SISTER (system implementation of select transfers in emergency room) model to reduce ED boarding.

OBJECTIVE: This study describes a novel transfer model implemented between an academic, level 1 trauma center (Hospital A) and a nearby affiliate community hospital (Hospital B). Primary outcome is change in boarding hours and percentage of boarders in the Hospital A emergency department. Secondary objectives of this study include how improved flow in the emergency department to reduce boarding improves length of stay, prevents patients from escalating to more acute acuity levels of care, reduces patient morbidity and mortality and therefore improves health care costs as well. METHODS: A retrospective chart review was conducted over a consecutive 14-months period of all patients that presented to main hospital emergency department who were transferred to the Hospital B for inpatient admission. This included analysis of patient cohort characteristics, hospital LOS, return rate to the Hospital A (boomerang), rates of against medical advice (AMA) dispositions, post-discharge recidivism, in addition to enterprise data on total number of boarders, percent of boarders, and total boarding hours. RESULTS: There was a total of 718 transfer encounters during the study period. Percent boarding decreased from 70.6% in the pre-period to 63.8% in the post-period (p < 0.001). Total boarding hours decreased at both the main hospital and the sister hospital with this transfer process. The median length of stay at the sister hospital was 74 h, with 9 upgrades to ICU admissions. Five patients were dispositioned back to the hospital A after admission to hospital B. CONCLUSION: A distributive model was useful in transferring admissions within a healthcare system, reducing number of boarders, percent of boarders, and boarding hours in Hospital A emergency department. Furthermore, the Hospital B was an appropriate location for transfers, based on the low number of ICU transfers and dispositions back to the main hospital.

Mankind's first natural stem cell transplant.

The timing of the umbilical cord clamping at birth is still controversial. In the modern era of medicine, the cord has been clamped early to facilitate resuscitation and stabilization of infants. However, recently delayed cord clamping has been supported by physicians because it allows for the physiological transfer of blood from the placenta to the infant. Many clinical studies have revealed that the delayed cord clamping elevates blood volume and haemoglobin and prevents anaemia in infants. Moreover, since it was known that umbilical cord blood contains various valuable stem cells such as haematopoietic stem cells, endothelial cell precursors, mesenchymal progenitors and multipotent/pluripotent lineage stem cells, the merit of delayed cord clamping has been magnified. In this review, we discuss the advantages and disadvantages of delayed cord clamping at birth. We highlight the importance of delayed cord clamping in realizing mankind's first stem cell transfer and propose that it should be encouraged in normal births.

Intravenous administration of human umbilical cord blood cells in an animal model of MPS III B.

Sanfilippo syndrome type B (MPS III B) is caused by a deficiency of alpha-N-acetylglucosaminidase enzyme (Naglu), leading to accumulation of heparan sulfate (HS), a glycosaminoglycan (GAG), within lysosomes and to eventual progressive cerebral and systemic multiple organ abnormalities. Treatment of MPS patients is mainly supportive and enzyme replacement cell therapy shows promise for treating this disease. One new approach for potential treatment of MPS III B is human umbilical cord blood (hUCB) cell transplantation. Recently, we demonstrated that administration of hUCB cells into the cerebral ventricle of presymptomatic Naglu mice had a beneficial effect, probably due to enzyme delivery into the enzyme-deficient mutant mice. However, administration of these cells into the systemic circulation of mutant mice could be more advantageous and may lead to new strategies of enzyme replacement for Sanfilippo. The aim of this study was to determine the effect of intravenous administration of hUCB cells into a mouse model of Sanfilippo Syndrome type B. The major findings in our study were that hUCB cell administration improved behavioral outcomes (decreased hyper/stereotypical activity and improved cognitive function). Cells widely distribute within and outside the CNS and intraparenchymally migrate. Administered cells have an antiinflammatory effect (Th2-associated cytokines) in the brain and reduce heparan sulfate accumulation in the liver and spleen. Our results demonstrate the advantages of intravenously administering hUCB cells into a mouse model of Sanfilippo Syndrome type B, the advantages probably a result of Naglu delivery to enzyme-deficient organs.

Inflammation and stem cell migration to the injured brain in higher organisms.

Current treatments of neurological disorders such as Parkinson's disease and stroke are only partially effective. Consequently new therapies such as cell transplantation are of great interest. Cell therapy has shown promising results in animal models and in limited clinical trials. This form of treatment does have its own concerns, such as what factors control the survival and/or migration of the transplanted cells and how do they exert their benefit. Recent studies on tracking the transplants, such as prelabeling of the cells prior to transplant, and those elucidating the role of chemokines, as well as microglial and inflammatory responses, that may initiate the movement and survival of these cells are discussed in this review. A better understanding of these mechanism-driven pathways of neural repair will facilitate the clinical application of cell therapy for neurological disorders.

From the basics to application of cell therapy, a steppingstone to the conquest of neurodegeneration: a meeting report.

The annual meeting of the American Society for Neural Therapy and Repair (ASNTR) showcases the latest research trends in neurodegenerative disease and the related medical regenerative science. The 2008 ASNTR meeting covered a variety of different topics ranging from basic research to exploration of currently unknown pathogenesis and mechanisms for specific neurodegenerative disease such as Parkinson's disease, Alzheimer's disease, or stroke. This included studies to characterize stem cells, such as neural stem cells, embryonic stem cells, bone marrow mesenchymal stem cells, and human umbilical cord blood cells, for transplantation and the conditions necessary to maximize the efficacy of endogenous and exogenous stem cells, such as isolation, purification, differentiation, and migration. Moreover, a number of studies looked at methods for more advanced application of transplantation of cells or specific factors, through tissue engineering or manipulation beyond simple injection. Finally, well-known or previously un-known dietary supplementation or pharmacological materials that can affect the nervous system positively or negatively, were also important topics.

Stem Cell Research and Health Education.

Stem cells are being touted as the greatest discovery for the potential treatment of a myriad of diseases in the new millennium, but there is still much research to be done before it will be known whether they can live up to this description. There is also an ethical debate over the production of one of the most valuable types of stem cell: the embryonic form. Consequently, there is public confusion over the benefits currently being derived from the use of stem cells and what can potentially be expected from their use in the future. The health educator's role is to give an unbiased account of the current state of stem cell research. This paper provides the groundwork by discussing the types of cells currently identified, their potential use, and some of the political and ethical pitfalls resulting from such use.

Umbilical cord blood research: current and future perspectives.

Umbilical cord blood (UCB) banking has become a new obstetrical trend. It offers expectant parents a biological insurance policy that can be used in the event of a child or family member's life-threatening illness and puts patients in a position of control over their own treatment options. However, its graduation to conventional therapy in the clinical realm relies on breakthrough research that will prove its efficacy for a range of ailments. Expanding the multipotent cells found within the mononuclear fraction of UCB so that adequate dosing can be achieved, effectively expanding desired cells ex vivo, establishing its safety and limitations in HLA-mismatched recipients, defining its mechanisms of action, and proving its utility in a wide variety of both rare and common illnesses and diseases are a few of the challenges left to tackle. Nevertheless, the field is moving fast and new UCB-based therapies are on the horizon.

Collision course: the privatization of graduate medical education at one university.

On December 18, 2003, Tenet Healthcare Corporation, an investor-owned hospital corporation, announced the closure of Medical College of Pennsylvania Hospital, a historic institution that was home to many of Drexel University College of Medicine's (DUCOM's) faculty, residents, and medical students. The authors summarize the steps that were taken and lessons learned to avoid a disruption in the education of over 200 residents. The authors highlight the response by the medical school; the concerns of the Accreditation Council for Graduate Medical Education (ACGME); the interaction between the Center for Medicare and Medicaid Services (CMS) and the ACGME; the importance of the designated institutional official (DIO) in a crisis situation; and the role of residents as students versus employees when their employer wishes to move or "trade" them to another institution. Through the lens of the DUCOM experience, the authors explore the legal, political, and educational conflicts that occur when an investor-owned company or private hospital employs residents but another entity holds moral and academic accountability for their future. Finally, the authors outline five lessons learned: (1) the important role the ACGME plays as the educational conscience of graduate medical education (GME), (2) the dramatically different roles that the ACGME and the CMS play in regulating and funding the national GME system, (3) the need for constant communication with the affected residents, (4) the important role that the DIO plays in GME, and (5) the need for medical school leaders to remain focused on their educational mission and responsibilities to young physicians.

Novel cell therapy approaches for brain repair.

Numerous reports elucidate that tissue-specific stem cells are phenotypically plastic and their differentiation pathways are not strictly delineated. Although the identity of all the epigenetic factors which may trigger stem cells to make a lineage selection are still unknown, the plasticity of adult stem cells opens new approaches for their application in the treatment of various disorders. There is increasing researcher interest in hematopoietic stem cells for treatment of not only blood-related diseases but also various unrelated disorders including neurodegenerative diseases. Human umbilical cord blood (hUCB) cells, due to their primitive nature and ability to develop into nonhematopoietic cells of various tissue lineages, including neural cells, may be useful as an alternative cell source for cell-based therapies requiring either the replacement of individual cell types and/or substitution of missing substances. Here we focus on recent findings showing the robustness of adult stem cells derived from hUCB and their potential as a source of transplant cells for the treatment of diseased or injured brains and spinal cords. Depending upon the pathological microenvironment in which the hUCB cells are introduced, neuroprotective and/or trophic effects of these cells, from release of various growth or anti-inflammatory factors to moderation of immune-inflammatory effectors, may be more likely than neural replacement. These protective effects may prove essential to maintaining restored tissue integrity over the course of various diseases or injuries.

Maternal transplantation of human umbilical cord blood cells provides prenatal therapy in Sanfilippo type B mouse model.

Numerous data support passage of maternal cells into the fetus during pregnancy in both human and animal models. However, functional benefits of maternal microchimerism in utero are unknown. The current study attempted to take advantage of this route for prenatal delivery of alpha-N-acetylglucosaminidase (Naglu) enzyme into the enzyme-deficient mouse model of Sanfilippo syndrome type B (MPS III B). Enzymatically sufficient mononuclear cells from human umbilical cord blood (MNC hUCB) were intravenously administered into heterozygote females modeling MPS III B on the 5th day of pregnancy during blastocyst implantation. The major findings were 1) administered MNC hUCB cells transmigrated and diffused into the embryos (E12.5); 2) some transmigrated cells expressed CD34 and CD117 antigens; 3) transmigrated cells were found in both the maternal and embryonic parts of placentas; 4) transmigrated cells corrected Naglu enzyme activity in all embryos; 5) administered MNC hUCB cells were extensively distributed in the organs and the blood of heterozygote mothers at one week after transplantation. Results indicate that prenatal delivery of Naglu enzyme by MNC hUCB cell administration into mothers of enzyme-deficient embryos is possible and may present a significant opportunity for new biotechnologies to treat many inherited disorders.

Umbilical cord blood-derived stem cells and brain repair.

Human umbilical cord blood (HUCB) is now considered a valuable source for stem cell-based therapies. HUCB cells are enriched for stem cells that have the potential to initiate and maintain tissue repair. This potential is especially attractive in neural diseases for which no current cure is available. Furthermore, HUCB cells are easily available and less immunogenic compared to other sources for stem cell therapy such as bone marrow. Accordingly, the number of cord blood transplants has doubled in the last year alone, especially in the pediatric population. The therapeutic potential of HUCB cells may be attributed to inherent ability of stem cell populations to replace damaged tissues. Alternatively, various cell types within the graft may promote neural repair by delivering neural protection and secretion of neurotrophic factors. In this review, we evaluate the preclinical studies in which HUCB was applied for treatment of neurodegenerative diseases and for traumatic and ischemic brain damage. We discuss how transplantation of HUCB cells affects these disorders and we present recent clinical studies with promising outcome.