the application of nanotechnology to regenerative medicine

The Application of

Nanotechnology to

Regenerative Medicine

Heather Goodwin

2

Background

The field of regenerative medicine aims to restore, repair, or replace damaged tissues and

organs through in vivo and ex vitro approaches1. Unlike most medical disciplines,

regenerative medical therapies target the source of disease, rather than just symptoms

alone. Even though organ transplants and artificial implants are regenerative therapies

much focus has been shifted to stem cell therapy and tissue engineering as a result of

technology advancements2. These therapies give patients the opportunity to heal and not

just manage the pain or discomfort associated with their disease or disorder.

Embryonic stem cells are of particular interest in the field of regenerative

medicine because they possess unlimited proliferation and unrestricted differentiation

potential3. Physical and chemical methods can be utilized to direct cell differentiation

into a wide variety of cell types, such as such as bone, immune, cartilage, blood, cardiac,

skeletal, and neural cells4. In contrast, adult stem cells are less useful because they are

available in minimal quantities and only possess the abilities to create new cells in the

tissues in which they reside. In order for adult, or tissue-specific stem cells, to hold the

same differential potential they must be genetically altered to better resemble an

embryonic cell5. The use of stem cells would allow for the treatment of any disease

caused from tissue malfunction, damage, or failure because they are capable of self-

renewal and differentiation into any needed cell type.

Figure 1: Process of stem cell differentiation

6.

3

As a result of the ethical implications of steam cell research, the majority of

research and product development in regenerative medicine is based on tissue

engineering. In tissue engineering, healthy cells are isolated from a patient and embedded

into a three-dimensional structure known as a scaffold7. The scaffold may be composed

of natural or synthetic materials, as long as it is biodegradable, biocompatible, and tissue-

specific. The scaffold, which may also contain growth factors, is placed into a chemical

media that resembles the in vivo environment. The use of bioreactors, such as pH,

temperature, oxygen levels, and mechanical forces are controlled in order to further assist

cell growth. The scaffold is then implanted into the body for the purpose of

reconstruction8. The native cells have been used successfully in joint replacement,

construction of artificial ligaments and tendons, and bone, heart, and wound repair9.

Figure 2: Process of tissue engineering

10

Regardless of the advances in regenerative medicine, it is often difficult to fully

integrate tissues, especially with enough mechanical support11

. However, the introduction

of nanotechnology has resulted in numerous advances in regenerative medicine.

Conventional therapies and early regeneration approaches often utilize biomaterials with

large surface features, often on the micron scale12

. The issue is that most surfaces and

processes on natural tissues function on the nanoscale. Even though the typical cell is

approximately 10 μm in diameter, the cellular components and proteins are much smaller,

often only 5 nm in diameter13

. The use of nanotechnology and nanoparticles in medicine

4

allows for better assess to small cellular components that may be responsible for

dysfunction and disease.

Medical Need:

The most obvious benefit of regenerative medicine is its wide application to a

variety of diseases and disorders. Some areas of clinical application involving

regenerative medicine techniques include skin replacement for burn victims and

diabetics, bone and cartilage regenerations, bladder repair, repair of heart muscle

following myocardial infarction, restoration of the spinal cord or peripheral nerve

following injury, the regeneration of pancreatic tissue to produce insulin in diabetics, and

preventing tissue deterioration following an injury, burn, or stroke14

. Other areas of

research include improving the biocompatibility between tissues and medical devices,

improving the duration of implant materials with the body, and increasing the interaction

between cells and topography of coatings and surfaces15

.

The increase in life expectancy in many countries has resulted in an increased

incidence of chronic diseases, such as, cancer, renal failure, osteoporosis, cardiovascular

disease, diabetes, and degenerative diseases. According to the Center for Disease Control,

seven out of ten deaths among Americans are a result of chronic disease16

, such as those

listed above. Furthermore, arthritis and osteoporosis leaves nearly nineteen million

Americans disabled and diabetes is the leading cause of kidney failure, amputations, and

blindness among Americans aged 20 to 7417

. Even more surprising, one out of two

Americans was diagnosed with at lease one chronic illness in 200518

. It is estimated that

there will be a 6% increase, or 32 million more, Americans living over the age of 65 by

203019

. With this shift in demographics in the United States, an increase in chronic

disease cases is inevitable.

Even though chronic diseases are often untreatable or difficult to treat numerous

in vivo approaches within the field of regenerative medicine have successfully stimulated

the required healing processes. One benefit of regenerative medicine is the ability to

repair and restore dysfunctional tissues in order to avoid organ transplants20

. The

potential to treat the underlying cause of a disease, rather than the symptoms, would

provide an enormous benefit to Americans. This would not only reduce death rates

among individuals with chronic illness, but also cut healthcare costs significantly.

The American Heart Association recently reported that that treatment related to

heart disease is responsible for 17% of the national healthcare expenditure21

. The

associated estimated that with an increased incidence the cost of heart disease is projected

to increase from $237 billion in 2010 to $818 billion in 203022

. In addition, medical

treatment cost for heart failure and stroke are expected to increase by approximately

238% within the next 20 years23

. In the United States alone, medical cost for late-stage

Parkinson’s disease, spinal cord injuries, heart failure, stroke, and diabetes was

approximately $250 billion in 201024

. The total healthcare cost during 2010 exceeded

$2.6 trillion25

, using 17.6% of the United States’ gross domestic product26

. Medical

techniques that are focused on cure and not symptom management are crucial to cutting

healthcare costs and saving lives.

5

Figure 3: Estimates for healthcare costs as a result of shifting demographics

27

For diseases where the organ is beyond repair, the ability to grow organ and

tissues for transplantation and implantation through ex vitro approaches has also provided

additional benefits to patients waiting for organ transplants or compatible donors. The use

of a patient’s own cells, as in tissue engineering, provides other added benefits, such as a

lowered risk of immune responses, tissue rejection, and infection28

. Another serious issue

in cellular therapies and organ transplantation is a lack of donors for patients awaiting

organs. It was reported that over 110,000 people in the United States were placed on the

organ donation waiting list in 2011, with an average death rate of 18 people per day29

.

The field of regenerative medicine has demonstrated potential for creating compatible

artificial organs and cells, reducing the need for organ donors.

Because the biological processes operate on the nanoscale level, nanotechnology

has obvious benefits for restoration and repair. Much of the failure experienced in the

medical field may be a result of using micron-sized products to impact processes that are

on a nanoscale. Nanotechnology advancements may allow medical professions to better

treat disease and more effectively repair and restore normal function.

6

FDA Approved Regenerative Medicine Products:

There are currently 55 approved regenerative products available to consumers on

the market. While these products cover a wide variety of diseases, 14 of the top 15

regenerative products, are products designed for skin repair and regeneration30

. Since the

introduction of the first regenerative product, Apligraf®, to the market in 1998 over

500,000 patients have received some form of regenerative therapy31

. Figure 4

demonstrates the application of commercially available regenerative products to different

branches of medicine.

Figure 4: Application of regenerative medicine products to different medical

disciplines32

.

In 1998, the FDA approved Apligraf®, making it the first commercially available

regenerative product on the market. It was first approved for the treatment of venous leg

ulcers, but the approval later expanded to include diabetic foot ulcers as well33

. Apligraf®

is a bi-layered, cell-based product that is created from cells found in healthy human

skin34

. The lower dermal layer is a combination of type 1 collagen, common skin cell

proteins, and human fibroblasts35

, which assist in the natural healing process. The upper

layer is formed through the multiplication and differentiation of keratinocytes. This layer

is composed of protective skin cells and resembles the structure of human epidermis36

.

While the exact therapeutic mechanism is not completely understood, the therapy does

produce cytokines and growth factors found in healthy skin37

. The comparison of

Apligraf® and human skin are shown in figure 5. It is a circular disc, approximately 75

mm in diameter, which is placed directly on venous leg and diabetic foot ulcers to assist

in the natural healing process38

. A non-adhesive dressing is applied before final wrapping

is performed. Apligraf® typically dissolves into wounds, turning into a gel-like substance

until healing is complete39

. Organogenesis, the developers of Apligraf®, just reported a

revenue exceeding $100 million in 2011, demonstrating the potential commercial success

for regenerative products40

.

7

Figure 5. The comparison of Aligraf® and healthy human skin

41.

More recently, in 2012, the FDA approved a cell-based therapy for the treatment

of metastatic hormone-refractory prostate cancer. Provenge® is developed by isolating

white blood cells from the patient in need and incubating them with a prostatic acid

phosphatase (PAP) and GM-CSF fusion protein42

. This protein functions as a prostate

cancer-associated antigen, which ultimately stimulates the patient’s immune system to

find and destroy prostate cancer cells43

. After successful incubation the mixture is

shipped back to the medical center, where it is administered to the patient44

. The

treatment process usually requires six appointments, all of which can be completed in one

month’s time45

. An article, released in early 2011, estimated that sales of Provenge®

would reach over $1 billion dollars in the United States alone46

.

Other companies have utilized regenerative therapies solely for cosmetic reasons.

In June of 2011, Fibrocell, Inc. became the first company to develop a personalized

cellular therapy strictly for aesthetic use. Their product, Laviv®, received FDA approval

for the treatment of moderate and severe nasolabial fold wrinkles, or “smile lines47

.” The

company eventually hopes to expand this approval to include acne and burn scars. To

develop the product, a person’s fibroblasts are extracted from a small skin sample behind

the ear. Fibroblasts in human skin are responsible for the production of collagen, which in

turn gives the tone and structure of young, healthy skin48

. As a person ages, the number

of fibroblast capable of collagen production decreases, resulting in lost skin tone.

Laboratory techniques involving antibiotics, bovine serum, and dimethyl sulfoxide

eventually result in the multiplication of the fibroblasts into millions of copies49

. The

product is then shipped back to the medical center and injected into the nasolabial folds

of the patient. It is typically administered in three treatments, where injections are

administered six weeks apart50

. The CEO of Fibrocell, David Pernock, predicts that the

sales from Laviv will exceed $500 million within the next few years51

.

Avance Nerve Graft®, produced and manufactured by AxoGen, Inc., is a therapy

used for the reconstruction of peripheral nerve gaps. The allograft is produced after

decellularizing the extracellular matrix of a donor’s peripheral nerve52

. The decellularized

extracellular matrix is then implanted into a patient at the site of injury. The scaffold has

successfully provided the structural support for axonal regeneration in 3,000 patients53

.

8

DentoGen® is one of the FDA-approved regenerative medicine products that

utilizes nanotechnology. The product is developed by OrthoGen and is approved for bone

grafting in dentistry. The company explains that the long-term success of dental implants

is dependent on the presences of vital bone54

. Bone grafting products commonly used in

dentistry are only successful in grafting dead and non-vital bones55

. DentoGen® is

manufactured by converting microcrystalline calcium sulfate into nano-sized grains of

calcium sulfate56

, which is biocompatible, biodegradable, non-toxic, and

osteoconductive57

. The calcium sulfate in implanted into the body, where it dissolves into

calcium and sulfate ions. The calcium ions then combine with phosphate to form calcium

phosphate, which is vital to bone growth. The calcium sulfate also degrades once

implanted as a result of the decrease in local pH. This results in demineralization of the

defective bone, causing the release of bone growth factors, such as bone morphogenetic

protein-2 (BMP-2), BMP-7, TGF-ß, AND PDGF-BB58

.

Other examples of leading commercial cell therapy products are shown below in

figure 6. These products helped contribute to global revenue that reached $55.9 billion in

201059

. It is important to note that none of these regenerative medicine products utilize a

nano-based approach, but there are many products in development or waiting FDA

approval60

.

Figure 6: List of leading commercial cell therapies for regenerative medicine

61.

9

Current Developments:

Regenerative medicine is a rapidly growing medical discipline, which is estimated

to include nearly 700 hundred multinational corporations and smaller organizations62

.

The Alliance for Regenerative Medicine revealed that at the conclusion of 2012, more

than 17,000 patients were enrolled in clinical trials being tested by nearly 250

companies63

. These clinical trials, which are all in different stages, may have a strong

impact on a variety of diseases and disorders, as demonstrated by figure 6. Experts

estimate the addition of tissue engineering and new regenerative products will reach

$40.4 billion by 201664

. The expected revenue is shown in figure 7.

Figure 6: Percentage of clinical regenerative products in the different stages of

clinical testing65

.

10

Figure 7: Estimated revenue for new tissue engineering and regenerative products66

.

There have been numerous advances and accomplishments in regenerative

medicine with the past few years. In January 2012, Advanced Cell Technology, Inc.

released and published Phase I and Phase II data that demonstrated the safety and

efficacy of human embryonic steam cells for the treatment of Stargardt’s macular

dystrophy and dry age-related macular degeneration67

. While this study only enrolled two

patients, both showed significant improvement in vision that extended for over four

months68

.

During the same month, Sangamo BioScience, Inc. began two new phase II

clinical trials for a regenerative treatment that they believe will be the “functional cure”

for HIV and AIDs. The company has used zinc finger nuclease technology to disrupt the

coding of CC5, which is used for HIV entry into the cells, by interfering with the DNA

encoding sequence69

. Sangamo’s approach has resulted in the production of T-cells that

are resistant to HIV infections. The company has just received a $14.5 million CIRM

Disease research grant to continue efforts with their regenerative approach70

.

In February of 2012, Baxter International, Inc. began phase III trials for the

regenerative treatment of chronic myocardial ischemia. This disease is characterized by

reduced blood flow to cardiac muscle due to a blockage in one or more heart arteries71

.

Baxter is using a patient’s own CD34+ stem cells, which have demonstrated potential to

reduce angina and amputation rates in patients, while improving exercise time in patients

and inducing vascularization in other clinical trials72

. This study, which currently has

450 enrolled patients73

, hopes to demonstrate the safety and efficacy of this regenerative

treatment for FDA approval.

11

Even more recently, Harvard Bioscience, Inc. announced that their biomarker and

scaffolding was utilized in the second successful transplantation of a synthetic tissue-

engineered windpipe. The windpipe was grown after isolation of the patient’s own cells74

.

As for the use of nanotechnology in the field of regenerative medicine, most

nanoparticles are being assessed for their use in bone regeneration, skin regeneration,

bladder reconstruction, cell encapsulation, and cardiac function restoration75

. In studies

performed between 2004 and 2008, researchers were able to demonstrate that nano-

materials were more effective in producing osteoblasts, or bone-forming cells when

compared to conventional orthopedic implants. These studies showed that nanoparticles,

such as nano-hydroxyapatite, electro-spun silk, and anodized titanium had a larger

surface energy when compared to the most commonly used products on the market. The

increase surface energy resulted in a lager adsorption of proteins, such as vitonectin,

fibronectin, and collagen, which are essential for bone growth. Other researchers have

shown that nano-phase titanium, such as Ti6AlV4 and CoCrMo, promotes better calcium

crystallization when compared to micro-scale samples of the same material. It has

become evident that bone cell growth is not necessary dependent on the material used,

but the size of the surface area implanted76

.

Regardless of the major advancement in skin generation, made possible through

tissue engineering, these products are extremely expensive because they require such a

long in vitro cell culture time77

. In a 2006 article, Chung et al. was able to demonstrate

that nano-materials can be used to increase cell proliferation time, thus decreasing the

time needed for in vitro cultures. Chung utilized poly (ε-caprolactone) and nano-chitosan

to form a human dermal fibroblast scaffold. The use of these non-materials created a

higher surface roughness when compared to smooth chitosan and poly (ε-caprolactone)

surfaces, ultimately resulting in quicker fibroblast proliferation and better viability78

.

With heart disease being the number one cause of death in the United States, it is

obvious that much effort is directed at regenerating cardiac tissue and reestablishing

normal function. In 2005, Zong et al became the first group to successful develop

cardiac tissue by using cardiac myocytes and scaffolds composed of poly(l-lactide) and

poly(lactic-co-glycolic) acid nano-fibers79

. Researchers found that cells were able to align

with the local orientation of the fibers inside of the scaffold and respond to external pace

rates up to 6 hertz80

. The potential to repair and restore electrical signaling would not

only provide health benefits to millions of people and cut healthcare costs immensely.

Other researchers have been studying the benefits of using nano-materials in

vascular grafts and vascular stent materials. Many groups have found that changing the

surface topography of grafts and stents to operate on the nanoscale allows for better cell

interaction. In 2004 Miller et al. and Lui et al. reported an increase in endothelial and

vascular smooth muscle cell proliferation and adhesion when nanostructured poly(lactic-

co-glycolic) acid, titanium, and nitinol stents when compared to micron scale surfaces81

.

Much work has also been performed on returning disease and nonfunctional

bladder tissue, as in the case of bladder cancer. Even though poly-dl-lactide-co-glycolide

has demonstrated potential to grow and restore function in bladder tissue problems of

poor mechanical stability and adverse tissue and immune responses are often

demonstrated82

. Researchers have found that bladder cell growth differs depending on the

scale and surface features of the materials used. In 2003, Tapa et al. reported that smooth

12

muscle cell growth in the bladder was best when poly-dl-lactide-co-glycolide and

polyurethane with nanoscale surface features were used because extracellular matrix

proteins in the bladder operate on the nanoscale83

. Furthermore, in 2008, a group of

researchers found when rough nanometer polyurethane was used in reconstruction a

significantly lower amount of calcium oxalate stones, which pose serious risks, were

formed when compared to conventional polymers84

.

Another one of the major areas of nanotechnology and regenerative medicine is

cell encapsulation. In the medical disciplines concerning type I diabetes, central nervous

system regenerations, and cancer treatment cell encapsulation is of great interest. The

process involves protecting living, genetically engineered cells, which will be used as

drug delivery systems, immunotherapies, and engineered tissues, with polymeric and

biocompatible layers85

. When these cells are delivered, they can provide an unlimited

drug supply, as long as they are functional. Technologies can be used to nanoscale

coatings to the surface of the cells in order to prevent an immune response that would

destroy the cell’s function. The benefit to using nanocoating, instead of micro-scale

coating, is that oxygen and vital nutrients can diffuse more readily and the smaller

volume of material needed greatly reduces clotting86

.

Key Challenges:

Even though regenerative medicine techniques have the ability to help million of

people suffering from chronic illnesses, untreatable diseases, and severely painful and

debilitating diseases, there are still many challenges to overcome. While this report

primarily focused on cellular therapies and tissue engineering, regenerative therapies that

utilize inanimate implant materials often fail as a result of tissue rejection and lack of

mechanical support87

. Another issue occurs when the implant begins to deteriorate and

degrade, resulting in an immune response and necrosis in tissues surrounding the

implant88

. The use of biocompatible, biodegradable nano-scale products and polymers

has increased tissue bonding and comfort level within a patient, but the process is far

from perfect. Because the biocompatibility of devices and inanimate objects depends on

size, surface, shape, roughness and charge89

, it may be beneficial to look at current

products on the market and ways to alter their surfaces. For example, some researchers

believe that creating minor indents within implants may have some benefit. These

indentations can be coated with materials known to attract healing proteins90

. This could

ultimately decrease healing time required after surgery and reduce the rejection of the

implant during the healing processes.

For products that utilize viable cells, limited proliferation capacity is a major

issue. Researchers have found ways to grow functional cells outside the human body, but

once implanted these cells may not interact with other cells and proteins as they do in a

healthy individual. If these cells cannot interact, they do not offer the regenerative

therapeutic properties because the number of available cells is limited. The problem with

decreased cell interaction may require subsequent or long-term treatments, which are

often extremely expensive.

Additional problems arise when adult stem cells or donor cells are needed. When

adult stem cells are used in a regenerative therapy, they are only available in minimal

quantities91

. Another restriction is that adult stem cells can only differentiate into cells

found within their tissue of origin. For patients that require donor cells, the obvious issues

13

are immune reactions and tissue rejection. One way to overcome these challenges is to

use embryonic stem cells, instead of viable cells, adult stem cells, or donor cells.

Embryonic stem cells are undifferentiated cells that can proliferate into any needed cell

type for long periods of time92

. However, ethical concerns make this solution difficult

because human embryos must be destroyed in order to create a cell line. A number of

pro-life organizations protest the use of these stem cells in research and medicine because

they believe life begins at the moment of conception. They argue that their use in

medicine should be considered murder.

The lack of federal funding also poses a major problem for products in

development. The majority of funding for regenerative products has come from private

capital, totaling $4 billion between 1998 and 200493

. During those years, federal funding

for the regenerative medicine was only $250 million94

. Dependence of private capital,

instead of federal funding, creates the problem of competition between companies.

Because these companies are more focused on developing products faster than other

companies to prevent a huge monetary loss, commercially available products are

limited95

. See figure 8 for the estimates of technology readiness in major areas of

regenerative medicine. In order to overcome this challenge, the federal government must

fully understand the benefit of regenerative techniques and the potential to cut healthcare

costs significantly.

Figure 8. Estimates of the readiness of technology in regenerative medicine as of

2010. Achieved areas are shown in green96

.

14

Unique Opportunities:

Regardless of the number of challenges and improvements needed in the field of

regenerative medicine, there are many opportunities as well. These include new treatment

options and improvements of currently available products. The application of

nanotechnology to both new and already developed products could provide immense

benefits over the conventionally used micron materials.

New Treatments:

The field of regenerative medicine is applicable to nearly every disease and

disorder. There is not one medical discipline that would not benefit from the repair,

restoration, and replacement of damaged organs or tissues. Even still, most of the

regenerative products are for skin or wound repair. By looking at figure 4, there are only

minimal amounts of products on the market for the treatment cancer, cardiac disease, and

diabetes. Heart disease and cancer are among the leading causes of death worldwide, and

diabetes is often difficult to treat and manage. The only positive to these health facts is

that there are many opportunities for students, business people, and researchers to

develop products or companies centered on these medical disciplines.

Improvement of Currently Available Products:

As demonstrated above, there is definitely room for improvement in the currently

available regenerative products. Over the last few years, developers have shown that the

surface modifications on currently available devices and products resulted in better cell

proliferation and regeneration. The use of nanotechnology has increased cell growth and

biocompatibility, making these devices and products more successful. Therefore, for

students and researchers who would prefer to work in a company, instead of developing

new ideas for products, there is potential to still impact the field of regenerative medicine.

Conclusion:

In conclusion, the field of regenerative medicine hopes to repair, restore, and

repair function in damaged tissues and organs. Currently available regenerative products

have helped hundred of thousands of patients suffering from severe and painful diseases

and disorders by stimulating healing processes, immune cells, and growth factors. The

ability to stimulate healing and restore function is a major advancement in medicine,

which is normally focused on symptom management and long-term treatment. However,

even with their potential, the number of regenerative products on the market is still

relatively low. This may be a result of low funding, incompatible devices, and

competition between companies. Therefore, there are many opportunities to develop new

products or improve previous products, which could save the lives of millions of

individuals.

15

1 Glökler, J., Werner, M. and Moore, R. (2010) Nanotechnology in Regenerative

Medicine: Focus Report. Retrieved from

<http://www.observatorynano.eu/project/filesystem/files/Nano%20regenerative%20medi

cine%20technical%20economic%20-%20final%20-%2023%20April%202010.pdf> 2 Sahoo, S. (2012). Nanotechnology in health care. Singapore: Pan Stanford Publishing

Pte. Ltd. 3 Sahoo, S. (2012). Nanotechnology in health care. Singapore: Pan Stanford Publishing


Pte. Ltd. 5 The National Institute of Health. (2012). Stem cell basics. Retrieved from <

http://stemcells.nih.gov/info/basics/pages/basics4.aspx> 6 The National Institute of Health. (2012). Stem cell basics. Retrieved from <

http://stemcells.nih.gov/info/basics/pages/basics4.aspx> 7 Sahoo, S. (2012). Nanotechnology in health care. Singapore: Pan Stanford Publishing


Pte. Ltd. 9 Glökler, J., Werner, M. and Moore, R. (2010) Nanotechnology in Regenerative



cine%20technical%20economic%20-%20final%20-%2023%20April%202010.pdf> 10

Mayorga, M., Oyalowo, A., Rementer, C., Soucy, M., Weng, L. (n.d). Biomaterials

based tissue engineering. Retrieved from <

http://biomed.brown.edu/Courses/BI108/BI108_2007_Groups/group12/Homepage.html> 11

Sahoo, S. (2012). Nanotechnology in health care. Singapore: Pan Stanford Publishing

Pte. Ltd. 12

Khang, D., Carpenter, J., Chun, Y, Pareta, R., Webster, T. (2010). Nanotechnology for

regenerative medicine. Biomedical Devices, 12, 575-587. Retrieved from

<http://link.springer.com/article/10.1007%2Fs10544-008-9264-6?LI=true> 13




Glökler, J., Werner, M. and Moore, R. (2010) Nanotechnology in regenerative

medicine: focus report. Retrieved from







Centers for Disease Control and Prevention. (2012). Chronic diseases and health

promotion. Retrieved from < http://www.cdc.gov/chronicdisease/overview/index.htm> 17


promotion. Retrieved from < http://www.cdc.gov/chronicdisease/overview/index.htm>

16

18


promotion. Retrieved from < http://www.cdc.gov/chronicdisease/overview/index.htm> 19

Werner, M., Ruffin, M., and West, E. (2011). Regenerative medicines: a paradigm shift

in healthcare. Drug Discovery World. Retrieved from <http://www.ddw-

online.com/personalised-medicine/p142741-

regenerative%20medicines%3A%20a%20paradigm%20shift%20in%20healthcare.%20%

20spring%2011.html> 20

McGowan Institute for Regenerative Medicine. (2010). What is regenerative medicine?

Retrieved from < http://www.regenerativemedicine.net/What.html> 21





















The Henry J. Kaiser Family Foundation. (2012). U.S health care costs. Retrieved from

<http://www.kaiseredu.org/issue-modules/us-health-care-costs/background-brief.aspx> 26

Kane, J. (2012). Health costs: how the U.S. compares with other countries. PBS.

Retrieved from <http://www.pbs.org/newshour/rundown/2012/10/health-costs-how-the-

us-compares-with-other-countries.html> 27

Alliance for Regenerative Medicine. (2012). Annual industry report. Retrieved from <

http://alliancerm.org/sites/default/files/ARM-Annual-Industry-Report-2012.pdf> 28

McGowan Institute for Regenerative Medicine. (2010). What is regenerative medicine?

Retrieved from < http://www.regenerativemedicine.net/What.html> 29

U.S Health and Human Services. (2012). Organ Donor Awareness. Retrieved from <

http://organdonorawareness.org/> 30




http://alliancerm.org/sites/default/files/ARM-Annual-Industry-Report-2012.pdf>

17

32



Organogenesis. (2010). Apligraf: what does it treat? Retrieved from <

http://www.apligraf.com/professional/what_is_apligraf/what_does_it_treat/> 34

Organogenesis. (2010). Apligraf: how is it made? Retrieved from <

http://www.apligraf.com/professional/what_is_apligraf/how_is_it_made/> 35





Zaulyanov, L. and Kirsner, R. (2007). A review of bi-layered living cell treatment

(Apligraf ) in the treatment of venous leg ulcers and diabetic foot ulcers. Clinical

Interventions in Aging, 1, 93-98. Retrieved from

<http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2684073/> 38

Organogenesis. (2010). Apligraf: clinical data. Retrieved from <

http://www.apligraf.com/professional/clinical_data/index.html> 39

Suriano, R. (2001). Babies’ skin cells heal stubborn wounds. Sun Sentinel. Retrieved

from < http://articles.sun-sentinel.com/2001-04-08/news/0104070412_1_stubborn-

wounds-apligraf-surgeon-and-wound> 40

Organogenesis. (2012) Bioactive wound healing. Retrieved from <

http://www.organogenesis.com/products/bioactive-woundhealing.html> 41

Organogenesis. (2012). What is Apligraf? Retrieved from <

http://www.apligraf.com/patient/what_is_apligraf/how_works/the_science_behind_apligr

af.html> 42






Dendreon Corporation. (2012). How does Provenge work? Retrieved from

<http://www.provenge.com/science-and-treatment.aspx> 44






Dendreon Corporation. (2012). How does Provenge work? Retrieved from

<http://www.provenge.com/science-and-treatment.aspx> 46






Fibrocell Science. (2013). Fibrocell. Inc. announces recognition for LAVIV (azficel-T)

at the 2012 cell & gene therapy forum, Washington, DC. Retrieved from

18

<http://www.fibrocellscience.com/fibrocell-science-inc-announces-recognition-for-laviv-

azficel-t-at-the-2012-cell-gene-therapy-forum-washington-d-c/> 48

Fibrocell Science. (2013). Fibrocell. Inc. announces recognition for LAVIV (azficel-T)

at the 2012 cell & gene therapy forum, Washington, DC. Retrieved from

<http://www.fibrocellscience.com/fibrocell-science-inc-announces-recognition-for-laviv-

azficel-t-at-the-2012-cell-gene-therapy-forum-washington-d-c/> 49

Fibrocell (2013). Frequently asked questions. Retrieved from

<http://mylaviv.com/faq/> 50

Fibrocell (2013). Frequently asked questions. Retrieved from

<http://mylaviv.com/faq/> 51

Chase, B. (2011). Fibrocell plans show launch of new wrinkle drug. Retrieved from <

http://www.minyanville.com/businessmarkets/articles/fibrocell-science-david-pernock-

laviv-botox/6/24/2011/id/35385?page=full> 52

Schmidt, C, MD. (2013). Bridging nerve gaps for faster regeneration. Retrieved from

<http://www.engr.utexas.edu/features/bridgingnervegaps 53

Schmidt, C, MD. (2013). Bridging nerve gaps for faster regeneration. Retrieved from

<http://www.engr.utexas.edu/features/bridgingnervegaps> 54

Orthogen. (2012). Technology. Retrieved from <

http://orthogencorp.com/dental_professional/technology.php> 55





Orthogen (2008). DentoGen: a new approach to bone grafting. OsseoNews. Retrieved

from <http://www.osseonews.com/dentogen-a-new-approach-to-bone-grafting/> 58

Orthogen (2008). DentoGen: a new approach to bone grafting. OsseoNews. Retrieved

from <http://www.osseonews.com/dentogen-a-new-approach-to-bone-grafting/> 59















BCC Research. (2010). Tissue engineering and regeneration: technologies and global

markets. Retrieved from <http://www.bccresearch.com/report/tissue-engineering-

regeneration-technologies-markets-hlc101a.html>

19

65



BCC Research. (2010). Tissue engineering and regeneration: technologies and global

markets. Retrieved from <http://www.bccresearch.com/report/tissue-engineering-

regeneration-technologies-markets-hlc101a.html> 67









MayoClinic. (2012). Myocardial ischemia. Retrieved from <

http://www.mayoclinic.com/health/myocardial-ischemia/DS01179> 72

Sahoo, S. Klychko, E., Thorn, T., Misener, S., Schultz, K., Millay, M., Ito, A. (2011).

Exosomes from human CD34+ stem cells mediate their proangiogenic paracrine activity.

Circulation Research, 107, 724-728. Retrieved from

<http://www.ncbi.nlm.nih.gov/pubmed/21835908> 73

























<http://link.springer.com/article/10.1007%2Fs10544-008-9264-6?LI=true>

20

82
















Glökler, J., Werner, M. and Moore, R. (2010) Nanotechnology in Regenerative




Glökler, J., Werner, M. and Moore, R. (2010) Nanotechnology in Regenerative




Kingston Technical Software. (2012). Introduction to corrosion of implants. Retrieved

from <http://corrosion-doctors.org/Implants/biocompatib.htm> 90

Kingston Technical Software. (2012). Introduction to corrosion of implants. Retrieved

from <http://corrosion-doctors.org/Implants/biocompatib.htm> 91

The National Institute of Health. (2012). Stem cell basics. Retrieved from <

http://stemcells.nih.gov/info/basics/pages/basics4.aspx> 92

Sahoo, S. (2012). Nanotechnology in health care. Singapore: Pan Stanford Publishing

Pte. Ltd. 93

U.S Department of Health and Human Services. (n.d.) 2020: A new vision. A future for

regenerative medicine. Retrieved from

<http://medicine.osu.edu/regenerativemedicine/documents/2020vision.pdf> 94








http://alliancerm.org/sites/default/files/ARM-Annual-Industry-Report-2012.pdf>

the application of nanotechnology to regenerative medicine

Documents