Neurologic Stem Cell Surgery 3030724190, 9783030724191

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Neurologic Stem Cell Surgery
 3030724190, 9783030724191

Table of contents :
Contents
Introduction
1: ClinicalTrials.gov Listings
Neurologic Bone Marrow Derived Stem Cell Treatment Study (NEST)
Introduction
Objectives
Methods/Design
Type of Research
Neurologic Treatment Arms
Randomization
Withdrawal
Anesthesia
BMSC Collection and Preparation
Post-procedure Neurologic Exams
Trial Status
Initial Results
Discussion
References
Informed Consent and Permission
Neurologic Bone Marrow Derived Stem Cell Treatment Study
NEST Study
Introduction
Background
Terms of the Study
Reproductive Information for Females
Benefits/Outcomes of Treatment
Description of Procedure
Follow-up Exams
Alternative Treatments
Medical Treatments and Costs
Treatment Location
Acceptance of Risks
Medical Clearance
Anesthesia
Treatment Procedure
Preoperative Neurologic Exam
Treatment Location
Treatment Procedure
Possible Side Effects/Complications
Post-procedure Neurologic Exams
Collection and Use of Data
Confidentiality of Records
Available Information
Termination
Participant Statement and Authorization
Protocol Title
Stem Cell Spinal Cord Injury Exoskeleton and Virtual Reality Treatment Study
Working Title
SCiExVR Study
Principal Investigator
Sub-Investigators
Study Director
Primary Site
Supplemental Sites
Introduction
Type of Research
Purpose and Objective of the Study
Background of the Study
Background of the Neurologic Stem Cell Treatment Study (NEXT or NEST)
Participant Selection
Inclusions
Restrictions
Study Design/Method/Procedures
Summary of Research Design
Preoperative Neurologic Exam
Treatment Location
Randomization
Treatment Procedure
Anesthesia
BMSC Collection and Preparation
Neurologic Treatment
Performance of Injections of Adult Stem Cell Material
Possible Side Effects/Complications
General
Bone Marrow Aspiration
Spinal Cord Treatment
Post-procedure Neurologic Exams
Collection and Use of Data
Analysis of Study Results
Monitoring
Storage of Data
Confidentiality of Data
Risk/Benefit Assessment
Risks
General
Bone Marrow Aspiration
Neurologic Treatment
Prevention of Risks
Adverse Events
Serious Adverse Event
Unanticipated Adverse Event
Anticipated Adverse Event
Benefits
Participant Recruitment and Informed Consent
Recruitment
Length of Study
Informed Consent/Assent
BMSC References
Arm 3. Exoskeleton
Background
Phoenix Device Description (For Example)
Device Usage
Anticipated Risk/Benefits
Subject Conditions
Inclusion Criteria
Exclusion Criteria
Study Protocol Arm 3
References
Literature References
Virtual Reality
ASIA Scoring Diagram
Informed Consent and Permission
Stem Cell Spinal Cord Injury Exoskeleton and Virtual Reality
Treatment Study
SCiExVR Treatment Study
Introduction
Background
Terms of the Study
Reproductive Information for Females
Benefits/Outcome of Treatment
Description of Procedures
Follow-up Exams
Alternative Treatments
Medical Treatments and Costs
Treatment Location
Acceptance of Risks
Medical Clearance
Anesthesia
Treatment Procedure
Preoperative Neurologic Exam
Treatment Location
Treatment Procedure
Possible Side Effects/Complications
Post-procedure Neurologic Exams
Collection and Use of Data
Confidentiality of Records
Available Information
Termination
Participant Statement and Authorization
Protocol Title
Alzheimer’s and Cognitive Impairment Stem Cell Treatment Study
ACIST Study
Principal Investigator
Sub-Investigators
Study Director
Primary Site
Supplemental Site
Introduction
Type of Research
Purpose and Objective of the Study
Background of the Study
Participant Selection
Inclusions
Restrictions
Study Design/Method/Procedures
Summary of Research Design
Preoperative Neurologic Exam
Treatment Location
Treatment Procedure
Anesthesia
BMSC Collection and Preparation
Neurologic Treatment
Performance of Injections of Adult Stem Cell Material
Possible Side Effects/Complications
General
Bone Marrow Aspiration
Neurologic Treatment
Post-procedure Neurologic Exams
Collection and Use of Data
Analysis of Study Results
Monitoring
Storage of Data
Confidentiality of Data
Risk/Benefit Assessment
Risks
General
Bone Marrow Aspiration
Neurologic Treatment
Prevention of Risks
Adverse Events
Serious Adverse Event
Unanticipated Adverse Event
Anticipated Adverse Event
Benefits
Participant Recruitment and Informed Consent
Recruitment
Length of Study
Informed Consent/Assent
References
Publications
Near Infrared Light / WARP 10 Application
Informed Consent and Permission
Alzheimer’s Autism and Cognitive Impairment Stem Cell Treatment Study
Introduction
ACIST Study
Cost
Background
Terms of the Study
Reproductive Information for Females
Benefits/Outcome of Treatment
Description of Procedure
Pre-op and Follow-up Neurologic Exams
Alternative Treatments
Medical Treatments and Costs
Treatment Location
Acceptance of Risks
Medical Clearance
Anesthesia
Treatment Procedure
Preoperative Neurologic Exam
Treatment Location
Treatment Procedure: 1. Anesthesia
BMSC Collection and Preparation
Neurologic Treatment
Possible Side Effects/Complications
General
Bone Marrow Aspiration
Neurologic Treatment
Post-procedure Neurologic Examinations
Collection and Use of Data
Confidentiality of Records
Available Information
Termination
Participant Statement and Authorization
2: Procedure – Additional Patient Explanation
3: Some Thoughts
Quantitative Assessment
Bone Marrow Aspirate Separation
Bibliography
4: Other Treatment Modalities
Light
Questions
PBM for Acute Stroke
NEST-1
NEST-2
NEST-3
Traumatic Brain Injury (TBI)
Dementia
Transcranial Magnetic Stimulation (TMS)
Problems
Repetitive TMS (rTMS)
Transcranial Direct Current Stimulation (tDCS)
Transcranial Doppler Sonography (TCD)
Hyperbaric Oxygen [22–26]
Neurofeedback [27]
Virtual Reality [28, 29]
External Stimulation [34]
References
Index

Citation preview

Neurologic Stem Cell Surgery Jeffrey N. Weiss

123

Neurologic Stem Cell Surgery

Jeffrey N. Weiss

Neurologic Stem Cell Surgery

Jeffrey N. Weiss Parkland, FL USA

ISBN 978-3-030-72422-1    ISBN 978-3-030-72420-7 (eBook) https://doi.org/10.1007/978-3-030-72420-7 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

To the patients that have allowed me the privilege to serve.

Contents

1 ClinicalTrials.gov Listings������������������������������������������������������������������������   1 Neurologic Bone Marrow Derived Stem Cell Treatment Study (NEST)��    1 Introduction��������������������������������������������������������������������������������������������    1 Objectives����������������������������������������������������������������������������������������������    2 Methods/Design ������������������������������������������������������������������������������������    3 Trial Status ��������������������������������������������������������������������������������������������    6 Initial Results ����������������������������������������������������������������������������������������    6 Discussion����������������������������������������������������������������������������������������������    6 References����������������������������������������������������������������������������������������������    8 Informed Consent and Permission ������������������������������������������������������������    9 Neurologic Bone Marrow Derived Stem Cell Treatment Study������������    9 Introduction������������������������������������������������������������������������������������������������    9 Background������������������������������������������������������������������������������������������������    9 Terms of the Study ������������������������������������������������������������������������������������   10 Reproductive Information for Females��������������������������������������������������   10 Benefits/Outcomes of Treatment���������������������������������������������������������������   10 Description of Procedure ��������������������������������������������������������������������������   11 Follow-up Exams ��������������������������������������������������������������������������������������   11 Alternative Treatments������������������������������������������������������������������������������   11 Medical Treatments and Costs ������������������������������������������������������������������   12 Treatment Location��������������������������������������������������������������������������������   12 Acceptance of Risks������������������������������������������������������������������������������   12 Medical Clearance ��������������������������������������������������������������������������������   13 Anesthesia����������������������������������������������������������������������������������������������   13 Treatment Procedure������������������������������������������������������������������������������   13 Collection and Use of Data��������������������������������������������������������������������   16 Confidentiality of Records ��������������������������������������������������������������������   16 Available Information��������������������������������������������������������������������������������   16 Termination������������������������������������������������������������������������������������������������   17 Participant Statement and Authorization ��������������������������������������������������   17 Protocol Title����������������������������������������������������������������������������������������������   18 Stem Cell Spinal Cord Injury Exoskeleton and Virtual Reality Treatment Study������������������������������������������������������������������������������������   18

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Contents

Purpose and Objective of the Study����������������������������������������������������������   20 Background of the Study ��������������������������������������������������������������������������   20 Background of the Neurologic Stem Cell Treatment Study (NEXT or NEST)����������������������������������������������������������������������������������   22 Participant Selection����������������������������������������������������������������������������������   22 Inclusions ����������������������������������������������������������������������������������������������   22 Restrictions��������������������������������������������������������������������������������������������   23 Study Design/Method/Procedures ������������������������������������������������������������   24 Summary of Research Design����������������������������������������������������������������   24 Treatment Procedure������������������������������������������������������������������������������   25 Possible Side Effects/Complications ����������������������������������������������������   27 Post-procedure Neurologic Exams��������������������������������������������������������   29 Collection and Use of Data��������������������������������������������������������������������   29 Analysis of Study Results��������������������������������������������������������������������������   29 Monitoring ��������������������������������������������������������������������������������������������   30 Storage of Data��������������������������������������������������������������������������������������   30 Confidentiality of Data��������������������������������������������������������������������������   30 Risk/Benefit Assessment����������������������������������������������������������������������������   30 Risks������������������������������������������������������������������������������������������������������   30 Prevention of Risks��������������������������������������������������������������������������������   31 Adverse Events��������������������������������������������������������������������������������������   32 Benefits��������������������������������������������������������������������������������������������������   33 Participant Recruitment and Informed Consent����������������������������������������   33 Recruitment��������������������������������������������������������������������������������������������   33 Length of Study��������������������������������������������������������������������������������������   33 Informed Consent/Assent����������������������������������������������������������������������   33 BMSC References����������������������������������������������������������������������������������   34 Arm 3. Exoskeleton ������������������������������������������������������������������������������   35 Study Protocol Arm 3��������������������������������������������������������������������������������   39 References����������������������������������������������������������������������������������������������   39 Literature References ����������������������������������������������������������������������������   40 Virtual Reality����������������������������������������������������������������������������������������   40 ASIA Scoring Diagram��������������������������������������������������������������������������   41 Informed Consent and Permission ������������������������������������������������������������   42 Stem Cell Spinal Cord Injury Exoskeleton and Virtual Reality������������   42 Introduction������������������������������������������������������������������������������������������������   42 Background������������������������������������������������������������������������������������������������   42 Terms of the Study ������������������������������������������������������������������������������������   43 Reproductive Information for Females��������������������������������������������������   43 Benefits/Outcome of Treatment ����������������������������������������������������������������   43 Description of Procedures��������������������������������������������������������������������������   44 Follow-up Exams ��������������������������������������������������������������������������������������   44 Alternative Treatments������������������������������������������������������������������������������   45 Medical Treatments and Costs ������������������������������������������������������������������   45 Treatment Location��������������������������������������������������������������������������������   45 Acceptance of Risks������������������������������������������������������������������������������   45

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Medical Clearance ��������������������������������������������������������������������������������   46 Anesthesia����������������������������������������������������������������������������������������������   46 Treatment Procedure������������������������������������������������������������������������������   46 Treatment Location��������������������������������������������������������������������������������   46 Collection and Use of Data��������������������������������������������������������������������   49 Confidentiality of Records ��������������������������������������������������������������������   49 Available Information��������������������������������������������������������������������������������   50 Termination������������������������������������������������������������������������������������������������   50 Participant Statement and Authorization ��������������������������������������������������   50 Protocol Title����������������������������������������������������������������������������������������������   51 Alzheimer’s and Cognitive Impairment Stem Cell Treatment Study������������������������������������������������������������������������������������   51 Introduction������������������������������������������������������������������������������������������������   52 Type of Research������������������������������������������������������������������������������������   52 Purpose and Objective of the Study������������������������������������������������������   53 Background of the Study ����������������������������������������������������������������������   53 Participant Selection������������������������������������������������������������������������������   55 Study Design/Method/Procedures ������������������������������������������������������������   57 Summary of Research Design����������������������������������������������������������������   57 Treatment Procedure������������������������������������������������������������������������������   58 Possible Side Effects/Complications ����������������������������������������������������   60 Post-procedure Neurologic Exams��������������������������������������������������������   61 Collection and Use of Data��������������������������������������������������������������������   62 Analysis of Study Results��������������������������������������������������������������������������   62 Monitoring ��������������������������������������������������������������������������������������������   62 Storage of Data��������������������������������������������������������������������������������������   62 Confidentiality of Data��������������������������������������������������������������������������   63 Risk/Benefit Assessment����������������������������������������������������������������������������   63 Risks������������������������������������������������������������������������������������������������������   63 Prevention of Risks��������������������������������������������������������������������������������   64 Adverse Events��������������������������������������������������������������������������������������   64 Benefits��������������������������������������������������������������������������������������������������   65 Participant Recruitment and Informed Consent����������������������������������������   65 Recruitment��������������������������������������������������������������������������������������������   65 Length of Study��������������������������������������������������������������������������������������   66 Informed Consent/Assent����������������������������������������������������������������������   66 References����������������������������������������������������������������������������������������������   66 Publications������������������������������������������������������������������������������������������������   67 Near Infrared Light / WARP 10 Application ����������������������������������������   68 Informed Consent and Permission ������������������������������������������������������������   89 Alzheimer’s Autism and Cognitive Impairment Stem Cell Treatment Study��������������������������������������������������������������������   89 Cost������������������������������������������������������������������������������������������������������������   90 Background������������������������������������������������������������������������������������������������   90 Terms of the Study ������������������������������������������������������������������������������������   90 Reproductive Information for Females��������������������������������������������������   91

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Benefits/Outcome of Treatment ����������������������������������������������������������������   91 Description of Procedure ��������������������������������������������������������������������������   91 Pre-op and Follow-up Neurologic Exams��������������������������������������������������   92 Alternative Treatments������������������������������������������������������������������������������   92 Medical Treatments and Costs ������������������������������������������������������������������   93 Treatment Location��������������������������������������������������������������������������������   93 Acceptance of Risks������������������������������������������������������������������������������   93 Medical Clearance ��������������������������������������������������������������������������������   93 Anesthesia����������������������������������������������������������������������������������������������   94 Treatment Procedure������������������������������������������������������������������������������   94 Treatment Location��������������������������������������������������������������������������������   94 BMSC Collection and Preparation��������������������������������������������������������   94 Neurologic Treatment����������������������������������������������������������������������������   95 Collection and Use of Data��������������������������������������������������������������������   97 Confidentiality of Records ��������������������������������������������������������������������   97 Available Information��������������������������������������������������������������������������������   97 Termination������������������������������������������������������������������������������������������������   98 Participant Statement and Authorization ��������������������������������������������������   98 2 Procedure – Additional Patient Explanation������������������������������������������  99 3 Some Thoughts ������������������������������������������������������������������������������������������ 101 Quantitative Assessment����������������������������������������������������������������������������  101 Bone Marrow Aspirate Separation������������������������������������������������������������  102 Bibliography����������������������������������������������������������������������������������������������  104 4 Other Treatment Modalities���������������������������������������������������������������������� 105 Light����������������������������������������������������������������������������������������������������������  105 Questions������������������������������������������������������������������������������������������������  105 PBM for Acute Stroke����������������������������������������������������������������������������  106 NEST-1��������������������������������������������������������������������������������������������������  106 NEST-2��������������������������������������������������������������������������������������������������  106 NEST-3��������������������������������������������������������������������������������������������������  106 Traumatic Brain Injury (TBI)����������������������������������������������������������������  107 Dementia������������������������������������������������������������������������������������������������  109 Transcranial Magnetic Stimulation (TMS)������������������������������������������������  109 Problems������������������������������������������������������������������������������������������������  109 Repetitive TMS (rTMS)������������������������������������������������������������������������  109 Transcranial Direct Current Stimulation (tDCS) ��������������������������������������  110 Transcranial Doppler Sonography (TCD)��������������������������������������������������  111 Hyperbaric Oxygen������������������������������������������������������������������������������������  111 Neurofeedback ������������������������������������������������������������������������������������������  112 Virtual Reality��������������������������������������������������������������������������������������������  112 External Stimulation����������������������������������������������������������������������������������  113 References��������������������������������������������������������������������������������������������������  113 Index�������������������������������������������������������������������������������������������������������������������� 117

Introduction

This is a different type of book. Most books discuss current and proven therapies. Unfortunately, other than medications and rehabilitation therapies, there have been little new “proven” therapies to significantly improve the condition of patients with brain diseases and injuries. As Albert Einstein said, “If you want different results, do not do the same things.” In the old movies, when someone fell onto the floor, they were pronounced “dead.” Now, patients can be resuscitated. Death is continuously being pushed back. A recent animal study demonstrated that supposedly “dead” cells could be reactivated. When I was a medical student, hepatitis C was eventually fatal. Now it can be cured in 98% of the cases. This will one day be the case for brain diseases and injuries. I began performing retinal and optic nerve stem cell surgery in 2010 and noted that patients with concomitant neurologic problems, such as cerebrovascular accident (CVA), traumatic brain injury (TBI), and chronic multiple sclerosis (MS), also experienced improvements in their neurologic conditions. This led to the development of the NEST (Neurologic Bone Marrow Derived Stem Cell Treatment Study) protocol in 2016 followed by the SCiExVr (Stem Cell Spinal Cord Injury Exoskeleton and Virtual Reality Treatment Study) protocol in 2018, and the ACIST (Alzheimer’s and Cognitive Impairment Stem Cell Treatment Study) protocol in 2019. All three protocols are IRB approved and listed on www.clinicaltrials.gov. These and other neurologic protocols will be discussed in this book. Brain damage implies a permanent condition. Brain injury offers the promise of treatment. The “one day” begins with the first step. I will also discuss new “potential” noninvasive treatments for brain injury. Some of these may work, some will not, but the “thinking outside the box” will persist. As Sir William Osler once said to his medical students, “Half of what we have taught you is in error, and furthermore we cannot tell you which half it is.” Parkland, FL, USA 2020

Jeffrey N. Weiss, MD

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ClinicalTrials.gov Listings

 eurologic Bone Marrow Derived Stem Cell Treatment N Study (NEST) Introduction A significant number of the approximately 600 known neurologic diseases have no or limited medical interventions; many treatments are temporizing or only marginally effective and have changed little over decades. To help address the persistent chasm between need and effectiveness, there has been a widening of approaches under preclinical and clinical investigation. In the course of treating optic neuropathies in the Stem Cell Ophthalmology Treatment Study (SCOTS), we have noted collateral improvements in neurologic impairments in certain patients. We have begun the Neurologic Stem Cell Treatment study (NEST) to determine if specific intervention with autologous BMSC can provide effective treatment for certain neurologic diseases and injuries. Intravenous administration of BMSC is a well-established approach to neurologic disease and injury with much support for its effectiveness in the pre-clinical and clinical literature. BMSC and the associated bone marrow fraction are posited to have a number of different mechanisms by which they improve neurologic function. In regards their ability to penetrate the blood-brain barrier following intravenous administration: within the diencephalon, there are specific circumventricular organs that lie in the wall of the third ventricle and are characterized by their high permeability, fenestrated capillaries, and absence of a normal blood–brain barrier (BBB). The lack of a BBB facilitates their function of coordinating homeostatic mechanisms of the endocrine and nervous systems. This absence of a normal BBB Trial Registration: ClinicalTrials.gov; Identifier NCT02795052; Registered: June 6, 2016. Ethics: This study protocol was Institutional Review Board (IRB) approved and will be performed in accordance with standard international research accords. Informed Consent: Signed informed consent will be obtained from the patients or their guardians. © The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 J. N. Weiss, Neurologic Stem Cell Surgery, https://doi.org/10.1007/978-3-030-72420-7_1

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appears to allow for direct entry of the BMSC and associated neurotrophic growth factors into the brain parenchyma, potentially impacting the neurons, glial tissues, and neuronal transdifferentiation of the BMSC. In addition to the use of intravenous BMSC, the study will provide a treatment arm using the application of BMSC to the cribriform plate in the upper nasal passages as a means of introducing BMSC to the central nervous system (CNS). The cribriform plate is an area of the ethmoid bone at the superior portion of the nasal cavity where the primary olfactory nerves enter the CNS (see Fig. 1.1). Within the cribriform plate, there are approximately 40 tiny openings through which the axons of the primary olfactory sensory neurons pass into the CNS and synapse with the secondary neurons that form the olfactory bulb continuing as the olfactory nerve (see Fig. 1.2). These small boney passages within the cribriform plate may allow BMSC to traverse and enter the CNS. The trigeminal nerve provides sensory input from the nasal cavity and has been shown to provide a separate pathway into the pons and brain parenchyma for various substances provided intranasally.

Objectives The purpose of the study is to evaluate the use of autologous bone marrow derived stem cells for neurologic tissue disease and damage. We hope to support their value in improving neurologic function and activities of daily living for different neurologic diseases or injury including, but not limited to, cerebral vascular accident

Cribriforms Plate

Olfactory Bulb

Fibers of the Olfactory Nerves

Fig. 1.1  First-order sensory olfactory neurons enter the central nervous system from the nasal cavity through the cribriform plate located at the superior aspect of the nasal cavity. They synapse in the olfactory bulb forming the first cranial nerve. Associated with these sensory neurons are basal cells that are local stem cells capable of transdifferentiation into these sensory neurons

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Perpendicular plate Ala

Crista galli

Cribriform plate Anterior ethmoidal groove

Posterior ethmoidal groove

Fig. 1.2  Cribriform plate

(CVA or stroke), traumatic brain injury (TBI), multiple sclerosis (MS), Parkinson’s disease (PD), and diabetic neuropathy. The objective is to document the neurologic deficits caused by various central and peripheral nervous system diseases and injuries that may be mitigated by the use of BMSC.

Methods/Design Type of Research This is a human clinical study involving the isolation of autologous bone marrow derived stem cells (BMSC) and transfer to the vascular system or cribriform plate area in order to determine if such a treatment will provide a statistically significant improvement in neurologic function for patients with certain neurologic conditions. BMSC are predominantly mesenchymal stem cells, cluster differentiation (CD) 34. In this study, we will be providing a transfer of these stem cells with their associated neurotrophic factors from the bone marrow to areas of neurologic tissue disease or damage via the vascular system and cribriform plate. Neurologic Treatment Arms The two arms of the study are as follows:

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• Arm 1. Intravenous – approximately 16 cc of BMSC fraction filtered with a 150 micron filter and administered intravenously • Arm 2. Intravenous and cribriform plate administrated via intranasal placement or inhalation

Randomization NEST is an open-label, non-randomized, efficacy study. There is no sham or placebo arm. Unless medically contraindicated or anticipated that there could be impairment of intranasal delivery, patients will be assigned to Arm 2. Inclusion criteria • Have documented functional damage to the central or peripheral nervous system unlikely to improve with present standard of care. • Be at least 6 months post-onset of the disease. • If under current medical therapy (pharmacologic or surgical treatment) for the condition be considered stable on that treatment and unlikely to have reversal of the associated neurologic functional damage as a result of the ongoing pharmacologic or surgical treatment. • In the estimation of Dr. Weiss and the neurologists have the potential for improvement with BMSC treatment and be at minimal risk of any potential harm from the procedure. • Be over the age of 18 and capable of providing informed consent. • Be medically stable and able to be medically cleared by their primary care physician for the procedure. Medical clearance means that in the estimation of the primary care practitioner, the patient can reasonably be expected to undergo the procedure without significant medical risk to health. Restrictions • All patients must be capable of an adequate neurologic examination and evaluation to document the pathology. This will include the ability to cooperate with the exam. • Patients must be capable and willing to undergo follow-up neurologic exams with the sub-investigators or their own neurologists as outlined in the protocol. • Patients must be capable of providing informed consent. • In the estimation of Dr. Weiss, the BMSC collection and treatment will not present a significant risk of harm to the patient’s general health or to their neurologic function. • Patients who are not medically stable or who may be at significant risk to their health undergoing the procedure will not be eligible. • Women of childbearing age must not be pregnant at the time of treatment and should refrain from becoming pregnant for 3 months post-treatment. • There are no gender, racial/ethnic, or upper age restrictions. Vulnerable populations are not eligible.

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Withdrawal Patients may withdraw from the NEST study at any time without consequence. Medical records within NEST will be available upon request to the patient or required agencies. Anesthesia Anesthesia will be provided by the anesthesia physicians and staff at the Park Creek Surgery Center in accord with good medical judgment and regulations of the surgery center and the State of Florida. Typically, the patients have general anesthesia for the bone marrow aspiration. Risk of mortality from general anesthesia is estimated to be 8.2 per million hospital surgical discharges in the United States from 1999 to 2005 according to Li et al. [1] and 8.8 per 10,000 in the 24-hour perioperative period from 1995 to 1997 according to Arbous et al. [2] In a large meta-analysis by Bainbridge et al., 87 studies involving 21.4 million general anesthesia administrations showed a significant decline in associated deaths over the last 50  years; most recently risk of mortality was 34 per million in the 1990s to 2000s [3]. We believe that there is sufficient evidence to support the safety of general anesthesia as will be provided in the NEST study.  MSC Collection and Preparation B Approximately 180 cc of bone marrow aspirate will be collected in the operating room, the exact volume being based on medical judgment. The bone marrow aspirate is collected from one or both of the patient’s iliac bones in the pelvis and may involve one, two, or more separate sites. The bone marrow aspirate will not leave the operating room. For separation and collection of the mononuclear cell layer including the stem cells and additional components, an FDA-cleared Class 2 medical device will be used. The collected bone marrow aspirate will be placed in the device that will separate the components of the bone marrow and isolate the portion containing the adult stem cells. This is done in a completely sterile, automated and self-contained fashion with minimal manipulation. Approximately 16 cc of mononuclear cell material containing the adult stem cells (adult stem cell material) will be available for injection.  ost-procedure Neurologic Exams P The follow-up neurologic exams will be obtained the day after the procedure and are then requested at 1 month, 3 months, 6 months, and 12 months following the procedure or at the recommended intervals of the neurologist examining the patient. We will provide a follow-up schedule and will contact the patients postoperatively to remind them to comply with the follow-up examinations. Intent to Treat (ITT) criteria will be used in the event of incomplete data collection. The study director and the principal investigator will be responsible for collecting required data and coordinating retention. Patients agree to allow Dr. Weiss and his associates to release any medical information to their neurologists and medical doctors. They also agree to provide access to their exams from their neurologist and medical doctor to Dr. Weiss and his associates. Scales for scoring patient outcomes may include the following:

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• UPDRS scale pre and post for Parkinson’s disease • EDSS pre and post for multiple sclerosis • Neuropsychiatric evaluation pre and post for traumatic brain injury

Trial Status Recruiting

Initial Results Early participants in NEST include a patient with Parkinson’s disease for 6 years, maintained on carbidopa, levodopa, and entacapone. Within one month of NEST treatment, patient reported the following: ability to smell has improved, balance is improving, facial muscles working better  – losing mask appearance, fine muscle control is improving, posture has improved, gate and speed of walking improving, less swallowing/aspiration problems, less incontinence problems, voice level is improving, lessening of disconnects during discussions, improving memory, reduced fatigue issues and less depressed, and an improvement in sleep.

Discussion The treatment with BMSC is a tissue transfer of mesenchymal stem cells and the growth factors in the associated bone marrow fraction (BMF or liquid containing the BMSC) from the bone marrow to the tissues surrounding or within the nervous system for the purpose of improving function of that tissue. Bosi and Bartolozzi reviewed donation of hematopoietic stem cells and concluded it to be a safe procedure [4]. Diminished neurologic function can occur as a result of progressive damage to the nervous system from disease or injury. The exact disease or injury process causing the damage may vary, but the end result may be damage to neurons in the central or peripheral nervous tissue and/or to the glial cells which support the neurons and their function. Our treatment protocol relates to transferring cells from one part of the body (bone marrow) in a way that will maximize the damaged tissue’s access to those cells in a safe and reasonable fashion. There are many diseases and injuries that cause progressive damage to these tissues – our goal is treatment of the damaged tissue rather than a specific disease. The safety of BMSC has been well established. Wakitani et  al. followed 41 patients following use of BMSC for joint treatment for up to 11 years and 5 months. They found no tumors or infections and concluded autologous BMSC transplantation to be a safe procedure [5]. In a meta-analysis of BMSC used to treat acute myocardial infarction, Cong et al. found an overall significant improvement in left

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ventricular ejection fraction (LVEF) and other cardiac measurements at 3–6 months and 12  months following BMSC and concluded that intracoronary BMSC post ST-elevation myocardial infarction (STEMI) was safe and effective [6]. In a recent meta-analysis of 23 randomized controlled studies of BMSC therapy for chronic ischemic heart disease (IHD) and congestive heart failure (CHF) involving 255 patients, Fisher et al. found moderate evidence that BMSC improves LVEF even in the long term (greater than 1 year) in patients suffering from chronic IHD and CHF [7]. In a study by Nishida et al. involving dogs with acute spinal cord injury (SCI), autologous BMSC were cultured and injected into a spinal cord lesion. Follow-up from 29 to 62 months following treatment showed no complications or worsening of neurologic function [8]. We conclude that the safety of providing BMSC intravenously in NEST is well supported in the literature. Cribriform plate administration may be provided by direct application of the BMSC material or through intranasal inhalation done with a nebulizer and inhalation into the nose alone. The complications of intranasally administered nebulized material are limited to potential local irritation, rhinorrhea, and to the side effects of inhaled BMSC.  We have identified no unique side effects of BMSC material provided intranasally. If directly placed intranasally, the BMSC material will allow movement to the cribriform plate at the superior nasal cavity. Chapman et al. reviewed intranasal treatment of central nervous system (CNS) dysfunction in humans. They identified both olfactory and trigeminal pathways of BMSC entry allowing both anterior and posterior regions of the brain exposure. The authors remark on the efficacy and noninvasiveness of intranasal delivery of BMSC. Several studies of preclinical application and improvements in models of stroke, cerebral hypoxia, and Parkinson’s disease were discussed. They conclude that intranasal delivery is clinically safe and effective [9]. In a review of intranasal delivery of stem cells to the brain, Jiang et al. indicate that the approach overcomes the difficulties of other methods of delivery for the treatment of many neurologic disorders [10]. A number of recent preclinical studies utilizing BMSC as well as other types of stem cells in various neurologic diseases (stroke, ischemia, Alzheimer’s disease, spinal cord lesions, intracerebral hemorrhage) may be cited in support of the effect of stem cells delivered via the intranasal route as suggested by Zhao et al., Ji et al., Mita et al., and Ninomizy et al. [11–14]. Danielyan et  al. have elegantly demonstrated the direct intranasal delivery of mesenchymal stem cells to the murine brain and identified two prime migratory pathways that allow the cells to enter via the olfactory bulb to various portions of the brain and separately into the cerebral spinal fluid with movement across the cortex and into the brain parenchyma [15]. We conclude that intranasal delivery of BMSC is safe and efficacious and provides the BMSC the ability to cross the blood-brain barrier successfully in a noninvasive fashion. Physicians and the healthcare industry typically require multiple studies and continuing efforts to explore the value of procedures before broad adoption. We conclude that intravenous and intranasal administration of BMSC is safe and their combination may allow for improved responses. It is the goal of the Neurologic

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Stem Cell Treatment (NEST) study to provide treatment of identified neurologic conditions within an IRB-approved protocol to allow for publishing of further clinical results.

References 1.  Li G, Warner M, Lang BH, et al. Epidemiology of anesthesia-related mortality in the United State, 1999–2005. Anesthesiology. 2009;110(4):759–65. 2.  Arbout MS, Grobbee DE, van Kleef JW, et al. Mortality associated with anaesthesia: a qualitative analysis to identify risk factors. Anaesthesia. 2001;56(12):1141–53. 3.  Bainbridge D, Martin J, Arango M, Cheng D. Perioperative and anaesthetic-­ related mortality in developed and developing countries: a systematic review and meta-analysis. The Lancet. 2012;380(9847):1075–81. 4.  Bosi A, Bartolozzi B.  Safety of bone marrow stem cell donation: a review. Transplant Proc. 2010;42(6):2192–4. 5.  Wekitani S, Okabe T, Horibe S, et al. Safety of autologous bone marrow-derived mesenchymal stem cell transplantation for cartilage repair in 41 patients with 45 joints followed for up to 11 years and 5 months. J Tissue Eng Regen Med. 2011;5(2):146–50. 6.  Cong XQ, Li Y, Zhao X, et al. Short-term effect of autologous bone marrow stem cells to treat acute myocardial infarction: a meta-analysis of randomized controlled clinical trials. J Cardiovasc Transl Res. 2015;8(4):221–31. 7.  Fisher SA, Brunskill SJ, Doree C, et al. Stem cell therapy for chronic ischaemic heart disease and congestive heart failure. Cochrane Database Syst Rev. 2014;(4):CD007888. 8.  Nishida H, Nakayama M, Tanaka H, et al. Safety of autologous bone marrow stromal cell transplantation in dogs with acute spinal cord injury. Vet Surg. 2012;41(4):437–42. 9.  Chapman CD, Frey WH, Craft S, et al. Intranasal treatment of central nervous system dysfunction in humans. Pharm Res. 2013;30(10):2475–84. 10. Jiang Y, Shu J, Xu G, Liu X.  Intranasal delivery of stem cells to the brain. Expert Opin Drug Deliv. 2011;8(5):623–32. 11. Zhao Q, Hu J, Xiang J, et al. Intranasal administration of human umbilical cord mesenchymal stem cells-conditioned medium enhances vascular remodeling after stroke. Brain Res. 2015;1624:489–96. 12. Ji G, Liu M, Zhao XF, et al. NF-κB signaling is involved in the effects of intranasally engrafted human neural stem cells on neurofunctional improvements in neonatal rat hypoxic-ischemic encephalopathy. CNS Neurosci Ther. 2015;21(12):926–35. 13. Mita T, Furukawa-Hibi Y, Takeuchi H, et  al. Conditioned medium from the stem cells of human dental pulp improves cognitive function in a mouse model of Alzheimer’s disease. Behav Brain Res. 2015;293:189–97.

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14. Ninomizy K, Iwatsuki K, Ohnishi Y, et al. Intranasal delivery of bone marrow stromal cells to spinal cord lesions. J Neurosurg Spine. 2015;23(1):111–9. 15. Danielyan L, Schafer R, von Ameln-Mayerhofer A, et al. Intranasal delivery of cells to the brain. Eur J Cell Biol. 2009;88:315–24.

Informed Consent and Permission Neurologic Bone Marrow Derived Stem Cell Treatment Study NEST Study Jeffrey N. Weiss, MD The Healing Institute 1308 A/B North State Road 7 Margate, Florida 33063 Telephone 954-975-0044

Introduction To decide whether or not you want to have the Neurologic Bone Marrow Derived Stem Cell Treatment Study (called “the procedure” in this document) – also known as an Adult Stem Cell Treatment, the risks and possible benefits are described in this form so that you can make an informed decision. This process is known as informed consent. This consent form describes the purpose, procedures, possible benefits, and risks of the procedure. You may have a copy of this form to review at your leisure or to ask advice from others. Dr. Weiss and his associates will answer any questions you may have about this form or about the procedure. Please read this document carefully and do not hesitate to ask anything about this information. This form may contain words that you do not understand. Please ask Dr. Weiss or his associates to explain the words or information that you do not understand. After reading (or having it read to you) the consent form, if you would like to be treated, you will be asked to sign this form.

Background Bone marrow derived stem cells (BMSC) are adult stem cells that come from a patient’s own bone marrow. There is evidence that patients with certain eye diseases have improved visual function following treatment with BMSC. The exact mechanisms by which adult stem cells can provide improvement are complex and still undergoing assessment in the medical and scientific community. Adult stem cell treatments have been performed and continue to be performed in various parts of the world including the United States for a number of medical conditions. It is unknown whether this treatment will be of benefit in your particular disease or condition.

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Terms of the Study Dr. Weiss will determine if you and your condition are eligible for inclusion in the study. If you have been approved for inclusion in the study, you are being asked to participate in a clinical research study to determine if the use of bone marrow derived stem cell (BMSC) can benefit damaged nerve tissue and improve neurologic function for patients. While there have been many patients worldwide treated with BMSC in various ways including treatment of neurologic disease, sufficient proof, such as may be demonstrated with scientific studies, has not been developed to convince the majority of physicians that the procedure is of benefit. The purpose of this study is to determine if improvement in neurologic function – movement, sensation, steadiness, balance, speech, etc.– can be obtained by using BMSC treatment. The type of treatment used will be determined by Dr. Weiss after your neurologic examination. The treatment may include intravenous (in the vein) and intranasal (in your nose to treat the cribriform plate at the top of your nose). You understand that participation in this study will be voluntary and the treatment of your illness is not dependent upon you participating in this study. There will be approximately 500 participants enrolled in the study at one site in the United States. It is anticipated you will participate in this research study for one year.

Reproductive Information for Females There is no evidence that treatment with autologous bone marrow derived stem cells has adverse effects on human reproduction or a developing unborn fetus. However, female patients who are pregnant or attempting to become pregnant should not undergo treatment. It is suggested that female patients do not attempt to become pregnant for at least 3 months following treatment. If female, in signing this informed consent, you attest that you believe that you are not pregnant and, if you are of childbearing potential, that you are using an adequate form of birth control and will continue to do so for 3 months following treatment.

Benefits/Outcomes of Treatment The potential benefits of this treatment may include improvement in neurologic function. Neurologic function includes many things that the nervous system does including, but not limited to, movement, sensation, cranial and peripheral nerve function, brain function, speech, balance, etc. However, it is possible that your neurologic function may experience no change or worsen. Any improvement may take several months. At this time, Dr. Weiss cannot make predictions as to the effectiveness of the stem cell treatment for individual patients. In signing this informed consent, you acknowledge that no promise of beneficial results has been made to you, nor have any guarantees been offered, either

Alternative Treatments

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formally or implied, and that treatment with bone marrow derived stem cells will be successful or of benefit.

Description of Procedure In this procedure, the bone marrow derived stem cells (BMSC) will be isolated from your bone marrow and then the stem cell material obtained will be injected intravenously (into the vein of your arm) and possibly within your nose via inhalation or direct application. This procedure is considered invasive and includes removal of bone marrow from the iliac crest (one or both) of your pelvis and injection of the separated stem cells. The removal of bone marrow from a patient’s pelvis is an established medical procedure. However, the use of bone marrow derived stem cells in neurologic disease or damage is not considered to be evidence-based medicine. This means that there is not enough scientific evidence to determine if this procedure is beneficial to the neurologic function of patients.

Follow-up Exams The first follow-up eye exam must be obtained on the day after treatment at the office. You should have follow-up neurologic exams at 1 month, 3 months, 6 months, and 12 months following the procedure with either our neurologist or your own neurologist. The follow-up exams are extremely important to monitor the health of your nervous system and to assess for potential improvement. If you notice any sudden changes or deterioration following the procedure such as pain, swelling, increasing redness in the bone marrow aspiration site, fever, or deteriorating neurologic function, please get in touch with Dr. Weiss or your local physician or neurologist immediately as this could represent a threat to your health. This permission also provides for access to your follow-up neurologic exams to Dr. Weiss and his associates and the ability to discuss your treatment and results freely with your health providers. We strongly request that all follow-up exams be forwarded to Dr. Weiss and his associates. This may require that the patient gives permission to their neurologist to forward their records or may involve the patient obtaining those records and then forwarding it themselves.

Alternative Treatments Some of the neurologic diseases that are offered BMSC treatment may have existing drug or surgical treatments that have scientific evidence or general medical community acceptance for use in maintaining or improving neurologic function. If there are such existing treatments, we advise you to pursue those treatments initially before considering BMSC treatment. If you elect to undergo stem cell treatment, it

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is recommended that you continue all current medical therapies prescribed by your existing physician or neurologist including their recommended follow-up exams until they can examine you and make their own assessment of the need for their therapies or examinations. In signing this informed consent, you assert you are aware of any potential alternative treatments from discussions with your own physicians or neurologists and elect to undergo the stem cell procedure.

Medical Treatments and Costs This procedure is not considered evidence-based by insurance companies. You understand that your participation in this study is at your own expense and will not be reimbursed by any insurance. Should a study-related medical problem or injury occur, appropriate medical care, as determined by your physician or neurologist, may be provided by your physician or neurologist. You understand you will be financially responsible for such medical treatment, although your insurance company may cover any such treatment under your existing policy. You understand that no additional financial compensation will be available for any injury resulting from your participation. This does not constitute a waiver of any rights that you may have under federal or state laws and regulations.

Treatment Location Treatments will be performed at the Park Creek Surgery Center located at 6806 North State Road 7, Coconut Creek, Florida 33073, at which Dr. Weiss is a member of the medical staff. The procedures will be performed in accordance with all surgery center regulations.

Acceptance of Risks The treatment provided is experimental and no guarantees are provided as to the outcome of the procedure. The patient’s neurologic function may become better, stay the same, or worsen. I accept these risks freely and agree to hold harmless Dr. Weiss and Retina Associates of South Florida; Dr. Levy and MD Stem Cells; and the participating neurologist and the personnel who participate in performing the procedure. Initial___________

Medical Treatments and Costs

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Medical Clearance Medical clearance for anesthesia and surgery will be obtained by the patient through their own medical doctor prior to the procedure and provided to Dr. Weiss and the associated physicians and staff of the Park Creek Surgery Center. The medical clearance must give permission for the use of anesthesia and provide such laboratory tests and examination as Dr. Weiss and the additional physicians at Park Creek Surgery Center believe are needed to properly assess your risks and provide proper care for you while you undergo the procedure.

Anesthesia Anesthesia will be provided by the anesthesia physicians and staff at the Park Creek Surgery Center in accord with good medical judgment and regulations of the surgery center and the State of Florida. This includes all types of anesthesia from local injection to general anesthesia. Typically, the patients may have general anesthesia for the bone marrow aspiration, and general anesthesia, sedation, or local anesthesia may be used for the injection of the stem cells.

Treatment Procedure  reoperative Neurologic Exam P The preoperative neurologic exam will be provided by the patients’ neurologist and will be evaluated by the sub-investigators for inclusion criteria. Immediate preoperative exams and informed consent will be performed by Dr. Weiss and/or the sub-­ investigators at their office location. Treatment Location Treatments will be performed at the Park Creek Surgery Center located at 6806 North State Road 7, Coconut Creek, Florida, 33073 at which Dr. Weiss is a member of the medical staff. The procedures will be performed in accordance with all surgery center regulations. Randomization  – no patients are to be randomized. All eligible patients who participate will receive treatment if deemed safe by Dr. Weiss.

Treatment Procedure 1. Anesthesia Anesthesia will be provided by the anesthesia physicians and staff at the Park Creek Surgery Center in accord with good medical judgment and regulations of

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the surgery center and the State of Florida. This includes all types of anesthesia from local injection to general anesthesia. Typically, the patients may have general anesthesia for the bone marrow aspiration, and general anesthesia, sedation, or local anesthesia may be used for the injection of the stem cells. 2. BMSC Collection and Preparation Approximately 120 cc of bone marrow aspirate will be collected in the operating room, the exact volume being based on medical judgment. The bone marrow aspirate is collected from one or both of the patient’s iliac bones in the pelvis and may involve one, two, or more separate sites. The bone marrow aspirate will not leave the operating room. For separation and collection of the mononuclear cell layer including the stem cells and additional components, a medical device called the Angel System manufactured by Arthrex, Inc., or equivalent will be used. The Angel System and its components is a Class 2 device per the FDA guidelines. The collected bone marrow aspirate will be placed in the device that will separate the components of the bone marrow and isolate the portion containing the adult stem cells. This is done in a completely sterile, automated, and self-contained fashion with minimal manipulation. The device will be operated by Dr. Weiss’ assistants under Dr. Weiss’ supervision. Approximately 16 cc of mononuclear cell material containing the adult stem cells (adult stem cell material) will be available for injection. 3. Neurologic Treatment The two arms of the study are as follows: • Arm 1. Intravenous  – approximately 16  cc of BMSC fraction filtered with 150 micron filter and administered intravenously • Arm 2. Intravenous and cribriform plate administrated via intranasal placement or inhalation Based on the patient’s neurologic examinations, diagnosis, and selection of treatment arm, Dr. Weiss will provide the BMSC fraction via intravenous injection alone, or with intravenous injection and intranasal placement or inhalation. Any excess bone marrow material including other cells and plasma will be discarded in accordance with normal surgery center practice. No material will be retained for future use. An intravenous injection is the injection of the bone marrow stem cells (BMSC) into the vein in the patient’s arm. It is standard procedure during anesthesia that the patient will have an intravenous line available for administration of medications and fluids. This same line is used for intravenous injection of the BMSC. There is a risk of a thrombotic event called pulmonary embolism occurring as a result of a clot forming either prior to or during the passage of the cells through the lungs. Because of the anticoagulation and filtering employed in processing the bone marrow aspirate, we believe this risk is very small. In an analysis performed by the European Group for Blood and Marrow Transplantation on HSCT in over 27,000 patients between 1993 and 2005, this risk was calculated to be approximately 0.000037. To reduce this risk, a filter of appropriate size (typically 150 microns) will be used to filter the delivered BMSC.

Medical Treatments and Costs

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4. Performance of injections of adult stem cell material: 1. Intravenous injections may be performed while the patient is recumbent or seated and intranasal while the patient is seated. 2. Anesthesia is given as needed for patient comfort and safety under the direction of the anesthesiologist. 3. The procedure bone marrow aspiration is performed under sterile conditions.

 ossible Side Effects/Complications P 1. General This is a surgical procedure involving the aspiration of bone marrow and injection of the separated bone marrow stem cell intravenously and by direct placement or inhalation intranasally. The procedure will include the administration of medications to provide anesthesia during the procedure. There is always the risk of unanticipated reactions to the procedure itself, the medications, and the anesthesia. Under very rare circumstances, patients may have serious complications as a result of the procedure or medications including serious abnormal drug reactions, serious allergic reactions, very low blood pressure, seizures, cardiac, or respiratory problems including cardiac or pulmonary arrest. These may result in harm to your body or death. 2. Bone Marrow Aspiration Common side effects may include mild local pain, tenderness, and localized bleeding in the area where the doctor aspirates the bone marrow. Very rare complications may include infection or bleeding that is difficult to control. 3. Neurologic Treatment An intravenous injection is the injection of the bone marrow stem cells (BMSC) into the vein in the patient’s arm. It is standard procedure during anesthesia that the patient has an intravenous line available for administration of medications and fluids. This same line is used for intravenous injection of the BMSC. There is a risk of a thrombotic event called pulmonary embolism occurring as a result of a clot forming either prior to or during the passage of the cells through the lungs. Because of the anticoagulation and filtering employed in processing the bone marrow aspirate, we believe this risk is very small. In an analysis performed by the European Group for Blood and Marrow Transplantation on HSCT in over 27,000 patients between 1993 and 2005, this risk was calculated to be approximately 0.000037. To reduce this risk, a filter of appropriate size will be used to filter the delivered BMSC. Cribriform plate administration may be provided by direct application of the BMSC material or through intranasal inhalation done with a nebulizer and inhalation into the nose alone. The complications of intranasally administered nebulized material are limited to potential local irritation, rhinorrhea, and the side effects of inhaled BMSC. We have identified no specific side effect of BMSC material intranasally. If directly placed intranasally, the BMSC material will be placed in the nasal passages to allow movement to the cribriform plate at the superior nasal cavity.

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 ost-procedure Neurologic Exams P The follow-up neurologic exams will be obtained the day after the procedure and are then requested at 1 month, 3 months, 6 months, and 12 months following the procedure or at the recommended intervals of the neurologist examining the patient. Patients agree to allow Dr. Weiss and his associates to release any medical information to their neurologists and medical doctors. They also agree to provide access to their exams from their neurologist and medical doctor to Dr. Weiss and his associates.

Collection and Use of Data Patients give permission to use their medical information for their own care and for any publication, presentation, or public communication about the procedure and results. In the case of non-direct patient care communication, the patient name and contact information will be held in confidence and not released to protect your privacy. However, if required by law, state or federal agencies may be given access to your full name, data, medical records, and information.

Confidentiality of Records You understand that your identity and certain information pertaining to you that are collected for this study will remain confidential. However, in order to meet the obligations of federal law, you understand that records from this study may be subject to review by representatives of the International Cellular Medicine Society Institutional Review Board and authorized Food and Drug Administration or other government regulatory agencies’ personnel. You hereby consent to such review and disclosure.

Available Information You understand that any significant new information developed during the course of this study, which may relate to your willingness to continue as a participant, will be provided to you. If you have any questions or desire further information with respect to this study, or if you experience a study-related injury, you should contact: Jeffrey N. Weiss, MD Principal Investigator 5800 Colonial Drive, Suite 300 Margate, Florida 33063. 1308 A/B North State Road 7 Margate, Florida 33063 Phone: (954) 975-0044

Steven Levy, MD Study Director 3 Sylvan Road South Westport, CT 06880 Phone: (203) 423-9494

Participant Statement and Authorization

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If you wish to contact an impartial third party not associated with this study, you may contact: Reed Davis at 702-664-0017.

Termination You understand that your participation in this study is voluntary and you are under no obligation to participate. Your decision on whether to participate in the study will in no way impact upon the treatment you will receive. You may refuse to participate or may discontinue participation at any time during the study without penalty or loss of benefits to which you are otherwise entitled. If you choose not to participate, or to discontinue your participation in this study, Jeffrey N. Weiss, MD, and his associates will continue to take care of your illness to the best of their ability. In addition, you understand that your participation may be terminated by Jeffrey N. Weiss, MD, and/or your physician without regard to your consent, should he/ she determine that continued participation would be detrimental to you in any way. You understand that at the completion of the study, you may not be able to continue participation.

Participant Statement and Authorization In affixing my signature, I acknowledge that I have read or had read to me this informed consent and permission form, that all my questions have been answered, and that I fully understand the information it contains. I consent to the procedure of bone marrow stem cell treatment for my neurologic disease or damage as performed by Dr. Jeffrey Weiss and his associates. This informed consent and permission (also called an authorization) will have no end date. ____________________________________________ Printed Name of Patient ____________________________________________  _______________ Signature of Patient                  Date _______________________________________________________________ Name of and Relationship of Responsible Party if patient unable to sign ____________________________________________  _______________ Signature of Responsible Party if patient unable to sign     Date ____________________________________________ Printed Name of Person Explaining Consent ____________________________________________  _______________ Signature of Person Explaining Consent          Date

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Protocol Title  tem Cell Spinal Cord Injury Exoskeleton and Virtual Reality S Treatment Study Protocol Number: 1 Date of Protocol: February 12, 2017

Working Title SCiExVR Study Stem Cell (Spinal Cord) Injury Exoskeleton and Virtual Reality Treatment Study Principal Investigator Jeffrey N Weiss MD The Healing Institute 1308 A/B North State Road 7 Margate, FL 33063 Telephone 954-975-0044 Sub-Investigators Steven Silberfarb DO Study Director Steven Levy MD MD Stem Cells 3 Sylvan Road South Westport, CT 06880 Telephone 203-423-9494 Primary Site Dr. Jeffrey Weiss, MD The Healing Institute 1308 A/B North State Road 7 Margate, FL 33063 Telephone 954-975-0044 Supplemental Sites Park Creek Surgery Center 6806 North State Road 7 Coconut Creek, Florida 33073

Protocol Title

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Introduction Type of Research This is a human clinical study involving the isolation of autologous bone marrow derived stem cells (BMSC) and transfer to the vascular system, intranasal mucosa, and paraspinal region with or without post-injection treatment with exoskeletal stimulation. BMSC are predominantly mesenchymal stem cells (MSC) and are considered by investigators to be multipotent. In this study, we will be providing transfer of these multipotent stem cells from the bone marrow to areas of damage of the human spinal cord via the vascular system, intranasal mucosa, and paraspinal injection. There will be a second arm of the study which provides external stimulation of the muscular system via exoskeletal manipulation with or without virtual reality input and a third arm with virtual reality simulation. This research is not federally funded nor subject to federal oversight. There is no HDE involved. This treatment involves human cells and tissue (bone marrow derived stem cells or BMSC) and is exempt from IND requirement 21CFR312.2(b) and not subject to FDA oversight because it satisfies the following requirements: • The material transferred is Human Cells, Tissues and Cellular and Tissue Based Products (HCT/P’s) defined as “articles containing or consisting of human cells or tissues intended for implantation, transplantation, infusion or transfer into a human recipient” under 21 CFR 1261.3(d) (2011). • The patient involved remains in the operating room during the entire surgical procedure and the bone marrow and separated cells will remain in the same operating room as the patient during the entire procedure. This would exempt the procedure from FDA oversight as the exception set forth in Section 1271.15(b) “removing HCT/P's from an individual and implanting such HCT/P's into the same individual during the same surgical procedure.” • The HCT/P's will undergo centrifugation only and therefore are considered minimally manipulated by FDA under 21 CRF 1271.10(a)(1). Specifically, “Minimal manipulation” is defined in 21 CFR 1271.3 (f) (2) as follows: “For cells or nonstructural tissues, processing that does not alter the relevant biological characteristics of cells or tissues.” • In the preamble to the final HCT/P registration rule, the FDA listed several techniques that could be undertaken without causing tissues to be more than minimally manipulated including tissues that are centrifuged, subjected to density gradient separation, subjected to selective removal of a specific type of cell, sterilized, or frozen. • In our protocol, the bone marrow tissue will be centrifuged in an FDA Class 2 device to separate the stem cells satisfying the minimally manipulated criteria. There will be no amplification or other interference with the function of the

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HCT/P. There is no drug used in the separation process. Furthermore, the device used for this centrifugation has complied with the regulatory processes and met the requirements of a Class 2 device per FDA guidelines, including minimal manipulation. • The material obtained is for homologous use only meeting the requirements of 21 CFR 1271.10(a) (2) which include the repair, reconstruction, replacement, or supplementation of a recipient’s cells or tissues with HCT/P.  We believe that bone marrow derived stem cells function in the same fashion, no matter their location. The HCT/P is not being combined with a drug or device.

Purpose and Objective of the Study The purpose of the study is to evaluate the use of autologous bone marrow derived stem cells for spinal cord injury, disease, or damage. We hope to support their value in improving neurologic function for patients with loss of muscular control and/ or sensation as a result of spinal cord injury, disease, or damage. The objective is to document that neurologic deficits caused by spinal cord deficits may be mitigated by use of BMSC and potentially subsequent stimulation with an exoskeletal mechanical device and/or virtual reality simulation of movement.

Background of the Study A. Rational for the Stem Cell Spinal Cord Injury Exoskeleton and Virtual Reality Treatment Study (SCiExVR) Various clinical studies have registered with the National Institutes of Health (NIH) to study BMSC in spinal cord injury and damage. The most recent using cultured bone marrow mesenchymal stem cells concluded that intralesional injection was safe, well tolerated, and resulted in subjects having variable improvements in tactile sensitivity and some having improvement in motor function [1]. There have also been a number of journal reports of the benefits of treatment with BMSC for diseases and damage to nervous tissue (see Addendum A.). In the course of treating optic nerve damage in the Stem Cell Ophthalmology Treatment Study (SCOTS), we have incidentally noted improvements in neurologic function in patients with TBI and CVA, and thus far in the Neurologic Stem Cell Treatment study improvements in Parkinson’s disease. We would like to add to the volume of literature supporting the use of BMSC in spinal cord injury with augmentation using stimulation of the motor and sensory pathways with a new study called SCiExVR. Intravenous administration of BMSC is a well-established approach to neurologic disease and injury with much support for its effectiveness in the pre-clinical and clinical literature. BMSC and the associated bone marrow fraction are posited to have a number of different mechanisms by which they improve neurologic function.

Background of the Study

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In regard to their ability to penetrate the blood-brain barrier for potential transdifferentiation and direct impact on the neurons and glial tissue within the brain, it should be remembered that within the diencephalon there are specific circumventricular organs that lie in the wall of the third ventricle. These are noteworthy for lacking a blood-brain barrier that facilitates their function of coordinating homeostatic mechanisms of the endocrine and nervous systems including regulation of blood pressure, fluid balance, hunger, and thirst. In addition to the use of intravenous BMSC, the SCiExVR study will provide application of BMSC to the higher nasal passages as a means of introducing BMSC to the central nervous system (CNS). Similarly, this allows access of the BMSC and growth factors to the brain and CSF. In spinal cord injury, the  upper motor neurons arising in the cerebral cortex, extrapyramidal cerebellar motor neurons, and autonomic motor fibers traveling inferiorly into the spinal cord may be interrupted at the site of the spinal cord injury. Similarly, those second-order somatic sensory neurons and autonomic sensory fibers arising from below the damaged spinal cord segment or from brain stem and synapsing in the thalamus may be interrupted. All may be subject to disuse changes. It is hoped that the presence of BMSC and growth factors in the brain will improve their neurologic function. In addition, entry of BMSC provided via the intravenous or intranasal route into the cerebral spinal fluid (CSF) is possible. The CSF circulates in the subarachnoid space surrounding the spinal cord and in the central canal that is in the middle of the spinal cord. In addition to intravenous and intranasal, paraspinal injections of BMSC concentrate will be provided in some arms. Paraspinal injections adjacent to the spinal nerves as they exit the intervertebral foramen and divide into anterior and posterior rami are readily performed by physicians familiar with facet and nerve block injections – as is Dr. Silberfarb. As with intranasal, the BMSC and growth factors may have the opportunity to travel along the spinal nerve through the ventral motor roots (lower motor neurons) and dorsal sensory roots (first-order sensory) to the spinal cord and help repair and potentially replace neurons. Paraspinal will be provided superior and inferior to the identified site of injury in order to assist repair of the ascending and descending somatic motor and sensory nerve fibers. Autonomic sympathetic and parasympathetic fibers may also be positively affected. We will also have the opportunity to treat patients with exoskeletal stimulation of their muscles and sensory fibers. It is hoped that stimulation of disused skeletal muscles, somatic sensory fibers, and proprioceptive fibers (muscle stretch, Golgi tendon, joint proprioception) will assist improvement. The specialty of neurology is very traditional and slow to adopt new procedures and approaches to treatment. Physicians and the healthcare industry typically require multiple studies and continuing effort to explore and establish procedures. Therefore, it is our goal to treat patients with the identified neurologic conditions within an IRBapproved protocol which will allow publishing of results in reputable medical journals. The SCiExVR study will allow us to recruit patients with spinal cord damage and to increase the numbers of patients experiencing improvements with BMSC.

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 ackground of the Neurologic Stem Cell Treatment Study (NEXT B or NEST) The recruitment for NEXT has progressed steadily, but the number of participants remains limited at this time and we have not submitted any papers as of this point. However, we can report that patients have been showing improvements. We recently had a patient with a basal ganglion infarct have improvement in gait  – strength and speed  – by his physician at 1-month post-treatment. We have had positive reports from patients with Parkinson’s disease. Our observation of prior treatment results has been positive in certain neurologic conditions with improvements in gait, speech, anosmia, and other neurologic deficits. One of our initial patients in NEST with Parkinson’s disease for 6  years, maintained on carbidopa, levodopa, and entacapone, reported these improvements following treatment: ability to smell has improved, balance is improving, facial muscles working better – losing mask appearance, fine muscle control is improving, posture has improved, gate and speed of walking improving, less swallowing/aspiration problems, less incontinence problems, voice level is improving, lessening of disconnects during discussions, improving memory, reduced fatigue issues and less depressed, and improvement in sleep.

Participant Selection A. Inclusion and exclusion criteria

Inclusions The treatment with BMSC is a tissue transfer of mesenchymal stem cells (MSC) and growth factors in the associated bone marrow fraction (BMF or liquid containing the BMSC) from the bone marrow to the tissues surrounding or within the nervous system for the purpose of improving function of that tissue. Diminished neurologic function can occur as a result of damage to the spinal cord from disease or injury. The exact disease or injury process causing the damage may vary, but the end result may be damage to neurons in the central or peripheral nervous tissue and/ or to the glial cells which support the neurons and their function. It is important to understand that our treatment protocol relates to transferring cells from one part of the body (bone marrow) in a way that will maximize the damaged tissue’s access to those cells in a safe and reasonable fashion. There are various traumatic events and diseases that may cause damage to the spinal cord at various levels – our goal is treatment of the damaged tissue rather than a specific disease. To be eligible for treatment patients must:

Participant Selection

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1. Have documented functional damage to the spinal cord unlikely to improve with present standard of care. 2. If under current medical therapy (pharmacologic or surgical treatment) for the condition be considered stable on that treatment and unlikely to have reversal of the associated spinal cord damage as a result of the ongoing pharmacologic or surgical treatment. 3. In the estimation of Dr. Weiss and Dr. Silberfarb have the potential for improvement with BMSC treatment and be at minimal risk of any potential harm from the procedure. 4. Be over the age of 18 and capable of providing informed consent. 5. Be medically stable and able to be medically cleared by their primary care physician or a licensed primary care practitioner for the procedure. Medical clearance means that in the estimation of the primary care practitioner, the patient can reasonably be expected to undergo the procedure without significant medical risk to health.

Restrictions 1. All patients must be capable of an adequate neurologic examination and evaluation to document the pathology. This will include the ability to cooperate with the exam. 2. Patients must be capable and willing to undergo follow-up neurologic exams as outlined in the protocol. 3. Patients must be capable of providing informed consent. 4. In the estimation of Dr. Weiss and Dr. Silberfarb, the BMSC collection and treatment will not present a significant risk of harm to the patient’s general health or to their neurologic function. 5. Patients who are not medically stable or who may be at significant risk to their health undergoing the procedure will not be eligible. 6. Women of childbearing age must not be pregnant at the time of treatment and should refrain from becoming pregnant for 3 months post-treatment. B. Gender – no restrictions. Women of childbearing age are eligible but must not be pregnant at the time of treatment. C. Racial/ethnic origin – no restrictions. D. Vulnerable populations – no vulnerable populations will be eligible. E. Age – no patients under the age of 18 are to be enrolled. For those 18 years and older, there will be no age restrictions. F. Total number of participants to be enrolled: 300

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There will be an initial group of 40 patients for proof of concept before the enrollment of the larger anticipated clinical trial following consideration by the ICMS IRB. Explanation of participant number chosen: We propose to address nerve tissue damage caused by spinal cord diseases and injury. Many spinal cord injuries and diseases, although varying in etiology, have similar detrimental effects on neural tissue including neurons themselves and the supporting glial tissue. The sample size or number of participants proposed is based on the following: 1 . The size of the effect the trial should detect. 2. The alpha or probability of type I error (error of reporting the treatment is effective, but in reality, it is not). 3. Power or the probability of avoiding type II error (beta or the error of reporting the treatment is ineffective, but in reality, it is effective ). 4. The potential loss of data from inadequate follow-up on the part of the patients over the five requested patient exams (1 day, 1 month, 3 months, 6 months, and 12 months). 5. Alpha is set to generally accepted statistical significance for clinical trials which is p less than or equal to .05. 6. The standard deviation is high because the variance is correspondingly high (σ = √var). These will include variance in patient age, patient gender, disease subtype, disease severity, disease duration, rate of disease progression, degree of neurologic function loss, variety of neurologic function loss, and medical comorbidities. The high standard deviation/variance supports the need for a higher total number of enrolled patients for the study to generate meaningful data. “Recent studies show that enrollment rates have decreased from 75% in 2000 to 59% in 2006 and retention rates have fallen from 69% to 48% during same period. (Getz, “Public Confidence”) http://www.ciscrporg/professional/facts_pat.html If we choose a 60% retention rate, the needed number of patients would be approximately 310.

Study Design/Method/Procedures Summary of Research Design  reoperative Neurologic Exam P The preoperative neurologic exam will be provided by the patients’ neurologist and will be evaluated by the sub-investigators for inclusion criteria. Immediate preoperative exams and informed consent will be performed by Dr. Weiss or the sub-­ investigators at their office.

Study Design/Method/Procedures

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Treatment Location Treatments will be performed at the Park Creek Surgery Center located at 6806 North State Road 7, Coconut Creek, Florida 33073, at which Dr. Weiss and Dr. Silberfarb are members of the medical staff. The procedures will be performed in accordance with all surgery center regulations. Randomization No patients are to be randomized. All eligible patients who participate will receive treatment if deemed safe.

Treatment Procedure Anesthesia Anesthesia will be provided by the anesthesia physicians and staff at the Park Creek Surgery Center in accordance with good medical judgment and regulations of the surgery center and the State of Florida. This includes all types of anesthesia from local injection to general anesthesia. Typically, the patients have general anesthesia, sedation, or local anesthesia for the bone marrow aspiration and the injection of the stem cells. According to Li et al. who performed an epidemiology study of anesthesia-related mortality in the United States from 1999 to 2005, the estimated mortality was 1.1 per million population per year and 8.2 per million hospital surgical discharges [2]. Arbour et  al. explored the risk factors associated with anesthetic mortality in 869,483 patients undergoing general, regional, or combination anesthesia between January 1995 and January 1997. There were 119 deaths giving a mortality incidence of 8.8 per 10,000 anesthetics or less than 1 per 100,000 [2]. In a meta-analysis performed by Bainbridge et  al., 87 studies involving 24.1 million general anesthetic administrations from before the 1970s through the 2000s were reviewed. There was a progressive decline in anesthetic mortality each decade to 1176 per 1,000,000 in the 1990s to 2000s [2]. We believe there is sufficient evidence to support the safety of general anesthesia as will be provided in the SCiExVR study.  MSC Collection and Preparation B Approximately 120 cc of bone marrow aspirate will be collected in the operating room, the exact volume being based on medical judgment. The bone marrow aspirate is collected from one or both of the patient's iliac bones in the pelvis and may involve one, two, or more separate sites. The bone marrow aspirate will not leave the operating room. For separation and collection of the mononuclear cell layer including the stem cells and additional components, a medical device called the Angel System manufactured by Arthrex, Inc., or equivalent will be used. The Arthrex Angel System and its components is a Class 2 device per the FDA guidelines.

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The collected bone marrow aspirate will be placed in the device that will separate the components of the bone marrow and isolate the portion containing the adult stem cells. This is done in a completely sterile, automated, and self-contained fashion with minimal manipulation. The device will be operated by Dr. Weiss’ assistants under Dr. Weiss' supervision. Approximately 16 cc of mononuclear cell material containing the adult stem cells (adult stem cell material) will be available for injection.

Neurologic Treatment The three arms of the study are as follows: • Arm 1. Intravenous, intranasal, and paraspinal – approximately 6 cc of BMSC fraction filtered with 150 micron filter and administered intravenously; approximately 2 cc of BMSC fraction administered topically to the nasal mucosa of the superior  one-third of the nose (1  cc bilaterally); approximately 1  cc for each injection administered paraspinally including the following locations: bilaterally at the main spinal cord injury level, approximately two spinal cord levels above and two and four spinal cord levels below. Total paraspinal injection will be approximately 8 cc. • Arm 2. Same as Arm 1 but with additional exoskeletal stimulation as prescribed in the attached protocol within Addendum B. • Arm 3. Same as Arm 1 or 2 but with additional virtual reality stimulation as prescribed in the attached protocol within Addendum C. Any excess bone marrow material including other cells and plasma will be discarded in accordance with normal surgery center practice. No material will be retained for future use. An intravenous injection is the injection of the bone marrow stem cells (BMSC) into the vein in the patient’s arm. It is standard procedure during anesthesia that the patient will have an intravenous line available for administration of medications and fluids. This same line is used for intravenous injection of the BMSC. There is a risk of a thrombotic event called pulmonary embolism occurring as a result of a clot forming either prior to or during the passage of the cells through the lungs. Because of the anticoagulation and filtering employed in processing the bone marrow aspirate, we believe this risk is very small. In a review of the safety of BMSC donation for hematopoietic stem cell transplantation (HSCT), Bosi and Bartolozzi quoted the analysis in the European Group for Blood and Marrow Transplantation on HSCT performed between 1993 and 2005. One fatal event of pulmonary embolism was found in over 27,000 patients receiving HSCT; the risk of this complication is calculated to be approximately 0.000037 per procedure. To reduce this risk, a filter of appropriate size (typically 150 microns) will be used to filter the delivered BMSC.

Study Design/Method/Procedures

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 erformance of Injections of Adult Stem Cell Material P 1. Intravenous injections will generally be performed while the patient is recumbent and intranasal while the patient is seated. Intravenous injection may be performed recumbent or while the patient is sitting. 2. Anesthesia is given as needed for patient comfort and safety under the direction of the anesthesiologist. 3. The procedure is performed under sterile conditions.

Possible Side Effects/Complications General This is a surgical procedure involving the aspiration of bone marrow and injection of the separated bone marrow stem cell intravenously and by direct placement or inhalation intranasally. The procedure will include the administration of medications to provide anesthesia during the procedure. There is always the risk of unanticipated reactions to the procedure itself, the medications, and the anesthesia. Under very rare circumstances, patients may have serious complications as a result of the procedure or medications including serious abnormal drug reactions, serious allergic reactions, very low blood pressure, seizures, and cardiac or respiratory problems including cardiac or pulmonary arrest. These may result in harm to your body or in death.  one Marrow Aspiration B Common side effects may include mild local pain, tenderness, and localized bleeding in the area where the doctor aspirates the bone marrow. Very rare complications may include infection or bleeding that is difficult to control. Spinal Cord Treatment An intravenous injection is the injection of the bone marrow stem cells (BMSC) into the vein in the patient’s arm. It is standard procedure during anesthesia that the patient has an intravenous line available for administration of medications and fluids. This same line is used for intravenous injection of the BMSC. There is a risk of a thrombotic event called pulmonary embolism occurring as a result of a clot forming either prior to or during the passage of the cells through the lungs. Because of the anticoagulation and filtering employed in processing the bone marrow aspirate, we believe this risk is very small. To reduce this risk, a filter of appropriate size (typically 150 microns) will be used to filter the delivered BMSC. Wakitani et al. followed 41 patients following the use of BMSC for joint treatment for up to 11 years and 5 months. They found no tumors or infections and concluded autologous BMSC transplantation to be a safe procedure. In a meta-analysis

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of BMSC used to treat acute myocardial infarction, Cong et al. found an overall significant improvement in left ventricular ejection fraction (LVEF) and other cardiac measurements at 3–6 months and 12 months following BMSC and concluded that intracoronary BMSC post-STEMI was safe and effective. In a recent meta-analysis of 23 randomized controlled studies of BMSC therapy for chronic ischemic heart disease (IHD) and congestive heart failure (CHF) involving 1255 patients, Fisher et al. found moderate evidence that BMSC improves LVEF even in the long term (greater than 1 year) in patients suffering from chronic IHD and CHF. In a study by Nishida et al. involving dogs with acute spinal cord injury (SCI), autologous BMSC were cultured and injected into the spinal cord lesion. Follow-up from 29 to 62 months following treatment showed no complications or worsening of neurologic function. We conclude that the safety of providing BMSC intravenously in SCiEXVr is well supported in the literature. Intranasal administration may be provided by direct application of the BMSC material topically to the nasal mucosa of the inferior one-third of the nose bilaterally. The complications of topical intranasal administered drugs or material is limited to potential local irritation, rhinorrhea, and to the side effects of inhaled material. We have identified no specific side effect of BMSC material intranasally. If directly placed intranasally, the BMSC material will be placed in the nasal passages to allow movement along the trigeminal nerve (5th cranial nerve) pathways. Chapman et al. reviewed intranasal treatment of central nervous system (CNS) dysfunction in humans. They identified both olfactory and trigeminal pathways of BMSC entry allowing both anterior and posterior regions of the brain exposure. The authors remark on the efficacy and noninvasiveness of intranasal delivery of BMSC. They review several studies of preclinical application and improvements in models of stroke, cerebral hypoxia, and Parkinson’s disease. They conclude that it is clear that intranasal delivery is clinically safe and effective. In a review of intranasal delivery of stem cells to the brain, Jiang et al. indicate that the approach overcomes the difficulties of other methods of delivery for the treatment of many neurologic disorders [3]. A number of recent preclinical studies utilizing BMSC as well as other types of stem cells in various neurologic diseases (stroke, ischemia, Alzheimer’s, spinal cord lesions, intracerebral hemorrhage) may be cited in support of the effect of stem cells delivered via intranasal [4, 5]. Danielyan et  al. have elegantly demonstrated the direct intranasal delivery of mesenchymal stem cells to the murine brain and identified two prime migratory pathways that allow the cells to enter via the olfactory bulb to various portions of the brain and separately into the cerebral spinal fluid with movement across the cortex and into the brain parenchyma. The cerebral spinal fluid also circulates adjacent to the spinal cord in the subarachnoid space and within the central canal through the middle of the spinal cord. We conclude that intranasal delivery of BMSC is safe, efficacious, and provides the BMSC the ability to cross the blood-brain barrier successfully in a noninvasive fashion.

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Post-procedure Neurologic Exams The follow-up neurologic exams will be obtained the day after the procedure and are then requested at 1 month, 3 months, 6 months, and 12 months following the procedure or at the recommended intervals of the neurologist examining the patient. We will provide a follow-up schedule for the patients that they will be given in Dr. Weiss's office. We will email and call the patients post-op to remind them to comply with follow-up. In order to avoid unnecessary loss of information through contact changes and to ensure that at least early data is gathered to enable Intent to Treat (ITT) to be used, we will remind patients of the need for upcoming appointments approximately 2 weeks before these appointment dates. The study director will be responsible for ensuring that the required data is collected and for coordinating retention in conjunction with the principal investigator. Patients agree to allow Dr. Weiss and his associates to release any medical information to their neurologists and medical doctors. They also agree to provide access to their examinations from their neurologist and medical doctor to Dr. Weiss and his associates. The following specific scales for scoring patient outcomes may include the following: • • • • •

American Spinal Injury Association (ASIA) scoring American Spinal Injury Association Impairment (AIS) scoring Functional improvement in muscle strength Functional improvement in sensory function Functional improvement in sphincter control (bowel and bladder)

Collection and Use of Data Patients give permission to use their medical information for their own care and for any publication, presentation, or public communication about the procedure and results. In the case of non-direct patient care communication, the patient name and contact information will be held in confidence and not released to protect patient privacy. However, if required by law, state or federal agencies may be given access to the patient’s name, data, medical records, and information. Access will be granted to the International Cellular Medicine Society Institutional Review Board as required for monitoring of the Institutional Review Board (IRB).

Analysis of Study Results Data will be collected and analyzed for significance as outlined under Number 4 – Section F (number of participants to be enrolled). Standard statistical methodology will be used.

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Monitoring This will be provided by Dr. Weiss, the sub-investigators, and his staff, including the collaborator. Any worsening of neurologic status will be investigated by a neurologist.

Storage of Data Data will be stored in paper files and will be accessible by Dr. Weiss, his staff, and associates. This will be kept in the usual manner as other medical files and for the required period of time as provided by state of Florida law.

Confidentiality of Data All data will be maintained in a confidential manner equal to other medical data and records.

Risk/Benefit Assessment Risk and discomforts are minimal including the risks of bone marrow aspiration and intravenous and intranasal administration of BMSC.

Risks General This is a surgical procedure involving aspiration of bone marrow and intravenous injection and/or intranasal placement or inhalation of the separated bone marrow stem cell isolate. The procedure may include the administration of medications to sedate the patient during the procedure. There is always the risk of unanticipated reactions to the procedure itself or medications. Under very rare circumstances, patients may have serious complications as a result of the procedure or medications including serious abnormal drug reactions, serious allergic reactions, very low blood pressure, cardiac or respiratory problems including cardiac or pulmonary arrest. These may result in harm to the patient or death.  one Marrow Aspiration B Common side effects may include mild local pain, tenderness, and localized bleeding in the area where the doctor aspirates the bone marrow. Very rare complications may include infection or bleeding that is difficult to control.

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Neurologic Treatment An intravenous injection is the injection of the bone marrow stem cells (BMSC) into the vein in the patient’s arm. It is standard procedure during anesthesia that the patient will have an intravenous line available for administration of medications and fluids. This same line is used for intravenous injection of the BMSC. There is a risk of a thrombotic event called pulmonary embolism occurring as a result of a clot forming either prior to or during the passage of the cells through the lungs. Because of the anticoagulation and filtering employed in processing the bone marrow aspirate, we believe this risk is very small. In an analysis performed by the European Group for Blood and Marrow Transplantation on HSCT in over 27,000 patients between 1993 and 2005, this risk was calculated to be approximately 0.000037. To reduce this risk, a filter of appropriate size will be used to filter the delivered BMSC. An intranasal inhalation will be done topically into the nose alone. The complications of intranasally administered material are limited to potential local irritation, rhinorrhea, and to the side effects of the BMSC. We have identified no specific side effect of BMSC material intranasally. If directly placed intranasally, the BMSC material will be placed in the superior onethird of the nasal passages to allow movement to the trigeminal nerve bilaterally. Paraspinal injections will be performed in a manner similar to paraspinal injections for neuropathic pain with the goal of placing the BMSC concentrate adjacent to the spinal nerve as it exits the intravertebral foramen and divides into dorsal and ventral rami. It is anticipated that the material will migrate into the spinal cord following the motor and sensory neurons present in this area. Paraspinal injections are a frequent and well understood means of introducing medications to the spinal nerves and have been provided for over 50 years. Selective nerve root blocks (SNRD) may be performed for disc herniations to allow relief during the time the disc needs to partially repair itself. Steroids are widely used in nerve root blocks and facet joint injections to provide temporary relief from pain and inflammation. Lidocaine and other local anesthetics are used in a similar fashion. Complications of facet injections or nerve root blocks are rare and usually minor but may include bleeding, infection, and inadvertent intravascular injection. Paraspinal injection of BMSC concentrate is anticipated to be similar. These risks will be minimized by careful technique including drawing back of the syringe to assess for any inadvertent entry of a vessel. This is a Patient Sponsored Study and there is a cost for the patient to participate. There is a possibility that there will be no improvement following treatment in this study.

Prevention of Risks Medical clearance will be required for all patients treated. Dr. Weiss will follow all standard means to minimize the risks of intravenous injection and intranasal placement. The physicians involved in bone marrow aspiration similarly have extensive

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experience with orthopedic procedures and bone marrow aspiration and will perform the technique in a way to minimize risks. Dr. Silberfarb will use his experience in facet and paraspinal injections to minimize risk of injury or complications. Procedures will be done in one of the assigned operating rooms of the Park Creek Surgical Center, Coconut Creek, Florida Standard procedures and staffing as required by local law for surgical procedures will be provided. Anesthesia services will be provided by board-certified anesthesiologists and their staff. Equipment will include all supportive equipment required for safe operative care of patients and required by local law and certification organizations. This will include anesthetic and pharmacologic drugs and equipment for routine operative patient care and anesthesia administration as well as that needed for emergent care (respiratory or cardiac arrest). The bone marrow processing device with disposable components for safe and sterile processing of bone marrow aspirate will be used.

Adverse Events  erious Adverse Event S A serious adverse event will be considered any undesirable sign, symptom, or medical condition which is fatal, life-threatening, requires hospitalization or prolongs existing hospitalization, results in persistent or significant disability or capacity, and is medically significant and which the investigator regards as serious based on appropriate medical judgment. An important medical event is any adverse event that may not result in death, be life threatening, or require hospitalization but may be considered a serious adverse event when, based upon appropriate medical judgment, it may jeopardize the patient and may require medical or surgical intervention to prevent one of the outcomes listed in the definitions of serious adverse events. Every serious adverse event must be reported, even if the event does not appear to be associated with the study protocol. The Serious Adverse Event must be reported by filing an Adverse Event Report within 5 days of discovery of the occurrence. In addition, the IRB should be notified by phone or email within 48 hours of discovery of any serious adverse events. The IRB may be notified at (702) 664-0017 or [email protected]  nanticipated Adverse Event U An adverse event will be considered any undesirable sign, symptom, or medical condition even if the event is not considered to be related to the intervention. In the case of pre-existing medical conditions, if the condition worsens beyond the rate of normal disease progression, such worsening will be considered an adverse event. An adverse event is also any undesirable and unintended effect occurring in human subjects as a result of the collection of identifiable private information (for example, misplacing a subject’s records would constitute an increased risk event that should be reported).

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Adverse events also include any problems associated with the treatment/intervention that adversely affects the rights, safety, or welfare of subjects. Unanticipated adverse events must be reported to the IRB by submission of the Adverse Events form within 14 days of discovery of occurrence.

 nticipated Adverse Event A An adverse event will be considered anticipated if it is reasonably expected in nature, severe, and frequent, and is included in the protocol and consent form as a possible risk of participating in the research. Anticipated adverse events should be reported to the IRB only if they result in a modification of the protocol to mitigate and/or detail this event. Anticipated adverse events are reviewed by the IRB to assure that protocol modifications are initiated if necessary. Reportable anticipated adverse events must be reported to the IRB by submission of the Adverse Events form within 30 days of the discovery of the occurrence.

Benefits The patient may obtain improvements of spinal cord and neurologic function.

Participant Recruitment and Informed Consent Recruitment Recruitment will be brought to the attention of potential patients through announcements on the internet, email, press releases, direct communications with healthcare providers, and potentially paid advertising in accordance with normal and ethical recruiting practices. Recruitment will continue until 300 patients have been enrolled. No coercion will be used. In the course of providing information about the study, it will be communicated that patients will be participating in a clinical study conducted under an IRB protocol approved and monitored by the International Cellular Medicine Society.

Length of Study The study will begin on the date of IRB approval and continue until 1 year following the treatment of the last recruited patient.

Informed Consent/Assent See Informed Consent

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BMSC References 1.  Mendonca MV, LaroccaTF, de Freitas Souza BS, et al. Safety and neurological assessments after autologous transplantation of bone marrow mesenchymal stem cells in subjects with chronic spinal cord injury. Stem Cell Res Ther. 2014;5(6):126. https://doi.org/10.1186/scrt516. 2.  Li G, Warner M, Lang BH, et al. Epidemiology of anesthesia-related mortality in the United State, 1999–2005. Anesthesiology. 2009;110(4):759–65. 3.  Arbout MS, Grobbee DE, van Kleef JW, et al. Mortality associated with anaesthesia: a qualitative analysis to identify risk factors. Anaesthesia. 2001;56(12):1141–53. 4.  Bainbridge D, Martin J, Arango M, Cheng D. Perioperative and anaesthetic-­ related mortality in developed and developing countries: a systematic review and meta-analysis. Lancet. 2012;380(9847):1075–81. 5.  Bosi A, Bartolozzi B.  Safety of bone marrow stem cell donation: a review. Transplant Proc. 2010;42(6):2192–4. 6.  Wekitani S, Okabe T, Horibe S, et al. Safety of autologous bone marrow-derived mesenchymal stem cell transplantation for cartilage repair in 41 patients with 45 joints followed for up to 11 years and 5 months. J Tissue Eng Regen Med. 2011;5(2):146–50. 7.  Cong XQ, Li Y, Zhao X, et al. Short-term effect of autologous bone marrow stem cells to treat acute myocardial infarction: a meta-analysis of randomized controlled clinical trials. J Cardiovasc Transl Res. 2015;8(4):221–31. 8.  Fisher SA, Brunskill SJ, Doree C, et al. Stem cell therapy for chronic ischaemic heart disease and congestive heart failure. Cochrane Database Syst Rev. 2014;(4):CD007888. 9.  Nishida H, Nakayama M, Tanaka H, et al. Safety of autologous bone marrow stromal cell transplantation in dogs with acute spinal cord injury. Vet Surg. 2012;41(4):437–42. 10. Chapman CD, Frey II WH, Craft S, et  al. Intranasal Treatment of Central Nervous System Dysfunction in Humans. Pharm Res. 2013;30(10):2475–84. 11. Jiang Y, Shu J, Xu G, Liu X.  Intranasal delivery of stem cells to the brain. Expert Opin Drug Deliv. 2011;8(5):623–32. 12. Zhao Q, Hu J, Xiang J, et al. Intranasal administration of human umbilical cord mesenchymal stem cells-conditioned medium enhances vascular remodeling after stroke. Brain Res. 2015;1624:489–96. 13. Ji G, Liu M, Zhao XF, et al. NF-κB signaling is involved in the effects of intranasally engrafted human neural stem cells on neurofunctional improvements in neonatal rat hypoxic-ischemic encephalopathy. CNS Neurosci Ther. 2015;21(12):926–35. 14. Mita T, Furukawa-Hibi Y, Takeuchi H, et  al. Conditioned medium from the stem cells of human dental pulp improves cognitive function in a mouse model of Alzheimer's disease. Behav Brain Res. 2015;293:189–97. 15. Ninomizy K, Iwatsuki K, Ohnishi Y, et al. Intranasal delivery of bone marrow stromal cells to spinal cord lesions. J Neurosurg Spine. 2015;23(1):111–9.

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16. Danielyan L, Schafer R, von Ameln-Mayerhofer A, et al. Intranasal delivery of cells to the brain. Eur J Cell Biol. 2009;88:315–24. 17. Sharma A, Gokulchandran N, Sane H, Badhe P, Kulkarni P, Lohia M, Nagrajan A, Thomas N. Detailed analysis of the clinical effects of cell therapy for thoracolumbar spinal cord injury: an original study. J Neurorestoratol. 2013;1:13–22 18. Sharma A, Sane H, Gokulchandran N, Kulkarni P, Thomas N, et  al. Role of autologous bone marrow mononuclear cells in chronic cervical spinal cord injury-a longterm follow up study. J Neurol Disord. 2013;1:138. 19. Kumar AA, Kumar SR, Narayanan R, Arul K, Baskaran M. Autologous bone marrow derived mononuclear cell therapy for spinal cord injury: a phase I/II clinical safety and primary efficacy data. Exp Clin Transplant. 2009;7(4):241–8. 20. Yoshihara T, Ohta M, Itokazu Y, Matsumoto N, Dezawa M, Suzuki Y, Taguchi A, Watanabe Y, Adachi Y, Ikehara S, Sugimoto H, Ide C. Neuroprotective effect of bone marrow-derived mononuclear cells promoting functional recovery from spinal cord injury. J Neurotrauma. 2007;24(6):1026–36. 21. Sharma A, Gokulchandran N, Chopra G, Kulkarni P, Lohia M, Badhe P, Jacob VC. Administration of autologous bone marrow-derived mononuclear cells in children with incurable neurological disorders and injury is safe and improves their quality of life. Cell Transplant. 2012;21 Suppl 1:S79–90. https://doi.org/1 0.3727/096368912X633798. 22. Vaquero J, Zurita M. Bone marrow stromal cells for spinal cord repair: a challenge for contemporary neurobiology. Histol Histopathol. 2009;24:107–116. 23. Bang OY, Lee JS, Lee PH, Lee G. Autologous mesenchymal stem cell transplantation in stroke patients. Ann Neurol. 2005;57(6):874–82. 24. Anbari F, Khalili MA, Bahrami AR, et al. Intravenous transplantation of bone marrow mesenchymal stem cells promotes neural regeneration after traumatic brain injury. Neural Regen Res. 2014: 9(9):919–23. 25. Eckert MA, VuQ, Xie K, et al. Evidence for high translational potential of mesenchymal stromal cell therapy to improve recovery from ischemic stroke. J Cereb Blood Flow Metab. 2013;33(9):1322–34. 26. Fan X, Wang JZ, Lin XM, Zhang L. Stem cell transplantation for spinal cord injury: a meta-analysis of treat-ment effectiveness and safety. Neural Regen Res. 2017;12(5):815–25.

Arm 3. Exoskeleton Background An exoskeletal system will be chosen for Arm 3. The exact system or device is yet to be determined. The approach and device chosen may range from a simple motor moving two surfaces that would articulate a single joint to a complex system involving full patient support. There are multiple robotic-assisted powered exoskeleton devices such as SuitX or the Phoenix System, ReWalk, Indego, and Ekso/Ekso GT that have been evaluated in studies to be safe and effective for standing and

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walking by individuals suffering from paraplegia. The system supports the individual with external braces and provides locomotion with electrical motors that move the bracing. The use of biomechanical support is called neuroprosthetics and the use of locomotor exercise is called neurotherapeutics. Neuroprosthetics has been shown to improve upright stance and ambulation in some paraplegics [1–3]. Neurotherapeutics has been shown to improve balance and ambulation in some patients with incomplete spinal cord injuries [4, 5]. This stimulation has been shown to improve the ability to more otherwise paralyzed limbs to a certain degree after a number of months of stimulation. Brain-machine interface protocols have resulted in partial recovery of neurologic function in paraplegics [6]. The concept to  use external movement alone is that the  physical stimulation of atrophic muscles and sensory input from proprioceptor receptors in externally moved joints and muscles can improve control by the damaged central nervous system. However, improvements have been limited and required many months of persistent effort to achieve. In the SCiExVR study, all patients admitted to the study will first be treated with bone marrow derived stem cells to provide the potential for both improvement of existing neuron function as well as the development of new motor and sensory neurons. In Arm 3, concomitant external stimulation with the exoskeletal system may augment the potential improvements from the stem cell treatment, and the stem cell treatment may augment the benefit of the exoskeletal stimulation.

 hoenix Device Description (For Example) P Phoenix, revision Mk II, is a wearable exoskeleton device that allows individuals with lower extremity mobility disorders to stand up and walk. Phoenix comprises a pair of battery-powered actuators at the hip joints, a pair of leg braces with semi-­ passive mechanisms at the knee joints, a lithium-ion battery pack, a main controller unit, and a user-operated wireless communicator mounted on the handle of a crutch or walker. Phoenix is controlled by user operated buttons mounted on an assistive device (such as a crutch or walker handle), as well as a tilt sensor which locates the specific body position. The modular design of Phoenix may allow the user to wear the device in his/her own wheelchair, without needing to transfer to another chair. Phoenix weighs up to 15 kg, varying by user. Device Usage Phoenix is intended for individuals with spinal cord injury levels (thoracic) T7 to (lumbar) L5 to perform ambulatory functions under supervision of a companion in accordance with the user assessment and training program. Phoenix is also intended for individuals with more severe spinal cord injuries at levels T4 to L5 to perform ambulatory functions in rehabilitation institutions, in accordance with the user assessment and training certification program. Phoenix is not intended for sports or stair climbing.

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Anticipated Risk/Benefits The risks and benefits of the device are based on both non-clinical and pre-clinical study data. Pre-clinical data was collected from: SuitX, Berkeley Robotics and Human Engineering Laboratory at the University of California, Berkeley, and the Villa Beretta Rehabilitation Center at Valduce Hospital in Italy. As of October 2016, Phoenix has been tested through 290 test sessions with 24 test participants of different conditions: eighteen individuals with complete and incomplete SCI level ranging from T4 to L1, three individuals with cerebral palsy, two individuals with stroke, one individual who had a tumor, and one individual who had encephalitis. All sessions were open-label, non-comparative, non-­ randomized trials to evaluate performance and usability of Phoenix. For participants who met the inclusion criteria, training time required for test participants to walk using Phoenix with moderate assistance varied from 20 minutes to 6 hours. Results have shown that Phoenix is safe and effective for its intended use. Adverse events (AE) that occurred during the study sessions included minor instances of redness due to improper fitting or improper padding. Similar results are expected from this planned clinical trial. The possible risks of using the Phoenix include falls, redness, bruising, skin abrasions, pressure sores, increased spasticity, lightheadedness, soft tissue injury, and changes in blood pressure (diastolic hypertension or hypotension) and heart rate. Additionally, users may injure themselves or their companions due to a device malfunction during normal use or while performing higher risk activities (e.g., ambulating over uneven terrain). These hazards are similar to the risks of other lower extremity orthotics on the market today. Mitigations to these risks have been evaluated, as well as residual risk benefit analysis. These are included in the Phoenix Mk II Risk Management Files. Despite these risks, Phoenix promotes the ability to stand up, walk, and begin rehabilitation after injury. The ability to perform more regular ambulatory movement may reduce the risk of incurring secondary injuries from extensive sitting, including urinary tract infections, blood clots, reduced cardiovascular function, decreased bone mineral density, bone density loss, osteoporosis, acute pressure ulcer development, muscular atrophy, muscle spasticity, decreased joint range of motion, and reduced digestive and bowel function. Studies have also shown that being able to stand upright and walk has positive psychological and social effects. Subject Conditions Subject conditions will be based on the complexity of the exoskeletal device ultimately chosen. For simple systems that articulate one or two joints and do not support the patient, only the ability to move the joint in the required range of motion will be required. If a complex supportive system such as US Bionics is ultimately chosen, the following criteria will apply.

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Inclusion Criteria Investigators shall recruit study participants with all of the following: 1. Should be 18 years of age or older in general good health. 2. Should not weigh more than 220 lbs. 3. Skin must be healthy where it touches the Phoenix. 4. Able to stand using a device such as a standing frame. 5. Have enough strength in your hands and shoulders to support yourself standing and walking using crutches or a walker 6. Have good control of upper body 7. Determined to have enough bone health to walk full weight bearing without risk for fracture. Meeting this condition is at the discretion of your personal MD. 8. Passive range of motion (PROM) at shoulders, trunk, upper extremities, and lower extremities within functional limits for safe gait and use of appropriate assistive device/stability. 9. Hip width not greater than 18” (46 cm) measured when sitting. 10. Femur length between 12.3 inches (31.3 cm) and 19.8 inches (50.2 cm) measured between centers of hip and knee joints. 11. Tibia length between 13.4 inches (33.9  cm) and 21.2 (53.9  cm) inches measured between the knee joint and bottom of the foot. 12. Should be in general good health and able to tolerate moderate levels of activity. 13. Blood pressure and heart rate within established guidelines for locomotive training: • At rest: systolic 150 or less, diastolic 90 or less, and heart rate 100 or less • Exercise: systolic 180 or less, diastolic 105 or less, and heart rate 145 or less

Exclusion Criteria Subjects shall be excluded if they have any of the following conditions: 1. Pregnant or lactating females 2. Spinal cord injury level higher than T4 3. Severe muscle stiffness/tightness 4. Significant spasticity (Modified Ashworth Scale score of 3 or above) 5. Trunk or lower extremity pressure ulcer 6. Open wounds 7. Unstable spine, unhealed limbs, or fractures 8. Severe sensitivity to touch 9. Presence of bone in soft tissue where bone normally does not exist (heterotopic ossification), limiting range of motion in the hip or knee joints 10. Joint instability, dislocation, moderate to severe hip dysplasia 11. Significant scoliosis (>40 degrees) 12. Hardware, implant, or any external device impeding with safe fitting or use of Phoenix 13. Femoral or tibial rotation deformity (>15 degrees) 14. Significant flexion contractures limited to 35° at the hip and 20° at the knee

Study Protocol Arm 3

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Study Protocol Arm 3 Subjects will be screened for inclusion and exclusion criteria and sign informed consent if suitable and interested in participation. After stem cell treatment as outlined in Arm 1 or 2 which will be accomplished on a Tuesday at the ParkCreek Surgery Center, patients will receive follow-up on postoperative day 1 and 3. If continuing to meet criteria, they will begin engagement with the chosen exoskeletal system on post-op day 6 (Monday) or 7 (Tuesday). This will include an initial training period and then up to three sessions per week for 4 weeks. Each session will be for 1 hour.

References 1.  Bernardi M, Canale I, Castellano V, Di Filippo L, Felici F, Marchetti M.  The efficiency of walking of paraplegic patients using a reciprocating gait orthosis. Paraplegia. 1995;33(7):409–15. 2.  Kawashima N, Taguchi D, Nakazawa K, Akai M. Effect of lesion level on the orthotic gait performance in individuals with complete paraplegia. Spinal Cord. 2006;44(8):487–94. 3.  Massucci M, Brunetti G, Piperno R, Betti L, Franceschini M. Walking with the advanced reciprocating gait orthosis (ARGO) in thoracic paraplegic patients: energy expenditure and cardiorespiratory performance. Spinal Cord. 1998;36(4):223–7. 4.  Harkema SJ, Schmidt-Read M, Lorenz DJ, Edgerton VR, Behrman AL. Balance and ambulation improvements in individuals with chronic incomplete spinal cord injury using locomotor training-based rehabilitation. Arch Phys Med Rehabil. 2012;93(9):1508–17. 5.  Nooijen CF, Ter Hoeve N, Field-Fote EC. Gait quality is improved by locomotor training in individuals with SCI regardless of training approach. J Neuroeng Rehabil. 2009;6:36. 6.  Donati ARC, et al. Long-term training with a brain-machine interface-based gait protocol induces partial neurological recovery in paraplegic patients. Sci Rep. 2016;6:30383. https://doi.org/10.1038/srep30383. 7.  Gad PN, Gerasimenko YP, Zdunowski S, et al. Iron ‘ElectriRx’ man: overground stepping in an exoskeleton combined with noninvasive spinal cord stimulation after paralysis. Conf Proc IEEE Eng Med Biol Soc. 2015;2015:1124–7. 8.  Gerasimenko YP, Lu DC, Modaber M, et al. Noninvasive reactivation of motor descending control after paralysis. J Neurotrauma. 2015;32;1968–80. 9.  Esquenazi, A, Talaty M, Packel A, Saulino M. The ReWalk powered exoskeleton to restore ambulatory function to individuals with thoracic-level motor-complete spinal cord injury. Am J Phys Med Rehabil. 2012;91(11):911–21.

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Literature References • Rehabilitation Measures Database. Rehab measures: timed up and go. http:// www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=903. Accessed 1 Oct 2016. • Center for Disease Control. The timed up and go test. http://www.cdc.gov/steadi/ pdf/tug_test-­a.pdf. Accessed 1 Oct 2016. • Rehabilitation Measures Database. Rehab Measures: 6 Minute Walk Test. http:// www.rehabmeasures.org/Lists/RehabMeasures/PrintView.aspx?ID=895. Accessed 1 Oct 2016. • Heart Online. Six minute walk test instructions. http://www.heartonline.org.au/ media/DRL/6MWT_standardised_instructions.pdf. Accessed 1 Oct 2016. • Rehabilitation Measures Database. Rehab measures: timed 10 meter walk test. http://www.rehabmeasures.org/PDF%20Library/10%20Meter%20Walk%20 Test%20Instructions.pdf. Accessed 1 Oct 2016. • Physiopedia. 10 metre walk test. http://www.physio-­pedia.com/10_Metre_ Walk_Test. Accessed 1 Oct 2016. • The American Academy of Orthotists and Prosthetists. Timed ten-meter walk test (10MWT) Reference guide. http://www.oandp.org/olc/lessons/video/orc_ how-­to/Walking_Tests.pdf?frmCourseSectionId=2D306CB3-­6D0E-­473F-­85E9-­ 18962BD7B684. Accessed 1 Oct 2016. • American Thoracic Society. ATS statement: guidelines for the six-minute walk test. https://www.thoracic.org/statements/resources/pfet/sixminute.pdf. Accessed 1 Oct 2016. • Verdecchia P, Schillaci G, Borgioni C, et al. White coat hypertension and white coat effect similarities and differences. Am J Hypertens. 1995;8(8):790–8. https://doi.org/10.1016/0895-­7061(95)00151-­E. • Andrews A, Williams E, Chinworth S, et  al. Update on distance and velocity requirements for community ambulation. J Geriatr Phys Ther. 2010;33(3):128–34. https://doi.org/10.1097/JPT.0b013e3181eda321.

Virtual Reality Virtual reality is the use of visual stimulation to mimic a real-world condition. This condition typically has interaction between the viewer and the subject matter. The term can apply to videos of real images in which the viewer rotates their head to see behind them or to the side. This is typically done with goggles viewing images on a smartphone but can involve other projection techniques. Virtual reality can also apply to an artificial scene through which the viewer can move or interact with parts of their body. While this can be done with goggles as in video gaming, it can also be performed on a screen. Patients are treated with the BMSC injections of Arm 1 or 2 and then will participate in VR activities that are designed to stimulate the motor cortexes involving the

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lower limbs or trunk of the patient. This can be seen as movement of an avatar in the goggle or screen or be translated to motion through the environment. A representation of the person also known as an Avatar may be employed. The concept is that regular activation of the primary motor cortex and associated areas will result in stimulation of upper motor neurons (UMN). This stimulation may stimulate axonal and synaptic growth, as well as the growth of oligodendrocytes and astrocytes, thereby improving the UMN ability to transmit information to lower motor neurons. We also hope that there will be increased synaptic interaction and additional growth of interneurons at and below the damaged spinal cord segment. It is also possible that receptivity in the primary sensory cortex and associated areas as a consequence of the cerebrum anticipating movement and interacting in the environment will similarly act to enhance axonal and synaptic connectivity from the first- and second-order neurons related to injury at or below a segment. We are considering several off-the-shelf VR devices to accomplish these goals. Some may use EEG recording or functional near-infrared spectroscopy (fNirS) to identify parts of the brain associated with movement of the leg or torso and then move that portion of, or the entire Avatar. After the day 1 post-op, training would be initiated and the patient would be able to continue use of the device at home. Suggested use would be for approximately 30-minute sessions, 3–5 days per week between 3 and 6 months.

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Informed Consent and Permission Stem Cell Spinal Cord Injury Exoskeleton and Virtual Reality Treatment Study SCiExVR Treatment Study Jeffrey N. Weiss, MD The Healing Institute 1308 A/B North State Road 7 Margate, Florida 33063 Telephone 954-975-0044

Introduction To decide whether or not you want to participate in the Stem Cell Spinal Cord Injury Exoskeleton and Virtual Reality Treatment Study (called “the procedure” in this document) – also known as an Adult Stem Cell Treatment, the risks and possible benefits are described in this form so that you can make an informed decision. This process is known as informed consent. This consent form describes the purpose, procedures, possible benefits, and risks of the procedure. You may have a copy of this form to review at your leisure or to ask advice from others. Dr. Weiss and his associates will answer any questions you may have about this form or about the procedure. Please read this document carefully and do not hesitate to ask anything about this information. This form may contain words that you do not understand. Please ask Dr. Weiss or his associates to explain the words or information that you do not understand. After reading (or having it read to you) the consent form, if you would like to be treated, you will be asked to sign this form.

Background Bone marrow derived stem cells (BMSC) are adult stem cells that come from a patient's own bone marrow. There is evidence that patients with certain eye diseases have improved visual function following treatment with BMSC. The exact mechanisms by which adult stem cells can provide improvement are complex and still undergoing assessment in the medical and scientific community. Adult stem cell treatments have been performed and continue to be performed in various parts of the world including the United States for a number of medical conditions. It is unknown whether this treatment will be of benefit in your particular disease or condition.

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Terms of the Study This is a human clinical study involving the isolation of autologous bone marrow derived stem cells (BMSC) and transfer to the vascular system, intranasal mucosa, and paraspinal region with or without post-injection treatment with exoskeletal stimulation. BMSC are predominantly mesenchymal stem cells (MSC) and are considered by investigators to be multipotent. In this study, we will be providing transfer of these multipotent stem cells from the bone marrow to areas of damage in the human spinal cord via the vascular system, intranasal mucosa, and paraspinal injection. There will be a second arm of the study which provides external stimulation of the muscular system via exoskeletal manipulation with or without virtual reality input and a third arm with virtual reality simulation. You understand that participation in this study will be voluntary and the treatment of your illness is not dependent upon you participating in this study. There will be approximately 300 participants enrolled in the study at one site in the United States. It is anticipated you will participate in this research study for one year.

Reproductive Information for Females There is no evidence that treatment with autologous bone marrow derived stem cells has adverse effects on human reproduction or a developing unborn fetus. However, female patients who are pregnant or attempting to become pregnant should not undergo treatment. It is suggested that female patients do not attempt to become pregnant for at least 3 months following treatment. If female, in signing this informed consent, you attest that you believe that you are not pregnant and, if you are of childbearing potential, that you are using an adequate form of birth control and will continue to do so for 3 months following treatment.

Benefits/Outcome of Treatment The potential benefits of this treatment may include improvement in neurologic function. Neurologic function includes many things that the nervous system does including, but not limited to, movement, sensation, cranial and peripheral nerve function, brain function, speech, balance, etc. However, it is possible your neurologic function may experience no change or worsen. Any improvement may take several months. At this time, Dr. Weiss cannot make predictions as to the effectiveness of the stem cell treatment for individual patients.

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In signing this informed consent, you acknowledge that no promise of beneficial results has been made to you, nor have any guarantees been offered, either formally or implied, that treatment with bone marrow derived stem cells will be successful or of benefit.

Description of Procedures The three arms of the study are as follows: • Arm 1. Intravenous, intranasal and paraspinal – approximately 6 cc of BMSC fraction filtered with 150 micron filter and administered intravenously; approximately 2 cc of BMSC fraction administered topically to the nasal mucosa of the superior one-third of the nose (1/2 cc bilaterally); approximately 1 cc for each injection administered paraspinally including the following locations: bilaterally at the main spinal cord injury level, approximately two spinal cord levels above and two and four spinal cord levels below. Total paraspinal injection will be approximately 8 cc. • Arm 2. Same as Arm 1 but with additional exoskeletal stimulation as prescribed in the attached protocol within Addendum B. • Arm 3. Same as Arm 1 or 2 but with additional virtual reality stimulation as prescribed in the attached protocol within Addendum C.

Follow-up Exams The first follow-up eye exam must be obtained on the day after treatment at the office. You should have follow-up neurologic exams at 1 month, 3 months, 6 months, and 12 months following the procedure with either our neurologist or your own neurologist. The follow-up exams are extremely important to monitor the health of your nervous system and to assess for potential improvement. If you notice any sudden changes or deterioration following the procedure such as pain, swelling, increasing redness in the paraspinal injection sites, bone marrow aspiration site, fever, or deteriorating neurologic function, please get in touch with Dr. Weiss or your local physician or neurologist immediately as this could represent a threat to your health. This permission also provides for access to your follow-up neurologic exams to Dr. Weiss and his associates and the ability to discuss your treatment and results freely with your health providers. We strongly request all follow-up exams be forwarded to Dr. Weiss and his associates. This may require that the patient giving permission to their neurologist to forward their records or may involve the patient obtaining those records and then forward.

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Alternative Treatments Some of the neurologic diseases that are offered BMSC treatment may have existing drug or surgical treatments that have scientific evidence or general medical community acceptance for use in maintaining or improving neurologic function. If there are such existing treatments, we advise you to pursue those treatments initially before considering BMSC treatment. If you elect to undergo stem cell treatment, it is recommended that you continue all current medical therapies prescribed by your existing physician or neurologist including their recommended follow-up exams until they can examine you and make their own assessment of the need for their therapies or examinations. In signing this informed consent, you assert you are aware of any potential alternative treatments from discussions with your own physicians or neurologists and elect to undergo the stem cell procedure.

Medical Treatments and Costs This procedure is not considered evidence-based by insurance companies. You understand that your participation in this study is at your own expense and will not be reimbursed by any insurance. Should a study-related medical problem or injury occur, appropriate medical care, as determined by your physician or neurologist, may be provided by your physician or neurologist. You understand you will be financially responsible for such medical treatment, although your insurance company may cover any such treatment under your existing policy. You understand that no additional financial compensation will be available for any injury resulting from your participation. This does not constitute a waiver of any rights that you may have under federal or state laws and regulations.

Treatment Location Treatments will be performed at the Park Creek Surgery Center located at 6806 North State Road 7, Coconut Creek, Florida 33073, at which Dr. Weiss is a member of the medical staff. The procedures will be performed in accordance with all surgery center regulations.

Acceptance of Risks The treatment provided is experimental and no guarantees are provided as to the outcome of the procedure. The patient’s neurologic function may become better, stay the same, or worsen. I accept these risks freely and agree to hold harmless Dr.

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Weiss and The Healing Institute; Dr. Silverfarb and Dr. Levy and MD Stem Cells; and the participating neurologist and the personnel who participate in performing the procedure. Initial___________

Medical Clearance Medical clearance for anesthesia and surgery will be obtained by the patient through their own medical doctor prior to the procedure and provided to Dr. Weiss and the associated physicians and staff of the Park Creek Surgery Center. The medical clearance must give permission for the use of anesthesia and provide such laboratory tests and examination as Dr. Weiss and the additional physicians at Park Creek Surgery Center believe are needed to properly assess your risks and provide proper care for you while you undergo the procedure.

Anesthesia Anesthesia will be provided by the anesthesia physicians and staff at the Park Creek Surgery Center in accordance with good medical judgment and regulations of the surgery center and the State of Florida. This includes all types of anesthesia from local injection to general anesthesia. Typically, the patients may have general anesthesia, sedation, or local anesthesia for the bone marrow aspiration and the injection of the stem cells.

Treatment Procedure  reoperative Neurologic Exam P The preoperative neurologic exam will be provided by the patients’ neurologist and will be evaluated by the sub-investigators for inclusion criteria. Immediate pre-­ operative exams and informed consent will be performed by Dr. Weiss and/or the sub-investigators at their office location.

Treatment Location Treatments will be performed at the Park Creek Surgery Center located at 6806 North State Road 7, Coconut Creek, Florida, 33073 at which Dr. Weiss is a member of the medical staff. The procedures will be performed in accordance with all surgery center regulations. Randomization  – no patients are to be randomized. All eligible patients who participate will receive treatment if deemed safe by Dr. Weiss.

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Treatment Procedure 1. Anesthesia Anesthesia will be provided by the anesthesia physicians and staff at the Park Creek Surgery Center in accordance with good medical judgment and regulations of the surgery center and the State of Florida. This includes all types of anesthesia from local injection to general anesthesia. Typically, the patients may have general anesthesia, sedation, or local anesthesia for the bone marrow aspiration and the injection of the stem cells. 2. BMSC collection and preparation Approximately 120 cc of bone marrow aspirate will be collected in the operating room, the exact volume being based on medical judgment. The bone marrow aspirate is collected from one or both of the patient’s iliac bones in the pelvis and may involve one, two, or more separate sites. The bone marrow aspirate will not leave the operating room. For separation and collection of the mononuclear cell layer including the stem cells and additional components, a medical device called the Angel System manufactured by Arthrex, Inc., or equivalent will be used. The Angel System and its components is a Class 2 device per the FDA guidelines. The collected bone marrow aspirate will be placed in the device that will separate the components of the bone marrow and isolate the portion containing the adult stem cells. This is done in a completely sterile, automated, and self-contained fashion with minimal manipulation. The device will be operated by Dr. Weiss’ assistants under Dr. Weiss' supervision. Approximately 16 cc of mononuclear cell material containing the adult stem cells (adult stem cell material) will be available for injection. 3. Neurologic treatment The three arms of the study are as follows: • Arm 1. Intravenous, intranasal, and paraspinal – approximately 6 cc of BMSC fraction filtered with 150 micron filter and administered intravenously; approximately 1  cc of BMSC fraction administered topically to the nasal mucosa of the superior  one-third of the nose (1/2  cc bilaterally); approximately 1 cc for each injection administered paraspinally including the following locations: bilaterally at the main spinal cord injury level, approximately two spinal cord levels above and two and four spinal cord levels below. Total paraspinal injection will be approximately 8 cc. • Arm 2. Same as Arm 1 but with additional exoskeletal stimulation as prescribed in the attached protocol within Addendum B. • Arm 3. Same as Arm 1 or 2 but with additional virtual reality stimulation as prescribed in the attached protocol within Addendum C. Dr. Weiss will supervise the obtaining and separation of the BMSC fraction. Dr. Silverfarb will perform the bone marrow aspiration and the paraspinal injections. Exoskeleton and virtual reality treatments will be administered by Dr. Weiss and his staff. Any excess bone marrow material including other cells and plasma will be discarded in accordance with normal surgery center practice. No material will be retained for future use.

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An intravenous injection is the injection of the bone marrow stem cells (BMSC) into the vein in the patient’s arm. It is standard procedure during anesthesia that the patient will have an intravenous line available for administration of medications and fluids. This same line is used for intravenous injection of the BMSC.  There is a risk of a thrombotic event called pulmonary embolism occurring as a result of a clot forming either prior to or during the passage of the cells through the lungs. Because of the anticoagulation and filtering employed in processing the bone marrow aspirate, we believe this risk is very small. In an analysis performed by the European Group for Blood and Marrow Transplantation on HSCT in over 27,000 patients between 1993 and 2005, this risk was calculated to be approximately 0.000037. To reduce this risk a filter of appropriate size (typically 150 microns) will be used to filter the delivered BMSC. 4. Performance of Injections of Adult Stem Cell Material 1. Intravenous injections may be performed while the patient is recumbent or seated and intranasal while the patient is seated. 2. Anesthesia is given as needed for patient comfort and safety under the direction of the anesthesiologist. 3. The procedure bone marrow aspiration is performed under sterile conditions.

 ossible Side Effects/Complications P 1. General This is a surgical procedure involving the aspiration of bone marrow and the injection of the separated bone marrow stem cell intravenously and by direct placement or inhalation intranasally. The procedure will include the administration of medications to provide anesthesia during the procedure. There is always the risk of unanticipated reactions to the procedure itself, the medications, and the anesthesia. Under very rare circumstances, patients may have serious complications as a result of the procedure or medications including serious abnormal drug reactions, serious allergic reactions, very low blood pressure, seizures, and cardiac or respiratory problems including cardiac or pulmonary arrest. These may result in harm to your body or in death. 2. Bone marrow aspiration Common side effects may include mild local pain, tenderness, and localized bleeding in the area where the doctor aspirates the bone marrow. Very rare complications may include infection or bleeding that is difficult to control. 3. Neurologic treatment An intravenous injection is the injection of the bone marrow stem cells (BMSC) into the vein in the patient’s arm. It is standard procedure during anesthesia that the patient has an intravenous line available for administration of medications and fluids. This same line is used for intravenous injection of the BMSC. There is a risk of a thrombotic event called pulmonary embolism occurring as a result of a clot forming either prior to or during the passage of the cells

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through the lungs. Because of the anticoagulation and filtering employed in processing the bone marrow aspirate, we believe this risk is very small. In an analysis performed by the European Group for Blood and Marrow Transplantation on HSCT in over 27,000 patients between 1993 and 2005, this risk was calculated to be approximately 0.000037. To reduce this risk, a filter of appropriate size will be used to filter the delivered BMSC. Intranasal administration will be provided by direct application of the BMSC material. The complications of intranasally administered nebulized material are limited to potential local irritation, rhinorrhea, and to the side effects of inhaled BMSC. We have identified no specific side effect of BMSC material intranasally. If directly placed intranasally, the BMSC material will be placed in the nasal passages to allow movement to the superior nasal cavity.

 ost-procedure Neurologic Exams P The follow-up neurologic exams will be obtained the day after the procedure and are then requested at 1 month, 3 months, 6 months, and 12 months following the procedure or at the recommended intervals of the neurologist examining the patient. Patients agree to allow Dr. Weiss and his associates to release any medical information to their neurologists and medical doctors. They also agree to provide access to their exams from their neurologist and medical doctor to Dr. Weiss and his associates.

Collection and Use of Data Patients give permission to use their medical information for their own care and for any publication, presentation, or public communication about the procedure and results. In the case of non-direct patient care communication, the patient name and contact information will be held in confidence and not released to protect your privacy. However, if required by law, state or federal agencies may be given access to your full name, data, medical records, and information.

Confidentiality of Records You understand that your identity and certain information pertaining to you that is collected for this study will remain confidential. However, in order to meet the obligations of federal law, you understand that records from this study may be subject to review by representatives of the International Cellular Medicine Society Institutional Review Board and authorized Food and Drug Administration or other government regulatory agencies’ personnel. You hereby consent to such review and disclosure.

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Available Information You understand that any significant new information developed during the course of this study, which may relate to your willingness to continue as a participant, will be provided to you. If you have any questions or desire further information with respect to this study, or if you experience a study-related injury, you should contact: • • • • • • • •

Steven Levy MD, Study Director 3 Sylvan Road South Westport, CT 06880 Phone: (203) 423-9494 Jeffrey N. Weiss, MD, Principal Investigator 1308 A/B North State Road 7 Margate, Florida 33063 Phone: (954) 975-0044

If you wish to contact an impartial third party not associated with this study, you may contact: Reed Davis at 702-664-0017.

Termination You understand that your participation in this study is voluntary and you are under no obligation to participate. Your decision on whether to participate in the study will in no way impact upon the treatment you will receive. You may refuse to participate or may discontinue participation at any time during the study without penalty or loss of benefits to which you are otherwise entitled. If you choose not to participate, or to discontinue your participation in this study, Jeffrey N. Weiss M.D. and his associates will continue to take care of your illness to the best of their ability. In addition, you understand that your participation may be terminated by Jeffrey N. Weiss M.D. and/or your physician without regard to your consent, should he/ she determine that continued participation would be detrimental to you in any way. You understand that at the completion of the study, you may not be able to continue participation.

Participant Statement and Authorization In affixing my signature, I acknowledge that I have read or had read to me this informed consent and permission form, that all my questions have been answered, and that I fully understand the information it contains. I consent to the procedure of bone marrow stem cell treatment for my neurologic disease or damage as performed

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by Dr. Jeffrey Weiss and his associates. This informed consent and permission (also called an authorization) will have no end date ____________________________________________ Printed Name of Patient ____________________________________________  _______________ Signature of Patient                  Date _______________________________________________________________ Name of and Relationship of Responsible Party if patient unable to sign ____________________________________________  _______________ Signature of Responsible Party if patient unable to sign     Date ____________________________________________ Printed Name of Person Explaining Consent ____________________________________________  _______________ Signature of Person Explaining Consent          Date

Protocol Title Alzheimer’s and Cognitive Impairment Stem Cell Treatment Study Protocol Number: 1 Date of Protocol: February 15, 2018 Working Title:

ACIST Study Alzheimer’s and Cognitive Impairment Stem Cell Treatment Principal Investigator Jeffrey N Weiss MD 1308 A/B North State Road 7 Margate, FL 33063 Telephone 954-975-0044 Sub-Investigators Abraham Chamely MBBS Neurologist Study Director Steven Levy MD MD Stem Cells 3 Sylvan Road South Westport, CT 06880 Telephone 203-423-9494

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Primary Site The Healing Institute 1308 A/B North State Road 7 Margate, FL 33063 Telephone 954-975-0044 Supplemental Site Park Creek Surgery Center 6806 North State Road 7 Coconut Creek, Florida 33073

Introduction Type of Research This is a human clinical study involving the isolation of autologous bone marrow derived stem cells (BMSC) and transfer to the vascular system and intranasal area in order to determine if such a treatment will provide a statistically significant improvement in neurologic function for patients with Alzheimer’s disease and other diseases manifesting with cognitive impairment. The method of providing the BMSC will be the same as the Neurologic Stem Cell Treatment study which has already been IRB approved and registered with NIH. BMSC are considered by investigators to be pluripotent. In this study, we will be providing a transfer of these pluripotent stem cells from the bone marrow where they predominantly reside to areas of neurologic tissue disease or damage via the vascular system and intranasal application. In addition to the BMSC, we will have arms that provide near-infrared light treatment preoperatively and postoperatively to the frontal cranial bone with penetration to the superficial cerebral tissue. This research is not federally funded nor subject to federal oversight. There is no HDE involved. This treatment involves human cells and tissue (bone marrow derived stem cells or BMSC) and is exempt from IND requirement – 21CFR312.2(b) and not subject to FDA oversight because it satisfies the following requirements: • The material transferred is Human Cells, Tissues, and Cellular and Tissue Based Products (HCT/P's) defined as “articles containing or consisting of human cells or tissues intended for implantation, transplantation, infusion or transfer into a human recipient” under 21 CFR 1261.3(d) (2011). • The patient involved remains in the operating room during the entire surgical procedure and the bone marrow and separated cells will remain in the same operating room as the patient during the entire procedure. This would exempt the procedure from FDA oversight as the exception set forth in Section 1271.15(b)

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“removing HCT/P's from an individual and implanting such HCT/P's into the same individual during the same surgical procedure.” • The HCT/P's will undergo centrifugation only and therefore are considered minimally manipulated by FDA under 21 CRF 1271.10(a)(1). Specifically “minimal manipulation” is defined in 21 CFR 1271.3 (f) (2) as follows: “For cells or nonstructural tissues, processing that does not alter the relevant biological characteristics of cells or tissues.” In the preamble to the final HCT/P registration rule, FDA listed several techniques that could be undertaken without causing tissues to be more than minimally manipulated including tissues that are centrifuged, subjected to density gradient separation, subjected to selective removal of a specific type of cell, sterilized, or frozen. In our protocol, the bone marrow tissue will be centrifuged in an FDA Class 2 device to separate the stem cells satisfying the minimally manipulated criteria. There will be no amplification or other interference with the function of the HCT/P. There is no drug used in the separation process. Furthermore, the device used for this centrifugation has complied with the regulatory processes and met the requirements of a Class 2 device per FDA guidelines, including minimal manipulation. The material obtained is for homologous use only meeting the requirements of 21 CFR 1271.10(a) (2), which include the repair, reconstruction, replacement, or supplementation of a recipient’s cells or tissues with HCT/P. We believe that bone marrow derived stem cells function in the same fashion, no matter their location. The HCT/P is not being combined with a drug or device.

Purpose and Objective of the Study The purpose of the study is to evaluate the use of autologous bone marrow derived stem cells for diseases associated with cognitive impairment and damage. We hope to support their value in improving cognitive function for different diseases or injury including, but not limited to, Alzheimer’s disease, vascular dementia, dementia with Lewy bodies, mixed dementia, Parkinson’s disease, frontotemporal dementia, Creutzfeldt-Jakob disease, normal pressure hydrocephalus, Huntington’s disease, Wernicke-Korsakoff syndrome, etc. It should be noted that the diseases mentioned, including Alzheimer’s, do not affect only cognitive function. Over time other areas of the brain not specifically associated with memory or cognition are also affected. The objective is to document that cognitive impairment system can be mitigated by the use of BMSC.

Background of the Study A. Alzheimer’s and Cognitive Impairment Stem Cell Treatment Study (ACIST Study)

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Various clinical studies have registered with the National Institutes of Health (NIH) to study neurologic diseases and damage including Alzheimer’s disease. There have also been a number of journal reports of the benefits of treatment with BMSC for diseases and damage to nervous tissue as well as for Alzheimer’s disease (see Addendum A.). In the course of treating patients in the NEST study, we have noted improvements in cognitive function of patients with PD, TBI, and CVA. We would like to add to the volume of literature supporting the use of BMSC in neurologic disease and injury we identify as likely to respond to our treatment. Intravenous administration of BMSC is a well-established approach to neurologic disease and injury with much support for its effectiveness in the pre-clinical and clinical literature. BMSC and the associated bone marrow fraction are posited to have a number of different mechanisms by which they improve neurologic function. In regard to their ability to penetrate the blood-brain barrier for potential transdifferentiation and direct impact on the neurons and glial tissue within the brain, it should be remembered that within the diencephalon, there are specific circumventricular organs which lie in the wall of the third ventricle. These are noteworthy for lacking a blood-brain barrier which facilitates their function of coordinating homeostatic mechanisms of the endocrine and nervous systems including regulation of blood pressure, fluid balance, hunger, and thirst. In addition to the use of intravenous BMSC, the ACIST study will provide a treatment arm using application of BMSC to the nasal passages as a means of introducing BMSC to the central nervous system (CNS). The mucosal membrane of the nose is innervated by the maxillary branches of the trigeminal nerve or 5th cranial nerve. BMSC have been shown to traverse the mucosal membrane, move along these afferent sensory neurons, and enter the central nervous system (CNS). The cribriform plate is an area of the ethmoid bone at the superior portion of the nasal cavity where the primary olfactory nerves enter the CNS. Within the cribriform plate, there are approximately 40 tiny openings through which the axons of the primary olfactory sensory neurons pass into the CNS and synapse with the secondary neurons which form the olfactory bulb continuing as the olfactory nerve. These small boney passages within the cribriform plate may also allow BMSC to traverse and enter the CNS. Physicians and the healthcare industry typically require multiple studies and continuing effort to explore and establish procedures. Therefore, it is our goal to treat patients with the identified neurologic conditions within an IRB-approved protocol which will allow publishing of results in reputable medical journals. The ACIST study will allow us to recruit cognitively impaired patients and to increase the numbers of patients experiencing improvements with BMSC. Infrared light therapy has been shown to have beneficial effects on mitochondria, specifically the cytochrome C enzyme in the electron chain transport (ECT) system found in the inner membrane of the mitochondria. The ECT is responsible for the bulk of ATP production under aerobic conditions in eukaryotic cells. Several recent studies in animal models of Alzheimer's and Parkinson's diseases have reported that low-level near-infrared light (Nir) therapy not only mitigates the behavioral deficits associated with these conditions but also has neuroprotective effects, slowing the

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underlying death of neurons. Current clinical therapies for both diseases do not achieve a comparable slowing of degeneration and neuroprotection, though they do relieve motor signs in Parkinson's disease and, to a lesser extent, the cognitive, and memory deficits in Alzheimer's disease. We believe combining that Nir and BMSC in Alzheimer’s disease and other cognitive impairments may provide additional benefits.

Participant Selection A. Inclusion and Exclusion Criteria

Inclusions The treatment with BMSC is a tissue transfer of active, predominately CD34 stem cells and the growth factors in the associated Bone Marrow Fraction (BMF or liquid containing the BMSC) from the bone marrow to the tissues surrounding or within the nervous system for the purpose of improving the function of that tissue. Diminished neurologic and cognitive function can occur as a result of progressive damage to the nervous system from disease or injury. The exact disease or injury process causing the damage may vary, but the end result may be damage to neurons in the central or peripheral nervous tissue and/or to the glial cells which support the neurons and their function. It is important to understand that our treatment protocol relates to transferring cells from one part of the body (bone marrow) in a way that will maximize the damaged tissue’s access to those cells in a safe and reasonable fashion. There are many diseases and injuries that cause progressive damage to these tissues. Our goal is the treatment of the damaged tissue rather than a specific disease. To be eligible for treatment patients must: 1. Have documented cognitive impairment or diagnosis of disease associated with cognitive impairment such as Alzheimer’s disease. 2. If under current medical therapy (pharmacologic or surgical treatment) for the condition be considered stable on that treatment and unlikely to have reversal of the associated cognitive impairment as a result of the ongoing pharmacologic or surgical treatment. 3. In the estimation of the investigator have the potential for improvement with BMSC treatment and be at minimal risk of any potential harm from the procedure. 4. Be over the age of 40 and capable of providing informed consent. 5. Be medically stable and able to be medically cleared by their primary care physician or a licensed primary care practitioner for the procedure. Medical clearance means that in the estimation of the primary care practitioner, the patient can reasonably be expected to undergo the procedure without significant medical risk to health.

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Restrictions 1. All patients must be capable of an adequate neurologic examination and evaluation to document the pathology. 2. Patients must be capable and willing to undergo follow-up neurologic exams with the investigators or their own neurologists as outlined in the protocol. 3. Patients or their designated power of attorney must be capable of providing informed consent. Cognitive or memory impairment does not necessarily mean the patient is incapable of giving informed consent. They may simply need more time to process or require repetition of the content of the consent to reach understanding and provide informed consent. 4. In the estimation of the investigator, the BMSC collection and treatment will not present a significant risk of harm to the patient's general health or to their neurologic function. 5. Patients who are not medically stable or who may be at significant risk to their health undergoing the procedure will not be eligible. 6. Women of childbearing age must not be pregnant at the time of treatment and should refrain from becoming pregnant for 3 months post-treatment. B. Gender – no restrictions. Women of childbearing age are eligible but must not be pregnant at the time of treatment. C. Racial/ethnic origin – no restrictions. D. Vulnerable populations – no vulnerable populations will be eligible. E. Age – no patients under the age of 40 are to be enrolled. For those 40 years and older, there will be no age restrictions. F. Total number of participants to be enrolled: 100. Explanation of participant number chosen: We propose to address nerve tissue damage caused by the neurologic diseases and injury. Many neurologic diseases, although varying in etiology, have similar detrimental effects on neural tissue including neurons themselves and the supporting glial tissue. The sample size or number of participants proposed is based on the following: 1 . The size of the effect the trial should detect. 2. The alpha or probability of type I error (error of reporting the treatment is effective, but in reality, it is not). 3. Power or the probability of avoiding type II error (beta or the error of reporting the treatment is ineffective, but in reality, it is effective). 4. The potential loss of data from inadequate follow-up on the part of the patients over the five requested patient exams (1 day, 1 month, 3 months, 6 months, and 12 months). 5. Alpha is set to generally accepted statistical significance for clinical trials which is P less than or equal to .05. In regard to the size of the effect the trial should detect, we have chosen a 10% improvement in neurologic function. This is the smallest effect size difference

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that we believe would have clinical significance. With alpha at 0.05 (p less than or equal to .05) and beta similarly set to 0.05, the power would be set at 95%. 6. The standard deviation is high because the variance is correspondingly high (σ = √var). To be as inclusive as possible and to sample various populations and statuses of neurologic tissue disease or damage, we have set the inclusion criteria to be broad. Therefore, the patients treated will have high variance or deviations from the means for any particular eye disease population. These will include variance in patient age, patient gender, disease subtype, disease severity, disease duration, rate of disease progression, degree of neurologic function loss, variety of neurologic function loss, and medical comorbidities. The high standard deviation/variance supports the need for a higher total number of enrolled patients for the study to generate meaningful data. “Recent studies show that enrollment rates have decreased from 75% in 2000 to 59% in 2006 and retention rates have fallen from 69% to 48% during same period. (Getz, “Public Confidence”) http://www.ciscrporg/professional/facts_pat.html If we choose a 60% retention rate, the needed number of patients would be approximately100. Our estimate is that we will be treating two patients per month in the first year. We therefore request 100 patients as a total number of participants to be enrolled in ACIST.

Study Design/Method/Procedures Summary of Research Design  reoperative Neurologic Exam P The preoperative neurologic exam will be provided by the patients’ neurologist and will be evaluated by the investigator for inclusion criteria. Immediate preoperative exams and informed consent will be performed by the investigator at their office. Scales for scoring patient outcomes may include: • Use of the Alzheimer’s Association Medicare Annual Wellness Visit Algorithm for Assessment of Cognition. • Use of non-invasive dynamic light scattering measurement of the inner retinal layer thickness which may correlate with degree of dementia • Mini-Mental State Examination (MMSE) for assessment • Patient and family description of specific cognitive problems that patient is experiencing

Treatment Location Treatments will be performed at the Park Creek Surgery Center located at 6806 North State Road 7, Coconut Creek, Florida 33073 at which Dr. Weiss is a member

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of the medical staff. The procedures will be performed in accordance with all surgery center regulations. Randomization  No patients are to be randomized. All eligible patients who participate will receive treatment if deemed safe by Dr. Weiss.

Treatment Procedure Anesthesia Anesthesia will be provided by the anesthesia physicians and staff at the Park Creek Surgery Center in accordance with good medical judgment and regulations of the surgery center and the State of Florida. This includes all types of anesthesia from local injection to general anesthesia. Typically, the patients have general anesthesia, sedation, or local anesthesia for the bone marrow aspiration and the injection of the stem cells. According to Li et  al. who performed an epidemiology study of anesthesiarelated mortality in the United States from 1999 to 2005, the estimated mortality was 1.1 per million population per year and 8.2 per million hospital surgical discharges [1]. Arbour et al. explored the risk factors associated with anesthetic mortality in 869,483 patients undergoing general, regional, or combination anesthesia between January 1995 and January 1997. There were 119 deaths giving a mortality incidence of 8.8 per 10,000 anesthetics or less than 1 per 100,000 [2]. In a metaanalysis performed by Bainbridge et al., 87 studies involving 24.1 million general anesthetic administrations from before the 1970s through the 2000s were reviewed. There was a progressive decline in anesthetic mortality each decade to 1176 per 1,000,000 in the 1990s to 2000s [3]. We believe there is sufficient evidence to support the safety of general anesthesia as will be provided in the ACIST study.  MSC Collection and Preparation B Approximately 120 cc of bone marrow aspirate will be collected in the operating room, the exact volume being based on medical judgment. The bone marrow aspirate is collected from one or both of the patient's iliac bones in the pelvis and may involve one, two, or more separate sites. The bone marrow aspirate will not leave the operating room. For separation and collection of the mononuclear cell layer including the stem cells and additional components, a medical device called the Angel System manufactured by Arthrex, Inc., or equivalent will be used. The Arthrex Angel System and its components is a Class 2 device per the FDA guidelines. The collected bone marrow aspirate will be placed in the device that will separate the components of the bone marrow and isolate the portion containing the adult stem cells. This is done in a completely sterile, automated, and self-contained fashion with minimal manipulation. The device will be operated by Dr. Weiss’ assistants under Dr. Weiss' supervision. Approximately 14 cc of mononuclear cell material containing the adult stem cells (adult stem cell material) will be available for injection.

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Neurologic Treatment The four arms of the study are as follows: • Arm 1. Intravenous – approximately 14 cc of BMSC fraction filtered with 150 micron filter and administered intravenously • Arm 2. Arm 1 with the addition of near-infrared light exposure the day before the procedure and postoperatively to the frontal cranial bone as tolerated • Arm 3. Intravenous + intranasal – approximately 13 cc of BMSC fraction filtered with 150 micron filter given intravenously and approximately 1/2 cc of BMSC fraction placed topically intranasally • Arm 4. Arm 3 with the addition of near-infrared light exposure the day before the procedure and postoperatively to the frontal cranial bone as tolerated Any excess material will be discarded in accordance with normal surgery center practice. No material will be retained for future use. Near-infrared light will be provided using the WARP 10 device, an FDA-cleared light application device. An intravenous injection is the injection of the bone marrow stem cells (BMSC) into the vein in the patient’s arm. It is standard procedure during anesthesia that the patient will have an intravenous line available for administration of medications and fluids. This same line is used for intravenous injection of the BMSC. There is a risk of a thrombotic event called pulmonary embolism occurring as a result of a clot forming either prior to or during the passage of the cells through the lungs. Because of the anticoagulation and filtering employed in processing the bone marrow aspirate, we believe this risk is very small. In a review of the safety of BMSC donation for hematopoietic stem cell transplantation (HSCT), Bosi and Bartolozzi quoted the analysis by the European Group for Blood and Marrow Transplantation on HSCT performed between 1993 and 2005. One fatal event of pulmonary embolism was found in the over 27,000 patients receiving HSCT; the risk of this complication is calculated to be approximately 0.000037 per procedure [4]. To reduce this risk, a filter of appropriate size (typically 150 microns) will be used to filter the delivered BMSC.

 erformance of Injections of Adult Stem Cell Material P 1. Intravenous injections will generally be performed while the patient is recumbent or is sitting and intranasal while the patient is seated. 2. Anesthesia is given as needed for patient comfort and safety under the direction of the anesthesiologist. 3. The procedure is performed under sterile conditions.

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Possible Side Effects/Complications General This is a surgical procedure involving the aspiration of bone marrow and injection of the separated bone marrow stem cell intravenously and by direct placement or inhalation intranasally. The procedure will include the administration of medications to provide anesthesia during the procedure. There is always the risk of unanticipated reactions to the procedure itself, the medications, and the anesthesia. Under very rare circumstances, patients may have serious complications as a result of the procedure or medications including serious abnormal drug reactions, serious allergic reactions, very low blood pressure, seizures, and cardiac or respiratory problems including cardiac or pulmonary arrest. These may result in harm to your body or in death.  one Marrow Aspiration B Common side effects may include mild local pain, tenderness, and localized bleeding in the area where the doctor aspirates the bone marrow. Very rare complications may include infection or bleeding that is difficult to control. Neurologic Treatment An intravenous injection is the injection of the bone marrow stem cells (BMSC) into the vein in the patient’s arm. It is standard procedure during anesthesia that the patient has an intravenous line available for administration of medications and fluids. This same line is used for intravenous injection of the BMSC. There is a risk of a thrombotic event called pulmonary embolism occurring as a result of a clot forming either prior to or during the passage of the cells through the lungs. Because of the anticoagulation and filtering employed in processing the bone marrow aspirate, we believe this risk is very small. To reduce this risk, a filter of appropriate size (typically 150 microns) will be used to filter the delivered BMSC. Wakitani et al. followed 41 patients following use of BMSC for joint treatment for up to 11 years and 5 months. They found no tumors or infections and concluded autologous BMSC transplantation to be a safe procedure [5]. In a meta-analysis of BMSC used to treat acute myocardial infarction, Cong et al. found an overall significant improvement in left ventricular ejection fraction (LVEF) and other cardiac measurements at 3–6 months and 12 months following BMSC and concluded that intracoronary BMSC post-STEMI was safe and effective [6]. In a recent meta-analysis of 23 randomized controlled studies of BMSC therapy for chronic ischemic heart disease (IHD) and congestive heart failure (CHF) involving 1255 patients, Fisher et al. found moderate evidence that BMSC improves LVEF even in the long term (greater than 1 year) in patients suffering from chronic IHD and CHF [7]. In a study by Nishida et  al. involving dogs with acute spinal cord injury (SCI), autologous BMSC were cultured and injected into the spinal cord lesion. Follow-up from 29 to 62  months following treatment showed no

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complications or worsening of neurologic function [8]. We conclude that the safety of providing BMSC intravenously in ACIST is well supported in the literature. Intranasal administration in Arm 3 and 4 will be provided by direct application of the BMSC material into the nose alone. The complications of intranasally administered nebulized material are limited to potential local irritation, rhinorrhea, and to the side effects of inhaled BMSC. We have identified no specific side effect of BMSC material intranasally. The BMSC material will be placed in the nasal passages to allow movement to the superficial branches of the second division of the trigeminal nerve bilaterally. Chapman et al. reviewed intranasal treatment of central nervous system (CNS) dysfunction in humans. They identified both olfactory and trigeminal pathways of BMSC entry allowing both anterior and posterior regions of the brain exposure. The authors remark on the efficacy and noninvasiveness of intranasal delivery of BMSC. They review several studies of preclinical application and improvements in models of stroke, cerebral hypoxia, and Parkinson’s. They conclude that it is clear that intranasal delivery is clinically safe and effective [9]. In a review of intranasal delivery of stem cells to the brain, Jiang et al. indicates that the approach overcomes the difficulties of other methods of delivery for the treatment of many neurologic disorders [10]. A number of recent preclinical studies utilizing BMSC as well as other types of stem cells in various neurologic diseases (stroke, ischemia, Alzheimer’s disease, spinal cord lesions, intracerebral hemorrhage) may be cited in support of the effect of stem cells delivered via the intranasal route [11–14]. Danielyan et  al. have elegantly demonstrated the direct intranasal delivery of mesenchymal stem cells to the murine brain and identified two prime migratory pathways that allow the cells to enter via the olfactory bulb to various portions of the brain and separately into the cerebral spinal fluid with movement across the cortex and into the brain parenchyma [15]. We conclude that intranasal delivery of BMSC is safe, efficacious, and provides the BMSC the ability to cross the blood-brain barrier successfully in a noninvasive fashion.

Post-procedure Neurologic Exams A follow-up exam will be obtained the day after the procedure and then requested at 1 month, 3 months, 6 months, and 12 months following the procedure or at the recommended intervals of the physician examining the patient. Exams will include a Mini-Mental State Examination. We will provide a follow-up schedule for the patients that they will be given in the investigator’s office. We will attempt to avoid unnecessary loss of information through contact changes and to ensure that at least early data is gathered to enable Intent to Treat (ITT) to be used. The study director will be responsible for ensuring that the required data is collected and for coordinating retention in conjunction with the principal investigator.

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Patients agree to allow Dr. Weiss and his associates to release any medical information to their neurologists and medical doctors. They also agree to provide access to their examinations from their neurologist and medical doctor to the investigator and his associates. Scales for scoring patient outcomes may include the following: • Use of the Alzheimer’s Association Medicare Annual Wellness Visit Algorithm for Assessment of Cognition. • Use of non-invasive measurement of the inner retinal layer thickness which may correlate with degree of dementia • Mini-Mental State Examination (MMSE) for assessment • Patient and family description of specific cognitive problems that the patient is experiencing

Collection and Use of Data Patients give permission to use their medical information for their own care and for any publication, presentation, or public communication about the procedure and results. In the case of non-direct patient care communication, the patient name and contact information will be held in confidence and not released to protect patient privacy. However, if required by law, state or federal agencies may be given access to the patient’s name, data, medical records, and information. Access will be granted to the International Cellular Medicine Society Institutional Review Board as required for monitoring by the Institutional Review Board (IRB).

Analysis of Study Results Data will be collected and analyzed for significance as outlined under Number 4 – Section F (number of participants to be enrolled). Standard statistical methodology will be used.

Monitoring This will be provided by the investigator, the sub-investigators, and his staff, including the collaborator. Any worsening of neurologic status will be investigated by a neurologist.

Storage of Data Data will be stored in paper files and will be accessed by Dr. Weiss, his staff, and associates. This will be kept in the usual manner as other medical files and for the required period of time as provided by state of Florida law.

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Confidentiality of Data All data will be maintained in a confidential manner equal to other medical data and records.

Risk/Benefit Assessment Risk and discomforts are minimal including the risks of bone marrow aspiration and intravenous and intranasal administration of BMSC.

Risks General This is a surgical procedure involving aspiration of bone marrow and intravenous injection and/or intranasal placement or inhalation of the separated bone marrow stem cell isolate. The procedure may include the administration of medications to sedate the patient during the procedure. There is always the risk of unanticipated reactions to the procedure itself or medications. Under very rare circumstances, patients may have serious complications as a result of the procedure or medications including serious abnormal drug reactions, serious allergic reactions, very low blood pressure, and cardiac or respiratory problems including cardiac or pulmonary arrest. These may result in harm to the patient or in death.  one Marrow Aspiration B Common side effects may include mild local pain, tenderness, and localized bleeding in the area where the doctor aspirates the bone marrow. Very rare complications may include infection or bleeding that is difficult to control. Neurologic Treatment An intravenous injection is the injection of the bone marrow stem cells (BMSC) into the vein in the patient’s arm. It is standard procedure during anesthesia that the patient will have an intravenous line available for administration of medications and fluids. This same line is used for intravenous injection of the BMSC. There is a risk of a thrombotic event called pulmonary embolism occurring as a result of a clot forming either prior to or during the passage of the cells through the lungs. Because of the anticoagulation and filtering employed in processing the bone marrow aspirate, we believe this risk is very small. In an analysis performed by the European Group for Blood and Marrow Transplantation on HSCT in over 27,000 patients between 1993 and 2005, this risk

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was calculated to be approximately 0.000037. To reduce this risk, a filter of appropriate size will be used to filter the delivered BMSC. An intranasal placement in Arm 2 will be done topically into the nose alone. The complications of intranasally administered material are limited to potential local irritation, rhinorrhea, and to the side effects of the BMSC. We have identified no specific side effect of BMSC material intranasally. If directly placed intranasally, the BMSC material will be placed in the nasal passages to allow movement to the middle branch of the trigeminal (5th) cranial nerve in the nasal passages. We are not aware of any complications possible with the WARP 10 device.

Prevention of Risks Medical clearance will be required for all patients treated. Dr. Weiss will follow all standard means to minimize the risks of intravenous injection and intranasal inhalation or placement. The physicians involved in bone marrow aspiration similarly have extensive experience with orthopedic procedures and bone marrow aspiration and will perform the technique in a way to minimize risks. Procedures will be done in one of the assigned operating rooms of the Park Creek Surgical Center, Coconut Creek, Florida. Standard procedures and staffing as required by local law for surgical procedures will be provided. Anesthesia services will be provided by board-certified anesthesiologists and their staff. Equipment will include all supportive equipment required for safe operative care of patients and required by local law and certification organizations. This will include anesthetic and pharmacologic drugs and equipment for routine operative patient care and anesthesia administration as well as that needed for emergent care (respiratory or cardiac arrest). The bone marrow processing device with disposable components for safe and sterile processing of bone marrow aspirate will be used.

Adverse Events  erious Adverse Event S A serious adverse event will be considered any undesirable sign, symptom, or medical condition which is fatal, is life-threatening, requires hospitalization or prolongs existing hospitalization, results in persistent or significant disability or capacity, and is medically significant and which the investigator regards as serious based on appropriate medical judgment. An important medical event is any adverse event that may not result in death, be life-threatening, or require hospitalization but may be considered a serious adverse event when, based upon appropriate medical judgment,

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it may jeopardize the patient and may require medical or surgical intervention to prevent one of the outcomes listed in the definitions of serious adverse events. Every serious adverse event must be reported, even if the event does not appear to be associated with the study protocol. The Serious Adverse Event must be reported by filing an Adverse Event Report within 5 days of discovery of the occurrence. In addition, the IRB should be notified by phone or email within 48 hours of discovery of any serious adverse event. The IRB may be notified at (702) 664-0017 or [email protected] cellmedicinesociety.com

 nanticipated Adverse Event U An adverse event will be considered any undesirable sign, symptom, or medical condition even if the event is not considered to be related to the intervention. In the case of preexisting medical conditions, if the condition worsens beyond the rate of normal disease progression, such worsening will be considered an adverse event. An adverse event is also any undesirable and unintended effect occurring in human subjects as a result of the collection of identifiable private information (for example, misplacing a subject’s results should be reported). Adverse events also include any problems associated with the treatment/intervention that adversely affects the rights, safety, or welfare of subjects. Unanticipated adverse events must be reported to the IRB by submission of the Adverse Events form within 14 days of discovery of occurrence.  nticipated Adverse Event A An adverse event will be considered anticipated if it is reasonably expected in nature, severe, and frequent, and is included in the protocol and consent form as a possible risk of participating in the research. Anticipated adverse events should be reported to the IRB only if they result in a modification of the protocol to mitigate and/or detail this event. Anticipated adverse events are reviewed by the IRB to assure that protocol modifications are initiated if necessary. Reportable anticipated adverse events must be reported to the IRB by submission of the Adverse Events form within 30 days of the discovery of the occurrence.

Benefits The patient may obtain improved neurologic function.

Participant Recruitment and Informed Consent Recruitment Recruitment will be brought to the attention of potential patients through announcements on the Internet, email, press releases, direct communications with healthcare providers, and potentially paid advertising in accordance with normal and ethical

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recruiting practices. Recruitment will continue until 100 patients have been enrolled. No coercion will be used. In the course of providing information about the study, it will be communicated that patients will be participating in a clinical study conducted under an IRB protocol approved and monitored by the International Cellular Medicine Society.

Length of Study The study will begin on the date of IRB approval and continue until 1 year following the treatment of the last recruited patient.

Informed Consent/Assent See Informed Consent.

References 1.  Li G, Warner M, Lang BH, et al. Epidemiology of anesthesia-related mortality in the United State, 1999–2005. Anesthesiology. 2009;110(4):759–65. 2.  Arbout MS, Grobbee DE, van Kleef JW, et al. Mortality associated with anaesthesia: a qualitative analysis to identify risk factors. Anaesthesia. 2001;56(12):1141–53. 3.  Bainbridge D, Martin J, Arango M, Cheng D.  Perioperative and anaesthetic-­ related mortality in developed and developing countries: a systematic review and meta-analysis. Lancet. 2012;380(9847):1075–81. 4. Bosi A, Bartolozzi B.  Safety of bone marrow stem cell donation: a review. Transplant Proc. 2010;42(6):2192–4. 5.  Wekitani S, Okabe T, Horibe S, et al. Safety of autologous bone marrow-derived mesenchymal stem cell transplantation for cartilage repair in 41 patients with 45 joints followed for up to 11 years and 5 months. J Tissue Eng Regen Med. 2011;5(2):146–50. 6.  Cong XQ, Li Y, Zhao X, et al. Short-term effect of autologous bone marrow stem cells to treat acute myocardial infarction: a meta-analysis of randomized controlled clinical trials. J Cardiovasc Transl Res. 2015;8(4):221–31. 7.  Fisher SA, Brunskill SJ, Doree C, et al. Stem cell therapy for chronic ischaemic heart disease and congestive heart failure. Cochrane Database Syst Rev. 2014;(4):CD007888. 8.  Nishida H, Nakayama M, Tanaka H, et al. Safety of autologous bone marrow stromal cell transplantation in dogs with acute spinal cord injury. Vet Surg. 2012;41(4):437–42.

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9.  Chapman CD, FreyII WH, Craft S, et al. Intranasal treatment of central nervous system dysfunction in humans. Pharm Res. 2013;30(10):2475–84. 10. Jiang Y, Shu J, Xu G, Liu X.  Intranasal delivery of stem cells to the brain. Expert Opin Drug Deliv. 2011;8(5):623–32. 11. Zhao Q, Hu J, Xiang J, et al. Intranasal administration of human umbilical cord mesenchymal stem cells-conditioned medium enhances vascular remodeling after stroke. Brain Res. 2015;1624:489–96. 12. Ji G, Liu M, Zhao XF, et al. NF-κB signaling is involved in the effects of intranasally engrafted human neural stem cells on neurofunctional improvements in neonatal rat hypoxic-ischemic encephalopathy. CNS Neurosci Ther. Dec;21(12):926–35. 13. Mita T, Furukawa-Hibi Y, Takeuchi H, et  al. Conditioned medium from the stem cells of human dental pulp improves cognitive function in a mouse model of Alzheimer’s disease. Behav Brain Res. 2015;293:189–97. 14. Ninomizy K, Iwatsuki K, Ohnishi Y, et al. Intranasal delivery of bone marrow stromal cells to spinal cord lesions. J Neurosurg Spine. 2015;23(1):111–9. 15. Danielyan L, Schafer R, von Ameln-Mayerhofer A, et al. Intranasal delivery of cells to the brain. Eur J Cell Biol. 2009;88:315–24.

Publications 1.  Danielyan L, Schäfer R, von Ameln-Mayerhofer A, Buadze M, Geisler J, Klopfer T, Burkhardt U, Proksch B, Verleysdonk S, Ayturan M, Buniatian GH, Gleiter CH, Frey WH 2nd. Intranasal delivery of cells to the brain. Eur J Cell Biol. 2009;88(6):315–24. https://doi.org/10.1016/j.ejcb.2009.02.001. Epub 2009 Mar 25. 2.  Duncan T, Valenzuela M. Alzheimer’s disease, dementia, and stem cell therapy. Stem Cell Res Ther. 2017;8(1):111. https://doi.org/10.1186/ s13287-­017-­0567-­5. Review. 3.  Johnstone DM, Moro C, Stone J, Benabid AL, Mitrofanis J. Turning on lights to stop neurodegeneration: the potential of near infrared light therapy in Alzheimer’s and Parkinson’s disease. Front Neurosci. 2016;9:500. https://doi.org/10.3389/ fnins.2015.00500. eCollection 2015. Review. 4.  Robbins JP, Price J. Human induced pluripotent stem cells as a research tool in Alzheimer’s disease. Psychol Med. 2017;47(15):2587–92. https://doi. org/10.1017/S0033291717002124. Epub 2017 Aug 14. Review. 5.  Park SE, Lee NK, Na DL, Chang JW. Optimal mesenchymal stem cell delivery routes to enhance neurogenesis for the treatment of Alzheimer’s disease: optimal MSCs delivery routes for the treatment of AD.  Histol Histopathol. 2018;33(6):533–41. https://doi.org/10.14670/HH-­11-­950. Epub 2017 Nov 29. Review.

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6.  Shroff G. Human embryonic stem cells in the treatment of autism: a case series. Innov Clin Neurosci. 2017;14(3–4):12–16. eCollection 2017 Mar-Apr. 7.  Chez M, Lepage C, Parise C, Dang-Chu A, Hankins A, Carroll M. Safety and observations from a placebo-controlled, crossover study to assess use of autologous umbilical cord blood stem cells to improve symptoms in children with Autism. Stem Cells Transl Med. 2018;7(4):333–41. https://doi.org/10.1002/ sctm.17-­0042. Epub 2018 Feb 6. 8.  Weiss JN, Levy S. Neurologic Stem Cell Treatment Study (NEST) using bone marrow derived stem cells for the treatment of neurological disorders and injuries: study protocol for a nonrandomized efficacy trial. Clin Trials Degener Dis. 2016 [cited 2019 Jun 18];1:176–80.

Near Infrared Light / WARP 10 Application 1.  Abdo A, Ersen A, Sahin M. Near-infrared light penetration profile in the rodent brain. J Biomed Opt. 2013;18:075001. https://doi.org/10.1117/1. JBO.18.7.075001. [PMC free article] [PubMed] [Cross Ref]. 2. Albarracin R, Natoli R, Rutar M, Valter K, Provis J. 670  nm light mitigates oxygen-­ induced degeneration in C57BL/6  J mouse retina. BMC Neurosci. 2013;14:125. https://doi.org/10.1186/1471-­2202-­14-­125. [PMC free article] [PubMed] [Cross Ref]. 3. Alzheimer A. Über eine eigenartige Erkrankung der Hirnr- inde. Allgemeine Zeitschrift Psychiatr Psych. 1907:146–8. 4.  Alzheimer A. Über eigenartige Krankheitsfälle des später- en Alters, Zbl. ges. Neurol Psychiat. 1911;4:356–85. https://doi.org/10.1007/BF02866241. [Cross Ref]. 5.  Ando T, Xuan W, Xu T, Dai T, Sharma SK, Kharkwal GB, et al. Comparison of therapeutic effects between pulsed and continuous wave 810-nm wavelength laser irradiation for traumatic brain injury in mice. PLoS One. 2011;6:e26212. https://doi.org/10.1371/journal.pone.0026212. [PMC free article] [PubMed] [Cross Ref]. 6.  Barrett DW, Gonzalez-Lima F. Transcranial infrared laser stimulation produces beneficial cognitive and emotional effects in humans. Neuroscience. 2013;230:13–23. https://doi.org/10.1016/j.neuroscience.2012.11.016. [PubMed] [Cross Ref]. 7.  Begum R, Powner MB, Hudson N, Hogg C, Jeffery G. Treatment with 670 nm light up regulates cytochrome C oxidase expression and reduces inflammation in an age-related macular degeneration model. PLoS One. 2013;8:e57828. https://doi.org/10.1371/journal.pone.0057828. [PMC free article] [PubMed] [Cross Ref]. 8.  Benabid AL, Chabardes S, Mitrofanis J, Pollak P. Deep brain stimulation of the subthalamic nucleus for the treatment of Parkinson’s disease. Lancet Neurol. 2009;8:67–81. https://doi.org/10.1016/S1474-­4422(08)70291-­6. [PubMed] [Cross Ref].

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9.  Bergman H, Deuschl G. Pathophysiology of Parkinson’s disease: from clinical neurology to basic neuroscience and back. Mov Disord 2002;17(Suppl. 3):S28– S40. https://doi.org/10.1002/mds.10140. [PubMed] [Cross Ref]. 10. Bezard E, Yue Z, Kirik D, Spillantini MG. Animal models of Parkinson’s disease: limits and relevance to neuroprotection studies. Mov Disord. 2013;28:61–70. https://doi.org/10.1002/mds.25108. [PMC free article] [PubMed] [Cross Ref]. 11. Blanco NJ, Maddox WT, Gonzalez-Lima F. Improving executive function using transcranial infrared laser stimulation. J.  Neuropsychol. 2015. https://doi. org/10.1111/jnp.12074. [Epub ahead of print]. [PMC free article] [PubMed] [Cross Ref]. 12. Blandini F, Nappi G, Tassorelli C, Martignoni E.  Functional changes of the basal ganglia circuitry in Parkinson’s disease. Prog Neurobiol 2000;62:63–88. https://doi.org/10.1016/S0301-­0082(99)00067-­2. [PubMed] [Cross Ref]. 13. Blesa J, Phani S, Jackson-Lewis V, Przedborski S.  Classic and new animal models of Parkinson’s disease. J Biomed Biotechnol 2012;2012:845618. https://doi.org/10.1155/2012/845618. [PMC free article] [PubMed] [Cross Ref]. 14.  Braak H, Braak E.  Staging of Alzheimer’s disease-related neurofibrillary changes. Neurobiol Aging. 1995;16:271–8. discussion: 278ssion: 278 E. (1995). Staging of Al[PubMed] [Cross Ref]. 15. Braverman B, McCarthy RJ, Ivankovich AD, Forde DE, Overfield M, Bapna MS. Effect of helium-neon and infrared laser irradiation on wound healing in rabbits. Lasers Surg Med. 1989;9:50–8. https://doi.org/10.1002/ lsm.1900090111. [PubMed] [Cross Ref]. 16. Brettschneider J, Tredici KD, Lee VMY, Trojanowski JQ. Spreading of pathology in neurodegenerative diseases: a focus on human studies. Nat Rev Neurosci. 2015;16:109–20. https://doi.org/10.1038/nrn3887. [PMC free article] [PubMed] [Cross Ref]. 17. Burchman M.  Using photobiomodulation on a severe Parkinson’s patient to enable extractions, root canal treatment, and partial denture fabrication. J Laser Dent. 2011;19:297–300. 18. Byrnes KR, Waynant RW, Ilev IK, Wu X, Barna L, Smith K, et al. Light promotes regeneration and functional recovery and alters the immune response after spinal cord injury. Lasers Surg Med. 2005;36:171–85. https://doi. org/10.1002/lsm.20143. [PubMed] [Cross Ref]. 19. Carvey PM, Hendey B, Monahan AJ. The blood-brain barrier in neurodegenerative disease: a rhetorical perspective. J Neurochem 111, 2009:291–314. https://doi.org/10.1111/j.1471-­4159.2009.06319.x. [PMC free article] [PubMed] [Cross Ref]. 20. Chaturvedi RK, Beal MF. Mitochondrial approaches for neuroprotection. Ann NYAcad Sci. 2008;1147:395–412. https://doi.org/10.1196/annals.1427.027. [PMC free article] [PubMed] [Cross Ref]. 21. Chung H, Dai T, Sharma SK, Huang YY, Carroll JD, Hamblin MR. The nuts and bolts of low-level laser (light) therapy. Ann Biomed Eng. 2012;40:516–33. https://doi.org/10.1007/s10439-­011-­0454-­7. [PMC free article] [PubMed] [Cross Ref].

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22. Copped F, Migliore L. DNA damage in neurodegenerative diseases. Mutat Res. 776:84–97. https://doi.org/10.1016/j.mrfmmm.2014.11.010. [PubMed] [Cross Ref]. 23. Corti O, Brice A. Mitochondrial quality control turns out to be the principal suspect in parkin and PINK1-related autosomal recessive Parkinson’s disease. Curr Opin Neurobiol. 2013;23:100–8. https://doi.org/10.1016/j. conb.2012.11.002. [PubMed] [Cross Ref]. 24. Cosgrove J, Alty JE, Jamieson S. Cognitive impairment in Parkinson’s disease. Postgrad Med J. 2015;91:212–20. https://doi.org/10.1136/ postgradmedj-­2015-­133247. [PubMed] [Cross Ref]. 25. Cullen KM. Pericapillary haem-rich deposits: evidence for microhaemorrhages in aging human cerebral cortex. J Cereb Blood Flow Metab. 25:1656–67. https://doi.org/10.1038/sj.jcbfm.9600155. [PubMed] [Cross Ref]. 26. Cullen KM. Microvascular pathology in the aging human brain: evidence that senile plaques are sites of microhaemorrhages. Neurobiol Aging. 27:1786–96. https://doi.org/10.1016/j.neurobiolaging.2005.10.016. [PubMed] [Cross Ref]. 27. Darlot F, Moro C, El Massri N, Chabrol C, Johnstone DM, Reinhart F, et al. Near-infrared light is neuroprotective in a monkey model of Parkinson’s disease. Ann Neurol. 2015. https://doi.org/10.1002/ana.24542. [Epub ahead of print]. [PubMed] [Cross Ref]. 28. De la Torre JC. Is Alzheimer’s disease a neurodegenerative or a vascular disorder? Data, dogma, and dialectics. Lancet Neurol. 2004;3:184–90. https://doi. org/10.1016/S1474-­4422(04)00683-­0. [PubMed] [Cross Ref]. 29. Del Tredici K, Braak H.  Dysfunction of the locus coeruleus-norepinephrine system and related circuitry in Parkinson’s disease-related dementia. J Neurol Neurosurg Psychiatr. 2013;84,:774–83. https://doi.org/10.1136/ jnnp-­2011-­301817. [PubMed] [Cross Ref]. 30. Desmet K, Buchmann E, Henry M, Wong-Riley M, Eells J, VerHoeve J, et al. Near-infrared light as a possible treatment option for Parkinson’s disease and laser eye injury. Proc SPIE. 2009;7165:716503-1–716503-10. https://doi. org/10.1117/12.803964. [Cross Ref]. 31. Desmet KD, Paz DA, Corry JJ, Eells JT, Wong-Riley MTT, Henry MM, et al. Clinical and experimental applications of NIR-LED photobiomodulation. Photomed. Laser Surg. 2006;24:121–8. https://doi.org/10.1089/ pho.2006.24.121. [PubMed] [Cross Ref]. 32.  DeTaboada L, Ilic S, Leichliter-Martha S, Oron U, Oron A, Streeter J. Transcranial application of low-energy laser irradiation improves neurological deficits in rats following acute stroke. Lasers Surg Med. 2006;38:70–3. https://doi.org/10.1002/lsm.20256. [PubMed] [Cross Ref]. 33. DeTaboada L, Yu J, El-Amouri S, Gattoni-Celli S, Richieri S, McCarthy T, et al. Transcranial laser therapy attenuates amyloid-β peptide neuropathology in amyloid-β protein precursor transgenic mice. J Alzheimers Dis. 2011;23:521–35. https://doi.org/10.3233/JAD-­2010-­100894. [PubMed] [Cross Ref].

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2014;122:50–53. https://doi.org/10.1016/j.exer.2014.02.023. [PubMed] [Cross Ref]. 46. Goedert M. Alzheimer’s and Parkinson’s diseases: the prion concept in relation to assembled Aβ, tau, and α-synuclein. Science 2015;349:1255555. https://doi. org/10.1126/science.1255555. [PubMed] [Cross Ref]. 47.  Goedert M, Spillantini MG.  A century of Alzheimer’s disease. Science 2006;314:777–81. https://doi.org/10.1126/science.1132814. [PubMed] [Cross Ref]. 48. Gonzalez-Lima F, Barksdale BR, Rojas JC. Mitochondrial respiration as a target for neuroprotection and cognitive enhancement. Biochem Pharmacol. 2014;88;584–93. https://doi.org/10.1016/j.bcp.2013.11.010. [PubMed] [Cross Ref]. 49. Grammas P, Martinez J, Miller B. Cerebral microvascular endothelium and the pathogenesis of neurodegenerative diseases. Expert Rev Mol Med. 2011;13:e19. https://doi.org/10.1017/S1462399411001918. [PubMed] [Cross Ref]. 50. Grillo SL, Duggett NA, Ennaceur A, Chazot PL. Non-invasive infra-red therapy (1072 nm) reduces β-amyloid protein levels in the brain of an Alzheimer’s disease mouse model, TASTPM. J Photochem Photobiol B Biol. 2013;123:13–22. https://doi.org/10.1016/j.jphotobiol.2013.02.015. [PubMed] [Cross Ref]. 51.  Hamblin MR, Demidova TN.  Mechanisms of low level light therapy, in Proceedings of SPIE-The International Society for Optical Engineering; 2006. 52. Hardy J, Selkoe DJ. The amyloid hypothesis of Alzheimer’s disease: progress and problems on the road to therapeutics. Science. 2002;297:353–356. https:// doi.org/10.1126/science.1072994. [PubMed] [Cross Ref]. 53. Haslinger B, Erhard P. Event-related functional magnetic resonance imaging in Parkinson’s disease before and after levodopa. Brain. 124:558–70. https://doi. org/10.1093/brain/124.3.558. [PubMed] [Cross Ref]. 54. Hausenloy DJ, Yellon DM.  Remote ischaemic preconditioning: underlying mechanisms and clinical application. Cardiovasc Res. 2008;79:377–86. https:// doi.org/10.1093/cvr/cvn114. [PubMed] [Cross Ref]. 55. Herrup K. The case for rejecting the amyloid cascade hypothesis. Nat Neurosci. 2015;794–9. https://doi.org/10.1038/nn.4017. [PubMed] [Cross Ref]. 56. Hou ST, Jiang SX, Smith RA.  Permissive and repulsive cues and signalling pathways of axonal outgrowth and regeneration. Int Rev Cell Mol Biol. 2008;267:125–81. https://doi.org/10.1016/S1937-­6448(08)00603-­5. [PubMed] [Cross Ref]. 57. Ilic S, Leichliter S, Streeter J, Oron A, DeTaboada L, Oron U. Effects of power densities, continuous and pulse frequencies, and number of sessions of lowlevel laser therapy on intact rat brain. Photomed. Laser Surg. 24:458–466. https://doi.org/10.1089/pho.2006.24.458. [PubMed] [Cross Ref]. 58. Jankovic J, Poewe W.  Therapies in Parkinson’s disease. Curr Opin Neurol. 2012;25:433–47. https://doi.org/10.1097/WCO.0b013e3283542fc2. [PubMed] [Cross Ref]. 59. Johnstone D, Coleman K, Moro C, Torres N, Eells J, Baker GE, et  al. The potential of light therapy in Parkinson’s disease. ChronoPhysiology Ther. 2014;4:1–14. https://doi.org/10.2147/CPT.S57180. [Cross Ref].

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60. Johnstone DM, El Massri N, Moro C, Spana S, Wang XS, Torres N, et  al. Indirect application of near infrared light induces neuroprotection in a mouse model of parkinsonism an abscopal neuroprotective effect. Neuroscience. 2014;274:93–101. https://doi.org/10.1016/j.neuroscience.2014.05.023. [PubMed] [Cross Ref]. 61. Johnstone DM, Mitrofanis J, Stone J. Targeting the body to protect the brain: inducing neuroprotection with remotely-applied near infrared light. Neural Regen Res. 2015;10:349–51. https://doi.org/10.4103/1673-­5374.153673. [PMC free article] [PubMed] [Cross Ref]. 62. Kortekaas R, Leenders KL, van Oostrom JCH, Vaalburg W, Bart J, Willemsen ATM, et al. Blood-brain barrier dysfunction in parkinsonian midbrain in vivo. Ann Neurol. 2005;57:176–9. https://doi.org/10.1002/ana.20369. [PubMed] [Cross Ref]. 63. Lampl Y, Zivin JA, Fisher M, Lew R, Welin L, Dahlof B, et al. Infrared laser therapy for ischemic stroke: a new treatment strategy: results of the NeuroThera Effectiveness and Safety Trial-1 (NEST-1). Stroke. 2007;38:1843–9. https:// doi.org/10.1161/STROKEAHA.106.478230. [PubMed] [Cross Ref]. 64. Lapchak PA. Taking a light approach to treating acute ischemic stroke patients: transcranial near-infrared laser therapy translational science. Ann Med. 2010;42:576–86. https://doi.org/10.3109/07853890.2010.532811. [PMC free article] [PubMed] [Cross Ref]. 65. Lapchak PA, Wei J, Zivin JA. Transcranial infrared laser therapy improves clinical rating scores after embolic strokes in rabbits. Stroke. 2004;35:1985–8. https://doi.org/10.1161/01.STR.0000131808.69640.b7. [PubMed] [Cross Ref]. 66. Liang HL, Whelan HT, Eells JT, Wong-Riley MTT.  Near-infrared light via light-emitting diode treatment is therapeutic against rotenone- and 1-methyl-­4phenylpyridinium ion-induced neurotoxicity. Neuroscience. 2008;153:963–974. https://doi.org/10.1016/j.neuroscience.2008.03.042. [PMC free article] [PubMed] [Cross Ref]. 67. Maloney R, Shanks S, Maloney J. The application of low-level laser therapy for the symptomatic care of late stage Parkinson’s disease: a non-controlled, non-­ randomized study [Abstract]. Am Soc Laser Med Surg. 2010;185. 68. McCarthy TJ, De Taboada L, Hildebrandt PK, Ziemer EL, Richieri SP, Streeter J. Long-term safety of single and multiple infrared transcranial laser treatments in Sprague-Dawley rats. Photomed Laser Surg. 2010;28:663–7. https://doi. org/10.1089/pho.2009.2581. [PubMed] [Cross Ref]. 69. Merry G, Dotson R, Devenyi R, Markowitz S, Reyes S. Photobiomodulation as a new treatment for dry age related macular degeneration. Results from the toronto and Oak ridge photobimodulation study in AMD (TORPA). Invest Ophthalmol Vis Sci. 2012;53, 2049. 70. Michalikova S, Ennaceur A, van Rensburg R, Chazot PL. Emotional responses and memory performance of middle-aged CD1 mice in a 3D maze: effects of low infrared light. Neurobiol Learn Mem. 2008;89:480–8. https://doi. org/10.1016/j.nlm.2007.07.014. [PubMed] [Cross Ref]. 71.  Moges H, Vasconcelos OM, Campbell WW, Borke RC, McCoy JA, Kaczmarczyk L, et al. Light therapy and supplementary Riboflavin in the SOD1

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transgenic mouse model of familial amyotrophic lateral sclerosis (FALS). Lasers Surg Med. 2009;41:52–59. https://doi.org/10.1002/lsm.20732. [PubMed] [Cross Ref]. 72. Moro C, El Massri N, Torres N, Ratel D, De Jaeger X, Chabrol C, et  al. Photobiomodulation inside the brain: a novel method of applying near-infrared light intracranially and its impact on dopaminergic cell survival in MPTPtreated mice. J Neurosurg. 2014;120:670–83. https://doi.org/10.3171/2013.9. JNS13423. [PubMed] [Cross Ref]. 73. Moro C, Torres N, El Massri N, Ratel D, Johnstone DM, Stone J, et  al. Photobiomodulation preserves behaviour and midbrain dopaminergic cells from MPTP toxicity: evidence from two mouse strains. BMC Neurosci. 2013;14:40. https://doi.org/10.1186/1471-­2202-­14-­40. [PMC free article] [PubMed] [Cross Ref]. 74. Muili KA, Gopalakrishnan S, Meyer SL, Eells JT, Lyons JA. Amelioration of experimental autoimmune encephalomyelitis in C57BL/6 mice by photobiomodulation induced by 670 nm light. PLoS One. 2012;7:e30655. https://doi. org/10.1371/journal.pone.0030655. [PMC free article] [PubMed] [Cross Ref]. 75. Naeser MA, Saltmarche A, Krengel MH, Hamblin MR, Knight JA. Improved cognitive function after transcranial, light-emitting diode treatments in chronic, traumatic brain injury: two case reports. Photomed Laser Surg. 2011;29:351–8. https://doi.org/10.1089/pho.2010.2814. [PMC free article] [PubMed] [Cross Ref]. 76. Naeser MA, Zafonte R, Krengel MH, Martin PI, Frazier J, Hamblin MR, et al. Significant improvements in cognitive performance post-transcranial, red/near-­ infrared light-emitting diode treatments in chronic, mild traumatic brain injury: open-protocol study. J Neurotrauma. 2014;31:1008–17. https://doi.org/10.1089/ neu.2013.3244. [PMC free article] [PubMed] [Cross Ref]. 77. Natoli R, Valter K, Barbosa M, Dahlstrom J, Rutar M, Kent A, et al. 670 nm photobiomodulation as a novel protection against retinopathy of prematurity: evidence from oxygen induced retinopathy models. PLoS One. 2013;8:e72135. https://doi.org/10.1371/journal.pone.0072135. [PMC free article] [PubMed] [Cross Ref]. 78. Natoli R, Zhu Y, Valter K, Bisti S, Eells J, Stone J. Gene and noncoding RNA regulation underlying photoreceptor protection: microarray study of dietary antioxidant saffron and photobiomodulation in rat retina. Mol Vis. 2010;16:1801–22. [PMC free article] [PubMed]. 79. Nelson L, Tabet N.  Slowing the progression of Alzheimer’s disease; what works? Ageing Res Rev. 2015;23(Pt B):193–209. https://doi.org/10.1016/j. arr.2015.07.002. [PubMed] [Cross Ref]. 80. Olanow CW, Kieburtz K, Schapira AHV. Why have we failed to achieve neuroprotection in Parkinson’s disease? Ann Neurol. 2008;64(Suppl. 2):S101–S110. https://doi.org/10.1002/ana.21461. [PubMed] [Cross Ref]. 81. Oron A, Oron U, Chen J, Eilam A, Zhang C, Sadeh M, et al. Low-level laser therapy applied transcranially to rats after induction of stroke significantly reduces long-term neurological deficits. Stroke. 2006;37:2620–4. https://doi. org/10.1161/01.STR.0000242775.14642.b8. [PubMed] [Cross Ref].

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2010;42:576–86. https://doi.org/10.3109/07853890.2010.532811. [PMC free article] [PubMed] [Cross Ref]. 187. Lapchak PA, Wei J, Zivin JA.  Transcranial infrared laser therapy improves clinical rating scores after embolic strokes in rabbits. Stroke 2004;35:1985–8. https://doi.org/10.1161/01.STR.0000131808.69640.b7. [PubMed] [Cross Ref]. 188. Liang HL, Whelan HT, Eells JT, Wong-Riley MTT.  Near-infrared light via light-emitting diode treatment is therapeutic against rotenone- and 1-methyl-­4phenylpyridinium ion-induced neurotoxicity. Neuroscience. 2008;153:963–74. https://doi.org/10.1016/j.neuroscience.2008.03.042. [PMC free article] [PubMed] [Cross Ref]. 189. Maloney R, Shanks S, Maloney J. The application of low-level laser therapy for the symptomatic care of late stage Parkinson’s disease: a non-controlled, non-randomized study [Abstract]. Am Soc Laser Med Surg. 2010;185. 190. McCarthy TJ, De Taboada L, Hildebrandt PK, Ziemer EL, Richieri SP, Streeter J.  Long-term safety of single and multiple infrared transcranial laser treatments in Sprague-Dawley rats. Photomed Laser Surg. 2010;28:663–7. https:// doi.org/10.1089/pho.2009.2581. [PubMed] [Cross Ref]. 191. Merry G, Dotson R, Devenyi R, Markowitz S, Reyes S. Photobiomodulation as a new treatment for dry age related macular degeneration. Results from the toronto and Oak ridge photobimodulation study in AMD (TORPA). Invest Ophthalmol Vis Sci. 2012;53:2049. 192. Michalikova S, Ennaceur A, van Rensburg R, Chazot PL. Emotional responses and memory performance of middle-aged CD1 mice in a 3D maze: effects of low infrared light. Neurobiol Learn Mem. 2008;89:480–8. https://doi. org/10.1016/j.nlm.2007.07.014. [PubMed] [Cross Ref]. 193.  Moges H, Vasconcelos OM, Campbell WW, Borke RC, McCoy JA, Kaczmarczyk L, et  al. Light therapy and supplementary Riboflavin in the SOD1 transgenic mouse model of familial amyotrophic lateral sclerosis (FALS). Lasers Surg Med. 2009;41:52–9. https://doi.org/10.1002/lsm.20732. [PubMed] [Cross Ref]. 194. Moro C, El Massri N, Torres N, Ratel D, De Jaeger X, Chabrol C, et  al. Photobiomodulation inside the brain: a novel method of applying near-infrared light intracranially and its impact on dopaminergic cell survival in MPTPtreated mice. J Neurosurg. 2014;120:670–83. https://doi.org/10.3171/2013.9. JNS13423. [PubMed] [Cross Ref]. 195. Moro C, Torres N, El Massri N, Ratel D, Johnstone DM, Stone J, et  al. Photobiomodulation preserves behaviour and midbrain dopaminergic cells from MPTP toxicity: evidence from two mouse strains. BMC Neurosci. 2013;14:40. https://doi.org/10.1186/1471-­2202-­14-­40. [PMC free article] [PubMed] [Cross Ref]. 196. Muili KA, Gopalakrishnan S, Meyer SL, Eells JT, Lyons J-A. Amelioration of experimental autoimmune encephalomyelitis in C57BL/6 mice by photobiomodulation induced by 670 nm light. PLoS One. 2012;7:e30655. https://doi. org/10.1371/journal.pone.0030655 [PMC free article] [PubMed] [Cross Ref].

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197. Naeser MA, Saltmarche A, Krengel MH, Hamblin MR, Knight JA. Improved cognitive function after transcranial, light-emitting diode treatments in chronic, traumatic brain injury: two case reports. Photomed. Laser Surg. 2011;29:351–8. https://doi.org/10.1089/pho.2010.2814. [PMC free article] [PubMed] [Cross Ref]. 198. Naeser MA, Zafonte R, Krengel MH, Martin PI, Frazier J, Hamblin MR, et al. Significant improvements in cognitive performance post-transcranial, red/ near-­infrared light-emitting diode treatments in chronic, mild traumatic brain injury: open-protocol study. J Neurotrauma. 2014;31:1008–17. https://doi. org/10.1089/neu.2013.3244. [PMC free article] [PubMed] [Cross Ref]. 199. Natoli R, Valter K, Barbosa M, Dahlstrom J, Rutar M, Kent A, et al. 670 nm photobiomodulation as a novel protection against retinopathy of prematurity: evidence from oxygen induced retinopathy models. PLoS One. 2013;8:e72135. https://doi.org/10.1371/journal.pone.0072135. [PMC free article] [PubMed] [Cross Ref]. 200. Natoli R, Zhu Y, Valter K, Bisti S, Eells J, Stone J. Gene and noncoding RNA regulation underlying photoreceptor protection: microarray study of dietary antioxidant saffron and photobiomodulation in rat retina. Mol Vis. 2010:16:1801–22. [PMC free article] [PubMed]. 201. Nelson L, Tabet N.  Slowing the progression of Alzheimer’s disease; what works? Ageing Res Rev. 2015;23(Pt B):193–209. https://doi.org/10.1016/j. arr.2015.07.002. [PubMed] [Cross Ref]. 202. Olanow CW, Kieburtz K, Schapira AHV. Why have we failed to achieve neuroprotection in Parkinson’s disease? Ann Neurol. 2008;64(Suppl. 2):S101– S110. https://doi.org/10.1002/ana.21461. [PubMed] [Cross Ref]. 203. Oron A, Oron U, Chen J, Eilam A, Zhang C, Sadeh M, et al. Low-level laser therapy applied transcranially to rats after induction of stroke significantly reduces long-term neurological deficits. Stroke. 2006;37:2620–4. https://doi. org/10.1161/01.STR.0000242775.14642.b8. [PubMed] [Cross Ref]. 204. Oron A, Oron U, Streeter J, De Taboada L, Alexandrovich A, Trembovler V, et al. Near infrared transcranial laser therapy applied at various modes to mice following traumatic brain injury significantly reduces long-term neurological deficits. J Neurotrauma. 2012;29:401–7. https://doi.org/10.1089/ neu.2011.2062. [PubMed] [Cross Ref]. 205. Peoples C, Spana S, Ashkan K, Benabid A-L, Stone J, Baker GE, et  al. Photobiomodulation enhances nigral dopaminergic cell survival in a chronic MPTP mouse model of Parkinson’s disease. Parkinsonism Relat Disord. 2012;18:469–76. https://doi.org/10.1016/j.parkreldis.2012.01.005. [PubMed] [Cross Ref]. 206. Postow MA, Callahan MK, Barker CA, Yamada Y, Yuan J, Kitano S, et  al. Immunologic correlates of the abscopal effect in a patient with melanoma. N Engl J Med. 2012;366:925–31. https://doi.org/10.1056/NEJMoa1112824. [PMC free article] [PubMed] [Cross Ref]. 207.  Purushothuman S, Johnstone DM, Nandasena C, Mitrofanis J, Stone J.  Photobiomodulation with near infrared light mitigates Alzheimer’s

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disease-related pathology in cerebral cortex—evidence from two transgenic mouse models. Alzheimers Res Ther. 2014;6:2. https://doi.org/10.1186/ alzrt232. [PMC free article] [PubMed] [Cross Ref]. 208. Purushothuman S, Johnstone DM, Nandasena C, van Eersel J, Ittner LM, Mitrofanis J, et al. Near infrared light mitigates cerebellar pathology in transgenic mouse models of dementia. Neurosci Lett. 2015;591:155–9. https://doi. org/10.1016/j.neulet.2015.02.037. [PubMed] [Cross Ref]. 209. Purushothuman S, Nandasena C, Johnstone DM, Stone J, Mitrofanis J. The impact of near-infrared light on dopaminergic cell survival in a transgenic mouse model of parkinsonism. Brain Res. 2013;1535:61–70. https://doi. org/10.1016/j.brainres.2013.08.047. [PubMed] [Cross Ref]. 210. Quirk BJ, Desmet KD, Henry M, Buchmann E, Wong-Riley M, Eells JT, et al. Therapeutic effect of near infrared (NIR) light on Parkinson’s disease models. Front Biosci (Elite. Ed). 2012;4:818–23. [PubMed]. 211. Quirk BJ, Torbey M, Buchmann E, Verma S, Whelan HT. Near-infrared photobiomodulation in an animal model of traumatic brain injury: improvements at the behavioral and biochemical levels. Photomed. Laser Surg. 2012;30:523–9. https://doi.org/10.1089/pho.2012.3261 [PMC free article] [PubMed] [Cross Ref]. 212. Recasens A, Dehay B, Bové J, Carballo-Carbajal I, Dovero S, Pérez-Villalba A, et al. Lewy body extracts from Parkinson disease brains trigger α-synuclein pathology and neurodegeneration in mice and monkeys: LB-induced pathology. Ann Neurol. 2014;75:351–62. https://doi.org/10.1002/ana.24066. [PubMed] [Cross Ref]. 213. Reinhart F, El Massri N, Darlot F, Moro C, Costecalde T, Peoples CL, et al. Evidence for improved behaviour and neuroprotection after intracranial application of near infrared light in a hemi-parkinsonian rat model. J Neurosurg. 2015. https://doi.org/10.3171/2015.5.JNS15735. [Epub ahead of print]. [PubMed] [Cross Ref]. 214. Reinhart F, El Massri N, Darlot F, Torres N, Johnstone DM, Chabrol C, et al. 810nm near-infrared light offers neuroprotection and improves locomotor activity in MPTP-treated mice. Neurosci Res. 2015;92:86–90. https://doi. org/10.1016/j.neures.2014.11.005. [PubMed] [Cross Ref]. 215.  Rinne JO.  Nigral degeneration in Parkinson’s disease. Mov Disord. 1993;8(Suppl. 1):S31–S35. https://doi.org/10.1002/mds.870080507. [PubMed] [Cross Ref]. 216. Rojas J, Gonzalez-Lima F. Low-level light therapy of the eye and brain. Eye Brain. 2011;3:49–67. https://doi.org/10.2147/EB.S21391. [Cross Ref]. 217. Sabatini U, Boulanouar K, Fabre N, Martin F, Carel C, Colonnese C, et al. Cortical motor reorganization in akinetic patients with Parkinson’s disease: a functional MRI study. Brain. 2000;123(Pt 2):394–403. https://doi.org/10.1093/ brain/123.2.394. [PubMed] [Cross Ref]. 218. Samuel M, Ceballos-Baumann AO, Blin J, Uema T, Boecker H, Passingham RE, et al. Evidence for lateral premotor and parietal overactivity in Parkinson’s disease during sequential and bimanual movements. A PET study. Brain.

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1997;120(Pt 6):963–76. https://doi.org/10.1093/brain/120.6.963. [PubMed] [Cross Ref]. 219. Schapira AHV, Olanow CW, Greenamyre JT, Bezard E. Slowing of neurodegeneration in Parkinson’s disease and Huntington’s disease: future therapeutic perspectives. Lancet. 2014;384:545–55. https://doi.org/10.1016/ S0140-­6736(14)61010-­2. [PubMed] [Cross Ref]. 220. Schiffer F, Johnston AL, Ravichandran C, Polcari A, Teicher MH, Webb RH, et al. Psychological benefits 2 and 4 weeks after a single treatment with near infrared light to the forehead: a pilot study of 10 patients with major depression and anxiety. Behav Brain Funct. 2009;5:46. https://doi.org/10.1186/1744-­ 9081-­5-­46. [PMC free article] [PubMed] [Cross Ref]. 221. Shaw VE, Keay KA, Ashkan K, Benabid A-L, Mitrofanis J.  Dopaminergic cells in the periaqueductal grey matter of MPTP-treated monkeys and mice; patterns of survival and effect of deep brain stimulation and lesion of the subthalamic nucleus. Parkinsonism Relat. Disord. 2010;16:338–44. https://doi. org/10.1016/j.parkreldis.2010.02.008. [PubMed] [Cross Ref]. 222. Shaw VE, Peoples C, Spana S, Ashkan K, Benabid A-L, Stone J, et al. Patterns of cell activity in the subthalamic region associated with the neuroprotective action of near-infrared light treatment in MPTP-Treated Mice. Parkinsons Dis. 2012;2012:296875. https://doi.org/10.1155/2012/296875. [PMC free article] [PubMed] [Cross Ref]. 223. Sommer AP, Bieschke J, Friedrich RP, Zhu D, Wanker EE, Fecht HJ, et al. 670 nm laser light and EGCG complementarily reduce amyloid-β aggregates in human neuroblastoma cells: basis for treatment of Alzheimer’s disease? Photomed Laser Surg. 2012;30:54–60. https://doi.org/10.1089/pho.2011.3073. [PubMed] [Cross Ref]. 224.   Stone J.  What initiates the formation of senile plaques? The origin of Alzheimer-like dementias in capillary haemorrhages. Med Hypotheses. 2008;71:347–59. https://doi.org/10.1016/j.mehy.2008.04.007. [PubMed] [Cross Ref]. 225. Stone J, Johnstone DM, Mitrofanis J. The helmet experiment in Parkinson’s disease: an observation of the mechanism of neuroprotection by near infra-red light, in 9th WALT Congress. QLD: Gold Coast; 2013. 226. Stone J, Johnstone DM, Mitrofanis J, O’Rourke M. The mechanical cause of age-related dementia (Alzheimer’s disease): the brain is destroyed by the pulse. J Alzheimers Dis. 2015;44:355–73. https://doi.org/10.3233/ JAD-­141884. [PubMed] [Cross Ref]. 227. Swerdlow RH, Khan SM. A “mitochondrial cascade hypothesis” for sporadic Alzheimer’s disease. Med Hypotheses. 2004;63:8–20. https://doi. org/10.1016/j.mehy.2003.12.045. [PubMed] [Cross Ref]. 228. Tang X, Luo Y-X, Chen H-Z, Liu D-P. Mitochondria, endothelial cell function, and vascular diseases. Front Physiol. 2014;5:175. https://doi.org/10.3389/ fphys.2014.00175. [PMC free article] [PubMed] [Cross Ref].

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229. Tata D, Waynant R. Laser therapy: a review of its mechanism of action and potential medical applications. Laser Photonics Rev. 2012;1:1–12. https://doi. org/10.1002/lpor.200900032 [Cross Ref]. 230. Taylor RC, Berendzen KM, Dillin A. Systemic stress signalling: understanding the cell non-autonomous control of proteostasis. Nat Rev Mol Cell Biol. 2014;15:211–217. https://doi.org/10.1038/nrm3752. [PubMed] [Cross Ref]. 231. Tierney TS, Vasudeva VS, Weir S, Hayes MT. Neuromodulation for neurodegenerative conditions. Front Biosci (Elite. Ed). 2013;5:490–9. https://doi. org/10.2741/E630. [PubMed] [Cross Ref]. 232. Trimmer PA, Schwartz KM, Borland MK, De Taboada L, Streeter J, Oron U. Reduced axonal transport in Parkinson’s disease cybrid neurites is restored by light therapy. Mol Neurodegener. 2009;4:26. https://doi.org/10.1186/1750-­ 1326-­4-­26. [PMC free article] [PubMed] [Cross Ref]. 233. Tuby H, Maltz L, Oron U. Induction of autologous mesenchymal stem cells in the bone marrow by low-level laser therapy has profound beneficial effects on the infarcted rat heart. Lasers Surg Med. 2011;43:401–409. https://doi. org/10.1002/lsm.21063. [PubMed] [Cross Ref]. 234. van Eersel J, Ke YD, Liu X, Delerue F, Kril JJ, Götz J, Ittner LM. Sodium selenate mitigates tau pathology, neurodegeneration, and functional deficits in Alzheimer’s disease models. Proc Natl Acad Sci. U S A. 107:13888–93. https://doi.org/10.1073/pnas.1009038107. [PMC free article] [PubMed] [Cross Ref]. 235.  Vos M, Lovisa B, Geens A, Morais VA, et  al. Near-infrared 808  nm light boosts complex IV-dependent respiration and rescues a Parkinson-related pink1 Model. PLoS One. 2013;8:e78562. https://doi.org/10.1371/journal. pone.0078562. [PMC free article] [PubMed] [Cross Ref]. 236.  Whelan HT, DeSmet KD, Buchmann EV, Henry MM, Wong-Riley M, Eells JT, et al. Harnessing the cell’s own ability to repair and prevent neurodegenerative disease. SPIE Newsroom. 2008;24:1–3. https://doi. org/10.1117/2.1200802.1014. [PMC free article] [PubMed] [Cross Ref]. 237. Wong-Riley MTT, Liang HL, Eells JT, Chance B, Henry MM, Buchmann E, et al. Photobiomodulation directly benefits primary neurons functionally inactivated by toxins: role of cytochrome c oxidase. J Biol Chem. 2005;280:4761–71. https://doi.org/10.1074/jbc.M409650200. [PubMed] [Cross Ref]. 238. Xuan W, Agrawal T, Huang L, Gupta GK, Hamblin MR. Low-level laser therapy for traumatic brain injury in mice increases brain derived neurotrophic factor (BDNF) and synaptogenesis. J Biophoton. 2015;8:502–11. https://doi. org/10.1002/jbio.201400069. [PMC free article] [PubMed] [Cross Ref]. 239. Xuan W, Vatansever F, Huang L, Hamblin MR. Transcranial low-level laser therapy enhances learning, memory, and neuroprogenitor cells after traumatic brain injury in mice. J Biomed Opt. 2014;19:108003. https://doi.org/10.1117/1. JBO.19.10.108003. [PMC free article] [PubMed] [Cross Ref]. 240. Xuan W, Vatansever F, Huang L, Wu Q, Xuan Y, Dai T, et al. Transcranial low-­ level laser therapy improves neurological performance in traumatic brain injury in mice: effect of treatment repetition regimen. PLoS One.

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2013;8:e53454. https://doi.org/10.1371/journal.pone.0053454. [PMC free article] [PubMed] [Cross Ref]. 241. Yetgin T, Manintveld OC, Groen F, Tas B, Kappetein AP, van Geuns R-J, et al. The emerging application of remote ischemic conditioning in the clinical arena. Cardiol Rev. 2012;20:279–87. https://doi.org/10.1097/ CRD.0b013e31826c15aa. [PubMed] [Cross Ref]. 242. Ying R, Liang HL, Whelan HT, Eells JT, Wong-Riley MTT. Pretreatment with near-infrared light via light-emitting diode provides added benefit against rotenone- and MPP+-induced neurotoxicity. Brain Res. 2008;1243:167–73. https://doi.org/10.1016/j.brainres.2008.09.057. [PMC free article] [PubMed] [Cross Ref]. 243. Zhao G, Guo K, Dan J. 36 case analysis of Parkinson’s disease treated by endonasal low energy He-Ne laser. Acta Acad Med Qingdao Univ (Chinese). 200339:398. 244. Zivin JA, Albers GW, Bornstein N, Chippendale T, Dahlof B, Devlin T, et al. Effectiveness and safety of transcranial laser therapy for acute ischemic stroke. Stroke. 2009;40,:1359–64. https://doi.org/10.1161/STROKEAHA.109.547547. [PubMed] [Cross Ref].

Informed Consent and Permission  lzheimer’s Autism and Cognitive Impairment Stem Cell A Treatment Study Introduction ACIST Study Jeffrey N. Weiss, MD The Healing Institute 1308 A/B North State Road 7 Margate, Florida 33063 Telephone 954-975-3563 or 954-975-0044 To decide whether or not you want to participate in the Alzheimer’s Autism and Cognitive Impairment Stem Cell Treatment Study (called “the procedure” in this document) – also known as an Adult Stem Cell Treatment, the risks and possible benefits are described in this form so that you can make an informed decision. This process is known as informed consent. This consent form describes the purpose, procedures, possible benefits, and risks of the procedure. You may have a copy of this form to review at your leisure or to ask advice from others. Dr. Weiss and his associates will answer any questions you may have about this form or about the procedure. Please read this document carefully and do not hesitate to ask anything about this information. This form may contain words that you do not understand. Please ask Dr. Weiss or his associates to explain the words or

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information that you do not understand. After reading (or having it read to you) the consent form, if you would like to be treated, you will be asked to sign this form.

Cost This is a patient sponsored clinical study in which the participants pay for treatment to be performed.

Background Bone marrow derived stem cells (BMSC) are adult stem cells that come from a patient's own bone marrow. There is evidence that patients with certain eye diseases have improved visual function following treatment with BMSC. The exact mechanisms by which adult stem cells can provide improvement are complex and still undergoing assessment in the medical and scientific community. Adult stem cell treatments have been performed and continue to be performed in various parts of the world including the United States for a number of medical conditions. It is unknown whether this treatment will be of benefit in your particular disease or condition.

Terms of the Study Dr. Weiss will determine if you and your condition are eligible for inclusion in the study. If you have been approved for inclusion in the study you are being asked to participate in a clinical research study to determine if the use of bone marrow derived stem cell (BMSC) can benefit damaged nerve tissue and improve neurologic function for patients. While there have been many patients worldwide treated with BMSC in various ways including treatment of neurologic disease, sufficient proof, such as may be demonstrated with scientific studies, has not been developed to convince the majority of physicians that the procedure is of benefit. The purpose of this study is to determine if improvement in neurologic function – primarily cognition or information processing by the brain – can be obtained by using BMSC treatment. The type of treatment used will be determined by Dr. Weiss after assessment of your neurologic examination. The treatment may include intravenous (in the vein), intranasal (topical application or injection to the upper one-third of your nasal passages), and near-infrared light treatment with an FDA-cleared device called the WARP 10. You understand that participation in this study will be voluntary and the treatment of your illness is not dependent upon you participating in this study. There will be approximately 100 participants enrolled in the study at one site in the United States. It is anticipated you will participate in this research study for one year.

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Reproductive Information for Females There is no evidence that treatment with autologous bone marrow derived stem cells has adverse effects on human reproduction or a developing unborn fetus. However, female patients who are pregnant or attempting to become pregnant should not undergo treatment. It is suggested that female patients do not attempt to become pregnant for at least 3 months following treatment. If female, in signing this informed consent, you attest that you believe that you are not pregnant and, if you are of childbearing potential, that you are using an adequate form of birth control and will continue to do so for 3 months following treatment.

Benefits/Outcome of Treatment The potential benefits of this treatment may include improvement in cognitive function. Cognitive function includes many things that the brain does including, but not limited to, organization, memory, social interactions, emotions, communication, awareness, and orientation to place, time, and self. In diseases causing cognitive impairment the cognitive impairment may naturally worsen over time. In autism spectrum disorder, the issues impairing the patient may naturally worsen over time. After treatment, it is possible your neurologic or cognitive function may experience no change or worsen. Any improvement may take several months. Stability of cognitive function in an otherwise deteriorating condition may be a possible outcome. It is also possible that an improvement following treatment may undergo regression or loss after a period of time. At this time, Dr. Weiss cannot make predictions as to the effectiveness of the stem cell treatment for individual patients. In signing this informed consent, you acknowledge that no promise of beneficial results has been made to you, nor have any guarantees been offered, either formally or implied, that treatment with bone marrow derived stem cells or near-infrared light will be successful or be of benefit.

Description of Procedure In this procedure, the bone marrow derived stem cells (BMSC) will be isolated from your bone marrow and then the stem cell material obtained will be injected intravenously (into the vein of your arm) and possibly to the superior one-third of the nasal mucosa with direct topical (non-injection) application. This procedure is considered invasive and includes removal of bone marrow from the iliac crest (one or both) of your pelvis and injection of the separated stem cells. The removal of bone marrow from a patient's pelvis is an established medical procedure. However, the use of bone marrow derived stem cells in neurologic disease or damage is not considered to be evidence-based medicine. This means that there is not enough scientific evidence to determine if this procedure is beneficial to the neurologic function of patients.

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You may also receive near-infrared light which is shining of the light on the general area of the frontal lobes (beneath the frontal cranial bone or front portion of the top of the head).

Pre-op and Follow-up Neurologic Exams Pre- and post-op neurologic exams by your neurologist or qualified physician will consist of Mini-Mental Status Exam (MMSE) for patients with cognitive impairment or autism spectrum quotient (AQ) testing for patients with autism spectrum disorder. You must have follow-up neurologic exams at 1 month, 3 months, 6 months, and 12 months and provide them to Dr. Weiss and Dr. Levy. The follow-up exams are extremely important to monitor the health of your nervous system and to assess for potential improvement. If you notice any sudden changes or deterioration following the procedure, such as pain, swelling, increasing redness in the bone marrow aspiration site, fever, or deteriorating neurologic function, please get in touch with Dr. Weiss or your local physician or neurologist immediately as this could represent a threat to your health. This permission also provides for access to your follow-up neurologic exams to Dr. Weiss and his associates and the ability to discuss your treatment and results freely with your health providers. We strongly request all follow-up exams be forwarded to Dr. Weiss and his associates. This may require that the patient gives permission to their neurologist to forward their records or may involve the patient obtaining those records and then forwarding them to Dr. Weiss and his associates.

Alternative Treatments Some of the neurologic diseases that are offered BMSC treatment may have existing drug or surgical treatments that have scientific evidence or general medical community acceptance for use in maintaining or improving neurologic function. If there are such existing treatments, we advise you to pursue those treatments initially before considering BMSC treatment. If you elect to undergo stem cell treatment, it is recommended that you continue all current medical therapies prescribed by your existing physician or neurologist including their recommended follow-up exams until they can examine you and make their own assessment of the need for their therapies or examinations. In signing this informed consent, you assert you are aware of any potential alternative treatments from discussions with your own physicians or neurologists and elect to undergo the stem cell procedure.

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Medical Treatments and Costs This procedure is not considered evidence-based by insurance companies. You understand that your participation in this study is at your own expense and will not be reimbursed by any insurance. Should a study-related medical problem or injury occur, appropriate medical care, as determined by your physician or neurologist, may be provided by your physician or neurologist. You understand you will be financially responsible for such medical treatment, although your insurance company may cover any such treatment under your existing policy. You understand that no additional financial compensation will be available for any injury resulting from your participation. This does not constitute a waiver of any rights that you may have under federal or state laws and regulations.

Treatment Location Treatments will be performed at the Park Creek Surgery Center located at 6806 North State Road 7, Coconut Creek, Florida 33073, at which Dr. Weiss is a member of the medical staff. The procedures will be performed in accordance with all surgery center regulations.

Acceptance of Risks The treatment provided is experimental and no guarantees are provided as to the outcome of the procedure. The patient’s neurologic function may become better, stay the same, or worsen. There are risks to my general health including the risk of neurologic injury or death. I accept these risks freely and agree to hold harmless Dr. Weiss and The Healing Institute; Dr. Levy and MD Stem Cells; and the participating neurologist and the personnel who participate in performing the procedure. Initial___________

Medical Clearance Medical clearance for anesthesia and surgery will be obtained by the patient through their own medical doctor prior to the procedure and provided to Dr. Weiss and the associated physicians and staff of the Park Creek Surgery Center. The medical clearance must give permission for the use of anesthesia and provide such laboratory tests and examination as Dr. Weiss and the additional physicians at Park Creek Surgery Center believe are needed to properly assess your risks and provide proper care for you while you undergo the procedure.

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Anesthesia Anesthesia will be provided by the anesthesia physicians and staff at the Park Creek Surgery Center in accord with good medical judgment and regulations of the surgery center and the State of Florida. This includes all types of anesthesia from local injection to general anesthesia. Typically, the patients may have general anesthesia, sedation, or local anesthesia for the bone marrow aspiration and for the injection of the stem cells.

Treatment Procedure  reoperative Neurologic Exam P The preoperative neurologic exam will be provided by the patients’ neurologist and will be evaluated by the sub-investigators for inclusion criteria. Immediate preoperative exams and informed consent will be performed by Dr. Weiss and/or the sub-­ investigators at their office location.

Treatment Location Treatments will be performed at the Park Creek Surgery Center located at 6806 North State Road 7, Coconut Creek, Florida 33073, at which Dr. Weiss is a member of the medical staff. The procedures will be performed in accordance with all surgery center regulations. Randomization  – No patients are to be randomized. All eligible patients who participate will receive treatment if deemed safe by Dr. Weiss.

 reatment Procedure: 1. Anesthesia T Anesthesia will be provided by the anesthesia physicians and staff at the Park Creek Surgery Center in accordance with good medical judgment and regulations of the surgery center and the State of Florida. This includes all types of anesthesia from local injection to general anesthesia. Typically, the patients may have general anesthesia, sedation, or local anesthesia for the bone marrow aspiration and for the injection of the stem cells. Anesthesia is given as needed for patient comfort and safety under the direction of the anesthesiologist.

BMSC Collection and Preparation Approximately 120 cc of bone marrow aspirate will be collected in the operating room, the exact volume being based on medical judgment. The bone marrow aspiration is performed under sterile conditions. The bone marrow aspirate is collected from one or both of the patient’s iliac bones in the pelvis and may involve one, two, or more separate sites. The bone marrow aspirate will not leave the operating room. For separation and collection of the mononuclear cell layer including the stem cells

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and additional components, a medical device called the Angel System manufactured by Arthrex, Inc., or equivalent will be used. The Arthrex Angel System and its components is a Class 2 device per the FDA guidelines. The collected bone marrow aspirate will be placed in the device that will separate the components of the bone marrow and isolate the portion containing the adult stem cells. This is done in a completely sterile, automated, and self-contained fashion with minimal manipulation. The device will be operated by Dr. Weiss’ assistants under Dr. Weiss’ supervision. Approximately 16 cc of mononuclear cell material containing the adult stem cells (adult stem cell material) will be available for injection.

Neurologic Treatment The three arms of the study will include are as follows: • Arm 1. Intravenous – approximately 14 cc of BMSC fraction filtered with 150 micron filter and administered intravenously • Arm 2. Arm 1 with the addition of near-infrared light exposure the day before the procedure and postoperatively to the frontal cranial bone as tolerated • Arm 3. Intravenous + intranasal – approximately 13 cc of BMSC fraction filtered with a 150 micron filter intravenously and approximately 1 cc of BMSC fraction placed topically intranasally. Patients will not be randomized. Patients will enter the arm of the study believed appropriate to them and the principal investigator after discussion of the risks and benefits of the procedure. Based on the patient’s neurologic examinations, diagnosis, and selection of treatment arm, Dr. Weiss will provide the BMSC fraction via intravenous injection alone or with intravenous injection and intranasal placement. Any excess bone marrow material including other cells and plasma will be discarded in accordance with normal surgery center practice. No material will be retained for future use. The WARP 10 will be used for near-infrared light exposure in Arm 2 for a duration to be specified by Dr. Weiss and which is comfortably tolerated by the patient. An intravenous injection is the injection of the bone marrow stem cells (BMSC) into the vein in the patient’s arm. It is standard procedure during anesthesia that the patient will have an intravenous line available for administration of medications and fluids. This same line is used for intravenous injection of the BMSC. There is a risk of a thrombotic event called pulmonary embolism occurring as a result of a clot forming either prior to or during the passage of the cells through the lungs. Because of the anticoagulation and filtering employed in processing the bone marrow aspirate, we believe this risk is very small. In an analysis performed by the European Group for Blood and Marrow Transplantation on HSCT in over 27,000 patients between 1993 and 2005, this risk was calculated to be approximately 0.000037. To reduce this risk, a filter of appropriate size (typically 150 microns) will be used to

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filter the delivered BMSC. This may be performed while the patient is recumbent (lying down) or seated. Intranasal application is a topical or injection application of the BMSC to the upper  one-third of the nasal passages. This is done through one or both external nares (nostrils) and may be applied to the nasal mucosa of the conchae and meatuses of one or both sides of the nose. The trigeminal nerves or 5th cranial nerves provide sensation to these areas as well as the face. The purpose of this application is to allow the passage of the BMSC and associated growth factors along the axons of the trigeminal nerves for access to the central nervous system (CNS), brain, and cerebral spinal fluid. This has been shown to occur in the preclinical literature.

Possible Side Effects/Complications General This is a surgical procedure involving the aspiration of bone marrow and injection of the separated bone marrow stem cell intravenously and by placement intranasally. The procedure will include the administration of medications to provide anesthesia during the procedure. There is always the risk of unanticipated reactions to the procedure itself, the medications, and the anesthesia. Under very rare circumstances, patients may have serious complications as a result of the procedure or medications including serious abnormal drug reactions, serious allergic reactions, very low blood pressure, seizures, and cardiac or respiratory problems including cardiac or pulmonary arrest. These may result in harm to your body or in death. Bone Marrow Aspiration Common side effects may include mild local pain, tenderness, and localized bleeding in the area where the doctor aspirates the bone marrow. Very rare complications may include infection or bleeding that is difficult to control. Neurologic Treatment An intravenous injection is the injection of the bone marrow stem cells (BMSC) into the vein in the patient’s arm. It is standard procedure during anesthesia that the patient has an intravenous line available for administration of medications and fluids. This same line is used for intravenous injection of the BMSC. There is a risk of a thrombotic event called pulmonary embolism occurring as a result of a clot forming either prior to or during the passage of the cells through the lungs. Because of the anticoagulation and filtering employed in processing the bone marrow aspirate, we believe this risk is very small. In an analysis performed by the European Group for Blood and Marrow Transplantation on HSCT in over 27,000 patients between 1993 and 2005, this risk was calculated to be approximately 0.000037. To reduce this risk, a filter of appropriate size will be used to filter the delivered BMSC. Intranasal administration may be provided by direct application of the BMSC material to the upper one-third of the nasal passages either by topical placement or by injection. The side effects of intranasally administered material may include potential local irritation, rhinorrhea (runny nose), and the presence of the BMSC

Available Information

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material in the saliva or mucus of the nose which may then look red for a time post-operatively.

 ost-procedure Neurologic Examinations P The follow-up neurologic exams will be obtained the day after the procedure and are then requested at 1month, 3 months, 6 months, and 12 months following the procedure or at the recommended intervals of the neurologist examining the patient. Patients agree to allow Dr. Weiss and his associates to release any medical information to their neurologists and medical doctors. They also agree to provide access to their exams from their neurologist and medical doctor to Dr. Weiss and his associates.

Collection and Use of Data Patients give permission to use their medical information for their own care and for any publication, presentation, or public communication about the procedure and results. In the case of non-direct patient care communication, the patient name and contact information will be held in confidence and not released to protect your privacy. However, if required by law, state or federal agencies may be given access to your full name, data, medical records, and information.

Confidentiality of Records You understand that your identity and certain information pertaining to you that is collected for this study will remain confidential. However, in order to meet the obligations of federal law, you understand that records from this study may be subject to review by representatives of the International Cellular Medicine Society Institutional Review Board and authorized Food and Drug Administration or other government regulatory agencies’ personnel. You hereby consent to such review and disclosure.

Available Information You understand that any significant new information developed during the course of this study, which may relate to your willingness to continue as a participant, will be provided to you. If you have any questions or desire further information with respect to this study, or if you experience a study-related injury, you should contact: • • • • •

Jeffrey N. Weiss, MD Principal Investigator The Healing Institute 1308 A/B North State Road 7 Margate, Florida 33063

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• • • • •

Steven Levy MD, Study Director The Acoma Group LLC dba MD Stem Cells 3 Sylvan Road South, Westport, CT 06880 Phone: (203) 423-9494 Phone: (954) 975-3563 or (954) 975-0044 If you wish to contact an impartial third party not associated with this study, you may contact: • Reed Davis at 702-664-0017.

Termination You understand that your participation in this study is voluntary and you are under no obligation to participate. Your decision on whether to participate in the study will in no way impact upon the treatment you will receive. You may refuse to participate or may discontinue participation at any time during the study without penalty or loss of benefits to which you are otherwise entitled. If you choose not to participate, or to discontinue your participation in this study, Jeffrey N. Weiss, MD, and his associates will continue to take care of your illness to the best of their ability. In addition, you understand that your participation may be terminated by Jeffrey N. Weiss, MD, and/or your physician without regard to your consent, should he/ she determine that continued participation would be detrimental to you in any way. You understand that at the completion of the study, you may not be able to continue participation.

Participant Statement and Authorization In affixing my signature, I acknowledge that I have read or had read to me this informed consent and permission form, that all my questions have been answered, and that I fully understand the information it contains. I consent to the procedure of bone marrow stem cell treatment for my neurologic disease or damage as performed by Dr. Jeffrey Weiss and his associates. This informed consent and permission (also called an authorization) will have no end date. ____________________________________________ Printed Name of Patient ____________________________________________  _______________ Signature of Patient                  Date _______________________________________________________________ Name of and Relationship of Responsible Party if patient unable to sign ____________________________________________  _______________ Signature of Responsible Party if patient unable to sign     Date ____________________________________________ Printed Name of Person Explaining Consent ____________________________________________  _______________ Signature of Person Explaining Consent          Date

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Procedure – Additional Patient Explanation

Patients first contact the Study Director, Dr. Steven Levy, the President of MD Stem Cells. Dr. Levy provides information and manages the logistics and data for the study. Patient records are sent to Dr. Levy at [email protected] Dr. Levy forwards the records to Dr. Jeffrey Weiss, the Principal Investigator, for review. Dr. Weiss independently determines patient eligibility. The surgery is usually performed using monitored or general anesthesia, and it takes less than 1 hour. A state-of-the-art fully licensed outpatient surgery center is used for all procedures. An orthopedic surgeon performs the bone marrow aspiration and the bone marrow fraction (BMF), which consists of the stem cells and multiple growth factors and is isolated using our protocol by an FDA-approved Class 2 device. Since the majority of our patients come to us from out of state or out of the country, much of the postoperative data is collected by a physician unrelated to us or the study. When the patient is to return home after surgery, they are given a chart detailing what testing is required at the 1-, 3-, 6-, and 12-month postoperative visits. In the past, we told the patient to ask the physician to send us the postoperative data. In order to increase the receipt of this important information, we now instruct the patients to ask for a copy of their records at the time of their examination and send them to us. There has been an exponential increase in the number of records we now receive. Helping patients who have never been helped before makes all the hard work extremely worthwhile.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 J. N. Weiss, Neurologic Stem Cell Surgery, https://doi.org/10.1007/978-3-030-72420-7_2

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As of July 12, 2000, there were 41 neurologic stem cell studies listed on www.clinicaltrials.gov worldwide that were; not yet recruiting, recruiting, enroll by invitation, or active, not recruiting, worldwide. A total of 23 studies are US-based and 17 are being carried out in Europe/Middle East (Table 3.1). Unlike pharmaceutical studies that are tied to their methods and protocols in order to obtain FDA approval for their drug, our neurology studies are dynamic. We can make improvements based upon experience and results.

Quantitative Assessment The ability to quantitatively and objectively detect molecular changes, before they become observable by standard imaging techniques, can allow the early detection and monitoring of patients undergoing diagnostic and therapeutic procedures,

Table 3.1  List of neurologic conditions and number of studies being conducted

Condition treated Multiple sclerosis Alzheimer’s disease Amyotrophic lateral sclerosis (ALS) Stroke TBI Spinal cord injury Duchenne muscular dystrophy Parkinson’s disease Cerebral palsy Hunter/Hurler Optic nerve

Number of studies 7 5 3 3 4 7 3 1 1 2 3

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 J. N. Weiss, Neurologic Stem Cell Surgery, https://doi.org/10.1007/978-3-030-72420-7_3

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including stem cell surgery. Other potential uses may include the ability to time-­ compress studies of new pharmaceuticals (as molecular effects should antedate the physiologic effects seen by imaging studies) and to predict, monitor, and determine the efficacy of treatment. In 1986, it was histopathologically demonstrated that patients diagnosed with Alzheimer’s disease have thinning of the retinal nerve fiber layer and a reduction in the quantity of retinal ganglion cells. With the development of ocular coherence tomography (OCT), the finding could be confirmed in vivo. Thus, OCT could serve as a biomarker for Alzheimer’s disease and for the efficacy of treatments. Later work, using a proprietary imaging agent based on a chemical in turmeric  – curcumin fluorescence imaging, enabled researchers to measure the levels of amyloid in the retina of the eye and found that beta amyloid levels in the eye strongly correlate to levels in the brain. Another study using fluorescent ligand eye scanning confirmed that there were significant correlations between amyloid levels in the brain and eye, suggesting that either technique has the potential to support Alzheimer’s disease diagnosis in the future. A change in image represents a late stage in the Alzheimer’s process. If the initial biochemical effect that led to the later physiologic effect could be detected, then the condition could possibly be prevented. It has been hypothesized that while hundreds of potential Alzheimer treatment drugs have been tested and failed, it may be that the time window to see a change was longer than the study duration. If a quantitative noninvasive method was developed that measured changes at the molecular level, the time window, and consequently the expense, of performing new drug studies could be shortened. Dynamic light scattering (DLS) measures the scattered light intensity fluctuations resulting from the thermal random motion (Brownian motion) at the molecular level. The back-scattered light is recorded as a time correlation function, which relates the light intensity at time 0 to that at a chosen sample time later (1 microsecond). DLS technology was used to predict the development of cataractogenesis in rabbits and detect diabetes mellitus in humans. The results demonstrated the utility of DLS to noninvasively quantitate subtle changes at the molecular level. A new upgraded instrument has been developed and studies in patients with cognitive impairments are beginning.

Bone Marrow Aspirate Separation We have been using an FDA-approved Class 2 Angel device by Arthrex, Inc., for stem cell and component separation. This is a centrifugal separating assembly for separating the bone marrow fraction into discrete components. The least dense particulates separate to form a top layer and the denser components will separate and form a bottom layer. Centrifugation of whole blood will result in a plasma top layer, a middle layer of white blood cells and platelets with plasma and red blood cells, known as the “buffy coat,” and a bottom layer of red blood cells (Figs. 3.1 and 3.2).

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Fig. 3.1  Dynamic light scattering (DLS) device. (Retinal and Optic Nerve Stem Cell Surgery 2020)

Fig. 3.2  Angel machine manufactured by Arthrex, Inc. (Retinal and Optic Nerve Stem Cell Surgery 2020)

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Bibliography 1. Chu B. Laser light scattering. New York: Academic Press, Inc.; 1974. 2. Nishio I, Weiss JN, Tanaka T, et al. In vivo observation of lens protein diffusivity in normal and x-ray irradiated rabbit lenses. Exp Eye Res. 1984;39:61–8. 3. Weiss JN, Rand LI, Gleason RE, Soeldner JS. Laser light scattering spectroscopy of in-vivo human lenses. Invest Ophthalmol Vis Sci. 1984;25:594–8. 4. Weiss JN, Bursell SE, Gleason RE, Eichold BH. Photon correlation spectroscopy of in-vivo human cornea. Cornea. 1986;5(1):19–24. 5. Koppel DE. Analysis of macromolecular polydispersity in intensity correlation spectroscopy: the method of cumulants. J Chem Phys. 1972;57:4814–20. 6. Weiss JN, Benes SC, Levy S. Stem cell ophthalmology treatment study: bone marrow derived stem cells in the treatment of non-arteritic ischemic optic neuropathy (NAION). Stem cell investigation. November 2017. http://sci.amegroups.com/issue/view/632.

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Other Treatment Modalities

Light Photobiomodulation (PBM) is the use of near-infrared (NIR) or red light (600–1100 nm) to positively affect brain function. PBM treatment of healthy human young and elderly volunteers has demonstrated improvements in mood, cognitive function, and memory, with increases in regional cerebral blood flow and tissue oxygenation. Improvements in sleep, executive function, and working memory have been reported in patients with chronic traumatic brain injury (TBI).

Questions 1 . What is the optimum light wavelength to have a biologic effect for treatment? 2. What is the depth penetration dependent on the light wavelength? 3. What is the optimum treatment location? 4. Are the reported beneficial effects a result of the light itself, or something else? Jagdeo et al. (2012) [1] Human Cadaver Skulls with Intact Soft Tissue 830 nm light Penetration amount: • 0.9% – temporal area • 2.1% – frontal region • 11.7% – occipital region Tedord et al. (2015) [2] Human Cadaver Skulls 660 nm, 808 nm, 940 nm 808 nm penetrated best to depth of 40–50 mm © The Author(s), under exclusive license to Springer Nature Switzerland AG 2021 J. N. Weiss, Neurologic Stem Cell Surgery, https://doi.org/10.1007/978-3-030-72420-7_4

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Pitzschke et al. (2015) [3] 670 nm, 810 nm transcranial versus transsphenoidal 810 nm best when delivered transsphenoidally The power density of the light is limited by skin heating. Skin heating may be felt at approximately 500 mW/cm2 and is severe at 1 W/cm2.

PBM for Acute Stroke Three clinical trials: Neurothera Effectiveness and Safety Trials 1 . NEST-1 Lampl et al. (2007) [4, 5] 2. NEST-2 Zivin et al. (2009) [6] 3. NEST-3 Lapchak, Boitano (2016) [7] 810 nm laser applied to shaved head at 20 points in the 10/20 EEG system within 24 hours of patient suffering an ischemic stroke.

NEST-1 120 patients, 40–85 years of age Significantly improved outcome (p