Expression of Concern to: Therapeutic potential of human embryonic stem cell transplantation in patients with cerebral palsy.

The Editor-in-Chief of the Journal of Translational Medicine is issuing an editorial expression of concern to alert readers that concerns have been raised regarding the ethics of this study [1] and the potential association of the risk of teratoma formation with the transplantation of embryonic stem cells. Appropriate editorial action will be taken once this has been fully investigated. The authors disagree with this notice.

Therapeutic potential of human embryonic stem cell transplantation in patients with cerebral palsy.

BACKGROUND: The present study evaluated the efficacy and safety of human embryonic stem cell (hESC) therapy in patients with CP. MATERIALS AND METHODS: This analysis included patients (30 days-18 yr) with documented diagnosis of CP. The study consisted of four treatment phases (T1, T2, T3, T4) separated by gap phases. Efficacy of hESC therapy was evaluated based on Gross Motor Function Classification Scores Expanded and Revised (GMFCS-E & R; 1-good to 5-bad). RESULTS: Ninety one patients were included and all received hESC therapy in T1, 66 patients returned for T2, 38 patients for T3, and 15 patients for T4. Overall, 30.2% patients achieved GMFCS-E & R score 1 during the study with different number of patients achieving GMFCS score 1 by the end of each treatment phase (T1: 6 [6.6%]; T2: 7 [10.6%]; T3: 11 [28.9%]; and T4: 5 [33.3%]). All patients in up to 2 yr (n = 10), 2-4 yr (n = 10), 4-6 yr (n = 9), and 6-12 yr (n = 8) age groups except one of the 5 patients in the age group of 12-18 yr transitioned from GMFCS-E & R score 5 to lower scores by end of T1. Most patients transitioned to GMFCS-E & R score 2 (n = 34) from higher scores by end of T2. Eleven patients achieved GMFCS-E & R score 1 by end of T3. No serious adverse events were observed. CONCLUSION: Use of hESC therapy in patients with CP is effective and safe. hESC therapy has demonstrated significant improvement in GMFCS-E & R scale.

A review on stem cell therapy for multiple sclerosis: special focus on human embryonic stem cells.

Multiple sclerosis (MS), a complex disorder of the central nervous system (CNS), is characterized with axonal loss underlying long-term progressive disability. Currently available therapies for its management are able to slow down the progression but fail to treat it completely. Moreover, these therapies are associated with major CNS and cardiovascular adverse events, and prolonged use of these treatments may cause life-threatening diseases. Recent research has shown that cellular therapies hold a potential for CNS repair and may be able to provide protection from inflammatory damage caused after injury. Human embryonic stem cell (hESC) transplantation is one of the promising cell therapies; hESCs play an important role in remyelination and help in preventing demylenation of the axons. In this study, an overview of the current knowledge about the unique properties of hESC and their comparison with other cell therapies has been presented for the treatment of patients with MS.

Single-photon emission tomography imaging in patients with Lyme disease treated with human embryonic stem cells.

Aim The purpose of this study was to evaluate the longitudinal changes in brain perfusion in patients with Lyme disease treated with human embryonic stem cells. Material and methods The study included 59 (age range 41.68 ± 16.37 years) patients with Lyme disease whose single-photon emission tomography imaging was performed before and after the human embryonic stem cell therapy. Technetium-hexa methyl propylene aminoxime single-photon emission tomography imaging was used to assess the hypoperfused lesions/regions in the brain prior to the therapy, as well as the improvement in perfusion after human embryonic stem cell treatment. Results After receiving human embryonic stem cell therapy, single-photon emission tomography imaging reflects a significant (>60%) improvement in 43 patients along with moderate (30-60%) and mild (<30%) improvement in 12 and four patients, respectively. The cerebral perfusion flow improved and the degree of hypoperfusion in the other regions significantly decreased after the human embryonic stem cell therapy. Interpretation of single-photon emission tomography imaging of brain images (before and after therapy) clearly presented the changes in color at various brain regions which represent the improvements in patients. Conclusion Single-photon emission tomography imaging could be used as a potential diagnostic tool to assess the response of Lyme disease patients to human embryonic stem cell therapy.

A Novel Scoring System Approach to Assess Patients with Lyme Disease (Nutech Functional Score).

INTRODUCTION: A bacterial infection by Borrelia burgdorferi referred to as Lyme disease (LD) or borreliosis is transmitted mostly by a bite of the tick Ixodes scapularis in the USA and Ixodes ricinus in Europe. Various tests are used for the diagnosis of LD, but their results are often unreliable. We compiled a list of clinically visible and patient-reported symptoms that are associated with LD. Based on this list, we developed a novel scoring system. METHODOLOGY: Nutech functional Score (NFS), which is a 43 point positional (every symptom is subgraded and each alternative gets some points according to its position) and directional (moves in direction bad to good) scoring system that assesses the patient's condition. RESULTS: The grades of the scoring system have been converted into numeric values for conducting probability based studies. Each symptom is graded from 1 to 5 that runs in direction BAD → GOOD. CONCLUSION: NFS is a unique tool that can be used universally to assess the condition of patients with LD.

Analysis of the regulation pathways via microarray and miRNA studies: human embryonic stem cells to treat diabetes mellitus type-II.

Diabetes mellitus occurs either due to an autoimmune destruction of ß cells (Type 1) or resistance to insulin effects (Type 2). Diverse conventional medications are used for treatment of diabetes, which is associated with long term complications such as kidney failure, blindness, and stroke. We recently showed the potential of human embryonic stem cells (hESCs) in 95 patients with type 2 diabetes. In the present study, we use the microarray and miRNA studies to prove why hESCs are effective in diabetes. Three samples of hESCs were cultured and microarray technology was used for the analysis of diabetic pathways. The gene targets for miRNA were analyzed using gene ontology (GO) and DAVID database. Genes involved in the diabetic pathways were classified in accordance with GO analysis. Pathways for these genes were determined using Reactome and Panther databases. The up and down-regulation of all the genes involved were confirmed with the significant p-values. Pathways for insulin secretion, binding and its positive regulation were up-regulated while the pathways for negative regulation of insulin were significantly down-regulated. hESCs cultured at our facility have the capability to regenerate the pancreatic ß cells after transplantation; as the insulin secretion pathways were significantly up-regulated.

Human Embryonic Stem Cell Derived from Early Stage Fertilized Ovum: Non Immunogenic and Universal, Neuronal and Non-neuronal Cell Lines.

BACKGROUND: Human embryonic stem cells (hESCs) have the potential to treat various human disorders currently labeled as incurable and/or terminal illness. However, the fear that the patients' immune system would recognize them as non self and lead to an immune rejection has hampered their use. The main cause for immune rejection is usually the incompatibility of both donor and recipient's major histocompatibility complex (MHC). METHODS: We describe a hESC line developed through a patented technology that does not lead to immune reaction upon transplantation. We have transplanted these cells in ＞1,400 patients with chronic/terminal conditions and did not observe any immune reaction. No immunosuppressant were administered to these patients. We analyzed the expression levels of MHC-I and MHC-II on the surface of these hESCs using microarray technology. The gene targets for miRNA were analyzed using Gene ontology and DAVID database and pathways for these genes were determined using Reactome and Panther databases. RESULTS: Our results showed that the levels of expression of MHC-I and MHC-II on hESCs is almost negligible and thus the hESCs are less susceptible to an immune rejection. CONCLUSIONS: The hESCs cultured at our facility expresses low levels of MHC-I and do not produce an immune reaction. These can be administered universally and need no cross matching before transplantation.

Expression of Concern to: Evaluation of patients with multiple sclerosis using reverse nutech functional score and expanded disability status scale after human embryonic stem cell therapy.

The Editors-in-Chief of Clinical and Translational Medicine are issuing an editorial expression of concern to alert readers that concerns have been raised regarding the ethics of this study [1]. Appropriate editorial action will be taken once this has been fully investigated. The author disagrees with this notice.

Comparison of Nutech Functional Score with European Stroke Scale for Patients with Cerebrovascular Accident Treated with Human Embryonic Stem Cells: NFS for CVA Patients Treated with hESCs.

PURPOSE: Stem cell therapy is a promising modality for treatment of patients with chronic cerebrovascular accident (CVA) in whom treatment other than physiotherapy or occupational therapy does not address the repair or recovery of the lost function. In this study, the author aimed at evaluating CVA patients treated with human embryonic stem cell (hESC) therapy and comparing their study outcomes with globally accepted European Stroke Scale (ESS) to that with novel scoring system, Nutech functional score (NFS), a 21-point positional and directional scoring system for assessing patients with CVA. MATERIALS AND METHODS: Patients diagnosed with CVA were assessed with NFS and ESS before and after hESC therapy. NFS assessed the patients in the direction of 1-5 (bad to good), where 5 was considered as the highest possible grade (HPG). The findings were obtained for the patients who scored HPG, and had shown improvement by at least one grade. RESULTS: Overall, 66.7% of patients scored HPG level on the NFS scale and about 62.5% of the patients scored HPG according to the ESS scale. Approximately, 52.2% patients showed an improvement of 100% (by at least one grade) on NFS scale. None of the patients showed 100% improvement in the alteration of the score by at least one grade when scored with ESS. CONCLUSION: NFS and ESS scores show that a large population of CVA patients was benefitted with hESC therapy. NFS was found to give more convincing results than ESS, and overcomes the shortcomings of ESS.

Human Embryonic Stem Cells in the Treatment of Autism: A Case Series.

Background: Autism spectrum disorder is a neurodevelopmental disorder accompanied by weak immune system and neuroinflammation. Multiple factors contribute to etiology of autism spectrum disorder including genetic disorders, environmental substances/toxins, imbalanced immune system, encephalitis, and viral infections. Autism spectrum disorder is an incurable disease; however, it can be managed by educational and medical interventions. Human embryonic stem cell therapy has been shown to improve blood perfusion in the brain; thus, this therapy may be effective in improving motor skills, social skills, and cognition in patients with autism spectrum disorder. Method: Three pediatric patients with autism spectrum disorder were administered human embryonic stem cell therapy. Their treatment plan comprised 3 to 4 therapy sessions (T1, T2, T3, T4) that were 4 to 6 weeks in length, with 4- to 8-month gap phases separating each therapy session. Results: The patients showed improvements in eye coordination, writing, balancing, cognition, and speech and showed reduced hypersensitivity to noises and smells. Conclusion: The use of human embryonic stem cell therapy may be a safe and effective treatment for patients with autism spectrum disorder. Studies with larger sample sizes are needed to support the use of human embryonic stem cell therapy in this patient population.

Magnetic resonance imaging tractography as a diagnostic tool in patients with spinal cord injury treated with human embryonic stem cells.

Introduction Spinal cord injury is a cause of severe disability and mortality. The pharmacological and non-pharmacological methods used, are unable to improve the quality of life in spinal cord injury. Spinal disorders have been treated with human embryonic stem cells. Magnetic resonance imaging and tractography were used as imaging modality to document the changes in the damaged cord, but the magnetic resonance imaging tractography was seen to be more sensitive in detecting the changes in the spinal cord. The present study was conducted to evaluate the diagnostic modality of magnetic resonance imaging tractography to determine the efficacy of human embryonic stem cells in chronic spinal cord injury. Materials and methods The study included the patients with spinal cord injury for whom magnetic resonance imaging tractography was performed before and after the therapy. Omniscan (gadodiamide) magnetic resonance imaging tractography was analyzed to assess the spinal defects and the improvement by human embryonic stem cell treatment. The patients were also scored by American Spinal Injury Association scale. Results Overall, 15 patients aged 15-44 years with clinical manifestations of spinal cord injury had magnetic resonance imaging tractography performed. The average treatment period was nine months. The majority of subjects ( n = 13) had American Spinal Injury Association score A, and two patients were at score C at the beginning of therapy. At the end of therapy, 10 patients were at score A, two patients were at score B and three patients were at score C. Improvements in patients were clearly understood through magnetic resonance imaging tractography as well as in clinical signs and symptoms. Conclusion Magnetic resonance imaging tractography can be a crucial diagnostic modality to assess the improvement in spinal cord injury patients.

Cell Viability of Human Embryonic Stem Cells Stored for a Period of 9 Years.

OBJECTIVES: Human embryonic stem cells are pluripotent cell lines usually derived from human blastocysts. Their potential critically depends on long-term proliferative capacity, developmental potential after prolonged culture, and karyotypic stability. Cell viability is an important parameter for assessing cell sample quality. Here, we elaborate the stored human embryonic stem cell lines' viability in a ready to use form for a period of 9 years (from 2007 to 2015). MATERIALS AND METHODS: Spare pre implantation stage in vitro fertilized ovum-derived cell lines were cultured in suitable media. Thereafter, they were centrifuged at 1000 revolutions/min over 5 minutes, and pellets were suspended in normal saline. Next, they were tested for viability from storage at -20°C. After being allowed to thaw slowly, the cells were stained with propidium iodide and analyzed using flow cytometry. Images of cells were taken at ×40 and ×100 magnification. RESULTS: At ×100 magnification, cell population size ranged from 0.2 to 2 µm. The percentage of live cells was more than 95% throughout the 9 years. Cells frozen in 2015 showed cell viability of 96.8%. CONCLUSIONS: We observed high cell viability in our cell lines for 9 years. Human embryonic stem cell lines in a ready-to-use form can be preserved for long-term purposes. Thus, they could be made available globally.

A review of the emerging potential therapy for neurological disorders: human embryonic stem cell therapy.

The first human embryonic stem cell (hESC) line was developed in the late nineties. hESCs are capable of proliferating indefinitely and differentiate into all the three embryonic germ layers. Further, the differentiation of hESC lines into neural precursor cells and neurons, astrocytes and oligodendrocytes showed their potential in treating several incurable neurological disorders such as spinal cord injury (SCI), cerebral palsy (CP), Parkinson's disease (PD). In this review, we will discuss the global scenario of research and therapeutic use of hESCs in the treatment of neurological disorders. Following this, we will discuss the development of a unique hESC line, how it differs from the other available hESC lines and its use in the treatment of neurological disorders. hESCs were isolated from mixture of neuronal and non-neuronal progenitor cells in their pre progenitor state in a Good Laboratory Practices, Good Tissue Practices and Good Manufacturing Practices compliant laboratory. Blastomere cells have served as a source to derive the hESCs and the xeno-free culture was demonstrated to be more safe and effective in clinical therapeutic application of hESCs. All the patients showed a remarkable improvement in their conditions and no serious adverse events were reported. This study concluded that hESC lines could be scalable and used in the treatment of various neurological disorders such as SCI, CP, and PD.

Nutech functional score: A novel scoring system to assess spinal cord injury patients.

AIM: To develop a new scoring system, nutech functional scores (NFS) for assessing the patients with spinal cord injury (SCI). METHODS: The conventional scale, American Spinal Injury Association's (ASIA) impairment scale is a measure which precisely describes the severity of the SCI. However, it has various limitations which lead to incomplete assessment of SCI patients. We have developed a 63 point scoring system, i.e., NFS for patients suffering with SCI. A list of symptoms either common or rare that were found to be associated with SCI was recorded for each patient. On the basis of these lists, we have developed NFS. RESULTS: These lists served as a base to prepare NFS, a 63 point positional (each symptom is sub-graded and get points based on position) and directional (moves in direction BAD → GOOD) scoring system. For non-progressive diseases, 1, 2, 3, 4, 5 denote worst, bad, moderate, good and best (normal), respectively. NFS for SCI has been divided into different groups based on the affected part of the body being assessed, i.e., motor assessment (shoulders, elbow, wrist, fingers-grasp, fingers-release, hip, knee, ankle and toe), sensory assessment, autonomic assessment, bed sore assessment and general assessment. As probability based studies required a range of (-1, 1) or at least the range of (0, 1) to be useful for real world analysis, the grades were converted to respective numeric values. CONCLUSION: NFS can be considered as a unique tool to assess the improvement in patients with SCI as it overcomes the limitations of ASIA impairment scale.

Human embryonic stem cell therapy for aplastic anemia.

Human embryonic stem cell (hESC) therapy is the potential therapeutic option for the treatment of patients with aplastic anemia (AA). The study showed a remarkable improvement in the AA patient subsequent to hESC administration. No adverse events occurred in the patient. hESC therapy is safe and effective for AA patients.

Expression of Concern to: Role of physiotherapy in the mobilization of patients with spinal cord injury undergoing human embryonic stem cells transplantation.

The Editors-in-Chief of Clinical and Translational Medicine are issuing an editorial expression of concern to alert readers that concerns have been raised regarding the ethics of this study [1]. Appropriate editorial action will be taken once this has been fully investigated. Geeta Shroff disagrees with this notice. Dipin Thakur, Varun Dhingra, Deepak Singh Baroli, Deepanshu Khatri and Rahul Dev Gautam have not responded to our correspondence about this article.

Transplantation of Human Embryonic Stem Cells in Patients with Multiple Sclerosis and Lyme Disease.

BACKGROUND Multiple sclerosis (MS) is an inflammatory and neurodegenerative disease in which the myelin sheath of nerve cells is damaged. It can cause delayed neurologic symptoms similar to those seen in Lyme disease (LD) patients. Thymus derived T-cells (myelin reactive) migrate to the blood brain barrier and stimulate an inflammatory cascade in the central nervous system. Cell based therapies play an important role in treating neurological diseases such as MS and LD. CASE REPORT Human embryonic stem cell (hESC) therapy was used to treat two patients with both MS and LD. The hESCs were administered via different routes including intramuscular, intravenous, and supplemental routes (e.g., deep spinal, caudal, intercostal through eye drops) to regenerate the injured cells. Both the patients showed remarkable improvement in their functional skills, overall stamina, cognitive abilities, and muscle strength. Furthermore, the improvement in the patients' conditions were assessed by magnetic resonance tractography and single photon emission computed tomography (SPECT). CONCLUSIONS Therapy with hESCs might emerge as an effective and safe treatment for patients with both MS and LD. Well-designed clinical trials and follow-up studies are needed to prove the long-term efficacy and safety of hESC therapy in the treatment of patients with MS and LD.

Human Embryonic Stem Cell Therapy in Crohn's Disease: A Case Report.

BACKGROUND: Crohn's disease is a chronic inflammatory disease of the intestines, mainly the colon and ileum, related with ulcers and fistulae. It is estimated to affect 565,000 people in the United States. Currently available therapies, such as antibiotics, thiopurines, and anti-tumor necrosis factor-alpha agents, are only observed to reduce the complications associated with Crohn's disease and to improve quality of life, but cannot cure the disease. Stem cell therapy appears to have certain advantages over conventional therapies. Our study aimed to evaluate the efficacy of human embryonic stem cell therapy in a patient with Crohn's disease. CASE REPORT: A 21-year-old male with chief complaints of intolerance to specific foods, abdominal pain, and diarrhea underwent human embryonic stem cell therapy for two months. After undergoing human embryonic stem cell therapy, the patient showed symptomatic relief. He had no complaints of back pain, abdominal pain, or diarrhea and had improved digestion. The patient had no signs and symptoms of skin infection, and had improved limb stamina, strength, and endurance. The condition of patient was stable after the therapy. CONCLUSIONS: Human embryonic stem cell therapy might serve as a new optimistic treatment approach for Crohn's disease.

Evaluation of patients with multiple sclerosis using reverse nutech functional score and expanded disability status scale after human embryonic stem cell therapy.

BACKGROUND: The expanded disability status scale (EDSS) is a validated and reliable tool to assess the extent of disabilities in patients with multiple sclerosis (MS). However, the use of this tool has been found to be limited in assessing various symptoms of MS that are important. Our study aimed at evaluating the efficacy of a new scoring system, reverse nutech functional score (RNFS) as compared to EDSS in assessing patients with MS treated with human embryonic stem cell (hESC) therapy. METHODS: The MS patients were treated with hESC therapy for one treatment period. All the patients were evaluated with EDSS and RNFS at baseline and after the hESC therapy. RESULTS: The study included a total of 24 MS patients with mean age of 45 year. The patients showed an improvement in parameters (sleeping disorders, paralysis, paraesthesia, myalgia, muscle weakness, memory, language, irritability, eye pain, depression and coordination, communication, breathing pattern, attention and appetite) associated with MS when evaluated with RNFS. This improvement went unnoticed when the patients were assessed with EDSS. CONCLUSION: RNFS can efficiently assess the effectiveness of hESC therapy in treating patients with MS. It could be a suitable scoring system for patients with MS as it can assess the slightest improvements in the patients. Use in other settings would be helpful in assessing its utility.

Therapeutic potential of human embryonic stem cells in type 2 diabetes mellitus.

AIM: To evaluate the safety and efficacy of human embryonic stem cells (hESCs) for the management of type 2 diabetes mellitus (T2DM). METHODS: Patients with a previous history of diabetes and its associated complications were enrolled and injected with hESC lines as per the defined protocol. The patients were assessed using Nutech functional score (NFS), a numeric scoring scale to evaluate the patients for 11 diagnostic parameters. Patients were evaluated at baseline and at the end of treatment period 1 (T1). All the parameters were graded on the NFS scale from 1 to 5. Highest possible grade (HPG) of 5 was considered as the grade of best improvement. RESULTS: Overall, 94.8% of the patients showed improvement by at least one grade of NFS at the end of T1. For all the 11 parameters evaluated, 54% of patients achieved HPG after treatment. The four essential parameters (improvement in glycated hemoglobin (HbA1c) and insulin level, and fall in number of other oral hypoglycemic drugs with and without insulin) are presented in detail. For HbA1c, 72.6% of patients at the end of T1 met the World Health Organization cut off value, i.e., 6.5% of HbA1c. For insulin level, 65.9% of patients at the end of T1 were able to achieve HPG. After treatment, the improvement was seen in 16.3% of patients who required no more than two medications along with insulin. Similarly, 21.5% of patients were improved as their dosage regimen for using oral drugs was reduced to 1-2 from 5. CONCLUSION: hESC therapy is beneficial in patients with diabetes and helps in reducing their dependence on insulin and other medicines.