Further understanding of the cellular and molecular mechanisms involved in traumatic injury, and how they are modulated during drug interaction, can facilitate novel treatment strategies for future trauma patients. We hypothesize that the pharmacological agent, Androstenetriol (AET), up regulates host immune response by modulating the continued expression of mediators, including cytokines. In a double-blinded experiment, rats were hemorrhaged, driven by volume or pressure conditions, then resuscitated with fluids and packed red blood cells following a subcutaneous injection of either vehicle or drug. Blood was collected at various time points and cytokine levels were determined by analyses with both multiplex and conventional ELISA assays. Both MCP-1 and GRO/KC increase in surviving animals; trauma increases IL-lα levels in rat plasma, whereas hemorrhage decreases IL-lα over time; IL-6 plasma levels measured 6 hours after hemorrhage may correlate with mortality; AET may act by mechanisms to modify specific TH1 cytokines (INF-y) to promote survival.

Catecholaminergic neurotransmission is regionally altered following injury, and drugs aimed at these systems offer promising avenues for post-TBI pharmacotherapies. Atomoxetine is a selective norepinephrine transporter (NET) inhibitor currently indicated for treatment of attention-deficit hyperactivity disorder (ADHD). The studies in this dissertation were designed to test the efficacy of atomoxetine for treating cognitive deficits following experimental TBI and the potential mechanism for any beneficial effect. The first part of the study focused on behavioral recovery following atomoxetine treatment. Several important questions of dose, therapeutic window, and duration of treatment were addressed in these studies. Sprague-Dawley rats were subjected to lateral fluid-percussion injury (L-FPI) of moderate severity (2.08 atm +/- .05). Four experiments were performed. In the first study, atomoxetine (.3 mg/kg, 1mg/kg, 3 mg/kg, or 9 mg/kg) or vehicle was administered daily on post injury days (PID) 1-15. Cognitive assessment was performed using the Morris water maze on PID 11-15. L-FPI resulted in significant cognitive impairment when compared to Sham-Injury. Treatment with lower doses of atomoxetine (.3mg/kg, 1mg/kg, and 3mg/kg) significantly attenuated the cognitive deficits in injured animals. Treatment with the higher dosage (9mg/kg) of atomoxetine resulted in animals that were not significantly different than injured-vehicle treated animals. The optimal response was achieved using 1 mg/kg atomoxetine. In the second study, treatment with atomoxetine (1mg/kg) or vehicle was delayed for 11 days post-injury. Rats were administered atomoxetine daily for 15 days and cognitive assessment was performed on PID 25-29. In this study, treatment with atomoxetine (1 mg/kg) did not result in improved cognitive performance. In the next study atomoxetine was given daily on PID 1-7 and then treatment was terminated. The animals were tested in the MWM on PID 11-15. We found that atomoxetine treatment for 7 days post-injury provides an enhancement of cognitive deficits that is not significantly different from sham animals. We then investigated whether a single treatment of atomoxetine 24 h after brain injury could influence behavioral outcome on days 11-15. From this study, we found a single dose of atomoxetine is not as effective as chronic treatment. Finally, we investigated changes in the protein expression of brain-derived neurotrophic factor, growth-associated protein-43, and synaptophysin on day 7 PID to investigate what effect atomoxetine may have on brain plasticity and regeneration. We found that atomoxetine can enhance both GAP-43 and BDNF, but not synaptophysin at this time point. In conclusion, this is the first study to show that low doses of atomoxetine initiated early after experimental traumatic brain injury results in improved cognition. Furthermore, we show that enhancement of catecholamines via atomoxetine treatment during periods of postinjury-induced plasticity can provide long-term functional and structural benefits.

Background Post Traumatic Stress Disorder (PTSD) is a psychiatric debilitating condition that can occur in individuals who experience extremely stressful or traumatic life events. Sexual assault is considered as one of the most traumatic stressor in life. Although few studies investigated the association between history of sexual assault and PTSD, no studies have examined the impact of age at sexual assault on PTSD.Method A cross-sectional telephone survey was conducted among adult female residents of Virginia from November 2002 to February 2003. A total of 1,769 women aged 18 and older were interviewed using a random digit dialing method. Detailed screening questionnaire was utilized to ascertain the occurrence of sexual assault, age at sexual assault and PTSD. The DSM-IV diagnostic criteria were used to define PTSD.Result The prevalence of PTSD among women with no history of sexual assault, those victimized before the age of 18 and 18 and above was 8.1%, 35.3%, and 30.2% respectively. Multivariate logistic regression model showed an increase risk of PTSD among women assaulted at a younger age. Compared to women with no history of sexual assault, women who were victimized before their 18th birthday were 2.8 times more likely to suffer from PTSD [OR=2.78 (95% C1=1.87- 4.23)]. The risk of PTSD among women victimized as adults was 2.6 times higher compared to women with no history of sexual assault [OR=2.59 (95%CI =1.43-4.70)].Conclusion This study provided important information on the association between PTSD and age at sexual assault. The risk of PTSD is relatively higher among those assaulted before the age of 18. The adverse effect of sexual assault as a risk for PTSD in addition to other negative health problems is a major public health concern. Primary prevention strategies should be in place to detect sexual assault victims and prevent the occurrence of PTSD.

Traumatic axonal injury (TAI) is a consistent feature of (TBI) and is responsible for much of its associated morbidity. TAI is now recognized to result from progressive/secondary axonal injury, though much remains unknown in regards to the pathobiology and the long-term consequences of axonal injury. TAI has been described in the perisomatic domain, located within the neocortex following mild TBI, and within this domain has been linked to neuronal recovery, not neuronal cell death in the acute setting. Due to technical limitations, our understanding of the long-term fate of this neuronal population and the mechanisms responsible for permitting neuronal survival, recovery and axon regeneration following injury are unknown. The studies presented in this thesis are centered upon the hypothesis that injury within the perisomatic domain is unique, and may allow for enhanced neuronal recovery and axonal regeneration. To address many of these questions, we have utilized a novel model of diffuse brain injury in mice, allowing for the use of transgenic mice to overcome previous limitations in the study of TAI. To address this hypothesis, we first assessed the impact of genetic deletion of cyclophilin D (CypD), a regulator of the mitochondrial permeability transition pore (mPTP), upon TAI within the perisomatic domain. Via this approach it was determined that CypD deletion reduced the number of injured axons by ~50%, indicating that CypD and mPTP formation contribute to TAI in the perisomatic domain. Next, using a fluorescent-based approach, we assessed the temporospatial events associated with TAI, acutely. Here it was determined that the axon initial segment (AIS) is uniquely susceptible to TAI following mild TBI (mTBI) and injury within this domain progresses rapidly to axon disconnection. Last we assessed the long-term fate of axotomized neurons and their associated axonal processes. We report that over a chronic time frame, TAI induces no overt cell death, instead results in significant neuronal atrophy with the simultaneous activation of a somatic program of axon regeneration and recovery of the remaining axonal processes. Taken together, the findings of this work reveal that TAI results in a unique axonal injury that results in a persistent axon regenerative attempt.

The ankyrins comprise a family of proteins serving as components of the membrane cytoskeleton, and participate in a diverse set of associations with multiple binding partners including the cytoplasmic domains of transporters, ion channels, some classes of receptors, and cell adhesion proteins. Moreover, evidence is accumulating that ankyrin participates in defining functionally distinct subcellular regions. The complex functional and structural roles of ankyrins indicate they are likely to play essential roles in the pathology of traumatic axonal injury. The current study examined changes in ankyrin-G expression following a moderate central fluid percussion injury administered to adult rats. At 1d, 3d, and 7d postinjury (or following a sham control injury), protein levels of ankyrin-G in the corpus callosum and cerebral cortex were assessed using Western Blot analysis. Three immunopositive bands were identified in both brain regions as 220,212, and 75 kD forms of ankyrin-G. Time-dependent changes in ankyrin-G were observed in the corpus callosum. At 1d injury-induced elevations were observed in the callosal 220 kD (+147% relative to sham levels) and in the 212 kD (+73%) forms of ankyrin-G, but in both cases the expression decreased to control levels by 3d and 7d. In contrast, the 75 kD form showed moderate increases at 1d postinjury, but was significantly below control levels at 3d (-54%) and at 7d (-41%). Ankyrin-G expression in the cerebral cortex was only slightly affected by the injury, with a significant decrease in the `220 kD form occurring between 1d and 3d. These data suggest that the 220 and 212 kD changes probably represent postinjury proteolytic fragments derived from intact ankyrin-G isoforms of 480 andor 270 kD, while the 75 kD effects are likely breakdown products of intact 190 kD ankyrin-G. These results were discussed as they relate to prior findings of differential vulnerabilities of callosal myelinated and unmyelinated axons to injury. In this context, the 220,212 kD changes may reflect pathology within myelinated axons, and alterations to the 75 kD form may reflect more persistent pathology affecting unmyelinated callosal fibers.

Each year in the U.S., approximately 7-8 million patients with non-traumatic chest pain visit hospital emergency departments (ED) for medical evaluation. It is estimated that approximately 2-5% of these patients are experiencing acute cardiac ischemia, but due to the shortcomings of current test methods, they are incorrectly diagnosed and discharged without appropriate treatment provided, thus leading to poor patient outcome and potential medical malpractice litigation.The goals of this research were to evaluate plasma samples for potential biomarker(s) of acute cardiac ischemia prior to heart tissue necrosis, and to ultimately develop a rapid method for detection of the potential biomarker(s) in human plasma. Initial experiments were performed using the mouse model, with subsequent evaluations on human plasma samples using high performance liquid chromatographic ultraviolet detection (HPLC-UV). The final phase of this research involved the development of a rapid luminometer test method (An HPLC-UV detection method was developed and utilized for inosine, hypoxanthine and other adenosine triphosphate (ATP) catabolic by-products in Krebs-Henseleit (Krebs) buffer solution, with analysis on perfusate samples from isolated mouse hearts undergoing 20 min acute global ischemia. The HPLC-UV method was modified for subsequent use on human plasma samples, obtained from hospital emergency department (ED) patients presenting with non-traumatic chest pain (potential acute cardiac ischemia) and from healthy normal individuals. The HPLC-UV (component quantification) and HPLC-MS (component identification) test methods utilized C18 column technology, mobile phases consisting of aqueous trifluoroacetic acid (0.05% TFA in deionized water pH 2.2, v/v) and methanol gradient to achieve component separation, with both utilizing simple sample preparations (e.g. direct injection of Krebs perfusate samples and centrifugal membrane filtration on plasma samples).Results of the animal experiments using isolated mouse hearts undergoing 20 min acute global ischemia demonstrated significant levels of endogenous inosine effluxed from the heart tissue, indicating its use as a potential candidate biomarker of acute cardiac ischemia. The HPLC results from human plasma representing ED non-traumatic chest pain patients demonstrated elevated levels of inosine (hypoxanthine precursor) and significant levels of hypoxanthine, which provided additional support for the use of these candidate biomarker(s) as a potential diagnostic tool for the initial acute cardiac ischemic event, prior to heart tissue necrosis.The final phase of this research focused on the development of a rapid, simple and sensitive chemiluminescence test method. Using a microplate luminometer with direct injectors and continuous mixing, the measurement of inosine and hypoxanthine in human plasma was achieved for healthy normal individuals and on patients with confirmed acute MI, with an analysis time of less than 5 minutes. The utility of this rapid luminescence technique would be the potential use at point-of-care (POC) services (e.g. hospital clinical laboratory or emergency medical services) as part of the initial ED treatment protocol on patients presenting with non-traumatic chest pain and signs/symptoms of acute myocardial ischemia or acute MI.

Excitotoxic calcium influx and activation of calcium-regulated systems is a common event in several types of neuronal injury. This mechanism has been the focus of intense research, with the hope that a more complete understanding of how neuronal injury affects calcium-regulated systems will provide effective treatment options. This study examines one such calcium-stimulated enzyme, calcineurin, in the context of two common neurological pathologies, status epilepticus and traumatic brain injury.Status epilepticus was induced by pilocarpine injection. NMDA-dependent increases in calcineurin activity were observed in cortical and hippocampal homogenates. Upon closer examination, the most profound increases in activity were found to be present in crude synaptoplasmic membrane fractions isolated from cortex and hippocampus. A concurrent status epilepticus-induced increase in calcineurin concentration was observed in membrane fractions from cortex and hippocampus. Immunohistochemical analysis revealed an increase in calcineurin immunoreactivity in apical dendrites of hippocampal pyramidal neurons. We examined a cellular effect of increased dendritic calcineurin activity by characterizing a calcineurin-dependent loss of dendritic spines. Increased dendritic calcineurin led to increased dephosphorylation and activation of cofilin, an actin-depolymerizing factor. Calcineurin-activated cofilin induced an increase in actin depolymerization, a mechanism shown to cause spine loss in other models. Finally, via Golgi impregnation, we demonstrated that status epilepticus-induced spine loss is blocked by calcineurin inhibitors.To demonstrate that the increase in dendritic calcineurin activity was not model-specific, we examined a moderate fluid-percussion model of brain injury. Calcineurin activity was significantly increased in hippocampal and cortical homogenates. This increased activity persisted for several weeks post-injury, and may be involved in injury-induced neuronal pathologies. Also similar to the SE model, calcineurin immunoreactivity was dramatically increased in synaptoplasmic membrane fractions from cortex and hippocampus, and immunohistochemistry revealed increased calcineurin content in dendrites of hippocampal CA1-3 pyramidal neurons. These changes in calcineurin distribution also persisted for several weeks post-injury.These studies demonstrate a novel, cellular mechanism of calcium-mediated pathology in two models of neuronal injury. Elucidation of cellular events involved in the acute and chronic effects of brain trauma is essential for the development of more effective treatment options.

Abstract This quasi-experimental design study compared two small samples of Emergency medicine residents after one group had an educational intervention on death notification skills and the other did not. Comparisons were made on residents’ confidence in their communication, interpersonal skills and level of compassion fatigue/satisfaction and EM Residents’ level of Secondary Traumatic Stress after an event of patient death and subsequent notification of Secondary Patients. Residents were interviewed to gather recommendations for designing death notification curriculum. Over an eight month period, forty emergency medicine residents at two sites, control and intervention, completed surveys designed to provide quantitative data on self-confidence and stress related to recent patient deaths. Residents who participated in a death notification event completed the Secondary Traumatic Stress Scale. Interviews were conducted to gather information on the impact of the notification and recommend changes in curriculum at the experimental site. The data infer that an educational intervention on death notification skills increased residents’ confidence in their ability to give compassionate death notification to families as compared with the control group. Residents in the intervention and control group had no significant differences in their potential for compassion satisfaction. Residents who had the educational intervention showed less Secondary Traumatic Stress symptoms than their non-intervention counterparts. The intervention group showed less risk for burnout (although it would only be significant at p < 0.10). The overall conclusion is that there is some evidence for a positive effect of the intervention. However, due to the small sample size the conclusion is tentative and more research is needed to evaluate the training.

Traumatic brain injury (TBI) is a serious health concern, causing cognitive, motor, and sensory deficits, including olfactory dysfunction. This dissertation explores the effects of TBI on synaptic plasticity within the olfactory system, seeking to define mechanisms guiding postinjury sensory reinnervation. Physical forces induced by TBI can axotomize olfactory receptor neurons (ORNs), which innervate olfactory bulb (OB). These axons regenerate OB projections after injury, a process involving growth through a complex extracellular matrix (ECM). As such, we investigated a potential molecular mechanism capable of modifying local OB ECM to support postinjury synaptogenesis. Since matrix metalloproteinases (MMPs) and their ECM substrates are recognized for TBI therapeutic potential, we explored the role of MMP9 and its substrate osteopontin (OPN) in promoting ORN reinnervation of the OB after mild fluid percussion injury (FPI). First, we confirmed that FPI deafferented the mouse OB. In Chapter 2, we showed concurrent activation of neuroglia, elevated spectrin proteolysis and reduction in ORN-specific olfactory marker protein (OMP). As OMP normalized during regeneration, growth associated protein-43kD (GAP-43) peaked, marking OB entry of ORN growth cones. Ultrastructural analysis revealed ongoing ORN axon shrinkage and degeneration, glial phagocytosis of cellular debris, and a reorganization of synaptic structure. To explore ECM role in mediating postinjury OB reinnervation, we defined the time course of MMP9 activity and several downstream targets. Chapter 3 reports biphasic MMP9 activity increase during acute/subacute degeneration, accompanied by robust generation of 48kD OPN cell signaling peptide. OPN receptor CD44 also increased during the acute/subacute interval, suggesting potential interaction of the two proteins. Finally, we utilized MMP9 knockout (MMP9KO) mice to confirm MMP9 role in OB synaptogenesis. In Chapter 4, MMP9KO reversed FPI-induced lysis of 49kD OPN and altered postinjury expression of ORN axon degeneration marker OMP. Additional ultrastructural analysis verified delayed recovery of OB synaptic features within the injured MMP9KO. Overall, we demonstrated that mild FPI elicits ORN axotomy to induce OB reactive synaptogenesis, and that MMP9 supports reinnervation by processing OPN for activation of local glia, cells which reorganize the ECM for synapse regeneration.

It is estimated that there are 12.5 million people in England living with neurological disorders (Neurological Alliance, 2014). People with neurological disorders as a result of acquired brain injury (ABI) are living with short and long-term disabilities. These include cognitive impairment, and physical and emotional distress. One of the most common complaints by individuals who have ABI is attention impairment. Attention difficulties can have serious ramifications for daily functioning. Although studies have explored the effects of evidence-based interventions such as mindfulness-based therapy on attention abilities, and have found that it improves individuals' attention skills (Moore et al, 2012), thus far research has been conducted mainly with non-clinical populations. This study set out to investigate whether a mindfulness-based intervention could prove beneficial for people with neurological disorders, particularly whether it could positively impact on attention impairment. The study employed a one group pre-test post-test design. The intervention was adapted from the MBSR programme developed by Kabat-Zinn. Twenty-two participants with ABI were recruited. The Conners Continuous Performance Test 3rd Edition (CPT-3), Mindful Attention Awareness Scale (MAAS), Attention Process Training-II Attention Questionnaire (APT-II AQ) and Clinical Outcome in Routine Evaluation-Outcome Measure (CORE-OM) were utilised to measure outcomes. The results revealed that there was a clinical improvement in self reported measures of mindfulness (MAAS) (Cohen d=0.28), attention (APT-II AQ) (Cohen d=0.33), and psychological distress (CORE-OM) (Cohen d=0.72). This was not observed using the neuropsychological test of attention (CPT-3) for overall group scores, but further evaluation showed some individuals' scores improved. The study is promising as it indicates that mindfulness based treatment can be effective with attentional problems as well as in reducing psychological distress for individuals with ABI. This could be valuable in terms of providing treatment for this client group and adds to the expanding research base on mindfulness-based intervention with this population.