The Implementation of a Pediatric Nonaccidental Trauma Evaluation Protocol: A Quality Improvement Analysis.

BACKGROUND: Pediatric nonaccidental trauma (NAT) accounts for more than 1500 deaths annually and is a source of incalculable lifelong morbidity. Evidence-based NAT evaluation protocols are available; however, compliance studies are lacking. Here, we analyze the quality of implementation of a new NAT evaluation protocol. METHODS: A review of registry data from a level 3 trauma center was performed for patients with a suspicion of NAT from September 2014 to May 2016. Compliance rates and results of 2 new age-based evaluation protocols were examined before (phase 1) and after (phase 2) a multidisciplinary conference was initiated to improve performance. RESULTS: Seventy-five children underwent evaluation for NAT during the study period. In phase 1, median compliance rates with all of the protocol elements were low (63%). After a bimonthly multidisciplinary conference was initiated, compliance rates improved to 75%. Some elements, which were often missed, were found to be clinically irrelevant. If only clinically relevant elements were included, median compliance in phase 2 is 86%. CONCLUSIONS: Compliance with a new protocol for NAT was improved with the institution of a multidisciplinary conference. Protocol elements, which are shown to be clinically unnecessary, have also been identified and will be eliminated.

Building a Local Research Symposium: The Crossroads of Scholarship, Education, and Faculty Development.

Introduction: Demonstrating research productivity for faculty and trainees is challenging in primarily community-based settings, where academic, structural, and financial resources for faculty development in scholarship may be limited. More tools are needed to guide faculty leaders in community-based settings to develop opportunities locally. Methods: At our community-based children's hospital with recent academic affiliation and a new residency program, we developed an annual research symposium targeted to faculty and trainees. We refined tools for solicitation and scoring of abstracts, speaker selection, skill-building workshops, scholarly case report presentations, and a mentored poster session. We worked with available resources, kept costs flexible and low, and secured local partnerships to defray expenses. Evaluation consisted of session evaluations and trends in abstract submissions, institutional review board (IRB) submissions, and resident scholarly productivity over 4 years. Results: Scholarship improved over the symposium's first 4 years, with increased attendance (from 80 to 150), abstract submissions (from 29 to >50), IRB-approved research projects (from 65 to 123), and positive feedback on symposium evaluations. From our first three resident classes, 61 resident-authored abstracts were presented at our symposia, with 33 presented at regional and national meetings and 15 converted to peer-reviewed manuscripts. Discussion: We have developed a local research symposium to meet the needs of a new hospital's faculty and trainees. Evaluation data have allowed us to tailor the program to stakeholder needs. We provide a tool kit of generalizable resources for community-based programs to build on these efforts in a high-yield and cost-effective manner.

The National Trauma Institute: Lessons learned in the funding and conduct of 16 trauma research studies.

BACKGROUND: To increase trauma-related research and elevate trauma on the national research agenda, the National Trauma Institute (NTI) issued calls for proposals, selected funding recipients, and coordinated 16 federally funded (Department of Defense) trauma research awards over a 4-year period. We sought to collect and describe the lessons learned from this activity to inform future researchers of barriers and facilitators. METHODS: Fifteen principal investigators participated in semistructured interviews focused on study management issues such as securing institutional approvals, screening and enrollment, multisite trials management, project funding, staffing, and institutional support. NTI Science Committee meeting minutes and study management data were included in the analysis. Simple descriptive statistics were generated and textual data were analyzed for common themes. RESULTS: Principal investigators reported challenges in obtaining institutional approvals, delays in study initiation, screening and enrollment, multisite management, and study funding. Most were able to successfully resolve challenges and have been productive in terms of scholarly publications, securing additional research funding, and training future trauma investigators. CONCLUSION: Lessons learned in the conduct of the first two funding rounds managed by NTI are instructive in four key areas: regulatory processes, multisite coordination, adequate funding, and the importance of an established research infrastructure to ensure study success. Recommendations for addressing institution-related and investigator-related challenges are discussed along with ongoing advocacy efforts to secure sustained federal funding of a national trauma research program commensurate with the burden of injury.

Human amnion-derived multipotent progenitor cell treatment alleviates traumatic brain injury-induced axonal degeneration.

To identify a viable cell source with potential neuroprotective effects, we studied amnion-derived multipotent progenitor (AMP) cells in a rat model of penetrating ballistic-like brain injury (PBBI). AMP cells were labeled with fluorescent dye PKH26 and injected in rats immediately following right hemispheric PBBI or sham PBBI surgery by ipsilateral i.c.v. administration. At 2 weeks post-injury, severe necrosis developed along the PBBI tract and axonal degeneration was prominent along the corpus callosum (cc) and in the ipsilateral thalamus. Injected AMP cells first entered the subventricular zone (SVZ) in both sham and PBBI rats. Further AMP cell migration along the cc only occurred in PBBI animals. No significant difference in injury volume was observed across all treatment groups. In contrast, treatment with AMP cells significantly attenuated axonal degeneration in both the thalamus and the cc. Interestingly, PKH26-labeled AMP cells were detected only in the SVZ and the cc (in parallel with the axonal degeneration), but not in the thalamus. None of the labeled AMP cells appeared to express neural differentiation, as evidenced by the lack of double labeling with nestin, S-100, GFAP, and MAP-2 immunostaining. In conclusion, AMP cell migration was specifically induced by PBBI and requires SVZ homing, yet the neuroprotective effect of intracerebral ventrical treatment using AMP cells was not limited to the area where the cells were present. This suggests that the attenuation of the secondary brain injury following PBBI was likely to be mediated by mechanisms other than cell replacement, possibly through delivery or sustained secretion of neurotrophic factors.

Immunogenicity and immunomodulatory effects of amnion-derived multipotent progenitor cells.

This is the first study on the immunologic properties of a clinically relevant population of cells derived from the amnion of human placenta. Unlike other cells from the amnion, these amnion-derived multipotent progenitor cells (AMP cells), from human amnion, grow in serum-free conditions and have never been cultured in the presence of medium containing animal-derived components. This study reports the immunologic characteristics of AMP cells and their roles as immunomodulators. Characterization of AMP cells revealed the presence of major histocompatibility complex (MHC) class I but the lack of class II antigens and absence of co-stimulatory molecules B7-1 and B7-2. The nonclassical human leukocyte antigen (HLA)-G was expressed at low levels on cultured AMP cells. Expression was significantly increased after interferon-gamma (IFN-gamma) treatment. Cultured peripheral blood mononuclear cells did not respond to irradiated AMP cells, indicated by lack of proliferation as measured by standard mixed lymphocyte reaction. Culturing AMP cells with IFN-gamma did not reverse this result and did not upregulate class II expression. The AMP cells were shown to have immunomodulatory capabilities by inhibiting peripheral blood mononuclear cell proliferative responses to mitogen, alloantigen, and recall antigen, but the AMP cells were unable to inhibit preactivated T-cell blast response to growth factor media. This immunomodulatory effect of AMP cells was found to be dependent on cell-to-cell contact.

The use of amnion-derived cellular cytokine solution to improve healing in acute and chronic wound models.

OBJECTIVE: Growth factors demonstrate mixed results improving wound healing. Amnion-derived multipotent cells release physiologic levels of growth factors and tissue inhibitors of metalloproteinases. This solution was tested in models of acute and chronic wound healing. METHODS: Acute model: Sprague-Dawley rats underwent laparotomy incisions. The midline fascia was primed with phosphate-buffered saline, unconditioned media, or amnion-derived cellular cytokine suspension prior to incision. Breaking strength of laparotomy wounds was tested with an Instron tensiometer. Incisional hernia formation was measured after 28 days. Chronic model: Chronic, infected granulating wounds were produced in rats by excising full thickness burn eschars inoculated with Escherica coli. Granulating wounds were treated with unconditioned media or amnion-derived cellular cytokine suspension. Treatments were applied either on day 0 and day 7 or day 0 and then every other day. Wounds were traced every 72 hours and biopsied for quantitative bacteriology. RESULTS: Acute model: Priming with amnion-derived cellular cytokine suspension increased the breaking strength of laparotomy incisions in comparison with phosphate-buffered saline or unconditioned media (P < .05). Acute wound failure and incisional hernia formation was 100% in the phosphate-buffered saline and unconditioned media groups and 18% in the amnion-derived cellular cytokine suspension-treated group (P <.05). Chronic model: The rate of wound closure was accelerated in amnion-derived cellular cytokine suspension-treated chronic wounds (P < .05). Multidosing improved the effect. CONCLUSIONS: A physiologic solution of cytokines and tissue inhibitors of metalloproteinases improves healing in models of acute and chronic wounds. Such a cocktail can be produced from amnion-derived multipotent progenitor cells.

Amnion-derived cellular cytokine solution: a physiological combination of cytokines for wound healing.

OBJECTIVE: Wound repair is a complex integration of dynamic processes mediated by humeral messages controlling the levels of cytokines, growth factors, and matrix metalloproteinases in the wound space. Isolated growth factors and growth factor combinations have been used to accelerate wound healing with limited success. A cellular cytokine solution can be collected by harvesting the proteins released from amnion-derived multipotent progenitor cells. The purpose of this study was to compare levels of cytokines/growth factors in amnion-derived cellular cytokine solution with physiological levels reported in the medical literature. METHODS: Amnion-derived multipotent progenitor cells were grown to confluency, and the proteins secreted were characterized by qualitative and quantitative analysis. These results were compared with physiologic levels reported in the medical literature. RESULTS: The results demonstrated that amnion-derived cellular cytokine solution contained physiologic levels of cytokines relevant to wound healing, including platelet-derived growth factor, vascular endothelial growth factor, angiogenin, transforming growth factor beta 2, tissue inhibitor of metalloproteinase-1, and tissue inhibitor of metalloproteinase-2. The ranges (mean +/- standard deviation) were as follows: platelet-derived growth factor, 86 +/- 33 pg/mL; vascular endothelial growth factor, 5.7 +/- 1.5 ng/mL; angiogenin, 1.0 +/- 0.33 ng/mL; transforming growth factor beta 2, 500 +/- 330pg/mL; tissue inhibitor of metalloproteinase-1, 530 +/- 140 ng/mL; and tissue inhibitor of metalloproteinase-2230 +/- 40 ng/mL. These levels are comparable with the physiologic levels reported in the literature. CONCLUSIONS: The physiologic levels of cytokines important to healing found in amnion-derived cellular cytokine solution suggest that amnion-derived cellular cytokine solution may be of benefit in healing certain acute and chronic wounds.

Amnion-derived multipotent progenitor cells increase gain of incisional breaking strength and decrease incidence and severity of acute wound failure.

OBJECTIVE: Acute wound failure is a common complication following surgical procedures and trauma. Laparotomy wound failure leads to abdominal dehiscence and incisional hernia formation. Delayed recovery of wound-breaking strength is one mechanism for laparotomy wound failure. Early fascial wounds are relatively acellular, and there is a delay in the appearance of acute wound growth factors and cytokines. The objective of this study was to accelerate and improve laparotomy wound healing using amnion-derived multipotent cells (AMPs). AMPs' nonimmunogenic phenotype and relative abundance support its role as a cell therapy. METHODS: AMPs were injected into the load-bearing layer of rat abdominal walls prior to laparotomy, and cell viability was confirmed. Wound mechanical properties were measured over 28 days. The incidence and severity of laparotomy wound failure was measured in an incisional hernia model. RESULTS: AMP cells were viable in laparotomy wounds for at least 28 days and did not migrate to other tissues. Laparotomy wound-breaking strength was increased by postoperative day 7 following AMP therapy. AMP therapy reduced the incidence of hernia formation and the size of hernia defects. Histology suggested stimulated wound fibroplasia and angiogenesis. CONCLUSIONS: AMP cell therapy reduces the incidence of laparotomy wound failure by accelerating the recovery of wound-breaking strength. This results in fewer incisional hernias and smaller hernia defects.

Efficient method for expressing transgenes in nonhuman primate embryos using a stable episomal vector.

Transgenesis in the nonhuman primate can enhance the study of human biology by providing animal models for the study of primate-specific physiology, pathophysiology, and embryonic development. Progress with this technology has been hindered by the inherent inefficiency of transgenesis, transgene silencing, and practical restrictions on the production of sufficient pronuclear stage nonhuman primate zygotes. We have developed a novel technique using an Epstein Barr virus (EBV)-based episomal vector to produce rhesus monkey (Macaca mulatta) embryos expressing a transgene. Plasmid DNA containing the latent origin of replication, oriP, and Epstein Barr Nuclear Antigen-1 (EBNA-1) of EBV, as well as a CMV IE-enhanced green fluorescent protein (eGFP) expression cassette, was introduced into rhesus embryos by direct pronuclear microinjection. We detected eGFP in early cleavage stage embryos (4-8 cell) and throughout the duration of culture (day 8-9 blastocysts) by epifluorescent microscopy. A 50% transduction rate was obtained with the EBV-based vector. Microinjected embryos expressed eGFP and retained their developmental capacity as evidenced by development to the blastocyst stage. EBV-based vectors present a novel and efficient means of delivering transgenes for the study of the molecular control of primate embryonic development.