Introduction: The incidence of traumatic brain injury was reported to be 360 per 100 000 in South Africa. The consequences of traumatic brain injury include physical, cognitive, psychological, behavioural and emotional deficits. Prognostic factors such as age, mechanism of injury and severity of injury as well as medical history (extent of intervention) assist in determining the outcome of the patient. It is believed that the predictors of recovery assist both the patient as well as family members in determining the duration of rehabilitation as well as potential outcomes for the patient. Aim: The aim of this study was to determine the factors that influence the functional mobility outcome of patients with traumatic brain injury. Method: A cross sectional study was used to collect data where participants were assessed pre-discharge. A self designed questionnaire was administered by the interviewer and the Modified Mini Mental State questionnaire and the Rivermead Mobility Index were also administered. Results: Of the 60 participants, 56 were male and four were female. Half of the patients were able to walk indoors with an assistive device at the time of assessment, with only 36.7 percent of the patients having a higher functional level than walking indoors. The following factors increased the likelihood of functional mobility: the gender of the patient, Grade 12 education, being either self employed or unemployed, an income of between R800 and R2000 as well as more than R5000, having both bowel and bladder continence and Occupational therapy sessions. Factors that were found to have a negative influence on functional mobility include: age, premorbid smoking and drinking, having a craniotomy and physiotherapy sessions. Conclusion: Male gender, high education, being either self employed or unemployed, high income, bowel and bladder continence positively impacted on the functional mobility of the patient on discharge. Older age, premorbid smoking and drinking, having a craniotomy has a negative impact on the physical function of the patient with traumatic brain injury on discharge.

by Wong Kin Ling. / Thesis (M.Phil.)--Chinese University of Hong Kong, 2002. / Includes bibliographical references (leaves 348-373). / Abstracts in English and Chinese. / Abstract --- p.ii / 撮要 --- p.iv / Acknowledgements --- p.vi / Table of Contents --- p.vii / List of Abbreviations --- p.xviii / List of Tables --- p.xxi / List of Figures --- p.xxii / Chapter CHAPTER 1. --- INTRODUCTION / Chapter 1.1. --- Events happened in brain injury --- p.1 / Chapter 1.2. --- An alternate approach based on neuronal regeneration --- p.3 / Chapter 1.3. --- Fate of astrocytes after brain injury --- p.4 / Chapter 1.3.1. --- General information of astrocytes --- p.4 / Chapter 1.3.2. --- Functions of astrocytes --- p.5 / Chapter 1.4. --- Factors relate to astrocytes proliferation --- p.7 / Chapter 1.4.1. --- TNF-α --- p.8 / Chapter 1.4.2. --- β adrenergic mechanism and astrocyte proliferation --- p.11 / Chapter 1.5. --- Cell cycle-related proteins --- p.13 / Chapter 1.5.1. --- Maturation promoting factor (MPF) --- p.15 / Chapter 1.5.2. --- Early G1 phase --- p.16 / Chapter 1.5.3. --- Retinoblastoma protein (pRb) --- p.18 / Chapter 1.5.4. --- Cyclin-dependent kinase (cdk) activating kinase (Cak) --- p.19 / Chapter 1.5.5. --- "Cyclin, cdks, cki" --- p.20 / Chapter 1.5.5.1. --- Cyclins --- p.20 / Chapter 1.5.5.1.1. --- Cyclin D --- p.21 / Chapter 1.5.5.1.2. --- Cyclin E --- p.22 / Chapter 1.5.5.1.3. --- Cyclin A --- p.23 / Chapter 1.5.5.1.4. --- Cyclin B --- p.23 / Chapter 1.5.5.2. --- Cyclin-dependent kinases (cdks) --- p.24 / Chapter 1.5.5.3. --- Cyclin-dependent kinase inhibitor (cki) --- p.24 / Chapter 1.5.5.3.1. --- INK4 proteins (inhibitors of cdk-4 and cdk-6) --- p.25 / Chapter 1.5.5.3.2. --- p21 family proteins --- p.25 / Chapter 1.5.5.3.2.1. --- p21 --- p.25 / Chapter 1.5.5.3.2.2. --- p27 --- p.25 / Chapter 1.6. --- Apoptosis related proteins --- p.26 / Chapter 1.6.1. --- bcl-2 family --- p.26 / Chapter 1.6.1.1. --- bcl-2 --- p.26 / Chapter 1.6.1.2. --- bcl-x --- p.27 / Chapter 1.6.1.3. --- bcl-xα --- p.27 / Chapter 1.6.1.4. --- bcl-w --- p.28 / Chapter 1.6.1.5. --- Myeloid cell leukemia factor 1 (Mcl-1) --- p.28 / Chapter 1.7. --- C6 glioma cell line --- p.28 / Chapter 1.8. --- Aim of this project --- p.30 / Chapter CHAPTER 2. --- MATERIALS & METHODS / Chapter 2.1. --- Materials / Chapter 2.1.1. --- Rat C6 glioma cell line --- p.32 / Chapter 2.1.2. --- Cell culture materials preparation / Chapter 2.1.2.1. --- Complete Dulbecco's Modified Medium (cDMEM) --- p.32 / Chapter 2.1.2.2. --- Serum-free Dulbecco's Modified Medium (sDMEM) --- p.33 / Chapter 2.1.2.3. --- Phosphate buffered saline (PBS) --- p.33 / Chapter 2.1.3. --- Drug preparation / Chapter 2.1.3.1. --- Recombinant cytokines --- p.34 / Chapter 2.1.3.2. --- Antibodies / Chapter 2.1.3.2.1. --- Antibodies used in expression analysis --- p.34 / Chapter 2.1.4. --- Antibodies used in Western blotting --- p.34 / Chapter 2.1.5. --- Reagents for RNA isolation --- p.36 / Chapter 2.1.6. --- Reagents for reverse transcription-polymerase chain reaction (RT-PCR) --- p.36 / Chapter 2.1.7. --- Reagents for Electrophoresis --- p.38 / Chapter 2.1.8. --- Reagents and buffers for Western blotting --- p.38 / Chapter 2.1.9. --- Other chemicals and reagents --- p.39 / Chapter 2.2. --- Methods / Chapter 2.2.1. --- Maintenance of C6 cells --- p.39 / Chapter 2.2.2. --- Preparation of cells for assays --- p.40 / Chapter 2.2.3. --- Drugs preparation --- p.40 / Chapter 2.2.4. --- Determination of RNA expression by RT-PCR analysis / Chapter 2.2.4.1. --- RNA extraction --- p.41 / Chapter 2.2.4.2. --- Spectrophotometric Quantitation of DNA and RNA --- p.43 / Chapter 2.2.4.3. --- RNA gel electrophoresis --- p.43 / Chapter 2.2.4.4. --- Reverse transcription-polymerase chain reaction (RT- PCR) --- p.43 / Chapter 2.2.4.5. --- Separation of PCR products by agarose gel electrophoresis --- p.43 / Chapter 2.2.4.6. --- Quantification of band density --- p.45 / Chapter 2.2.4.7. --- Restriction enzyme (RE) digestion --- p.45 / Chapter 2.2.5. --- Determination of protein expression by Western blotting / Chapter 2.2.5.1. --- Total protein extraction --- p.46 / Chapter 2.2.5.2. --- Western blotting analysis --- p.46 / Chapter CHAPTER 3. --- RESULTS / Chapter 3.1. --- Effects of TNF-α on cell cycle related genes and proteins expression --- p.49 / Chapter 3.1.1. --- Effects of TNF-α on the time courses of cyclin D1 gene and protein expression --- p.49 / Chapter 3.1.2. --- Effect of TNF-α on the time course of cyclin D2 gene expression --- p.50 / Chapter 3.1.3. --- Effects of TNF-α on the time courses of cyclin D3 gene and protein expression --- p.53 / Chapter 3.1.4. --- Effects of TNF-α on the time courses of cdk-4 gene and protein expression --- p.55 / Chapter 3.1.5. --- Effects of TNF-α on the time courses of cyclin E gene and protein expression --- p.55 / Chapter 3.1.6. --- Effects of TNF-α on the time courses of cdk-2 gene and protein expression --- p.58 / Chapter 3.1.7. --- Effects of TNF-α on the time courses of p15 gene and protein expression --- p.61 / Chapter 3.1.8. --- Effects of TNF-α on the time courses of p27 gene and protein expression --- p.61 / Chapter 3.1.9. --- Effects of TNF-α on the time courses of p21 gene and protein expression --- p.64 / Chapter 3.1.10. --- Effects of TNF-α on the time courses of p130 gene and protein expression --- p.66 / Chapter 3.1.11. --- Effects of TNF-α on the time courses of Cak gene and protein expression --- p.66 / Chapter 3.1.12. --- Effects of TNF-α on the time courses of cyclin H gene and protein expression --- p.68 / Chapter 3.1.13. --- Effects of TNF-α on the time courses of cyclin B gene and protein expression- --- p.71 / Chapter 3.1.14. --- Effect of TNF-α on the time course of bcl-2 protein expression --- p.71 / Chapter 3.1.15. --- Effects of TNF-α on the time courses of bcl-XL gene and protein expression --- p.73 / Chapter 3.1.16. --- Effect of TNF-α on the time course of bcl-xα gene expression --- p.73 / Chapter 3.1.17. --- Effects of TNF-α on the time courses of bcl-w gene and protein expression --- p.76 / Chapter 3.1.18. --- Effects of TNF-α on the time courses of Mcl-1 gene expression --- p.76 / Chapter 3.2. --- Effects of TNF-R1 and -R2 on cell cycle related genes and proteins expression --- p.81 / Chapter 3.2.1. --- Effects of blocking TNF-R1/ -R2 on the time courses of cyclin D1 gene and protein expression --- p.81 / Chapter 3.2.2. --- Effect of blocking TNF-R1/ -R2 on the time course of cyclin D2 gene expression --- p.82 / Chapter 3.2.3. --- Effects of blocking TNF-R1/ -R2 on the time courses of cyclin D3 gene and protein expression --- p.85 / Chapter 3.2.4. --- Effects of blocking TNF-R1/ -R2 on the time courses of cdk-4 gene and protein expression --- p.90 / Chapter 3.2.5. --- Effects of blocking TNF-R1/ -R2 on the time courses of cyclin E gene and protein expression --- p.93 / Chapter 3.2.6. --- Effects of blocking TNF-R1/ -R2 on the time courses of cdk-2 gene and protein expression --- p.93 / Chapter 3.2.7. --- Effects of blocking TNF-R1/ -R2 on the time courses of p15 gene and protein expression --- p.96 / Chapter 3.2.8. --- Effects of blocking TNF-R1/ -R2 on the time courses of p27 gene and protein expression --- p.99 / Chapter 3.2.9. --- Effects of blocking TNF-R1/ -R2 on the time courses of p21 gene and protein expression --- p.103 / Chapter 3.2.10. --- Effects of blocking TNF-R1/ -R2 on the time courses of pl30 gene and protein expression --- p.106 / Chapter 3.2.11. --- Effect of blocking TNF-R1/ -R2 on the time course of Cak gene expression --- p.110 / Chapter 3.2.12. --- Effects of blocking TNP-R1/ -R2 on the time courses of cyclin H gene and protein expression --- p.110 / Chapter 3.2.13. --- Effects of blocking TNF-R1/ -R2 on the time courses of cyclin B gene and protein expression --- p.112 / Chapter 3.2.14. --- Effect of blocking TNF-R1/ -R2 on the time course of bcl-2 protein expression --- p.116 / Chapter 3.2.15. --- Effects of blocking TNF-R1/ -R2 on the time courses of bcl-xL gene and protein expression --- p.119 / Chapter 3.2.16. --- Effect of blocking TNF-R1/ -R2 on the time course of bcl-xα gene expression --- p.122 / Chapter 3.2.17. --- Effects of blocking TNF-R1/ -R2 on the time courses of bcl-w gene and protein expression --- p.124 / Chapter 3.2.18. --- Effect of blocking TNF-R1/ -R2 on the time course of Mcl-1 gene expression --- p.124 / Chapter 3.3. --- "Effects of other cytokines (IL-6, IL-lα, IL-lβ, IFγ) on cell cycle related genes and proteins expression" --- p.129 / Chapter 3.3.1. --- "Effects of TNF-α, IL-6, IL-lα, IL-lβ, IFγ on cyclin D1 gene and protein expression" --- p.129 / Chapter 3.3.2. --- "Effects of TNF-a, IL-6, IL-lα, IL-lβ, IFγ on cyclin D2 gene and protein expression" --- p.132 / Chapter 3.3.3. --- "Effects of TNF-α, IL-6, IL-lα, IL-1β, IFγ on cyclin D3 gene and protein expression" --- p.136 / Chapter 3.3.4. --- "Effects of TNF-α, IL-6, IL-lα, IL-1β, IFγ on cdk-4 gene and protein expression" --- p.140 / Chapter 3.3.5. --- "Effects of TNF-α, IL-6, IL-lα, IL-1β, IFγ on cyclin E gene and protein expression" --- p.144 / Chapter 3.3.6. --- "Effects of TNF-α, IL-6, IL-lα, IL-1β, IFγ on cdk-2 gene and protein expression" --- p.148 / Chapter 3.3.7. --- "Effects of TNF-α, IL-6, IL-lα, IL-1β, IFγ on pl5 gene and protein expression" --- p.152 / Chapter 3.3.8. --- "Effects of TNF-α, IL-6, IL-lα, IL-1β, IFγ on p27 gene and protein expression" --- p.152 / Chapter 3.3.9. --- "Effects of TNF-α, IL-6, IL-lα, IL-ip, IFγ on p21 gene and protein expression" --- p.159 / Chapter 3.3.10. --- "Effects of TNF-α, IL-6, IL-lα, IL-lβ, IFγ on pl30 gene and protein expression" --- p.162 / Chapter 3.3.11. --- "Effects of TNF-α, IL-6, IL-lα, IL-lp, IFγ on Cak gene expression" --- p.166 / Chapter 3.3.12. --- "Effects of TNF-α, IL-6, IL-lα, IL-1β, IFy on cyclin H gene and protein expression -" --- p.170 / Chapter 3.3.13. --- "Effects of TNF-α, IL-6, IL-lα, IL-1β, IFγ on cyclin B gene and protein expression" --- p.174 / Chapter 3.3.14. --- "Effects of TNF-α, IL-6, IL-lα, IL-1β, IFγ on bcl-2 gene and protein expression" --- p.178 / Chapter 3.3.15. --- "Effects of TNF-a, IL-6, IL-lα, IL-1β, IFγ on bcl-xL gene and protein expression" --- p.178 / Chapter 3.3.16. --- "Effects of TNF-α, IL-6, IL-lα, IL-1β, IFγ on bcl-xα gene expression" --- p.184 / Chapter 3.3.17. --- "Effects of TNF-α, IL-6, IL-lα, IL-lβ, IFγ on bcl-w gene and protein expression" --- p.187 / Chapter 3.3.18. --- "Effects of TNF-α, IL-6, IL-lα, IL-1β, IFγ on Mcl-1 gene expression" --- p.191 / Chapter 3.4. --- Effects of P-ARs on cell cycle related genes expression --- p.194 / Chapter 3.4.1. --- Effects of β-AR agonists and antagonists on cyclin D1 gene expression --- p.195 / Chapter 3.4.2. --- Effects of β-AR agonists and antagonists on cyclin D2 gene expression --- p.198 / Chapter 3.4.3. --- Effects of β-AR agonists and antagonists on cyclin D3 gene expression --- p.201 / Chapter 3.4.4. --- Effects of β-AR agonists and antagonists on cdk-4 gene expression --- p.204 / Chapter 3.4.5. --- Effects of β-AR agonists and antagonists on cyclin E gene expression --- p.207 / Chapter 3.4.6. --- Effects of β-AR agonists and antagonists on cdk-2 gene expression - --- p.210 / Chapter 3.4.7. --- Effects of β-AR agonists and antagonists on p15 gene expression --- p.213 / Chapter 3.4.8. --- Effects of β-AR agonists and antagonists on p27 gene expression --- p.216 / Chapter 3.4.9. --- Effects of β-AR agonists and antagonists on p21 gene expression --- p.219 / Chapter 3.4.10. --- Effects of β-AR agonists and antagonists on p130 gene expression --- p.222 / Chapter 3.4.11. --- Effects of β-AR agonists and antagonists on Cak gene expression --- p.225 / Chapter 3.4.12. --- Effects of β-AR agonists and antagonists on cyclin H gene expression --- p.228 / Chapter 3.4.13. --- Effects of β-AR agonists and antagonists on cyclin B gene expression --- p.231 / Chapter 3.4.14. --- Effects of β-AR agonists and antagonists on bcl-XL gene expression --- p.233 / Chapter 3.4.15. --- Effects of β-AR agonists and antagonists on bcl-xα gene expression --- p.236 / Chapter 3.4.16. --- Effects of β-AR agonists and antagonists on bcl-w gene expression --- p.239 / Chapter 3.4.17. --- Effects of β-AR agonists and antagonists on Mcl-1 gene expression --- p.243 / Chapter CHAPTER 4. --- DISCUSSION & CONCLUSION --- p.247 / Chapter 4.1. --- Effects of TNF-α on the induction of cell cycle regulatory genes/proteins expression --- p.248 / Chapter 4.2. --- Effects of TNF-α on bcl-2 family apoptotic inhibitor genes expression --- p.250 / Chapter 4.3. --- The TNF-R subtype(s) responsible for the TNF-a-induced cell cycle regulatory genes and proteins expression --- p.251 / Chapter 4.4. --- Is the TNF-α-induced cell cycle regulatory genes and proteins expression cytokine specific? --- p.253 / Chapter 4.5. --- The relationship between TNF-α and β-adrenergic mechanism in C6 cell proliferation --- p.254 / Chapter 4.6. --- General Discussion --- p.256 / Chapter 4.7. --- Possible treatments for brain injury --- p.258 / APPENDIX --- p.259 / REFERENCES --- p.348

INTRODUÇÃO: Em pacientes vítimas de trauma crânio-encefálico é fundamental que se restabeleça a volemia intravascular, quando associado à hipotensão arterial, com o intento de manter a pressão de perfusão e não agravar a lesão do sistema nervoso central. A hipovolemia pode ser corrigida com infusão rápida de soluções cristalóides e/ou colóides, quando hemoderivados não estão disponíveis. Nesta condição, o hematócrito (Ht) pode reduzir-se para valores muito baixos. A anemia aguda altera a viscosidade do sangue e pode interferir na reatividade vascular encefálica. O objetivo deste estudo foi avaliar a pressão intracraniana(PIC) na presença de lesão criogênica encefálica, quando se realiza hemodiluição aguda com Ringer lactato ou hidroxietilamido 450/0,7 a 6%, estabelecendo-se como meta reduzir o hematócrito de 40% para 35% ou para 27%. MÉTODOS: Foram utilizados 35 cães machos sem raça definida, cujo hematócrito inicial era superior a 40%, anestesiados e submetidos à lesão encefálica criogênica durante 20 minutos. Após foram aleatoriamente distribuídos em 5 grupos experimentais: HES35, hemodiluídos com hidroxietilamido até Ht de 35%; RL35, hemodiluídos com Ringer lactato até Ht de 35%; HES27, hemodiluídos com hidroxietilamido até Ht de 27%; RL 27, hemodiluídos com Ringer lactato até Ht de 27%; e controle, sem hemodiluição. As variáveis hemodinâmicas sistêmicas foram obtidas por meio de cateter de artéria pulmonar; a PIC foi medida por sensor introduzido no espaço subaracnóideo no hemisfério contralateral à lesão criogênica; as variáveis laboratoriais foram obtidas de amostras de sangue arterial. RESULTADOS: A lesão criogênica encefálica levou a aumento da PIC em todos os animais, sem diferença entre os grupos(p>0,5). Este aumento foi exacerbado somente nos animais hemodiluídos até hematócrito de 27%(p<0,03). A solução utilizada não influenciou o comportamento da PIC(p>0,5). / Objective: Brain injury is responsible for significant morbidity and mortality in trauma patients, but controversy still exists over optimal fluid management for these patients. This study aimed to investigate the effects of acute hemodilution with hydroxyethyl starch (HES) or lactated Ringer\'s solution (LR) in intracranial pressure(ICP) and cerebral perfusion pressure in dogs submitted to a cryogenic brain injury model. Design: Prospective laboratory animal study. Setting: Research laboratory in a teaching hospital. Subjects: Thirty-five male mongrel dogs. Interventions: Animals were enrolled to 5 groups: control, hemodilution with lactated Ringer\'s solution (RL) or hydroxyethyl starch (HES) 6% to an hematocrit target of 27% or 35%. Measurements and Main Results: ICP and CPP levels were measured after cryogenic brain injury. Hemodilution promotes an increment of ICP levels, which decreases CPP when hematocrit target was estimated in 27% after hemodilution. However, no differences were observed regarding crystalloid or colloid solution used for hemodilution in ICP and CPP levels. Conclusions: Hemodilution to a low hematocrit level increases ICP and decreases CPP scores in dogs submitted to a cryogenic brain injury. These results suggest that excessive hemodilution to a hematocrit below 30% should be avoided in traumatic brain injury patients.

INTRODUÇÃO: Em pacientes vítimas de trauma crânio-encefálico é fundamental que se restabeleça a volemia intravascular, quando associado à hipotensão arterial, com o intento de manter a pressão de perfusão e não agravar a lesão do sistema nervoso central. A hipovolemia pode ser corrigida com infusão rápida de soluções cristalóides e/ou colóides, quando hemoderivados não estão disponíveis. Nesta condição, o hematócrito (Ht) pode reduzir-se para valores muito baixos. A anemia aguda altera a viscosidade do sangue e pode interferir na reatividade vascular encefálica. O objetivo deste estudo foi avaliar a pressão intracraniana(PIC) na presença de lesão criogênica encefálica, quando se realiza hemodiluição aguda com Ringer lactato ou hidroxietilamido 450/0,7 a 6%, estabelecendo-se como meta reduzir o hematócrito de 40% para 35% ou para 27%. MÉTODOS: Foram utilizados 35 cães machos sem raça definida, cujo hematócrito inicial era superior a 40%, anestesiados e submetidos à lesão encefálica criogênica durante 20 minutos. Após foram aleatoriamente distribuídos em 5 grupos experimentais: HES35, hemodiluídos com hidroxietilamido até Ht de 35%; RL35, hemodiluídos com Ringer lactato até Ht de 35%; HES27, hemodiluídos com hidroxietilamido até Ht de 27%; RL 27, hemodiluídos com Ringer lactato até Ht de 27%; e controle, sem hemodiluição. As variáveis hemodinâmicas sistêmicas foram obtidas por meio de cateter de artéria pulmonar; a PIC foi medida por sensor introduzido no espaço subaracnóideo no hemisfério contralateral à lesão criogênica; as variáveis laboratoriais foram obtidas de amostras de sangue arterial. RESULTADOS: A lesão criogênica encefálica levou a aumento da PIC em todos os animais, sem diferença entre os grupos(p>0,5). Este aumento foi exacerbado somente nos animais hemodiluídos até hematócrito de 27%(p<0,03). A solução utilizada não influenciou o comportamento da PIC(p>0,5). / Objective: Brain injury is responsible for significant morbidity and mortality in trauma patients, but controversy still exists over optimal fluid management for these patients. This study aimed to investigate the effects of acute hemodilution with hydroxyethyl starch (HES) or lactated Ringer\'s solution (LR) in intracranial pressure(ICP) and cerebral perfusion pressure in dogs submitted to a cryogenic brain injury model. Design: Prospective laboratory animal study. Setting: Research laboratory in a teaching hospital. Subjects: Thirty-five male mongrel dogs. Interventions: Animals were enrolled to 5 groups: control, hemodilution with lactated Ringer\'s solution (RL) or hydroxyethyl starch (HES) 6% to an hematocrit target of 27% or 35%. Measurements and Main Results: ICP and CPP levels were measured after cryogenic brain injury. Hemodilution promotes an increment of ICP levels, which decreases CPP when hematocrit target was estimated in 27% after hemodilution. However, no differences were observed regarding crystalloid or colloid solution used for hemodilution in ICP and CPP levels. Conclusions: Hemodilution to a low hematocrit level increases ICP and decreases CPP scores in dogs submitted to a cryogenic brain injury. These results suggest that excessive hemodilution to a hematocrit below 30% should be avoided in traumatic brain injury patients.