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Cytokine expression in post-mortem human brain tissue following acute traumatic brain injury
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Abstracts Trauma Melbourne 2009 / Injury 41S (2010) S49–S62
to major trauma services would be reduced. The refined criteria would also assist in decreasing discretionary decision-making by paramedics in the field. Acknowledgements: This abstract describes a study undertaken to evaluate the current Victorian adult pre-hospital trauma triage criteria, and was conducted with the assistance of funding from the Transport Accident Commission (TAC)/Victorian Neurotrauma Initiative (VNI). (Note at the time of funding the funding body was known as the Victorian Trauma Foundation.) doi:10.1016/j.injury.2010.01.075 POSTER POSTER-6
Analysis of white matter damage in the rat spinal cord following injury C.J. Ek ∗ , R. Dennis, M. Habgood, K. Dziegielewska, N.R. Saunders Department of Pharmacology, University of Melbourne, Parkville, Victoria, Australia The aim of this study was to assess damage to white matter in the spinal cord after a contusion injury in the rat. Methods: Young adult rats (8 weeks old) were anaesthetised with inhaled isoflurane (2–3%), lamenectomised at T10 and a 1 m/s impact injury induced directly onto the dorsal spinal cord. Wounds were closed and analgesics administered (buprenorphin 0.03 mg/kg) for three days after the injury. Groups of animals (n = 3–4 in each group) were killed, together with age-matched control animals, at 24 h, 1 week, 4 weeks or 10 weeks after injury using an overdose of halothane (>10%). Spinal cords were processed for electron microscopy. White matter damage and numbers of axons were assessed using stereology-based microscopy in dorsal and lateral parts of the cord at every 1 mm interval from 10 mm above to 10 mm below injury site. Results: Pathological changes were already apparent at 24 h after injury. At 1 week after injury, the spinal cord was invaded by large numbers of macrophages at injury site and by 4 weeks a cyst had formed around injury site. Axon pathology was no longer visible in the dorsal column at 4 weeks, but was still present in ventral white matter tracts. Axon counts showed extensive loss in the first 24 h (∼50%), further loss until 1 week but no further losses were detected thereafter up to 10 weeks after injury. At 1–10 weeks after injury only 3–5% of axons in dorsal column survived in the injury site whereas in the ventral and lateral tracts about 10–15% of axons were still present. Nine millimetre below injury site axon numbers were close to normal whereas above injury site loss of axons was still visible. Conclusions: The rapid loss of axon after injury suggests in order for therapeutic intervention to be beneficial reduce white matter damage, it needs to be administered in the first few days after injury. In addition, stereology-based microscopy appears a promising way to analyse white matter damage and it could be used to test the therapeutical effect of new treatments. doi:10.1016/j.injury.2010.01.076
POSTER POSTER-7
Assaulted nuts and other bits and pieces L. Freeman, R. Mitchell ∗ , K. Martin Department of Trauma Surgery, The Alfred Hospital, Prahran, Victoria, Australia Objectives: When comparing injury to of the various parts of the human body trauma involving the male external genitalia is relatively uncommon. Blunt trauma of the abdomen mainly leads to injuries of the liver, spleen, bowel, kidney, and/or bladder. In contrast the external genitals are often damaged directly leading to contusions, lacerations and even amputation. Yet occult genital injury is often overlooked or diagnosed late secondary to failure to examine the area or embarrassment of the patient in reporting symptoms. Furthermore symptoms of injury to the genitourinary system can be indistinct, with many cases revealing little more than nonspecific discomfort or microhaematuria. Immediate recognition of such injuries is essential as it leads to early treatment and substantially aids in avoiding potentially dire complications. Thus the aim of the present paper was to conduct a review of a male population of trauma patients who have sustained an injury to their genitalia in the context of their presentation to a tertiary trauma hospital. The intention was to highlight the need for a high index of suspicion in a specific trauma population, to encourage early and appropriate investigation and referral to a suitable unit, and to institute appropriate management and follow-up care in a timely manner for this cohort of patient. Patients and methods: A retrospective case based review was performed identifying all male trauma patients admitted to a tertiary trauma centre over a 5-year period who had sustained an injury to their genitalia. Mechanism of injury, time to identification of injury, injury pattern, time to referral to a urological unit, timing of surgery (if undertaken), other managements, and follow-up were all recorded. The rates of occurrence of the above information were used to draw generalised conclusions about trends in the identification and treatment of this patient population. Conclusion: Prompt identification of injury and early surgical intervention by a specialised urological unit when necessary is crucial. A high index of suspicion, simple radiological investigation and treatment via an interdisciplinary team all optimize appropriate management of patients with trauma to the external genital organs. doi:10.1016/j.injury.2010.01.077 POSTER POSTER-8
Cytokine expression in post-mortem human brain tissue following acute traumatic brain injury T. Frugier 1,2,∗ , D. O’Reilly 1,2 , M.C. Morganti-Kossmann 1,2,3 , C. McLean 2,3 1
National Trauma Research Institute, The Alfred Hospital, Melbourne, Victoria, Australia 2 Monash University, Melbourne, Victoria, Australia 3 Anatomical Pathology Department, The Alfred Hospital, Melbourne, Victoria, Australia
Abstracts Trauma Melbourne 2009 / Injury 41S (2010) S49–S62
Objectives: Little is known about the molecular events following severe traumatic brain injury (TBI) in humans. To date there are no efficient therapies for the treatment of TBI patients. The availability of human brain tissue from the Australian Neurotrauma Tissue and Fluid Bank is a unique opportunity to analyse the early inflammatory processes following TBI. Methods: In this study, a total of 21 trauma brain samples were analysed. Age and sex matched samples were used as controls. To explore the cerebral inflammation within the brain tissue, we measured the level of expression of nine major inflammatory cytokines at mRNA and protein levels by enzyme-linked immunosorbent assay, bioplex cytokine assay and real-time quantitative PCR. Results: All the pro-inflammatory mediators analysed (IL-6, IL-8, IFN-␥, TNF-␣, IL-1, GM-CSF, IL-2) showed a strong and statistically significant (p < 0.001) increase in the brain samples of individuals who died more than 6 h following brain injury (late group) compared to the control group and to the brain samples of individuals who died within 17 min of the injury (early group). Interestingly, in the samples from the early group, although modest, cytokine concentrations were found statistically increased when compared with the control group: IL-6 (p < 0.027), IFN-␥ (p < 0.018), TNF-␣ (p < 0.03) and GM-CSF (p < 0.022). However, in the early group the levels of both anti-inflammatory cytokines IL-4 and IL-10 remained at basal levels. In addition, in the late group no statistical difference was observed between the damaged cortex and the contralateral cortex for both the pro- and anti-inflammatory cytokines. Similarly, in the samples from the early group there was no difference in the levels of IL-6 and IL-1 mRNA compared with controls. However, mRNA levels were significantly increased in the cortex samples of individuals from the late group in both the cortex adjacent to the injury and the contralateral cortex compared with the control and the early groups: IL-6 (24 and 25-fold, respectively, p < 0.001) and IL-1 (5.2-fold, p < 0.003 and 5.5-fold, p < 0.024, respectively). IL-8 is the only cytokine showing the strongest mRNA level increase in the late group: 139-fold vs. control group (p < 0.001) and 56-fold vs. early group (p < 0.001). Interestingly, IL-8 mRNA levels were 7-fold higher in the ipsilateral brain cortex when compared to the un-injured region (p < 0.029). Finally, TNF-␣ was the only cytokine showing a significant 4-fold increase in the levels of mRNA in the samples of individuals from the early group (p < 0.014). Those levels remained elevated in the late group by 7-fold in the injured cortex (p < 0.006) and 3-fold (p < 0.035) in the contralateral cortex. Conclusions: These results show for the first time in the human brain tissue that the cerebral inflammatory response starts within minutes of acute TBI. The increased inflammatory mediator protein levels observed are coincidental with the increased levels of their mRNAs suggesting that TBI elicits an immediate cerebral and not a systemic inflammatory response. Altogether these data highlight the need to finely characterize the cellular source of cytokines to ultimately elucidate their mode of action and develop therapeutic strategies to attenuate inflammation-mediated secondary brain damage. Acknowledgements: This study was supported by the Victorian Neurotrauma Initiative. Tissues were received from the Neurotrauma Tissue & Fluid Bank, a subdivision of the Australian Brain Bank Network.
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POSTER POSTER-9
Queensland Trauma Registry K. Harvey ∗ , C. Pollard, J. Lang ∗ , N. Dallow, C. Spanagel, J. Carroll Queensland Trauma Registry, Centre of National Research on Disability and Rehabilitation Medicine, University of Queensland, Brisbane, Queensland, Australia Objectives: The Queensland Trauma Registry (QTR) has been established as a statewide registry since January 2002 and now collects data from 20 public hospitals in Queensland. Data collected by the QTR spans the acute care continuum, and includes data items from the pre-hospital, referring hospital, interfacility and definitive hospital phases of care. As such, the QTR is able to describe the patterns of injury incidence and patient movement through the trauma system. This poster provides a map of the 20 hospital sites included on the registry, with identification of the major trauma services, location of helicopter/RFDS bases and a description of referral patterns of injured patients occurring across the State. Methods: The QTR captures all patients who are admitted to a Registry hospital site for ≥24 h and have injuries codeable to an ICD-10-AM category from S00 to S99, T00 to T35, T63, T66 to T71 and T75 (with poisonings also collected in children aged ≤14 years). Patients who die during their Emergency Department presentation following commencement of active treatment or who die during hospital admission are also included. The QTR also includes elderly patients who have sustained a fractured neck of femur injury. Results: Of the 20 hospitals who contribute data to the QTR, 12 hospitals are in South East Queensland, five hospitals are in Central Queensland and three hospitals are in Northern Queensland. In 2008, 31% (4665) of all cases included on the QTR were referred from another hospital for definitive care. Over half (2557) of all referred patients were transported by road ambulance, with 15% (694) transported via helicopter and 7% (320) via fixed wing aircraft. In terms of types of injuries transferred, 52% of patients (2417) had fractures and 12% (562) had an intracranial injury. Conclusions: Queensland is a large state and the distances to specialist medial services are often vast. The data held by QTR concerning referral patterns of trauma patients around the State may prove useful for clinicians and policy makers interested in patient transport within the trauma system. doi:10.1016/j.injury.2010.01.079 POSTER POSTER-10
Incidence and outcomes of traumatic subdural haematoma across different age groups F. Irie 1,∗ , N. Bellamy 1 , C. Pollard 1,2 1
doi:10.1016/j.injury.2010.01.078
Centre of National Research on Disability and Rehabilitation Medicine (CONROD), The University of Queensland, Brisbane, Queensland, Australia 2 Royal Brisbane Women’s Hospital, Brisbane, Queensland, Australia Objectives: The purpose of this study was to investigate the magnitude of traumatic subdural haematoma (SDH) across different age groups and determine which groups are most affected by this severe brain trauma injury.
Abstracts Trauma Melbourne 2009 / Injury 41S (2010) S49–S62
to major trauma services would be reduced. The refined criteria would also assist in decreasing discretionary decision-making by paramedics in the field. Acknowledgements: This abstract describes a study undertaken to evaluate the current Victorian adult pre-hospital trauma triage criteria, and was conducted with the assistance of funding from the Transport Accident Commission (TAC)/Victorian Neurotrauma Initiative (VNI). (Note at the time of funding the funding body was known as the Victorian Trauma Foundation.) doi:10.1016/j.injury.2010.01.075 POSTER POSTER-6
Analysis of white matter damage in the rat spinal cord following injury C.J. Ek ∗ , R. Dennis, M. Habgood, K. Dziegielewska, N.R. Saunders Department of Pharmacology, University of Melbourne, Parkville, Victoria, Australia The aim of this study was to assess damage to white matter in the spinal cord after a contusion injury in the rat. Methods: Young adult rats (8 weeks old) were anaesthetised with inhaled isoflurane (2–3%), lamenectomised at T10 and a 1 m/s impact injury induced directly onto the dorsal spinal cord. Wounds were closed and analgesics administered (buprenorphin 0.03 mg/kg) for three days after the injury. Groups of animals (n = 3–4 in each group) were killed, together with age-matched control animals, at 24 h, 1 week, 4 weeks or 10 weeks after injury using an overdose of halothane (>10%). Spinal cords were processed for electron microscopy. White matter damage and numbers of axons were assessed using stereology-based microscopy in dorsal and lateral parts of the cord at every 1 mm interval from 10 mm above to 10 mm below injury site. Results: Pathological changes were already apparent at 24 h after injury. At 1 week after injury, the spinal cord was invaded by large numbers of macrophages at injury site and by 4 weeks a cyst had formed around injury site. Axon pathology was no longer visible in the dorsal column at 4 weeks, but was still present in ventral white matter tracts. Axon counts showed extensive loss in the first 24 h (∼50%), further loss until 1 week but no further losses were detected thereafter up to 10 weeks after injury. At 1–10 weeks after injury only 3–5% of axons in dorsal column survived in the injury site whereas in the ventral and lateral tracts about 10–15% of axons were still present. Nine millimetre below injury site axon numbers were close to normal whereas above injury site loss of axons was still visible. Conclusions: The rapid loss of axon after injury suggests in order for therapeutic intervention to be beneficial reduce white matter damage, it needs to be administered in the first few days after injury. In addition, stereology-based microscopy appears a promising way to analyse white matter damage and it could be used to test the therapeutical effect of new treatments. doi:10.1016/j.injury.2010.01.076
POSTER POSTER-7
Assaulted nuts and other bits and pieces L. Freeman, R. Mitchell ∗ , K. Martin Department of Trauma Surgery, The Alfred Hospital, Prahran, Victoria, Australia Objectives: When comparing injury to of the various parts of the human body trauma involving the male external genitalia is relatively uncommon. Blunt trauma of the abdomen mainly leads to injuries of the liver, spleen, bowel, kidney, and/or bladder. In contrast the external genitals are often damaged directly leading to contusions, lacerations and even amputation. Yet occult genital injury is often overlooked or diagnosed late secondary to failure to examine the area or embarrassment of the patient in reporting symptoms. Furthermore symptoms of injury to the genitourinary system can be indistinct, with many cases revealing little more than nonspecific discomfort or microhaematuria. Immediate recognition of such injuries is essential as it leads to early treatment and substantially aids in avoiding potentially dire complications. Thus the aim of the present paper was to conduct a review of a male population of trauma patients who have sustained an injury to their genitalia in the context of their presentation to a tertiary trauma hospital. The intention was to highlight the need for a high index of suspicion in a specific trauma population, to encourage early and appropriate investigation and referral to a suitable unit, and to institute appropriate management and follow-up care in a timely manner for this cohort of patient. Patients and methods: A retrospective case based review was performed identifying all male trauma patients admitted to a tertiary trauma centre over a 5-year period who had sustained an injury to their genitalia. Mechanism of injury, time to identification of injury, injury pattern, time to referral to a urological unit, timing of surgery (if undertaken), other managements, and follow-up were all recorded. The rates of occurrence of the above information were used to draw generalised conclusions about trends in the identification and treatment of this patient population. Conclusion: Prompt identification of injury and early surgical intervention by a specialised urological unit when necessary is crucial. A high index of suspicion, simple radiological investigation and treatment via an interdisciplinary team all optimize appropriate management of patients with trauma to the external genital organs. doi:10.1016/j.injury.2010.01.077 POSTER POSTER-8
Cytokine expression in post-mortem human brain tissue following acute traumatic brain injury T. Frugier 1,2,∗ , D. O’Reilly 1,2 , M.C. Morganti-Kossmann 1,2,3 , C. McLean 2,3 1
National Trauma Research Institute, The Alfred Hospital, Melbourne, Victoria, Australia 2 Monash University, Melbourne, Victoria, Australia 3 Anatomical Pathology Department, The Alfred Hospital, Melbourne, Victoria, Australia
Abstracts Trauma Melbourne 2009 / Injury 41S (2010) S49–S62
Objectives: Little is known about the molecular events following severe traumatic brain injury (TBI) in humans. To date there are no efficient therapies for the treatment of TBI patients. The availability of human brain tissue from the Australian Neurotrauma Tissue and Fluid Bank is a unique opportunity to analyse the early inflammatory processes following TBI. Methods: In this study, a total of 21 trauma brain samples were analysed. Age and sex matched samples were used as controls. To explore the cerebral inflammation within the brain tissue, we measured the level of expression of nine major inflammatory cytokines at mRNA and protein levels by enzyme-linked immunosorbent assay, bioplex cytokine assay and real-time quantitative PCR. Results: All the pro-inflammatory mediators analysed (IL-6, IL-8, IFN-␥, TNF-␣, IL-1, GM-CSF, IL-2) showed a strong and statistically significant (p < 0.001) increase in the brain samples of individuals who died more than 6 h following brain injury (late group) compared to the control group and to the brain samples of individuals who died within 17 min of the injury (early group). Interestingly, in the samples from the early group, although modest, cytokine concentrations were found statistically increased when compared with the control group: IL-6 (p < 0.027), IFN-␥ (p < 0.018), TNF-␣ (p < 0.03) and GM-CSF (p < 0.022). However, in the early group the levels of both anti-inflammatory cytokines IL-4 and IL-10 remained at basal levels. In addition, in the late group no statistical difference was observed between the damaged cortex and the contralateral cortex for both the pro- and anti-inflammatory cytokines. Similarly, in the samples from the early group there was no difference in the levels of IL-6 and IL-1 mRNA compared with controls. However, mRNA levels were significantly increased in the cortex samples of individuals from the late group in both the cortex adjacent to the injury and the contralateral cortex compared with the control and the early groups: IL-6 (24 and 25-fold, respectively, p < 0.001) and IL-1 (5.2-fold, p < 0.003 and 5.5-fold, p < 0.024, respectively). IL-8 is the only cytokine showing the strongest mRNA level increase in the late group: 139-fold vs. control group (p < 0.001) and 56-fold vs. early group (p < 0.001). Interestingly, IL-8 mRNA levels were 7-fold higher in the ipsilateral brain cortex when compared to the un-injured region (p < 0.029). Finally, TNF-␣ was the only cytokine showing a significant 4-fold increase in the levels of mRNA in the samples of individuals from the early group (p < 0.014). Those levels remained elevated in the late group by 7-fold in the injured cortex (p < 0.006) and 3-fold (p < 0.035) in the contralateral cortex. Conclusions: These results show for the first time in the human brain tissue that the cerebral inflammatory response starts within minutes of acute TBI. The increased inflammatory mediator protein levels observed are coincidental with the increased levels of their mRNAs suggesting that TBI elicits an immediate cerebral and not a systemic inflammatory response. Altogether these data highlight the need to finely characterize the cellular source of cytokines to ultimately elucidate their mode of action and develop therapeutic strategies to attenuate inflammation-mediated secondary brain damage. Acknowledgements: This study was supported by the Victorian Neurotrauma Initiative. Tissues were received from the Neurotrauma Tissue & Fluid Bank, a subdivision of the Australian Brain Bank Network.
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POSTER POSTER-9
Queensland Trauma Registry K. Harvey ∗ , C. Pollard, J. Lang ∗ , N. Dallow, C. Spanagel, J. Carroll Queensland Trauma Registry, Centre of National Research on Disability and Rehabilitation Medicine, University of Queensland, Brisbane, Queensland, Australia Objectives: The Queensland Trauma Registry (QTR) has been established as a statewide registry since January 2002 and now collects data from 20 public hospitals in Queensland. Data collected by the QTR spans the acute care continuum, and includes data items from the pre-hospital, referring hospital, interfacility and definitive hospital phases of care. As such, the QTR is able to describe the patterns of injury incidence and patient movement through the trauma system. This poster provides a map of the 20 hospital sites included on the registry, with identification of the major trauma services, location of helicopter/RFDS bases and a description of referral patterns of injured patients occurring across the State. Methods: The QTR captures all patients who are admitted to a Registry hospital site for ≥24 h and have injuries codeable to an ICD-10-AM category from S00 to S99, T00 to T35, T63, T66 to T71 and T75 (with poisonings also collected in children aged ≤14 years). Patients who die during their Emergency Department presentation following commencement of active treatment or who die during hospital admission are also included. The QTR also includes elderly patients who have sustained a fractured neck of femur injury. Results: Of the 20 hospitals who contribute data to the QTR, 12 hospitals are in South East Queensland, five hospitals are in Central Queensland and three hospitals are in Northern Queensland. In 2008, 31% (4665) of all cases included on the QTR were referred from another hospital for definitive care. Over half (2557) of all referred patients were transported by road ambulance, with 15% (694) transported via helicopter and 7% (320) via fixed wing aircraft. In terms of types of injuries transferred, 52% of patients (2417) had fractures and 12% (562) had an intracranial injury. Conclusions: Queensland is a large state and the distances to specialist medial services are often vast. The data held by QTR concerning referral patterns of trauma patients around the State may prove useful for clinicians and policy makers interested in patient transport within the trauma system. doi:10.1016/j.injury.2010.01.079 POSTER POSTER-10
Incidence and outcomes of traumatic subdural haematoma across different age groups F. Irie 1,∗ , N. Bellamy 1 , C. Pollard 1,2 1
doi:10.1016/j.injury.2010.01.078
Centre of National Research on Disability and Rehabilitation Medicine (CONROD), The University of Queensland, Brisbane, Queensland, Australia 2 Royal Brisbane Women’s Hospital, Brisbane, Queensland, Australia Objectives: The purpose of this study was to investigate the magnitude of traumatic subdural haematoma (SDH) across different age groups and determine which groups are most affected by this severe brain trauma injury.