The Translational Research in Normal and Disordered Development (TReNDD) Program is a collaborative interdisciplinary research endeavor organized by the Division of Neonatal Research for the Department of Pediatrics, with a focus on basic and translational research relevant to pediatrics. The TReNDD Program includes infrastructure and faculty of the Division of Neonatal Research, and additionally has faculty and infrastructure of other Divisions (Pediatric Pulmonology, Pediatric Nephrology, Pediatric Critical Care etc). The Division of Neonatal Research developed as an off-shoot from the Division of Neonatology in 2009, with a parallel administrative and fiscal structure, in order to optimize development and maintenance of research activities within the Division. The Division of Neonatal Research is in charge of the TReNDD program.

Program Mission

The mission of the TReNDD Program at UAB is to promote excellence in scientific investigation of the normal processes and acquired disorders of organ and tissue development in the interval between morphogenesis and maturity, and to promote the development of new investigators in this area.

Vision

The TReNDD Program at UAB will be a collaborative group of investigators applying state of the art biological approaches to understanding human disorders of organogenesis, including elucidating basic mechanisms of organ and tissue development, and normal and disordered responses to injury. Core facilities will provide physiologic and molecular analyses to support multiple projects. The laboratories within the TReNDD Program will provide training for pre- and postdoctoral trainees in related research. The collaborative environment will foster excellence and facilitate extramural funding through single investigator and multiple investigator projects from a wide range of disciplines.

Dr. Sims research goal is to understand the role of neural stem cells and their role in brain injury. He competed successfully for the Amos Medical Faculty Development Award through the Robert Wood Johnson Foundation from 2005-2009, and this work has increased his knowledge of the vulnerability of neural stem cells. During this time, his laboratory made some important links to the role of exosomes in cellular protection. Dr. Sims is on track to become one of the few investigators in the country analyzing the role of exosomes in cellular protection. Dr. Sims has secondary appointments in Cell, Developmental and Integrative Biology and Neurobiology. He is also a part of the Center for Glial Biology in Medicine and the Civitan International Research Center.

Dr. Sims is the Director of the Antepartum Consulting Service. The service is in collaboration with UAB Obstetrics/Maternal Fetal Medicine giving parents access to our Neonatology expertise. Dr. Sims rounds weekly and discusses cases with the MFM team as needed. Since implementation, the feedback has shown this service to be invaluable to both parents and staff.

Dr. Sims has published 7 articles in the last 2 years with a focus on cellular protection. These papers have led him and his lab to be leaders in understanding the role of exosomes in cell biology and pathology and it relates the central nervous system and other organs. Seminal work has been done investigating the interaction of exosomes and HIV which highlights the importance of these nanostructures in biology. In his lab, exosomes derived from human breast milk have been shown to be protective. These studies have led to clinically relevant targets that are under intense investigation.

Dr. Sims performed innovative clinical research in the B-natriuretic peptide and its role in pulmonary hypertension. Prior to his publications the correlation between BNP and BPD/pulmonary hypertension was not well studied. Currently, BNP is used internationally as a screening tool to follow babies with this severe condition.

Dr. Sims attends on an inpatient service 4 months per year, spends 3-4 nights on call in hospital per month and is the weekend rounder at UAB or Children’s of Alabama 7-8 weekends per year. Dr. Sims is also an expert in vascular access and is available to the units whenever the need arises in critically ill neonates.

Exposure to bromine gas inhalation during pregnancy causes preeclampsia-like symptoms, maternal death and severe fetal growth restriction. This project is supported by an NIH CounterACT U01 (Link to project in NIH Reporter). “The CounterACT program supports basic and translational research aimed at the identification of better therapeutic medical countermeasures against chemical threat agents, and facilitates their movement through the drug development and regulatory processes in collaboration with other federal departments, agencies, and initiatives.” (NIH CounterACT website). Briefly: The halogen bromine (Br2) is used as water disinfectant, for bleaching fibers, for manufacturing antiepileptic drugs, dyestuffs, flame-retardants, insecticides, drilling fluids, and gasoline additives. Exposure of pregnant mice at gestational day 15 (E15) to Br2 (600 ppm for 30 min.) results in 75% mortality over four days, in contrast to 25% mortality in males or non-pregnant females (p<0001). When delivered at E19, fetuses of surviving Br2-exposed mice exhibit severe fetal growth restriction (FGR) and fetal demise (FD). Placentas are poorly developed and express increased levels of short-FMS-like tyrosine kinase-1 (sFlt-1), an anti-angiogenic mediator and biomarker of both preeclampsia and pulmonary hypertension. When born naturally, none of the fetuses survive. Oral administration of an FDA- approved type 5 cyclic nucleotide-specific phosphodiesterase inhibitor (PDE5i; tadalafil) to the dams post- exposure, dramatically improved maternal survival, fetal growth restriction and neonatal survival. Specific aims: Specific Aim #1. To test the hypothesis that exposure of pregnant mice to Br2 at E15 causes extensive pulmonary injury as well as systemic endothelial injury, placental injury, pulmonary hypertension, right heart failure resulting in maternal mortality, fetal growth restriction and fetal demise/stillbirth. Specific Aim #2: To identify the sequence of events and mechanisms involved in the development of maternal vasoconstriction, pulmonary hypertension and right heart failure. Specific Aim #3. To investigate the efficacy of post halogen exposure administration of tadalafil to decrease maternal and fetal death and morbidity and to develop a rabbit (non-rodent) model of Br2 toxicity in pregnancy.  

This preeclampsia-oriented translational animal model project led to two clinical projects aimed at improved diagnostics and management in preeclampsia. One project is a biomarker discovery project, where specimens of plasma, CSF and placenta from control, and preeclamptic patients are used to identify novel biomarkers. The second project is to assess the utility of transthoracic echocardiography to test whether increased pulmonary vascular resistance and diminished right ventricle function can be used to identify high risk for poor outcomes in preeclampsia.

Exposure of neonatal lungs to Cl2, Br2 or COCl2 results in abnormal lung development similar to bronchopulmonary dysplasia: This project is Project#2 in a currently pending U54 application to the CounterACT program: Briefly: neonatal mice exposed to 600 ppm Br2 or to 400 ppm Cl2 for 30 min (Br2 600/30 and Cl2 400/30) at postnatal day 3 (P3) exhibited a high rate of mortality and surviving mice failed to thrive and displayed alveolar simplification on P14. Additionally, neonatal mice exposed to Br2 (600/30) exhibited impaired systemic oxygenation, pulmonary inflammation and persistent global gene expression changes in key pathways of lung development on P14 (PMID: 28912380). These structural and functional changes are reminiscent of findings commonly observed in neonatal murine models of bronchopulmonary dysplasia (BPD). Our specific aims are: SA#1 To test the hypothesis that the severity of toxic gas exposure-induced pulmonary remodeling is lung developmental stage-dependent. SA#2 To identify key mechanisms that cause pulmonary remodeling in mice exposed to toxic gases during lung development. SA#3 To test the efficacy of HPX and OGG1mt post-exposure to decrease lung injury and mortality.

The role of Platelet-activating factor in BPD and PAF-targeted potential therapeutic approaches for BPD: This project will be submitted as an R21 application in the next application cycle. In this exploratory/developmental proposal, based on solid preliminary data, we propose to test the role of the platelet-activating factor (PAF) signaling pathway that, to this pointy, has been unrecognized in the pathogenesis of BPD and we propose to test a novel strategy for BPD prevention based on interrupting the PAF pathway. Our preliminary data were generated using mice with three different genotypes exposed to hyperoxia (FiO2=85%) from postnatal day 4 (P4) to P14; a common murinw model of BPD: 1) Wild type (WT). 2) PAF receptor (PTAFR) gene knocked out (PTAFR KO); deficient of PAF signaling. 3) The PAF degrading enzyme PAF acetylhydolase (PAF AH), also known as phospholipase 2 group 7 (PLA2G7) knocked out (PLA2G7 KO); exhibit enhanced PAF signaling. Hyperoxia-exposed PTAFR KO mice exhibited less pulmonary inflammation and better alveolar development than hyperoxia-exposed WT and hyperoxia-exposed PLA2G7 KO mice showed exaggerated inflammation and more compromised lung development than hyperoxia-exposed WT. There was no difference in hyperoxia-induced macrophage recruitment between the three genotypes, but there was excessive neutrophil recruitment in hyperoxia-exposed PLA2G7KO, correlating with exaggerated hyperoxia-induced CXCL1 chemokine mRNA levels, which were PTAFR KO<WT<PLA2G7 KO. We hypothesize that 1) PAF signaling-mediated production of CXCL1 chemokine facilitates neutrophil recruitment to the lung, and that this process plays a critical role in hyperoxia-induced altered lung development and 2) inhibition of PAF signaling by administration of recombinant PAF AH into the airways can be used as a strategy to prevent the development of hyperoxia-induced neutrophil recruitment and altered lung development. We address these hypotheses in two specific aims. SA#1: To test the role of PAF-signaling-mediated recruitment of neutrophils into the lung in a murine model of BPD. SA#2: To test the therapeutic efficacy of recombinant murine PAF-AH (rm-PAF-AH) to mitigate hyperoxia-induced neutrophil recruitment and altered lung development in a murine model of BPD.

Dr. Ramani’s goal is to determine the mechanisms underlying neurodevelopmental impairment in preterm infants and to identify potential therapeutic strategies. Dr. Ramani is developing a Mitochondrial-Nuclear eXchange model in collaboration with Dr. Ballinger to determine whether reducing neonatal oxidative stress-induced hippocampal mitochondrial dysfunction will prevent oxygen-induced deficits in hippocampal function and development. Dr. Ramani is also characterizing mitochondrial complex I overexpressed mice model in collaboration with Dr. Chandel to determine the contribution of complex I dysfunction to oxidative stress-induced hippocampal mitochondrial dysfunction.

The Neonatal Neurophysiology Laboratory is housed within Dr. McMahon’s laboratory at the McCallum Basic Health Sciences Building. Neonatal Neurophysiology laboratory has all the equipment necessary for slice electrophysiology techniques. Common electrophysiology techniques conducted in this laboratory include extracellular dendritic field potential recordings (long-term potentiation [LTP] and long-term depression [LTD]), basal synaptic transmission, and presynaptic release probability. Our team has the unrestricted access to the High-Resolution Imaging Core (Confocal Microscopy, Super-resolution Microscopy, Transmission Electron Microscopy, Scanning Electron Microscopy, Sub-Micron Particle Imaging), Behavioral Assessment Core (SHIRPA Neurobehavioral assessment tests), and Bio-Analytical Redox Biology Core (mtDNA Damage Analysis, High-Resolution Respirometry, Mitochondrial Oxidative Phosphorylation Complex and other Mitochondrial Proteins' Activity Assays, Mitochondrial Complex I Assay, Mitochondrial Complex IV Assay, Mitochondrial Citrate Synthase Assay, Bioenergetics' Analysis of Tissues, Mitochondria, and Cells, Mitochondria Isolation and Preparation).

Neonatal Oxygen Supplementation Impairs Long-term Hippocampal development and Function: A BPD model of NDI: Many preterm infants often require prolonged and high concentrations of oxygen therapy in the neonatal intensive care unit and at home. Prolonged oxygen therapy leads to the development of bronchopulmonary dysplasia (BPD). Children with BPD are at risk for poor neurodevelopmental outcome even in the absence of obvious intracranial pathology. The etiology for such neurodevelopmental impairment (NDI) seen in children with BPD is not known. Though short-term effects of oxygen exposure on neuronal homeostasis are well known, a little is known about its long-term effect on the brain function and development. Dr.Ramani’s team developed a novel animal model can be used to determine mechanisms underlying developmental programming of NDI in preterm infants, and for evaluation of therapeutic strategies. Briefly, the neonatal mice pups are exposed to 85% oxygen from P2-14 and return them to room air for 10 more weeks. At 12-14 weeks we have done neurobehavioral assessment such as Morris water maze test (to assess the spatial memory), novel object recognition test (to test learning memory, elevated plus maze (to assess anxiety), open field test (to assess locomotion), and cliff test (to assess vision). The team have also done brain morphometery using T9.1 MRI at the small animal imagining facility UAB. We have found that young adult mice that receive oxygen therapy during their neonatal period have spatial and recognition memory deficits, exaggerated exploratory behavior, and reduced hippocampal size. This work was the first of its kind to provide insight into the long-term effects of early oxidative stress on hippocampal development and function. Dr. Ramani’s team is also studying the role MitoQ, a mitochondrial targeted antioxidant, on the prevention of early life oxidative stress-induced long-term congtive and neurodevelopmental deficits. Dr. Ramani’s team also study the impact of early life oxidative stress on the hippocampal mitochondrial function using unique mouse models; MNX, (a C57BL/6 mouse (C57n: C3Hmt) with ROS-resistant mitochondria transferred from C3H/HeN mouse) and NDI1 (a complex I overexpressed mouse) mice.

Dr. Lal is interested in studying the mechanisms by which the microbiome and virome modulates respiratory diseases in neonates and pediatric population such as bronchopulmonary dysplasia(BPD) and cystic fibrosis. Historically, the fetus and fetal lungs were considered sterile. Dr. Lal has recently made the seminal discovery that the airways of infants at birth harbor a distinct microbiome signature. In addition, an early microbial imbalance, or dysbiosis, is predictive for the development of chronic lung disease of prematurity. The lab discovered that the ELBW infants who went on to develop life-threatening BPD showed different microbial colonization patterns at birth, as compared to pre-term infants who did not develop BPD. They conducted 16s sequencing microbiome analysis on tracheal aspirate obtained from preterm and term intubated babies at birth from separate discovery and validation cohorts. Increased abundance of gammaproteobacteria was found to be associated with development of BPD whereas a lack of airway Lactobacillus was a predisposing factor for BPD. Hence the lab established the pathogenic and biomarker potential of airway microbiome in BPD. Recently Dr. Lal’s lab also discovered that lung microbiota is involved in exosome and exosomal microRNA (miRs) release from pulmonary cells in BPD. Gammaproteobacteria stimulate exosome release from pulmonary cells and also alter exosomal cargo (miRs) which contributes to BPD pathogenesis. Moreover, the lab has now now developed novel respiratory probiotic combinations which decrease inflammation in various chronic lung diseases.

Dr. Lal’s lab is also interested in studying the mechanisms of lung development and injury by utilizing translational and basic science experimental designs. His work involves studying the role of pulmonary microRNAs, exosomes, metabolome and neutrophilic inflammation in BPD. In addition, Dr. Lal studies the role of Ac-PGP (a neutrophilic chemoattractant and mediator of vascular permeability) in BPD and the associated pulmonary hypertension. Dr. Lal is currently funded by the Kaul Pediatric Research Grant, American Heart Association Scientist Development Grant, is a co-investigator on a NHLBI R01 grant, and has a pending K08 application to study the role of microbiome in pediatric lung diseases.

The MNH Registry, initially developed by Dr. Carlo, was implemented in the 7 GN sites. This registry is an innovative database that allows the GN to conduct population-based studies and provides an independent measure of outcomes for GN studies and trials. It is a model for developing countries’ databases. This database is used to collect data on pregnancies and maternal and newborn outcomes up to 6 weeks after birth from facility and home births. Dr. Carlo was the senior author of the first MNH Registry publication and remains an active participant.

The FIRST BREATH pilot trials led by UAB-Zambia investigators and conducted in Zambia showed that resuscitation and essential newborn care reduced stillbirths and early neonatal mortality in facilities. Further analysis of cost data revealed that ENC training and implementation is one of the most cost-effective perinatal interventions. However, a major undertaking was to scale up these interventions to lower level health care providers as many deliveries occur at home or in small delivery facilities. The initial Zambia ENC and resuscitation training trials were scaled up as the GN’s first common protocol (ENC) and the first RCT (FIRST BREATH TRIAL), a community-based cluster-RCT that taught neonatal resuscitation skills to all birth attendants in participating sites. More than 3,700 birth attendants from 96 GN communities at 6 sites attending 120,009 births were trained to resuscitate neonates at birth. This was the first RCT of neonatal resuscitation training; it demonstrated that perinatal mortality was decreased by 15% (45.9/1000 to 38.9/1000) with ENC training. The rate of 7-day outcome follow-up was greater than 99%. The Helping Babies Breathe (HBB) Program, developed in conjunction with NICHD personnel, was created using the materials developed for the FIRST BREATH Trial. The Helping Babies Breathe Program has now been introduced in over 80 countries. The Essential Care for Every Baby, that was created using the materials developed for this trial, is also being introduced worldwide.

Because of the concern that improved survival as found in the FIRST BREATH Common Protocol might have led to survivors with neurodevelopmental disabilities, the UAB-Zambian team designed the BRAIN-HIT RCT. This RCT was jointly funded by NICHD, NINDS, and Fogarty to test the impact of parent-provided early stimulation plus a program of anticipatory guidance developed by WHO for low-resource settings versus only this program of anticipatory guidance on neurodevelopmental outcomes of asphyxiated infants. Compared with control home visits, this trial showed that both Bayley cognitive and psychomotor outcomes were improved by 5 points in survivors of birth asphyxia in low- and middle-income countries using parent-provided infant stimulation.

To describe the staffing, availability of medical equipment and medications, and the performance of procedures at health facilities providing maternal and neonatal care as part of the EmONC multicenter trial, our UAB-Zambia team led a study in which we surveyed 136 hospitals and 228 clinics in 7 sites of the GN. The coverage of physicians and nurses/midwives was poor in Africa and Latin America. In Africa, only 20% of hospitals had full-time physicians. Only 70% of hospitals in Africa and Asia had performed cesarean sections in the last 6 months. Oxygen was unavailable in 40% of African hospitals and 17% of Asian hospitals. Blood was unavailable in 80% of African and Asian hospitals. These findings may in part explain the high maternal and perinatal mortality rates in these areas. The data suggest that to reduce mortality in these areas, improved staffing and sufficient equipment, supplies, and medication in addition to training may be required.

GN Single Center RCTs Conducted by the UAB-Zambia Team - UAB investigators (Leadford, Belches, Ramani, Manasyan, and Travers) have led 6 randomized clinical trials of plastic bags to prevent neonatal hypothermia in term and preterm infants in low-resource settings and are in the middle of two other ones. All the completed trials have shown benefits of the interventions and led to changes in practices worldwide.

GN Trial of Azithromycin - Dr. Alan Tita and Dr. Carlo have developed the protocol Prevention of maternal and neonatal death/infections with a single oral dose of azithromycin in women in labor (in low- and middle-income countries): a randomized controlled trial which was ranked number 1 in the GN and will start enrollment in 2019. A complementary grant application submitted to the Bill and Melinda Gates Foundation has been favorably reviewed and we are expecting funding.

In summary, the Global Health Research Program based in the Division has been extremely successful advancing the field through seminal research that is leading to major changes in care globally.