MSc(Med), Physiotherapy, Faculty of Health Sciences, University of the Witwatersrand / Introduction Many patients that have suffered traumatic injuries require admission to Intensive Care Unit (ICU). Mechanical ventilation (MV) is deemed to be the defining event marking many ICU admissions. As many as 30% of admissions, and 90% of all critically ill patients will require at least a short period of MV. There are many risks and complications associated with prolonged MV, such as rate of pneumonia, morbidity and mortality, increased cost, hospital LOS, emotional distress and decreased bed availability. To minimize these risks and complications it is important that patients be weaned and extubated from MV at the earliest possible time. However, just as delayed weaning and extubation carries the risk of complications, premature extubation and subsequent re-intubation should be avoided where possible, as extubation failure leads to an eight-fold higher risk of infection and a twelve-fold increase in mortality. Weaning is the transition from ventilatory support to spontaneous breathing and can often be achieved easily, but may be difficult in up to 25% of patients. Numerous studies have shown the benefit of allied health care worker (nurses and physiotherapists) driven weaning protocols in decreasing MV days and costs. Purpose To determine if the use of a nurse and therapist-driven weaning protocol to wean and extubate long-term patients with trauma from MV in an open ICU results in decreased total MV days and ICU length of stay (LOS), and to determine time to spontaneous breathing trial (SBT) failure. Methods A weaning protocol was developed by the researcher using clinical guidelines compiled for the American Association for Respiratory Care, American College of Chest Physicians and American College of Critical Care Medicine. A total of 56 mechanically ventilated trauma patients were enrolled in two phases of the study. A prospective cohort of 28 patients (Phase I), weaned according to the protocol, was matched retrospectively with a historical cohort of 28 patients (Phase II), weaned according to physician preference. Pairs in the two groups were matched to be similar for gender, age, type and severity of injury. Data analyzed for both groups were number of MV days, number of ICU days, self-extubation and need for re-intubation. For Phase I patients, time to SBT failure and reason for failure was recorded. v Results and Discussion With respect to the mean MV days it was found that the two protocol groups did not differ significantly (p = 0.3 ; Phase I = 14.4 days vs Phase II = 16.3 days), although the two day reduction in MV was considered clinically significant in view of the complications associated with additional MV days. The difference of 0.25 days for length of ICU stay between the groups was not statistically significant (p = 0.9; Phase I = 20.8 days vs Phase II = 21 days), and demonstrates that a reduction in MV days may not necessarily result in a reduction of ICU LOS. Rate of re-intubation was similar in the two groups (Phase I = 3/28 vs Phase II = 4/28). Eleven patients (39%) in Phase I failed at least one SBT and four of these patients (36%) failed two SBTs prior to successful extubation. Failure of the first SBT occurred an average of 18 hours after onset of SBT. Injury severity scores for these patients were higher than the average for Phase I (16.1 vs 14.5). Mean MV time in this group was 20.5 days as opposed to 14.4 days in the total Phase I group. This indicates that these patients were more critically ill and that they may require longer SBTs than advocated in many studies. All patients failed SBT due to increased RR. Conclusion In this study of longer-term ventilated patients who had traumatic injury as reason for admission to ICU and mechanical ventilation, the use of a standardized protocol to assist with weaning and extubation from MV demonstrated a clinically significant reduction in total MV time, even though this did not reach statistical significance. The reduction in MV time did not lead to a reduction in ICU LOS, however it reduces the risks of ventilator-associated complications such as VAP. The use of a weaning and extubation protocol did not lead to a higher rate of re-intubation, demonstrating its safety for use in this patient population. This protocol was driven by nurses and physiotherapists, and the role of physiotherapists and nursing staff in weaning and extubation of patients from MV could be greatly expanded in the majority of ICUs in South Africa.

Literature investigating trauma exposure, Posttraumatic stress disorder (PTSD) and cortisol secretion has produced conflicting results with regard to whether cortisol is increased or decreased. With trauma there is also a pro- inflammatory response which is intimately linked with the hypothalamic pituitary axis (HPA). The police population can offer useful information in this regard as they represent a sample that will undergo exposure to traumatic events as part of their normal duties. In South Africa few studies have examined biological correlates of the traumatic stress response in the police population. This study sought to determine whether correlations exist between cortisol and the inflammatory response in terms of the cytokines Interleukin 6 (IL6) and Tumour Necrosis Factor (TNF) in response to trauma exposure in a cohort of newly enrolled metro police officers, previously naïve to the duty related trauma exposure. Personality styles were assessed, as coping skills and personality have been suggested as factors determining responses to trauma. The study participants were followed up for one year with repeated measures analysis of urine, blood, and saliva cortisol as well as blood cytokine determination every 3 months. Measures for PTSD [the Clinician Administered Scale for Posttraumatic stress disorder (CAPS) and the revised version of the Impact of Event Scale (IES-R)] as well as for depression [the Hamilton Depression Rating Scale (HAM-D)] were undertaken. 145 new recruits volunteered for the study, of which 120 completed all 5 visits. There were slightly more females than males in the sample and almost 50% of the sample admitted to alcohol abuse. Trauma exposure on entry into the police force was remarkably high with 99% having been exposed to at least one traumatic event in their lives. The majority (61.1 %) had been exposed to more than one traumatic event. There was evidence for the influence of prior trauma on responses to current traumatic events. MVA’s were very common, both duty and non duty related. Certain traumas were associated with greater changes in scores for PTSD and depression in relation to baseline. Over the 5 visits, only a third submitted valid 24 hour urine samples. Of these, the profile of the entire group indicated that 24 hour urine cortisol tended to initially decrease, and then increase with time. Saliva and blood cortisol, which were more reliably measured, tended to decrease with time. Scores for depression and post traumatic stress disorder were generally low in response to duty related traumatic events, and tended to decrease over time. However, the prevalence of lifetime PTSD as measured by the CAPS was high. There was a strong linear correlation between TNF and IL6. Results indicate a proinflammatory response, particularly with regard to IL6. There were no significant correlations between blood cortisol and HAM-D and between blood cortisol and CAPS (lifetime). There was an inverse relationship between CAPS (current scores) and blood cortisol. Cortisol and IES-R scores were significant at visit 3 (inverse relationship). For saliva, there were no significant associations with any of the variables for PTSD and depression. For personality styles, aggressive and antisocial clinical patterns were associated with lower current CAPS scores, while schizoid clinical pattern and the severe syndrome scale of thought disorder showed an association with lower lifetime CAPS score. For the IES-R, only narcissistic clinical pattern was associated with lower scores. A further analysis of those with low (less than 25% of the median) and high (greater than 25% of the median) cortisol responses was undertaken. The results indicate a similar trend to some studies showing lowered cortisol levels with chronic trauma exposure, but this did not correlate with sufficiently high scores for PTSD as measured by the CAPS. Similarly, proinflammatory cytokine increases are evident with trauma exposure, but not with scores for PTSD and depression. There were more variables significantly associated with the low cortisol responders than the high cortisol responders; with a suggestion of cumulative trauma exposure correlating with low cortisol response and a corresponding pro inflammatory response in terms of IL6. The results are discussed with a view to assisting the metro police force with recruitment and counseling strategies and important future research is recommended.

Objectives: - The present research attempts to elicit children's perceptions and experiences of enduring a road traffic accident (RTA). It also examined their parents experiences of parenting such children and their own experiences and perceptions of the accident. Participants: - The study focussed on 14 children, aged from 9 years 9 months - 14 years and 4 months of age who had endured a RTA from between 9-33 months previously and their parents. Design: - The study employed a non-experimental design with a combination of quantitative and qualitative paradigms. Method: - The participants were identified via the hospital database of all children who had endured a RTA from between 6-24 months previously. Both the children and their parents were interviewed on specifically designed semi-structured interview schedules. Each interview was then tape-recorded and transcribed in its entirety. These transcripts then provided the universe of material for subsequent qualitative analysis. Results:- The results of this study demonstrated that approximately half of the children who had experienced a RTA were suffering from a post traumatic stress disorder (PTSD). In addition, the PTSD case children differed from the non-case children on factors such as awareness of the inpending RTA, feelings of self-blame regarding the accident, and more negative thoughts regarding their experience immediately after the impact and at the time of the assessment. In addition, the parents of the case children displayed similar responses to that of their children. Conclusion: - A theoretical Model was presented to account for the main findings in response to the research questions, also drawing on existing research. It is emphasised that this model is speculative due to the small sample size insofar as it draws upon the present findings, and as such can only relate to this study sample and further research would be required to fully test and validate it. In addition, recommendations were made for service delivery and clinical practice.

by Chan Won Shing, Raymond. / "May 2000." / Thesis (Ph.D.)--Chinese University of Hong Kong, 2000. / Includes bibliographical references (p. 177-191). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Mode of access: World Wide Web. / Abstracts in English and Chinese.

acase@tulane.edu / Increasing support for system-level solutions that recognize and respond to childhood trauma have called for teachers to become change agents in their schools by supporting students impacted by traumatic experiences. The current study explored the challenges that teachers may face in joining this movement and their perceived self-efficacy specifically in being able to support their students exposed to trauma (TIC self-efficacy). First, it was hypothesized that teachers will experience levels of Secondary Traumatic Stress (STS) and burnout at rates similar to the high rates of other helping professionals. It was also hypothesized that TIC self-efficacy among teachers would decrease over time. Further, it was hypothesized that teachers with higher levels of STS and burnout will show greater declines in self-efficacy over time. Finally, it was hypothesized that the relationships between STS and burnout, respectively, and self-efficacy will vary by years of experience. Descriptive results suggest that the majority of teachers in the current sample do not experience elevated symptoms of burnout or STS. Results further yielded main effects of burnout and STS on self-efficacy, as well as a significant decrease in self-efficacy over time. However, neither STS nor burnout significantly moderated TIC self-efficacy over time. Further, neither the relationship between TIC self-efficacy and STS nor the relationship between TIC self-efficacy and burnout varied by years of experience in the field. This study has made a significant contribution to the field by examining STS and burnout among teachers and by evaluating these stressors in relation to the adoption of new system-wide initiatives for combatting the impact of childhood trauma. / 1 / Lea Petrovic

Vascular endothelial growth factor (VEGF) may play a role in neuroprotection after traumatic brain injury (TBI) in addition to being a regulator of angiogenesis. Gene therapy using an adenovirus carrying an engineered zinc-finger protein (Adv-ZFP) and transcription factor construct targeted to the VEGF gene, has been shown to upregulate genomic expression of VEGF-A isoforms in skeletal muscle. Our objective was to use this gene therapy to explore cell survival in TBI. Rats were subjected to a unilateral fluid percussion injury (FPI) in the cortex. Groups consisted of control, injured and injured-treated animals. Adv-ZFP-VEGF was injected into the cortex and hippocampus. Engineered ZFP-VEGF increases VEGF-A protein levels and correlates with increased CA2 hippocampal cell survival and reduction in apoptotic cell death following TBI. NF200 expression in TBI+VEGF animals was comparable to levels in naive animals. This study suggests a therapeutic strategy to treat delayed cell death in a model of TBI.

Peroxynitrite, a highly oxidative molecule, plays a role in neuronal cell death following traumatic brain injury (TBI). A peptide comprised of the HIV-1 tat transduction domain fused to nine cysteine residues (Tat-9c) was previously designed to act as an exogenous target for nitrosylation by peroxynitrite. The present study’s aim was to explore the efficacy of Tat-9c in maintaining neurological function following TBI. Rats treated with Tat-9c exhibited significant improvement in performance compared to controls 24 hrs following TBI in the Beam-Walk task but not in the Rota-Rod task. Injured animals, given the drug, show a recovery as indicated by similar performance on the Morris Water Maze task compared to sham controls. These findings suggest Tat-9c may constitute a potential therapy for improving motor and cognitive function following TBI.

Peroxynitrite, a highly oxidative molecule, plays a role in neuronal cell death following traumatic brain injury (TBI). A peptide comprised of the HIV-1 tat transduction domain fused to nine cysteine residues (Tat-9c) was previously designed to act as an exogenous target for nitrosylation by peroxynitrite. The present study’s aim was to explore the efficacy of Tat-9c in maintaining neurological function following TBI. Rats treated with Tat-9c exhibited significant improvement in performance compared to controls 24 hrs following TBI in the Beam-Walk task but not in the Rota-Rod task. Injured animals, given the drug, show a recovery as indicated by similar performance on the Morris Water Maze task compared to sham controls. These findings suggest Tat-9c may constitute a potential therapy for improving motor and cognitive function following TBI.

Peroxynitrite, a highly oxidative molecule, plays a role in neuronal cell death following traumatic brain injury (TBI). A peptide comprised of the HIV-1 tat transduction domain fused to nine cysteine residues (Tat-9c) was previously designed to act as an exogenous target for nitrosylation by peroxynitrite. The present study’s aim was to explore the efficacy of Tat-9c in maintaining neurological function following TBI. Rats treated with Tat-9c exhibited significant improvement in performance compared to controls 24 hrs following TBI in the Beam-Walk task but not in the Rota-Rod task. Injured animals, given the drug, show a recovery as indicated by similar performance on the Morris Water Maze task compared to sham controls. These findings suggest Tat-9c may constitute a potential therapy for improving motor and cognitive function following TBI.

Peroxynitrite, a highly oxidative molecule, plays a role in neuronal cell death following traumatic brain injury (TBI). A peptide comprised of the HIV-1 tat transduction domain fused to nine cysteine residues (Tat-9c) was previously designed to act as an exogenous target for nitrosylation by peroxynitrite. The present study’s aim was to explore the efficacy of Tat-9c in maintaining neurological function following TBI. Rats treated with Tat-9c exhibited significant improvement in performance compared to controls 24 hrs following TBI in the Beam-Walk task but not in the Rota-Rod task. Injured animals, given the drug, show a recovery as indicated by similar performance on the Morris Water Maze task compared to sham controls. These findings suggest Tat-9c may constitute a potential therapy for improving motor and cognitive function following TBI.