Serial no.	Comment	Response
Review Round 1
Reviewer Message: “The world community should not lose out on the first human data on embryonic stem cell therapy in spinal injuries.”
Caveat: All regulatory/monitoring permissions have been claimed to be taken by the investigator.
1	That patients were not charged of any fees.	Patients were charged as a package which included the physical therapy, occupational therapy, food and lodging.
		The statement for the same has also been added in the letter drafted for the comment no. 8
2	Please mention if pregnant or lactating patients received any therapies.	The data for all the patients was validated by GVK Biosciences (NM-Hesc-10-1, 18 November 2010). We are providing the validation report from GVK for your reference. As per exclusion criteria, pregnant or lactating patients were not included in the study
3	The choice of patients in this study is widely disparate, ranging from 5 months to 21 years after injury, making interpretation of results difficult.	All the five patients in our study had a chronic injury. They came after taking others treatments that did not result in any benefits. All patients were injured since long duration (Patient 1: 14 yrs, Patient no. 2: 1 yr, Patient no. 4: 21 yrs, Patient no. 5: 3 yrs) except the Patient no. 3, who suffered recently (5 months).
4	Authors’ Nutech Mediworld’s hESC has no validated and published study on cell line or animal model for understanding the utility and mechanism of this patent on the CNS	The paper on cell utilities is under process.
		We have recently published two studies on the use of hESC therapy in patients with CP (http://www.ncbi.nlm.nih.gov/pubmed/25496119 and CVI (Accepted in Cell Sciences and Therapy, not yet published). Other papers have been submitted and are under review.
5	There is no investigation to prove that these hESCs homed into the spinal cord of the patient	Homing of stem cells in the patients with spinal cord injury and other medical conditions has been investigated by several studies. We are providing some references in support of the same.
		A review by Kang et al stated that chemokines, cytokines, and growth factors released upon injury provide migratory cues for systemically or locally administered stem cells. The cues induce upregulation of selectins and activation of integrins on the stem cell surface, enabling cells to interact with the endothelium. Stem cells subsequently adhere and transmigrate across the endothelial layer into tissues. Regarding the homing capability of MSCs, numerous studies have confirmed that systemically infused
		MSCs can migrate to injured, inflamed tissues and exert therapeutic effects. (Journey of mesenchymal stem cells for homing: strategies to enhance efficacy and safety of stem cell therapy. Stem Cells Int. 2012; 2012:342968. Epub 2012/07/04).
		A study by Chapel et al found that MSCs homed into numerous tissues following a severe multi-organ injury in primates. (Mesenchymal stem cells home to injured tissues when co-infused with hematopoietic cells to treat a radiation-induced multi-organ failure syndrome.J Gene Med. 2003 Dec;5(12):1028-38.)
6	The authors need to mention what was the “supplemental route” taken for injecting the stem cells	The following supplemental routes were used to inject the hESCs in our study patients: Brachial plexus block, intrathecal, caudal, epidural, popliteal block and/or deep spinal muscle and epidural cathetar
7	The mentioned videos should be given as supplementary data	We are providing the links where you can find the videos uploaded by the patients themselves. (http://pcsrf.org.au/) and (http://www.shannondavisjourney.com/)
8	The details of the patients’ clinical status before and after treatment can be shortened into ASIA grade. The details given in the text about the neurological grade and outcome can be given as supplemental data	We have shortened before and after clinical status of the patients in the manuscript.
		Patient no. 1: ASIA score before treatment: A
		SIA score after treatment: C
		Patient no. 2: ASIA score before treatment: A
		ASIA score after treatment: B
		Patient no. 3: ASIA score before treatment: A
		ASIA score after treatment: A
		Patient no. 4: ASIA score before treatment: A
		ASIA score after treatment: A
		Patient no. 5: ASIA score before treatment: A
		ASIA score after treatment: A
9	Their data has only been presented at the House of Lords which has not commented on its usefulness/validity	We have recently published two studies on the use of hESC therapy in patients with CP (http://www.ncbi.nlm.nih.gov/pubmed/25496119 and CVI (Accepted in Cell Sciences and Therapy, not yet published). Other papers have been submitted and are under review.
		The data has also been presented at the 13 different scientific events.
10	The Geron trial was not stopped only on financial grounds but there were litigations based on ethicality	Tom Okarma, CEO of Geron made a public statement that the decision to halt the clinical trial on hESC was completely based on financial concerns. By stopping its stem cell programme, the company will cut its workforce by more than a third and save millions of dollars. (http://www.bbc.com/news/health-15740133)
		(Money and Morals: Ending Clinical Trials for Financial Reasons. Eaton ML, Kwon BK, Scott CT. Curr Top Behav Neurosci. 2014 Jul 26. [Epub ahead of print])
		We are not aware if the study stopped based on ethical litigations.
11	What were the necessary regulatory permis-sions obtained for the 72 patients’ pilot study?	The approval for the pilot study on 72 patients was taken from the independent ethics committee of the institute.
12	What were the necessary regulatory permis-sions obtained for the 5 patients in this study?	The approval for this study was taken from independent ethics committee.
13	If this was a trial, then the necessary permission from DCGI and other authorities would be required and if this was a therapy, this is in direct contravention to ICMR-DBT Guidelines for Stem Cell Research which were already in place by 2012.	We followed the 2012 guidelines of Indian Council of Medical Research (http://icmr.nic.in/stem_cell/stem_cell_guidelines.pdf). Please see page no. 14 of the guideline.
Review Round 2
14	There is reference to pilot study for 72 patients conducted before the current study. Authors are requested to provide Ethical approval for the pilot study of 72 patients.	The study for 72 patients was a retrospective study. All patients had given consent to any study being carried out prior to the human embryonic stem cell transplantation.
15	It is difficult to interpret data from such a disparate patients	We agree that no analysis can be done from this patient population. That is why we have presented the results as such. Please note that this was the initial study and was not done to analyze anything. All these patients had irreversible conditions and no therapy had benefitted them.
		Our primary objective of giving hESC therapy was to collect the safety data. We also noted the efficacy of these cells as a secondary objective.
		Through this publication, we just want to convey to the audience that hESC cultured in our laboratory that are free of any animal products do not cause any adverse events as teratomas or immunogenicity and are clinically effective.
		Now, it’s been 13 years and we have data for more than 1300 patients with irreversible conditions who have benefitted from this therapy. Till date, none of our patient had any adverse event during or after the therapy.
		Everybody knows the potential of hESCs in curing irreversible conditions but the fear of adverse events is mainly because of the animal products that are used in culture and the immunogenic response. We use a unique technology. That’s why it has been awarded patent in over 126 countries including US.
16	It is not clear if author has published any animal or cell study.	Here is the list of our studies conducted in humans that have been published: Shroff G, Gupta A, Barthakur J. Therapeutic potential of human embryonic stem cell transplantation in patients with cerebral palsy. J Transl Med 2014; 12: 318.
		Shroff G, Das L. Human Embryonic Stem Cell Therapy in Cerebral Palsy Children with Cortical Visual Impairment: A Case Series of 40 Patients. Journal of Cell Science and Therapy 2015.
		Shroff G. A novel approach of human embryonic stem cells therapy in treatment of Friedrich’s Ataxia. Inter-national Journal of Case Reports and Images (IJCRI) Forthcoming 2015.
		Treatment of Lyme Disease with Human Embryonic Stem Cells: A Case Series. In Press
		Human Embryonic Stem Cells in the Treatment of Spinocerebellar Ataxia: A Case Series. In Press
17	Author was suggested to validate the homing of stem cells in the spinal cord of patients. Providing references does not mean that homing is done in current study presented by author	We have done tractography in our patients before and after the therapy that showed axonal reconnections. This could have been possible only if the injected hESCs migrated to the injury site.
		Validating homing of the stem cells is beyond the scope of this study. The references quoted have given proof that once injected any kind of stem cells have the tendency and capability of homing at the injured site.
18	Authors are requested mention all supple-mental routes in the text of paper.	We have added the supplemental routes as suggested.
19	The ASIA scores of patient 2 and 5 are different here as compared to Table. 1. Please incorporate whichever is the correct one.	Correction made
20	The reply is not related to que-ry(Comment-Their data has only been pre-sented at the House of Lords which has not commented on its usefulness/validity. Re-sponse- We have recently published two studies on the use of hESC therapy in patients with CP (http://www.ncbi.nlm.nih.gov/pubmed/25496119 and CVI (Accepted in Cell Sciences and Therapy, not yet published). Other papers have been submitted and are under review.	Please note that House of Lords does not accept evidences from one and all.
		Nutech Mediworld was invited by House of Lords to present evidence on hESC therapy. They publish the evidences only after screening them. We were the single entry from India to be accepted as written evidence.
		They found the data beneficial to the patients and interesting and published it.
21	12 These are not regulatory.(Comment - What were the necessary regulatory permissions obtained for the 72 patients’ pilot study? Response- The approval for the pilot study on 72 patients was taken from the independent ethics committee of the institute Comment -What were the necessary regulatory permissions obtained for the 5 patients in this study? Response- The approval for this study was taken from independent ethics committee	At the time when this therapy was started, the only guidelines available were Guidelines on Biomedical Research on Human participants (2000 version). We complied fully to these guidelines. The first National guidelines on stem cells were framed in the year 2005 and evolved yearly after that. Nutech Mediworld also adapted itself to the evolving guidelines in principle. As such, there is no law for regulatory oversight.
22	Author have mentioned that they have followed the 2012 ICMR guidelines. However reviewer interpretation is just the converse. There was no oversight/monitoring/regulatory mechanism in place which is entirely different from an Institutional Ethics Clearance.	As mentioned previously, ICMR and DBT were fully informed about the cases taken up and their progress or detailed after therapy report was also sent to time on a regular basis.