10a). We defined GRB TADs as the 1,000 TADs with the highest CNE density, split them into 1-kilobase (kb) bins, and mapped the bin centers from zebrafish to mouse. Using our multispecies approach over direct alignment reduced distances from the bin centers to their closest anchor by a factor of 16 in zebrafish and 29 in mouse (Fig. 8b).

We asked whether this method could discover conserved epigenomic subdomains by comparing epigenomic feature distribution across genomes. We used H3K27me3 ChIPseq data from phylotypic stages in zebrafish (Prim-5) and mouse (E10.5; Methods). H3K27me3 coordinates from zebrafish were projected onto the mouse genome, recovering mouse H3K27me3 features in the corresponding region. An example at the irx3a locus (Fig. 8c) shows H3K27me3 enrichment correlates between zebrafish and mouse, even in the absence of direct sequence conservation. On a genome-wide level, H3K27me3 enrichment is substantially more likely to be shared between zebrafish and mouse for both directly alignable and nonalignable genomic regions (Extended Data Fig. 10e), suggesting epigenomic subdomains and functional elements can be conserved in location and span. We see more GRB TADs showing regions of strong similarity in H3K27me3 extent, while others, such as TADs containing her9 or celf5a, show more zebrafish- or mouse-specific signal enrichment, and still others show little enrichment (Fig. 8d,e).

We next looked at conservation of functional elements marked by open chromatin. We classified zebrafish ATAC-seq peaks in the GRB TADs as directly conserved (DC) if they fall in a region of direct sequence alignment with mouse (16,188 elements, 11.5 %), indirectly conserved (IC) if they do not directly align (6,137 elements, 4.4%) but were alignable through bridging species and nonconserved (NC) for all other peaks (for example, irx3a in Fig. 8f). Notably, DC and IC elements shared regulatory features with their matched counterparts in mouse, including DNase hypersensitivity and ChromHMM feature classification, compared to NC elements (Fig. 8g,h). DC and IC regions were also more likely to share TF binding site (TFBS) motifs compared to nonoverlapping, randomly sampled mouse DNase-seq peaks within and across TAD boundaries (cis and trans in Fig. 8i and Supplementary Table 14). These results suggest a similar level of functional conservation of DC and IC elements, even though IC elements lack direct alignability. Next, we tested whether the early developmental H3K27ac ensembles detected in zebrafish embryos (Fig. 7) are conserved in mouse using our anchoring-based approach. As shown in Fig. 8j,k, H3K27ac signal in mouse was substantially enriched in zebrafish ensembles, suggesting these ensembles are evolutionarily conserved epigenetic subdomains in vertebrates. Genes associated with these conserved ensembles are listed in Supplementary Table 15. Our comparative epigenomic approach has maximized the identification of putative functional elements and epigenetic subdomains conserved between zebrafish and mouse, and highlights the utility of the DANIO-CODE annotations for discovery of vertebrate-conserved mechanisms.

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Did COVID derail FDA stem cell clinic plan? – The Niche

The FDA stem cell clinic problem just continues to grow, while the agency has been oddly quiet in this space for more than a year.

Its been a major disappointment, particularly as in recent years FDA leadership had implied that bold action was coming. Their own words spiked expectations that the agency would tackle unproven stem cell clinics in a bold way.

Whats going on and why the disconnect between words and actions lately?

Many of these unproven clinic firms unambiguously market unapproved drug products, seemingly in clear violation of the law. Some have been doing so for many years. We now know about numerous people hurt by specific clinics and indirectly by suppliers. Unproven stem cell therapy risksare clearer now than ever.

It was therefore refreshing to see FDA leaders use unprecedented language to describe the problem over the past 3-4 years. It seemed clear how seriously they took it. The expectation from the stem cell field was some kind of major action at least on the most egregious of the clinics.

The FDA further raised expectations when more than a year ago it let a discretionary period for firms marketing stem cells expire. No discretionary period means clinics have one less excuse.

Yet very little has actually happened on the unproven clinic front.

Maybe one or a few warning letters a year.Some untitled letters, which lack bite. Actually in 2022 the agency branch in charge of biologics, CBER, has only issued one untitled letter so far, at least thats in the public domain. See screenshot below. By comparison, last year by this time it had issued nine such letters. Clearly there is no shortage of firms that could receive untitled and even warning letters. Its not as though the FDA has run out of firms to send letters to.

How big is the problem now?

My colleague Leigh Turner and I published the first data on stem cell clinic numbers in the U.S. back in 2016. It shook people up. FDA officials told me it made a concrete difference to have data on clinics. Those numbers were in the hundreds.

Since that time, clinic numbers have grown again several-fold.

Leigh more recently documented over two thousand stem cell clinics in the U.S. Not all of these clinics are clearly noncompliant its clearly a vast problem that requires quick, strong action.

The leaderships own past words suggested some big steps were coming. Then Commissioner Steve Hahn and CBER Director Peter Marks wrote a 2020JAMA piece that was blunt. It ended this way (emphasis mine in the following quotes):

It is time for unproven and unapproved regenerative medicine products to be identified and recognized for what they frequently are: uncontrolled experimental procedures at a cost to patients, both financially and physically. Patients and their caregivers should feel empowered to report adverse events to help make sure that purveyors of unproved products are identified, and the FDA can take appropriate action to bring them into compliance and thereby help protect more patients from harm. This goes to the core of the mission to which the FDA is committed: promoting and protecting the public health.

A year earlier, Marks and then Commissioner Scott Gottlieb issued a strong statement on stem cell clinics on the FDA website. The key phrase was this:

And we will not shy away from taking further steps when we see bad actors taking advantage of patients, and putting them at serious risk, for their own financial profit.

Again, no shortage of bad actors out there for the agency to act on.

Then a few months later the FDA issued a warning on stem cell clinics including this strongly-worded passage:

some patients seeking cures and remedies are vulnerable to stem cell treatments that are illegal and potentially harmful. And the FDA is increasing its oversight and enforcement to protect people from dishonest and unscrupulous stem cell clinics

Illegal is a very strong word for the agency to use. Again, this seemingly totally conflicts with the little that has happened in the way of FDA action lately.

So why the minimal enforcement actions in the past thirteen months, especially since theres no enforcement discretion these days? Seems like a paradox to me. There might be some complexities here.

What about COVID? A recent JDSUPRA piece reporting on statements at events byFDA Chief Counsel Mark Razaand Dr. Wilson Bryan suggests COVID could have been a delaying factor. The piece is entitled, Unapproved stem cell therapies remains a top FDA enforcement priority. Heres a key quote:

Coming out of the COVID-19 pandemic, we expect to see more enforcement activity around claims/promotion of stem cell products and manufacturing compliance and quality of such products, likely to be focused on scenarios that present the highest or significant potential risk to patients and consumers.

This is just one possibility. I hope theyre right though. Also from the same piece:

At a recent regenerative medicine webinar, CBER Office of Tissues and Advanced Therapies (OTAT) Director Wilson Bryan, M.D.,saidhis office has been increasingly notifying, warning, and taking legal enforcement actions against manufacturers, clinics, and individuals administering unapproved regenerative medicine therapies.

Does increasingly refer to the past 3 or years or just more recently? The link embedded in that quote also goes to FDA text that has some very strong language from Bryan just last year on some clinics and activities being illegal.

From Raza:

Speaking Tuesday at the Food and Drug Law Institute (FDLI) Annual Conference, Mark Raza, FDA Acting Chief Counsel, discussed the investigations priorities for FDAs Office of the Chief Counsel (OCC), including its focus on stopping stem cell clinics that put patients at risk.

That sounds encouraging.

Beyond possible COVID issues or delays, another possible scenario here is that more has been going on behind the scenes on clinics. The FDA just hasnt told us about it or it hasnt reached fruition. Maybe theres a whole lot of investigations ongoing?

What else might explain the FDAs concerning lull?

Cell Surgical Network Lawsuit. There is that seeminglynever-ending court case with the FDA seeking permanent injunction on a California-centered stem cell clinic chain. Is the agency waiting to see the verdict? In a way that court case only or mainly pertains to so-called fat stem cell clinics. There are many hundreds of noncompliant clinics that seem unrelated to that case. Numerous suppliers too.

The FDA also only relatively recently got a new Commissioner. Robert Califf came on board again for a second term just four months ago. Sometimes a change in leadership can delay groundbreaking action by an agency for at least a little while.

Whatever has been going on, this lull has serious risks to the public. Also, Id say its not great for the agency either if it is seen to seemingly be passive on non-compliant and in some cases obviously unlawful stem cell marketing. Its especially bad timing for an enforcement discretion period to end and then almost nothing happen for more than a year after that.

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Did COVID derail FDA stem cell clinic plan? - The Niche

Akari Therapeutics Announces First Patient to Complete Course of Treatment in the Phase III Part A Clinical Trial of Investigational Nomacopan in…

Akari Therapeutics Plc

NEW YORK and LONDON, July 07, 2022 (GLOBE NEWSWIRE) -- Akari Therapeutics, Plc (Nasdaq: AKTX), a late-stage biotechnology company focused on developing advanced therapies for autoimmune and inflammatory diseases, today announced that a patient has completed the course of investigational nomacopan treatmentin the open-label, multi-center Phase IIIPart Aclinical trial in pediatric hematopoietic stem cell transplant-related thrombotic microangiopathy (HSCT-TMA). Nomacopan is a bispecific recombinant inhibitor of complement C5 and leukotriene B4 (LTB4).

Three patients with severe (nephrotic range proteinuria and elevated soluble C5b-9) HSCT-TMA have been enrolled in the clinical trial. One patient completed more than 60 days of nomacopan treatment and subsequently was discharged from the hospital. Another patient died from multi-organ failureunrelated to nomacopan treatment.Dosing has begun in the third patient.

This is promising news for children and families facing hematopoietic stem cell transplant-related TMAs who have unmet needs that are significant and urgent because there are no approved treatment options, said Rachelle Jacques, President and CEO of Akari Therapeutics. Recruitment into a study of treatment for a rare and emergent complication of stem cell transplants in children has inherent challenges, and it is testament to the passion and commitment of everyone involved that this important Phase III clinical trial is progressing on behalf of patients and their families.

Nomacopan was granted Orphan Drug and Fast Track designations by the U.S. Food and Drug Administration (FDA) for pediatric HSCT-TMA. Data from the Phase III Part A study of nomacopan in HSCT-TMA will inform the pivotal Phase III Part B study that will be the basis for potential regulatory submissions in the U.S. and Europe.

The six-year-old patient who was discharged wastreated at a clinical trial site in Manchester, England by investigator Rob Wynn, M.D. Thrombotic microangiopathy following a stem cell transplant procedure is a rare but devastating complication made even more tragic because there are currently no approved treatments, said Professor Rob Wynn, of Royal Manchester Childrens Hospital, part of Manchester University NHS Foundation Trust. As we advance this important clinical trial and offer treatment to children in Manchester where formerly there was none, we are bringing new hope to families who are in desperate need, and to other clinicians who very much want to offer a treatment option.

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Thrombotic microangiopathy following a stem cell transplant procedure is a rare but serious complication of HSCT that appears to involve complement activation, inflammation, tissue hypoxia and blood clots, leading to progressive organ damage and death. The mortality rate in patients who develop severe transplant-related TMAs is 80%.1 Currently, there are no approved treatment options in the U.S. or Europe.

Sites are open and recruiting in the U.S, U.K., and Poland for the Phase III Part A clinical trial of investigational nomacopan in pediatric patients who have undergone allogeneic or autologous HSCT and develop HSCT-TMA within a year of transplant. Patient dosing is underway in the multi-center, open-label study that has a recruitment goal of seven pediatric patients over six months old.

The primary study endpoints are either independence of red blood cell transfusion or urine protein creatinine ratio of 2 mg/mg maintained over 28 days immediately prior to any scheduled clinical visit up to Week 24. According to the study protocol, patients may discontinue therapy sooner than 24 weeks, if one, or both, of the primary endpoint components has been met and the treating clinician determines there is no longer a need for continued treatment with nomacopan. Patients who have achieved the primary endpoint and are no longer receiving nomacopan will have a follow-up clinic visit 30 days after the last dose, at 24 weeks and for long-term follow-up at one and two years.

References

Rosenthal J. Hematopoietic cell transplantation-associated thrombotic microangiopathy: a review of pathophysiology, diagnosis, and treatment.J Blood Med. 2016;7:181-186. Published 2016 Sep 2. doi:10.2147/JBM.S102235

About Akari Therapeutics

Akari Therapeutics, plc (Nasdaq: AKTX) is a biotechnology company focused on developing advanced therapies for autoimmune and inflammatory diseases. Akari's lead asset, investigational nomacopan, is a bispecific recombinant inhibitor of C5 complement activation and leukotriene B4 (LTB4) activity. The Akaripipeline includes two late-stage programs for bullous pemphigoid (BP) and thrombotic microangiopathy (TMA), as well as earlier stage research and development programs in eye and lung diseases with significant unmet need. For more information about Akari, please visit akaritx.com.

Cautionary Note Regarding Forward-Looking Statements

Certain statements in this press release constitute forward-looking statements within the meaning of the Private Securities Litigation Reform Act of 1995. These forward- looking statements reflect our current views about our plans, intentions, expectations, strategies and prospects, which are based on the information currently available to us and on assumptions we have made. Although we believe that our plans, intentions, expectations, strategies and prospects as reflected in or suggested by those forward- looking statements are reasonable, we can give no assurance that the plans, intentions, expectations or strategies will be attained or achieved. Furthermore, actual results may differ materially from those described in the forward-looking statements and will be affected by a variety of risks and factors that are beyond our control. Such risks and uncertainties for our company include, but are not limited to: needs for additional capital to fund our operations, our ability to continue as a going concern; uncertainties of cash flows and inability to meet working capital needs; an inability or delay in obtaining required regulatory approvals for nomacopan and any other product candidates, which may result in unexpected cost expenditures; our ability to obtain orphan drug designation in additional indications; risks inherent in drug development in general; uncertainties in obtaining successful clinical results for nomacopan and any other product candidates and unexpected costs that may result there; difficulties enrolling patients in our clinical trials; failure to realize any value of nomacopan and any other product candidates developed and being developed in light of inherent risks and difficulties involved in successfully bringing product candidates to market; inability to develop new product candidates and support existing product candidates; the approval by the FDA and EMA and any other similar foreign regulatory authorities of other competing or superior products brought to market; risks resulting from unforeseen side effects; risk that the market for nomacopan may not be as large as expected risks associated with the impact of the COVID-19 pandemic; inability to obtain, maintain and enforce patents and other intellectual property rights or the unexpected costs associated with such enforcement or litigation; inability to obtain and maintain commercial manufacturing arrangements with third- party manufacturers or establish commercial scale manufacturing capabilities; the inability to timely source adequate supply of our active pharmaceutical ingredients from third party manufacturers on whom the company depends; unexpected cost increases and pricing pressures and risks and other risk factors detailed in our public filings with the U.S. Securities and Exchange Commission, including our most recently filed Annual Report on Form 20-F filed with the SEC. Except as otherwise noted, these forward-looking statements speak only as of the date of this press release and we undertake no obligation to update or revise any of these statements to reflect events or circumstances occurring after this press release. We caution investors not to place considerable reliance on the forward-looking statements contained in this press release.

For more information

Investor Contact: Mike Moyer LifeSci Advisors (617) 308-4306 mmoyer@lifesciadvisors.com

Media Contact: Eliza Schleifstein Schleifstein PR (917) 763-8106 eliza@schleifsteinpr.com

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Akari Therapeutics Announces First Patient to Complete Course of Treatment in the Phase III Part A Clinical Trial of Investigational Nomacopan in...

Next-day manufacture of a novel anti-CD19 CAR-T therapy for B-cell acute lymphoblastic leukemia: first-in-human clinical study | Blood Cancer Journal…

Preclinical evaluation of FasT CAR-T cells FasT CAR-T (F-CAR-T) proliferation in vitro

To characterize the in vitro proliferative capacity of F-CAR-T cells, F-CAR-T and C-CAR-T cells were manufactured in parallel (Supplementary Methods, and Fig. S1) using T-cells from 6 B-ALL patients. To investigate the ex vivo proliferation of F-CAR-T, frozen CD19 F-CAR-T and C-CAR-T cells from each patient were thawed and stimulated with irradiated CD19-expressing K562 cells. The number of CD19-targeting CAR-T cells was then determined during the course of cell expansion in vitro. As shown in Fig. 1A, upon CD19 antigen stimulation, F-CAR-T proliferation was much more robust compared to C-CAR-T proliferation. On day 17 post co-culture, F-CAR-T expanded 1205.61226.3 fold (MeanSD), while C-CAR-T expanded only 116.437.2 fold (MeanSD), (p=0.001). To characterize the mechanism underlying the superior proliferative ability of F-CAR-T, we purified CD19+ CAR-T cells from both F-CAR-T and C-CAR-T. The expression of genes involved in cell proliferation, cell cycle, and apoptosis was analyzed using Nanostring (detailed gene sets are in Table S2). Gene expression profiles showed higher F-CAR-T expression scores for genes associated with cell cycle regulation (F-CAR-T vs. C-CAR-T, p<0.01) and lower expression scores for apoptosis-related genes (F-CAR-T vs. C-CAR-T, p<0.05) in F-CAR-T cells (Fig. S2A).

A Ex vivo cell proliferation of F-CAR-T and C-CAR-T derived from B-ALL patients (n=6) (***P=0.001, F-CAR-T vs. C-CAR-T, d17, unpaired student two-tailed t-test). B Tscm, Tcm, and Tem were characterized by surface staining of CD45RO and CD62L and analyzed with flow cytometry (***P<0.001 comparing F-CAR-T and C-CAR-T). C T-cell exhaustion was characterized by PD-1, LAG3, and TIM-3 staining; Statistical analyses of the percentage of PD1+ LAG3+ Tim3+ (***P<0.001, comparing F-CAR-T and C-CAR-T), unpaired student two-tailed t-test). D RTCA assay was used to examine the specific killing of HeLa-CD19 cells. Growth of target HeLa-CD19 or HeLa cells were monitored dynamically. E CD19+ target Nalm6-Luc cells or F Raji-Luc cells were co-cultured with either F-CAR-T or C-CAR-T for 6h. Target cell killing efficacy was calculated by luciferase activity. NS, P>0.05 F-CAR-T vs. C-CAR-T (unpaired student t-test, two-tailed). F-CAR-T FasT CAR-T, C-CAR-T conventional CAR-T, Tcm (CD45RO+CD62L+) T central memory cells, Tem (CD45RO+CD62L) T effector memory cells, Tscm (CD45ROCD62L+) T stem cell memory, PD1 programmed cell death protein 1, TIM-3 T cell immunoglobulin and mucin domain containing-3, LAG3 lymphocyte-activation gene 3, RTCA real-time cell analyzer, E:T effector cells: target cells, NT normal T-cell.

Phenotypes of unstimulated F-CAR-T from three healthy donors were analyzed by flow cytometry. The CD45ROCD62L+ population was 45.7%2.2% which was comparable to the un-transduced T-cells (data not shown). Upon stimulation with CD19+ tumor cells for 9 days, C-CAR-T central memory cells (Tcm, CD45RO+CD62L+ and effector memory cells (Tem, CD45RO+CD62L) were 56.62%11.97% and 40.48%9.70%, respectively, among the C-CAR-T cells (Fig. 1B and Figs. S2B and S2). In contrast, Tcm cells (87.92%4.36%) was predominant in F-CAR-T, with only a small fraction of Tem (7.84%3.79%). In addition, F-CAR-T cells demonstrated more abundant T stem cell memory (Tscm) (3.841.22% vs 2.342.48%, p<0.05) than C-CAR-T cells. We also examined the exhaustion status of the stimulated CAR-T cells. A higher percentage of PD-1+LAG3+Tim3+T-cells were detected in the C-CAR-T (11.19%2.54%) compared to F-CAR-T (3.59%2.51%, p<0.001) (Fig. 1C). Together these data indicated that the F-CAR-T exhibited a younger phenotype and was less exhausted compared to C-CAR-T.

We used a real-time cell analyzer (RTCA) assay to measure the cytotoxicity of F-CAR-T and C-CAR-T against CD19+ cells in vitro. F-CAR-T and C-CAR-T killing of Hela-CD19 target cells were comparable using this assay (Fig. 1D). Similar levels of IFN- and IL-2 production were also observed (Fig. S2D). In a luciferase-based cytotoxicity assay, CD19+ B leukemia cell lines, Raji and Nalm6, were both effectively killed to similar or better levels at different E:T ratios (Fig. 1E, F).

To compare the in vivo cytotoxicity of F-CAR-T and C-CAR-T, severe immunodeficient NOG mice were engrafted with Raji-luciferase cells. One week after the tumor grafts were established, F-CAR-T and C-CAR-T were intravenously injected at various doses. The engrafted tumors progressed aggressively in control groups with either vehicle alone or control T-cells (Fig. 2A). In contrast, F-CAR-T or C-CAR-T treatment greatly suppressed tumor growth in a dose-dependent manner (Fig. 2A). In the high dose group (2106/mice), both F-CAR-T and C-CAR-T eliminated the tumor rapidly. However, in the low dose group (5105/mice), F-CAR-T showed more effective tumor-killing compared to C-CAR-T. On day 20, mice in the low dose F-CAR-T group became tumor-free, while C-CAR-T treated mice exhibited tumor relapse (Fig. 2A). We examined the CAR-T cell expansion in vivo after infusion. As shown in Fig. 2B, both F-CAR-T and C-CAR-T began to expand in the peripheral blood 7 days after infusion. C-CAR-T cell numbers reached their peak on day 14 and receded on day 21. In contrast, the F-CAR-T cell number peaked on day 21 and declined to a baseline level on day 28. F-CAR-T not only persisted longer but also underwent 26 folds greater expansion than C-CAR-T (Fig. 2B).

A Raji-Luc cell engraftment NOG mice were given high dose (2106/mice, n=3) and low dose (5105/mice, n=3) F-CAR-T/C-CAR-T along with control groups. Tumor growth was monitored with IVIS scan once every 3 days; B CAR-T expansion in peripheral blood of mice was analyzed by flow cytometry (n=6). ***P<0.001 for F-CAR-T HD vs. C-CAR-T HD; F-CAR-T LD vs. C-CAR-T LD; F-CAR-T HD vs. F-CAR-T LD; C-CAR-T HD vs. C-CAR-T LD (two-way ANOVA statistical analysis); C Schematic of the Nalm6 (1106) xenograft model, CAR-T (2106) infused 1 day after cyclophosphamide (20mg/kg) treatment. Bone marrow infiltration of F-CAR-T was analyzed 10 days after CAR-T infusion (n=3); D CD45+CD2 F-CAR-T vs. C-CAR-T in peripheral blood of mice were analyzed by flow cytometry; *P<0.05 (unpaired student two-tailed t-test). IVIS in vivo imaging system, PB peripheral blood, i.v. intravenous, HD high dose, LD low dose, Cy cyclophosphamide; *p<0.05; #: number.

We examined the BM infiltration of F-CAR-T cells after infusion into Nalm6-bearing mice (Fig. 2C). A larger population of CAR-T cells was observed 10 days after infusion in BM in F-CAR-T infused group than that in the C-CAR-T group (p<0.05) (Fig. 2D), suggesting F-CAR-T cells possessed a better BM homing capability than C-CAR-T.

The chemokine receptor CXCR4 is known to be critical for BM homing of T-cells [25, 26]. Indeed, a higher percentage of CXCR4+ T cells were detected in F-CAR-T than in the C-CAR-T. Interestingly, this phenotype was more pronounced for CD4+ T cells than CD8+ T cells (Fig. S3A). In a two-chamber system, more F-CAR-T cells could be detected in the lower chamber than their C-CAR-T counterparts (Fig. S3B).

Between Jan. 2019 and Oct. 2019, 25 pediatric and adult patients with CD19+R/R B-ALL were enrolled onto our phase 1 trial, including two patients who had relapsed following a prior allo-HSCT. Patient characteristics are detailed in Table 1. The median age of patients was 20 (range: 344) years old. Twenty patients were >14 years old, and five were 14 years old. The median percentage of pre-treatment BM blasts was 9.05% (range: 0.1982.9%). As our pre-clinical studies demonstrated that F-CAR-T cells had a superior expansion capability as compared to C-CAR-T, we infused a relatively low doses of F-CAR-T cells, ranging from 104105 cells/kg: 3.0104 cells/kg (n=2), 6.5 (5.867.43)104 cells/kg (n=9), 1.01 (1.01.16)105 cells/kg (n=12), 1.52(1.471.56)105 cells/kg (n=2), (Fig. S4). The median time from apheresis to the infusion of CD19+F-CAR-T cells was 14 days (range: 1220). Although the manufacturing time of F-CAR-T was next day, the quality control time and detailed final product releases including sterility testing require a minimum of 710 days to complete. In addition, transportation of cell products requires approximately two days. Of the 25 patients who received CD19 F-CAR-T infusion, 22 (88%) received bridging chemotherapy between apheresis and lymphodepleting chemotherapy to control rapid disease progression (Table S3).

F-CAR-T cells were manufactured successfully for all patients. The mean transduction efficiency of F-CAR-T was 35.4% (range: 13.170.3%) (Fig. S5A). Both CD4+/CAR+ (mean, 49.6%; range: 13.673.2%) and CD8+/CAR+ (mean, 41.5%; range: 20.677.7%) subsets were present in the CD3+CAR+ T cell subsets of all products. The mean proportion of Tscm, Tem, and Tcm cells in the CD3+CAR+ T cell subsets of all products was 23.3% (range: 3.5545.3%), 33.2% (range: 17.267.9%), and 36.1% (range: 20.758.1%), respectively (Fig. S5B). F-CAR-T products exerted significant IFN- release and cytotoxic effects against the CD19+ cell line HELA-CD19 (Fig. S5, C, D).

All 25 infused patients experienced adverse events (AEs) of any grade, with 25 (100%) experiencing grade 3 or higher adverse events. No grade 5 events related to F-CAR-T treatment were observed (Table 2).

CRS occurred in 24 (96%) patients with 18 (72%) grade 12 CRS,6 (24%) of grade 3, and no grade 4 or higher CRS (Fig. S6). In the >14 years old group, 16/20 (80%) patients developed mild CRS, and only 2/20 (10%) developed grade 3 CRS. For 14 years old patients, 2/5 (40%) had mild CRS, yet 3/5 (60%) experienced grade 3 CRS (Table S4). ICANS was observed in 7 (28%) patients, with 2 (8%) grade 3 ICANS occurring in patients >14 years old and 5 (20%) grade 4 ICANS all occurring in patients 14 years old. No grade 5 ICANS was developed (Fig. S7 and Table S4). The most frequent presentation of CRS was fever, particularly a high fever of >39C. The first onset of CRS symptoms occurred between day 3 and 8 post-CAR-T infusion with a median onset at day 4 (range: 110 days). The most common symptoms of ICANS were seizure (5/7) and depressed consciousness (5/7). The median time to ICANS onset from CAR-T cell infusion was 7 days (range: 58), and the median time to resolution was 2 days (Fig. S7). All CRS and ICANS events were managed including early intervention when fever of 39C persisted for 24h. Sixteen (64%) patients received tocilizumab with a median total dose of 160mg (range: 160320mg). Twenty-one (84%) patients received corticosteroids including dexamethasone (median total dose, 43mg; range: 4127mg) and or methylprednisolone (median total dose, 190mg; range: 401070mg). The vast majority of these patients discontinued corticosteroids within 2 weeks. The change in IL-6, IFN-, IL-10, and GM-CSF levels after infusion are selectively shown in Fig. S8. The peak levels of these four cytokines were observed between day 710. Among all 21 cytokines examined, only post-infusion IL-6 levels were associated with moderate to severe CRS and/or ICANS (Figs. S9 and S10).

Superior in vivo proliferation and persistence of F-CAR-T compared to C-CAR-T cells were observed regardless of dose levels. The median peak level was reached on day 10 (range: 714 days) with 1.9105 transgene copies/g of genomic DNA (range: 0.225.2105 transgene copies/g of genomic DNA) by qPCR and 83 F-CAR-T cells per l blood (range: 42102 F-CAR-T cells per l blood) by FCM (Fig. 3A, B). No significant differences were observed among the different dose groups in the mean F-CAR-T copies peak (Fig. 3C). Importantly, there was no significant difference in the mean F-CAR-T copies peak between patients who received corticosteroids compared to those who did not (Fig. 3D).

A F-CAR-T cells in peripheral blood by qPCR. Purple, dose level 1; black, dose level 2; blue, dose level 3; red, dose level 4; B F-CAR-T cells in peripheral blood by flow cytometry. Purple, dose level 1; black, dose level 2; blue, dose level 3; red, dose level 4; C Comparison of the mean peak copy number of F-CAR-T cells in peripheral blood at each dose level. Statistical significance was determined by the MannWhitney test. D Comparison of the mean peak copy number of F-CAR-T cells in peripheral blood with or without steroids. Statistical significance was determined by the MannWhitney test.

Fourteen days after F-CAR-T cell infusion, all patients achieved morphologic CR including 2/25 with CR and 23/25 CR with incomplete hematologic recovery (CRi), which further improved to 11/25 CR and 14/25 CRi 28 days post F-CAR-T (Table 1 and Fig. 4). More importantly, 23/25 (92%) had the minimal residual disease (MRD)-negative remission on day 14 and day 28 after F-CAR-T treatment. Patients achieving remission through CAR-T were given the option to proceed to allo-HSCT. With a median time of 54 days (range: 4581 days) post F-CAR-T infusion, 20 of 23 patients with MRD-negative status decided to pursue consolidative allo-HSCT including one patient who received a 2nd transplant. As of 18 October 2021, with a median follow-up duration of 693 days (range: 84973 days) among the 20 patients who had received allo-HSCT, one patient relapsed on day 172 and died 3 months after relapse, and four patients died from transplant-related mortality (TRM) including infection (n=3) and chronic GVHD (n=1) on day 84, day 215, day 220, and day 312, respectively. The other 15 patients remained in MRD-negative CR with a median remission duration of 734 days (range: 208973) except for one who became MRD-positive on day 294 with CD19+ disease. Among the other three patients (F05, F06, F16), one remained in MRD-negative CR on day 304, one remained in MRD-negative CR until day 303, received allo-HSCT but died from an infection on day 505, and one was lost to follow-up after day 114. Two patients who had MRD-positive CR after infusion withdrew from the study on day 42 and day 44, respectively, to seek other studies.

Clinical outcomes and consolidative allo-HSCT for the 25 patients who were treated with F-CAR-T therapy are shown. On day 28, 23/25 patients achieved MRD-negative CR/CRi. With a median time of 54 days (range: 4581) post F-CAR-T infusion, 20 of 23 patients with MRD-negative status received consolidative allo-HSCT. Among the 20 patients, 1 patient (F23) relapsed on day 172 and died 3 months after relapse. Four patients (F04, F09, F11, F12) died from transplant-related mortality (TRM) including infection (n=3) and chronic GVHD (n=1) on day 84, day 215, day 220, and day 312, respectively. The remaining 15 patients were in MRD-negative CR except for one (F18) who became MRD-positive on day 294. Among the other 3 patients (F05, F06, F16), 1 remained MRD-negative CR on day 304, 1 remained in MRD-negative CR until day 303, received allo-HSCT, and subsequently died from an infection on day 505. One patient was lost to follow-up after day 114. MRD minimal residual disease, CR complete remission, Allo-HSCT allogeneic hematopoietic stem cell transplantation.

F-CAR-T/T ratio in cerebrospinal fluid (CSF) was evaluated by FCM in 13/25 patients with available samples (Table S5). Between days 10 and 32, 9 patients were found to have considerable F-CAR-T penetration in their CSF, ranging from 40.65 to 79.2%, including 4 who developed severe ICANS. Among the other 4 patients, F-CAR-T cell abundance in the CSF ranged from 1.29% to 3.57%, and none experienced severe ICANS. Patients with higher levels of CAR-T in PB on day 10 consistently had higher levels of CAR-T in CSF with the exception of patient F15. Notably, CAR-T cells were still detectable in the CSF on day 101 with a 2.36% CAR-T/T ratio in patient F06, who also had undetectable circulating CAR-T cells at the same time.

In addition, concentrations of seven cytokines (IL-1b, IL-6, IL-10, IFN-, TNF-, MCP-1, and GM-CSF) in CSF samples from the above 10 of 13 patients were measured. Specifically, IL-1b was not detected in any of the 10 patients, and only one patient had detectable GM-CSF. For the other five cytokines, patients with severe ICANS had higher IL-6 levels in contrast to patients without severe ICANS, and the difference between the median level of IL-6 among these two groups of patients was statistically significant (Fig. S11). We did not observe significant differences among the other 4 cytokines between the two groups of patients. No clear relation between the CSF cytokine levels and the F-CAR-T/T % was observed.

Continued here:
Next-day manufacture of a novel anti-CD19 CAR-T therapy for B-cell acute lymphoblastic leukemia: first-in-human clinical study | Blood Cancer Journal...

How abortion ruling could affect IVF and embryonic research – The Almanac Online

by Sue Dremann / Palo Alto Weekly

Uploaded: Fri, Jul 1, 2022, 11:33 am

The U.S. Supreme Court's June 24 ruling ending federal abortion rights under Roe v. Wade could inspire groups that seek to protect embryos to urge greater restrictions on in vitro fertilization (IVF) and embryonic stem cell research, according to Henry T. (Hank) Greely, director of the Stanford Law School Center for Biomedical Ethics.

Assisted reproductive technologies such as IVF aren't constitutionally protected and neither is preimplantation genetic testing, which screens for certain traits and DNA-caused conditions in embryos that haven't yet been implanted in the uterus, he said in a recent interview prior to the landmark ruling.

The court's ruling doesn't ban these technologies, which assist people seeking to have children, but it is likely to inspire some groups and states to seek to preserve unused embryos or ban embryonic stem cell research, Greely said.

His paper about the potential short- and long-term impacts of the decision is in preprint publication and is expected to be published in the Journal of Law and Biosciences in the coming weeks. In the short term, the technologies that embryo-protection groups might seek to ban or limit might be an alternative for women who can no longer receive an abortion in their home state.

Prenatal testing currently can determine if the fetus has a serious DNA defect that would cause disease or disability; a woman can then decide whether to continue with or terminate the pregnancy. That choice would likely disappear in states that restrict abortions, Greely said.

But a genetic testing technique that is used during in vitro fertilization could be utilized to prevent IVF pregnancies with fetal abnormalities. Preimplantation genetic testing, or PGT, screens out embryos with DNA-causing birth defects before the embryos are transferred to the uterus. The procedure can determine with a high degree of accuracy whether an embryo would develop into a baby who might have one of a large number of conditions. The decision not to transfer an embryo with genes that could cause a disability, condition or trait isn't illegal in the U.S., he said.

In states where abortion is illegal, it's likely there would be an increased interest in using PGT. The embryos are screened while outside the womb and prior to implantation and pregnancy.

"I think some people, some couples will say, well, if we have an embryo for the pregnancy that would have a severe disability as a child, our state wouldn't allow us to abort it. So let's go through preimplantation," he said.

But Greely doesn't think using PGT will skyrocket after the court's abortion decision. The technique requires that prospective parents use IVF, which is unpleasant and risky due to egg harvesting, he said.

IVF is also expensive. Most couples seeking the technique do so due to infertility and the decision isn't made lightly. Anyone with enough money to afford IVF would likely be able to afford to travel to another state for an abortion, he said.

Greely thinks it is unlikely embryo-protection groups would advocate for any kind of legislation that has a negative effect on IVF, however.

"Americans like IVF; almost everybody knows somebody or will know somebody who's either gone through IVF or who's actually the product of IVF. Two percent of the babies born every year in the U.S. with the product of IVF, and particularly the wealthier people are, the more likely they are to have either used IVF or know somebody who uses IVF, and also, the more likely they are to be politically powerful," he said.

There's a certain sort of law Greely thinks might be politically viable: limiting the selection or deselection of an embryo for IVF for a specific reason such as race, gender or disability.

"We've already seen it in abortion state statutes. A lot of abortion laws ban abortion for the purpose of discriminating on race, sex or disability status. And some of them explicitly say Down syndrome status.

"I can imagine the disability community coming together with protection groups to try to pass laws banning using PGT to select against embryos based on race, sex or disability. The important part of that would probably be disability and maybe even with the focus just on Down syndrome, which has a very strong support group and has some political sympathy," he said.

There isn't much political support for eliminating embryos that would have a fatal disease, however, he said.

"There's a more attractive case for protecting embryos that might become people with Down syndrome compared to protecting embryos that might become babies who would die within a year from Tay-Sachs disease," he said.

The court's decision on Roe v. Wade could invigorate efforts to pass new legislation to protect embryos outside the uterus among people who believe embryos are viable far earlier than at the 15 weeks in the Mississippi case that challenged Roe v. Wade. Some groups have claimed that human life starts far earlier and even at fertilization, which would make, in their view, all embryos for IVF "viable" regardless of whether they are implanted in the womb.

In the normal medical standard of care, no more than two embryos should be transferred into a woman's uterus at a time to minimize the chances of multiple pregnancies, Greely noted in his paper.

Most IVF cycles produce more than two eggs. Prospective parents can choose to have the extra embryos frozen for possible later use, donated to other couples, designated for research or destroyed and discarded.

Some legislation advocated by embryo-protection groups could limit or change the practice, he said. With the exception of Louisiana, there are no limitations on destroying embryos that aren't implanted, he said, though some other states have considered the legislation.

"The only limitation that I know of is the Louisiana law where you're not allowed to destroy embryos. So leftover embryos are kept frozen indefinitely in IVF clinics there," he said.

Legislation could lead clinics to build facilities to freeze and store unused embryos in perpetuity, he said, adding that the Louisiana law hasn't caused IVF clinics to close.

Embryo-protection groups might also try to get a law passed that's similar to a 2004 Italian law, which was subsequently limited by a court decision, Greely noted.

"They said you have to transfer for possible implantation every viable embryo you make, which means in Italy they typically only make one or two embryos at a time.

The embryo-protection groups "might try that, but all that would do is make IVF more difficult or expensive, and I don't think there's going to be political support for it. I don't think there'll be enough political support for it for people to adopt it," he said.

Greely noted that there could potentially be a significant change in embryo research as opposed to clinical treatments in an IVF clinic.

"Actually, embryo research in particular has really nothing to do with Roe v. Wade. As a matter of law, Roe v. Wade never protected embryo research, but I think it's connected in terms of the political dynamics after the death of Roe v. Wade," Greely said.

There's a good chance that at some stage, states will pass laws that eliminate human embryo research, in part because it is a huge issue, he said. Embryonic stem cells are taken from embryos created and then not used for pregnancy at IVF clinics.

"Twenty years ago, a number of states banned it; a number of states like California encouraged that research. But research into Type 1 diabetes and other major diseases has been disappointing.

"I think it has been useful, but there have been no miracles from it so far," he said.

The discovery in 2007 of a method to turn regular body cells into cells that can become any cell type in the human body makes the argument for using embryonic stem cells less compelling, he noted in his paper. Called induced pluripotent stem cells or iPSCs, these cells take away some of the urgency about using embryonic stem cells.

But iPSCs aren't exactly like human embryonic stem cells, Greely noted. Researchers would likely argue that human embryos are still required for research on embryonic development that would lead to ways for couples to succeed in having babies.

iPSCs might also play a role in the same types of research, since scientists have been creating "embryo-like things" or "embryo models" that provide more information about human embryonic development, he wrote.

How these laws might affect funding for embryonic research is also unknown.

The federal government has had little appetite for funding embryonic research and has refused to fund research that "destroys, discards, or knowingly subject(s) to risk of injury of death" embryos, Greely noted in his paper.

Yet, the federal government doesn't limit or ban the research itself; its actions have solely been about research it funds. Federal funds can be used for research on cells created from embryos that were destroyed somewhere else, he noted.

At least 11 states, however, have banned (or effectively banned) human embryo research on cells created from destroyed embryos that came from somewhere else, he wrote.

Some states allow such research, including California, Connecticut, Michigan, Montana and New York, Greely noted. California in particular continues to support stem cell research without a ban on the use of embryonic cells. In 2020, the state's voters passed Proposition 14 for $5.5 billion in bonds to advance the research.

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How abortion ruling could affect IVF and embryonic research - The Almanac Online

Diabetic foot treatment: Here’s all you need to know about stem cell therapy – Hindustan Times

Diabetes is nothing less than a pandemic as according to the World Health Organization, about 422 million people have diabetes worldwide. High blood sugar levels affect different organs and tissues of the body leading to a compromised quality of life for example, you might have experienced or heard of tingling sensation, numbness, or pain in the legs/feet of patients with diabetes which as per the health experts, occur due to nerve and blood circulation-related problems caused by the negative effects of high glucose levels on cells and tissues.

Foot-related problems occur commonly in patients with diabetes like if we hurt our toe/foot and have an open wound or cut, the nerve endings from the affected part send signals to the brain and cause pain. In case a person with uncontrolled and long-standing diabetes, the sensation of pain may not be transmitted properly due to nerve issues, leading to the patient ignoring the problem and in such cases, even a small cut can progress to a large size wound (as we know wound healing is affected in diabetic patients).

Infection can spread from the feet through the blood to other parts of the body as well and in the feet specifically, increased severity of the issue can lead to gangrene, ultimately necessitating amputation of the toes/foot. It is therefore important to look out for issues such as cuts, bruises, red spots, warm areas, swelling, blisters, corn, etc. in the feet to identify any issue at the earliest and initiate treatment.

From an advanced treatment perspective, Dr Pradeep Mahajan, Regenerative Medicine Researcher at Navi Mumbai's StemRx Bioscience Solutions Pvt Ltd, talked about regenerative medicine for diabetic foot in an interview with HT Lifestyle. He explained, Regenerative medicine is about using biological molecules to enhance the healing potential of the body. These molecules are cells, growth factors, exosomes, peptides, all of which function to enhance the function of other cells in the body, reduce inflammation, regulate the immune system, provide a constant pool of healthy cells, and clear tissue damage, among other functions.

He highlighted that the treatment for diabetic foot includes a combination of mesenchymal stem cells, growth factors that improve nerve health and blood vessel formation, oxygen therapy, as well as allied stimulation-based treatments. He said, We have seen successful outcomes in diabetic foot conditions following cell-based therapy. Patients experience relief from abnormal sensations in the feet, better wound healing and pain along with better control of diabetes.

Dr Mahajan added, When we target the pathology, we get more definitive treatment outcomes. Our patients with diabetic foot do not progress to develop gangrene. In fact, they even achieve better control of blood glucose levels, which prevents further complication and improves their quality of life. The key is a regenerative (not symptomatic) treatment along with lifestyle modifications.

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Diabetic foot treatment: Here's all you need to know about stem cell therapy - Hindustan Times

Cell Therapy Market With Manufacturing Process and CAGR Forecast by 2030 Designer Women – Designer Women

Theglobal cell therapy marketsize was valued atUSD 8.1 billion in 2021and is estimated to reachUSD 23.9 billion by 2030, growing at a CAGR of 14.5% over the forecast period. The development of precision medicine and advancements in cellular therapies in context to their efficiency & manufacturing are expected to be major drivers for the market. Moreover, the development of stem cell banking facilities and resultant enhancement of stem cells production, storage, and characterization are also expected to improve the volumetric capabilities of the market at a global level, which is anticipated to directly translate into revenue for this market at a larger level. Ongoing technological advancements in the parent and ancillary markets for stem and non-stem cells usage are expected to reinforce the demand over the forecast period. There are fewer commercialized cellular therapy products in the current market than the number of research products. This is partly due to stringent regulations and the high cost of stem cells.

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Cell lines, such as Induced Pluripotent Stem Cells (iPSC) and human Embryonic Stem Cells (hESC) are recognized as having high growth potential; as a result, many research entities and companies are making significant investments in R&D pertaining to iPSC- and hESC-derived products.

Pricing of stem cell transplantation varies from region to region. For instance, the cost of transplantation in the U.S. is higher than that in Germany or China. In March 2018, Alofisel by TiGenix received approval for marketing in Europe. This was the first allogeneic stem cell therapy to be approved in Europe. Furthermore, revenue for certain products varies for the country; for instance, products like INVOSSA received approval for marketing in Korea but have yet to receive marketing authorization in the U.S. Growth is also influenced by the commercialization of unauthorized stem cell treatments revenue generation.

Global Cell Therapy Market Definition

Therapy in which viable cells are injected, grafted, or implanted into a patient to effectuate a medicinal effect is known ascell therapy; for instance, In immunotherapy, T-cells capable of fighting cancer cells via cell-mediated immunity are transplanted, and stem cells are grafted to regenerate diseased tissues.

Cellular therapies hold a great therapeutic promise across various clinical applications. This has resulted in substantial global investments in research and their clinical translation. Rapid advances in stem cell research have the potential to fulfill the unmet demand of pharmaceutical entities, biotech entities, and doctors in disease management. Several unknown therapies are in clinical development.

Furthermore, government and private funding agencies are constantly offering grants to support projects at various stages of clinical trials, increasing the number of ongoing clinical trials.

Research on human embryonic stem cells is ethically controversial. Harvesting embryonic stem cells involves the destruction of human embryos, raising a moral concern. In addition, stringent regulations for obtaining Intellectual Property Rights (IPR) for products or materials used in research are major restraints for commercializing these services. Ethical approval should be obtained to store cell lines and tissues in biorepositories to avoid the usage of tissue for illegal purposes or to identify proxy diseases to claim insurance. Moreover, controversies surrounding the use of embryonic stem cells for research impede the market growth in several regions

The study categorizes the cell therapy market based on use type and therapy type at the regional and global levels.

The analysis of the cell therapy market is based on the use of stem cells for clinical and research purposes. The research-use segment dominated the market for the global cell therapy market and accounted for the largest revenue share of 58.3% in 2021. Currently, cell therapies (stem & non-stem cells) are majorly being used for research projects, which in turn, has led to a large revenue share of this segment in 2021. Cell-based therapies are all possibilities for the replacement, repair, restoration, and regeneration of damaged tissues, cells, and organs. As an alternative to traditional treatment strategies, researchers are investing heavily in developing effective and safe cell-based treatments.

As per the CGT Catapult database of clinical trials, 59 cell and gene therapy trials are ongoing in the UK. Out of all therapeutic areas, oncology has the highest number of ongoing clinical trials. T cells, CD34+ and CD133+ stem cells, mesenchymal stem/stromal cells are some predominantly employed cell types for clinical investigation. Neural cells, bone marrow mononuclear cells, fibroblasts, cornea cells, antigen-presenting cells, epithelial cells, and chondrocytes are some other cells that are being explored for the development of cell therapies.

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Asia Pacificaccounts for the highestCAGR during the forecast period

Based on the regions, the global cell therapy market has been segmented across North America, AsiaPacific, Europe, South America, and the Middle East & Africa.In the Asia Pacific, the market for cell therapy is anticipated to witness a lucrative growth rate of 15.5% over the forecast period. Advancements in stem cell therapy in Asian countries are observed to be better than those in the U.S. This has resulted in Asia leading stem cell research. Several stem cell consortiums in Asian countries aim to ensure coordinated and focused R&D programs. Moreover, patients from western countries migrate to Asian countries for treatment, owing to the flexible legal framework.

Companies from Japan, South Korea, India, China, Taiwan, Singapore, and the rest of Asia were active participants in the conference. In addition, the large regional population and untapped potential present in the region have resulted in global firms entering the market. Moreover, this region offers relatively inexpensive manufacturing & operating units for conducting research. These factors are expected to play a major role in expanding the stem cell market in this region.

The cell therapy market is mildly concentrated in nature with few numbers of global players operating in the market such as Kolon TissueGene, Inc., Anterogen Co., Ltd., JCR Pharmaceuticals Co., Ltd., Castle Creek Biosciences, Inc., MEDIPOST, Osiris Therapeutics, Inc., PHARMICELL Co., Ltd, Tameika Cell Technologies, Inc., Cells for Cells, NuVasive, Inc., Vericel Corporation, and Celgene Corporation.

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Cell Therapy Market With Manufacturing Process and CAGR Forecast by 2030 Designer Women - Designer Women

Regenerative Medicine is an Early Treatment for Osteoarthritis – Digital Journal

CHARLOTTE, NC, July 08, 2022 /24-7PressRelease/ An estimated 30 million Americans suffer from osteoarthritis. Osteoarthritis or degenerative arthritis is the most common type of arthritis. Its a painful, often debilitating, a condition caused when the cartilage or cushion between our joints breaks down, leaving bone to rub on bone. Osteoarthritis is a leading cause of hospitalization, resulting in over 600,000 joint replacement surgeries annually.

Baby boomers want to stay active, but there is an added factor to developing osteoarthritis from prior injuries. You have an increased risk of developing arthritis from injuries, such as a cartilage tear in the knee, even minor ones, in your 20s or 30s.

Once osteoarthritis sets in, common treatments include over-the-counter pain relievers, prescription medications, physical therapy, or chiropractic adjustmentsnone help improve the joints quality. When the pain gets too great, the last option is joint replacement.

For years, orthopedic surgeons have used regenerative medicine, such as Platelet-Rich Plasma (PRP), to help patients recover faster. As the field of regenerative medicine has grown, experienced physicians are emerging.

Dr. James Altizer, MD, is a board-certified medical doctor who has performed thousands of stem cell and PRP procedures since January 2016, making him the most experienced doctor in the Carolinas.

Osteoarthritis and Regenerative Medicine Treatment

Typically, traditional osteoarthritis treatment aims to control the symptoms and cover up the pain until its too late to save the joint. Dr. Altizer treats underlying arthritis by stimulating the bodys natural healing process using regenerative medicine.

Regenerative medicine deals with the process of replacing or regenerating human cells or tissues to restore normal function naturally. This new therapeutic strategy helps prevent osteoarthritis from advancing by stimulating tissue regeneration in the joints and reducing inflammation, which leads to a significant reduction in pain and improved physical activity levels.

At Neogenix, a leading regenerative medicine provider, we treat the patient, not just the pain. Our team provides a personalized treatment plan to improve the lives of those suffering from osteoarthritis using natural regenerative therapies. The first step is where we get to know the patient and give a thorough assessment to determine the root cause of their pain.

We are at a tipping point in medicine when it comes to using our bodies to heal ourselves, says Dr. Altizer. Our patients see a significant reduction in their arthritis pain level and improvement in overall function, which can prolong their active lifestyle for many years.

If you are suffering from arthritis pain and want to put off future joint replacement surgery, schedule a consultation with Dr. Altizer. Find out now if regenerative medicine can help repair tissue damage in your joints.

ABOUT NEOGENIX Neogenix has been a leading regenerative medicine provider in the Carolinas since 2020. Dr. James Altizer, MD, is a board-certified medical doctor who has performed thousands of stem cell and growth factor procedures since January 2016, making him the most experienced doctor in the Carolinas. These powerful, all-natural treatments regenerate and heal damaged tissues to get you back to living the life you deserve. They offer realistic assessments, not false hope or high-pressure sales tactics. Patients experience little to no downtime, and these all-natural, non-surgical treatments carry none of the potentially life-threatening risks of surgery.

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Regenerative Medicine is an Early Treatment for Osteoarthritis - Digital Journal