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Siniscalco D, Bradstreet JJ, Sych N, Antonucci N. Mesenchymal stem cells in treating autism: Novel insights. World J Stem Cells 2014; 6(2): 173-178
Dario Siniscalco, ChemD, PhD, Department of Experimental Medicine, Second University of Naples, Via S Maria di Costantinopoli, 16-80138 Napoli, Italy. dariosin@uab.edu
Medicine, Research and Experimental
Topic Highlight
Mesenchymal stem cells in treating autism: Novel insights
Apr 26, 2014 (publication date) through Jan 19, 2020
Times Cited (11)
World Journal of Stem Cells
Copyright ©2014 Baishideng Publishing Group Co., Limited. All rights reserved.
World J Stem Cells. Apr 26, 2014; 6(2): 173-178
Published online Apr 26, 2014. doi: 10.4252/wjsc.v6.i2.173
Dario Siniscalco, James Jeffrey Bradstreet, Nataliia Sych, Nicola Antonucci
Dario Siniscalco, Department of Experimental Medicine, Second University of Naples, 16-80138 Napoli, Italy
Dario Siniscalco, Centre for Autism, La Forza del Silenzio, 81036 Caserta, Italy
Dario Siniscalco, Cancellautismo, 50132 Florence, Italy
James Jeffrey Bradstreet, Brain Treatment Center, Buford, GA 30518, United States
Nataliia Sych, Clinical Department, Cell Therapy Center EmCell, 04073 Kiev, Ukraine
Nicola Antonucci, Biomedical Centre for Autism Research and Treatment, 70126 Bari, Italy
Author contributions: Siniscalco D designed the paper; Siniscalco D and Bradstreet JJ wrote the paper; Sych N contributed to the paragraph on MSCs; Antonucci N contributed to the paragraph on autism; Bradstreet JJ edited the English language.
Correspondence to: Dario Siniscalco, ChemD, PhD, Department of Experimental Medicine, Second University of Naples, Via S Maria di Costantinopoli, 16-80138 Napoli, Italy. dariosin@uab.edu
Telephone: +39-81-5665880 Fax: +39-81-5667503
Received: November 11, 2013
Revised: December 19, 2013
Accepted: March 17, 2014
Published online: April 26, 2014
Autism spectrum disorders (ASDs) are complex neurodevelopmental disorders characterized by dysfunctions in social interactions, abnormal to absent verbal communication, restricted interests, and repetitive stereotypic verbal and non-verbal behaviors, influencing the ability to relate to and communicate. The core symptoms of ASDs concern the cognitive, emotional, and neurobehavioural domains. The prevalence of autism appears to be increasing at an alarming rate, yet there is a lack of effective and definitive pharmacological options. This has created an increased sense of urgency, and the need to identify novel therapies. Given the growing awareness of immune dysregulation in a significant portion of the autistic population, cell therapies have been proposed and applied to ASDs. In particular, mesenchymal stem cells (MSCs) possess the immunological properties which make them promising candidates in regenerative medicine. MSC therapy may be applicable to several diseases associated with inflammation and tissue damage, where subsequent regeneration and repair is necessary. MSCs could exert a positive effect in ASDs through the following mechanisms: stimulation of repair in the damaged tissue, e.g., inflammatory bowel disease; synthesizing and releasing anti-inflammatory cytokines and survival-promoting growth factors; integrating into existing neural and synaptic network, and restoring plasticity. The paracrine mechanisms of MSCs show interesting potential in ASD treatment. Promising and impressive results have been reported from the few clinical studies published to date, although the exact mechanisms of action of MSCs in ASDs to restore functions are still largely unknown. The potential role of MSCs in mediating ASD recovery is discussed in light of the newest findings from recent clinical studies.
Key Words: Autism spectrum disorders, Autism treatment, Cell therapy, Mesenchymal stem cells
Core tip: Autism spectrum disorders are still untreatable pathologies. Mesenchymal stem cells possess the immunological properties which make them promising candidates as a novel therapeutic option.
Citation: Siniscalco D, Bradstreet JJ, Sych N, Antonucci N. Mesenchymal stem cells in treating autism: Novel insights. World J Stem Cells 2014; 6(2): 173-178
URL: https://www.wjgnet.com/1948-0210/full/v6/i2/173.htm
DOI: https://dx.doi.org/10.4252/wjsc.v6.i2.173
Autism spectrum disorders (ASDs) are complex neurodevelopmental disorders. Indeed, this term refers to a heterogenous group of varied conditions characterized by dysfunctions in social interactions, skills, and communication, restricted interests, and repetitive stereotypic verbal and non-verbal behaviors, influencing the ability to relate to others. Cognitive, emotional and neurobehavioral abnormalities characterize the core symptoms[1,2]. The prevalence of these disorders has dramatically increased in the last years, with present rates of 11.3 per 1000 (one in 88) children aged 8 years in the United States, according to Centers for Disease Control[3]. ASDs are presumed to be a lifelong disability with multiple impacts on child and adult health. Indeed, adult autistic individuals show limited independence because of their learning disability. In adulthood, communication is still impaired, as reading and spelling abilities are poor. Stereotyped behaviors and restricted interests still persist. The children affected require special and intensive parental, school, and social support[4]. ASD results in a substantial impact on a person's quality of life and that of their family[5]. Given the total lifetime societal cost of caring for one individual with autism, estimated in $3.2 million[6], autism should be considered as an urgent public health priority[2].
Together with the cognitive, emotional and neurobehavioral abnormalities, ASDs are disorders characterized by a broad range of biochemical, toxicological and immune involvement, including: oxidative stress, endoplasmic reticulum stress, decreased methylation capacity, limited production of glutathione, mitochondrial dysfunction, intestinal dysbiosis, increased toxic metal burden, and immune dysregulations including autoimmunity[7].
Currently, only a handful of medications are licensed for treating a limited number of autism-related symptoms[8]. Moreover, prescribed pharmaceuticals (i.e., anti-psychotics) fail to address the ASD core symptoms, have the potential of markedly adverse effects, and are at best palliative[9-12]. The alternative treatments for ASDs are diverse and include: behavioral, nutritional, and biomedical approaches. Thus the need for a definitive and effective therapy is an unfulfilled priority for autism research.
Presently, cell therapies and cell-based biopharmacies offer a valid intervention for several otherwise untreatable human diseases. Stem cells appear to represent the greatest potential for the future of molecular and regenerative medicine[13,14]. Among the various stem cell subtypes, mesenchymal stem cells (MSCs) provide a useful tool for the treatment of several diseases associated with inflammation, tissue damage, and subsequent regeneration and repair[15].
MSCs are multipotent stem cells that posses the capacity to differentiate in vivo or in vitro, under specific conditions, into cells of connective tissue lineages, including bone, fat, cartilage and muscle[16]. They are distinct from the hematopoietic lineage, and were initially described by Alexander Friedenstein in the 1960s after he extracted MSCs from bone marrow[17]. It is common practice for clinical and research applications, to acquire MSCs from bone marrow aspirates of the superior iliac crest under local anesthesia. The cells are then isolated by their adherence to plastic and amplified through passage in culture, where they exhibit a great replicative capacity[18].
In order to achieve a detailed classification of this type of stem cell, the International Society for Cellular Therapy has proposed the following minimal criteria to identify human MSCs: they must grow in standard, plastic-adherent culture conditions; must express the cyto-specific markers CD73, CD90 and CD105, without expression of CD45, CD34, CD14 or CD11b, CD79alpha or CD19 and HLA-DR surface molecules; and must be capable of in vitro differentiation into osteoblasts, adipocytes and chondroblasts[19].
Interestingly, MSCs seem to be the most promising clinical candidate for immune-modulatory cell-based therapy[20]. MSCs show immunomodulatory capacities, as they are able to induce tolerance in immunocompetent allotransplants or even xenotransplant recipients[21]. Interacting with a wide range of immune cells, probably through a cell-to-cell contact mechanism[22], MSCs are able to modulate T-cell phenotype and immune-suppress the local environment[23].
Their unique properties of immunomodulation, multipotency, and rapid self-renewal proliferation rate, distinguish them as useful tools for application in immunomodulatory therapy and neurological disorders. In addition, other desirable characteristics of MSCs, e.g., genetic stability, stable phenotype, and easy procedures for collection, storage and shipping from the laboratory to the bedside[24], direct us to MSC-based therapies as a potent intervention.
In clinical settings, MSCs can be transplanted directly without genetic modification or pretreatments (i.e., immunosuppressants). No host vs graft rejection has been observed[25]. Importantly, there is an absence of uncontrollable growth or tumorigenesis with MSCs, in contrast to the potential problems intrinsic to embryonic stem cells[26]. Crucially, MSCs create no moral objection or ethical-religious controversies, unlike embryonic or fetal stem cells[27].
MESENCHYMAL STEM CELLS IN TREATING AUTISM: THE RATIONALE
The potential application of cell therapy, in particular MSCs, for ASDs has already been discussed by our group[28,29]. After a brief description of MSC-mediated ameliorative effects in ASDs, we will review recent and ongoing clinical trials using MSC transplantation in ASD patients.
We hypothesize that MSCs exert a positive effect in ASDs through the following mechanisms: stimulation of the plastic response in the host damaged tissue (e.g., inflammatory bowel disorders); synthesizing and releasing anti-inflammatory cytokines and survival-promoting growth factors (paracrine and biopharmacy); integrating into existing neural and synaptic network (engrafting), and restoring plasticity[28,29]. Following transplantation, MSCs target and migrate to the site of injury. In some cases these cells respond to the local environment with appropriate secretion of soluble factors to ameliorate inflammation and promote repair[30]. This paracrine mechanism offers potential in ASD treatment.
ASDs are characterized by a coexistent, if not etiological, immune system dysregulation[31]. Changes in innate and adaptive immune responses have been reported in ASD patients[32]. Characteristically, ASD cases show alterations in both T cell- and B cell-mediated immunity, as well as an imbalance in CD3+, CD4+, and CD8+ T cells and natural killer (NK) cells[33]. On these bases, the regulatory effects mediated by MSCs present an optimal way to restore immune balance, which cannot otherwise be obtained through pharmaceutical interventions. Through inhibition of the proliferation of CD8+/CD4+ T lymphocytes and NK cells, suppression of the immunoglobulin production by plasma cells, and inhibition of the maturation of dendritic cells (DCs), MSC transplantation appears ideally suited to provide a unique therapeutic application for ASDs[34,35].
In addition, MSCs are able to inhibit T lymphocyte pro-inflammatory cytokine production[36]. MSCs function as an implanted biopharmacy: after homing in to the targeted tissue site, they synthesize and release a broad range of bioactive molecules[35,37], i.e., anti-inflammatory cytokines, trophic and growth factors, interleukin (IL)-6, IL-7, IL-8, IL-11, IL-12, IL-14, IL-15, macrophage colony-stimulating factor, Flt-3 ligand, and stem-cell factor[38], which in turn could be responsible for activating endogenous restorative mechanisms within injured tissues. This strong paracrine activity of MSCs seems to be the most plausible and reasonable mechanism for the functional benefit derived from MSC transplantation. Furthermore, transplanted MSCs can induce the host tissue to upregulate the production of anti-inflammatory molecules, such as IL-10, in this way restoring the pro-inflammatory processes noted in ASDs[39,40].
MESENCHYMAL STEM CELLS IN TREATING AUTISM: CLINICAL EVIDENCE
Despite insufficient pre-clinical models of MSC therapy for ASDs[41], several clinical studies on humans have been conducted. Recently, a non-randomized, open-label, controlled, single-center phase I/II clinical trial to examine the treatment safety and efficacy of transplantation of human cord blood mononuclear cell (CBMNCs) and/or human umbilical cord-derived mesenchymal stem cells (UCMSCs) in children with autism has been performed[42]. Stem cell administration was carried out via intravenous and intrathecal infusions. Autistic children transplanted with cells were followed for 24 wk. According to the authors, the cell treatment was safe, well tolerated without immediate or long term side effects, and no allergic, immunological reactions or other serious adverse events were observed at the time of injection or during the whole follow-up period. The cell transplantation showed efficacy; improvements were observed in visual, emotional and intellectual responses, body use, adaption to change, fear or nervousness, non-verbal communication and activity level, as measured by Childhood Autism Rating Scale, as well as in lethargy/social withdrawal, stereotypic behavior, hyperactivity and inappropriate speech evaluated by the Aberrant Behavior Checklist[42]. They noted that the group receiving CBMNCs and UCMNCs demonstrated a more robust therapeutic effect than the group receiving mono-cell line therapy, which may be attributed to the action of CBMNCs and UCMSCs in synergy. It has been proposed the synergistic mechanism is related to increased cell-mediated perfusion in brain areas and/or the regulation of immune dysfunction.
Intrathecally transplanted autologous bone marrow-derived mononuclear cells were efficacious in improving the quality of life in a 14-year-old boy with severe autism[43]. A detailed cell-sorting analysis was not done, but the cell extract contained a percentage of MSCs. We know bone marrow is comprised of a heterogeneous population of stem cells, encompassing hematopoietic stem cells, MSCs, endothelial progenitor cells, and very small embryonic-like stem cells. The bone marrow cell transplantation was safe, the patient had no noted side-effects and showed some immediate improvements within a week (eye contact and attention, fine motor activities). Significant improvements were observed over a period of 6 mo to 1 year (social interaction and emotions, impulse control, reading skills, tracing, recognition of all shapes and following commands, and hyperactivity). Interestingly, comparisons of pre/post cell therapy brain positron emission tomography scans revealed a markedly increased uptake in bilateral temporal lobes and bilateral calcarine cortices with mild increased uptake in the left medial pre-frontal cortex[43].
Transplanted stem cells therefore seemed to ameliorate neural hypoperfusion in the previous case report. Hypoperfusion may be a consequence of focal inflammation and would likely result in low-grade ischemic consequences: hypoxia, abnormal metabolites, neurotransmitters dysregulation, and potential neural tissue damage.
In the light of these encouraging, but limited observations, the authors launched an open-label proof-of-concept study using autologous bone marrow-derived mononuclear cell transplantation in 32 patients with autism[44]. The average number of intrathecally injected cells was 8 × 107 cells. Cell treatment was determined to be safe and adverse events were transient (hyperactivity). They hypothesize that the intrathecal administration route is able to enhance homing of the transplanted cells into the central nervous system. Clinical improvements after cellular therapy were observed in social relationships and reciprocity, emotional responsiveness, communication and behavior. As a putative mechanism of action, the authors further hypothesized that cellular transplantation was able to restore function to ASD patients by neuroprotection, neural circuit reconstruction, neural plasticity, neurogenesis, and immunomodulation.
The hypothesis that intrathecal administration increases the efficacy of stem cell therapies is not actually evaluated by these various studies. Clearly, it is a testable hypothesis and future studies should include arms with and without intrathecal administration to compare the therapeutic efficacy of the more invasive intrathecal implantations.
Despite these early clinical trials with MSCs, there are no apparent pre-clinical studies on the use of MSCs in ASD models[41]. Thus, more research into the mechanisms of action post transplantation is required to adequately understand the route, dosing and safety. However, the parental perspective is unlikely to wait on more detailed scientific studies. Stem cells are readily available from many centers in numerous countries, with various cell types and methodologies being utilized. Families recognize the devastating nature of autism on their children and are already seeking stem cell therapies. Based on a simple scan of the internet sites advertising cell therapies, it appears hundreds of ASD children have already been treated.
Another complexity in the research arises from stem cell sourcing. Some protocols use allogeneic (derived from a different person or collection of donors), while others use autologous donor (self-derived) cell types[15]. Some protocols for ASD also use expanded autologous MSCs (United States Patent Application: 20060182724). This adds another dimension to the discussion and a potential source of laboratory contamination. Expansion requires medium for growth from which the cells must then be isolated, and any medium washed sufficiently to prevent a reaction in the recipient. Typically bovine serum is used. This creates the further risk of prion infection of the medium. To avoid this, one group has proposed using pooled human serum[45]. This xeno-free methodology has many desirable features, but retains the concerns about human pathogen transmission. The group, however, screened extensively for contamination and it appeared they were able to ascertain that the samples were free of any disease vectors. This process should be considered for any use of expanded MSCs for ASD therapies.
Another challenge in the standardization of dosing derives from the varying efficacy amongst allogeneic donors in terms of: vitality, potency, and expansion potential. Every donor is different and this could affect efficacy and also paracrine effects. Indeed, it seems that the secretion of bioactive molecules could differ by a factor of 10 between different donors of matched age and gender[15]. Recently, in order to increase the adequate supply of stem cells from donor tissues, it has been demonstrated that a 3D co-culture system with murine-derived hematopoietic stem cells co-cultured with MSCs produces 3D-microaggregates of stem cells. These 3D-microaggregate systems support the expansion of approximately twice as many hematopoietic stem cell candidates as the 2D controls. In addition, the MSCs maintained in 3D aggregates are able to express significantly higher levels of hematopoietic niche factors compared with 2D cultures[46].
Finally, there are complex hurdles to overcome from the legal and regulatory restrictions placed by governments seeking to control cell therapies[27]. Several countries (i.e., United States and EU area) have attempted to create uniformity within the regulations governing cell trials, while creating very stringent regulations on cell culture conditions, diseases to be treated, and patient safety. However, in some other countries (e.g., Ukraine, China, Dominican Republic, Panama, and Mexico) the access to cell therapy is more readily available.
The rapidly increasing prevalence of ASDs worldwide is creating an urgent need for effective restorative therapies. The lack of safe and effective psychopharmaceuticals and other definitive medical therapies, together with the limited understanding of the pathophysiology, has created an urgency to identify novel and more effective therapies[47]. MSCs appear to offer a greater potential in regenerative medicine for complex disorder like autism than existing pharmaceutical protocols. Promising and impressive early results have been achieved from a few clinical studies, although the exact restorative mechanisms of action of MSCs in ASDs are still largely unknown.
The authors gratefully thank Mr. Enzo Abate, Ms. Giovanna Gallone, and the nonprofit ozrganizations "La Forza del Silenzio" and "Cancellautismo," Italy for their useful assistance.
P- Reviewers: Shawcross SG, Tanabe S, Yao CL S- Editor: Gou SX L- Editor: Cant MR E- Editor: Zhang DN
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NRA President under increased security due to threats
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On Wednesday, WSB-TV Atlanta reported that Cobb County, Ga., deputies are on standby in guarding the Marietta home of the president of the National Rifle Association (NRA), Carolyn Meadows.
Law enforcement officials have confirmed to Channel 2 Cobb County Bureau Chief Chris Jose that the group's head of Meadows security called the Cobb County Sheriff's Office in response to the mass shootings over the weekend.
Cobb County Bureau Chief Chris Jose stopped by Carolyn Meadows' Cobb County home on Wednesday and found a Cobb County police patrol car parked in front of her house.
Cobb County Republican Party Chairman Jason Shepherd told Jose that he immediately contacted Meadows after learning about potential threats against her in the wake of the recent mass shootings.
Shepherd stated, "I've known the NRA president for a number of years. She used to be very active in the Republican Party."
Carolyn Meadows was chosen to succeed Oliver North as the President of the National Rifle Association (NRA) in April 2019.
Carolyn has served in numerous positions in the Georgia Republican Party, including as the RNC National Committeewoman for 12 years. She chairs the Stone Mountain Memorial Association, the Government board which oversees the park, and is a board member of the American Conservative Union, the group that hosts the annual Conservative Political Action Conference (CPAC).
Meadows is paying off-duty deputies to safely guard her home with her own money.
A high-ranking source with the Sheriff's Office told Jose he's not sure if there were credible threats directed at Meadows or if the call for extra security is simply a precaution in response to the weekend massacres, WSB-TV reported.
While the Chairman of the Democratic Party in Cobb County has stated that they have nothing to do with the threats against Meadows, those responsible are unknown at this time.
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We have two quaint and cozy log cabins, The Loft and The Evergreen Cabin, tucked back in among 10 acres of trees available for 8-hour rental, no overnight stays allowed. These buildings are perfect for smaller gatherings such as birthday and family celebrations, company parties and church outings. These buildings are heated by wood stove and do not have plumbing. The Evergreen Cabin is located back with the trees, which is about a quarter of a mile from the front buildings. This cabin is used during the Christmas season to create wreaths and other evergreen decorations. This is a great space to accommodate a gathering with family, friends or work associates. (This space has no running water, electricity is provided by generator, heated with a wood stove and cooled by opening the doors. There are no overnight stays permitted in this building.) The Loft, also located back among the trees, sits on the highest spot overlooking the property providing some amazing views. There is space for a bonfire outside or stay inside and cozy up around the wood stove. (This cabin has no running water. Electricity is provided by generator. There are no overnight stays permitted in this building.) They also have The Lodge available for rent. The interior is a warm and inviting 1400 square foot space, heated by wood stove, 12 six-foot tables and 50 folding chairs are available for use and free wi-fi.


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Nov. 1, 2016 / 1:27 PM
Food labels may confuse shoppers with allergies
Kathleen Doheny, HealthDay News
TUESDAY, Nov. 1, 2016 -- Shoppers are often confused by food labels that warn of potential allergens, and the consequences can be serious, new research suggests.
"Up to 40 percent of consumers who either themselves have a food allergy or a child with a food allergy are purchasing products with precautionary allergen labels," said lead researcher Dr. Ruchi Gupta. She is a pediatrician at Ann & Robert H. Lurie Children's Hospital of Chicago.
The most misunderstood food labels, the researchers found, are those that say "may contain" or "manufactured on shared equipment."
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While those labels may sound like the foods aren't as dangerous as those that say a product definitely contains a particular allergen, that's not the case, Gupta stressed.
Gupta and her colleagues conducted an online survey of more than 6,600 respondents in the United States and Canada. Those answering the questions either had a food allergy, had someone in the family who did, or they were a parent or caregiver of someone with a food allergy and bought food for the person with an allergy.
Almost 8 percent of children and 2 percent of adults have food allergies, according to the study authors. And close to 40 percent of children with food allergies have experienced at least one life-threatening reaction.
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Under the U.S. Food Labeling and Consumer Protection Act, food companies must identify major allergens if that food is an intended ingredient. These foods include wheat, egg, milk, peanuts, fish, shellfish, soy and tree nuts.
However, if food is produced on shared equipment, there's still a risk that some trace of an allergen may be in the product. As a result, food makers began adding what is known as precautionary allergen labels. They state that a product "may contain" a specific allergen or that a food is "manufactured in a facility" that has products containing a specific allergen.
Those precautionary labels are voluntary, both in the United States and Canada, Gupta noted.
RELATED Early introduction of eggs, peanuts may cut kids' allergy risk: Study
In the survey, however, about half of the respondents thought those precautionary labels were required by law.
One-third thought the labels were based on the amounts of an allergen that might be present in a food product, which is not true, Gupta said.
And about 40 percent of shoppers dealing with food allergies bought products with precautionary labels.
RELATED Food allergies linked to raised risk of asthma, hay fever
The two precautionary labels are equally dangerous, Gupta said. The amount of allergen required to trigger a reaction varies from person to person, so it's impossible to know if a product that says "may contain" a specific allergen will prove dangerous or not, she said.
The study was published Nov. 1 in the Journal of Allergy and Clinical Immunology: In Practice. It was led by Food Allergy Research & Education (FARE) and Food Allergy Canada.
Food labels need an overhaul, Gupta suggested. In Canada, Health Canada advocates for the use of only the "may contain" label. Other research is looking at the value of listing the amount of an allergen, she said.
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Dr. Vivian Hernandez-Trujillo, chief of the section of pediatric allergy and immunology at Nicklaus Children's Hospital in Miami, agreed that labeling can be confusing.
The study not only points out "the reality that families with food allergies deal with on a day-to-day basis," but "it also points out the need for improvement in the clarity of food labeling," Hernandez-Trujillo said.
What to do until labels change? "I advise my patients to avoid foods with any label stating 'may contain' an allergen," she said.
Gupta agreed. "What we encourage our parents to do is try to avoid any food with any precautionary labeling if it has the food their child is allergic to," which can be difficult, she acknowledged.
Visit Food Allergy Research & Education for more on food labels.
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