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C4TS Newsletter Autumn 2018 Issue 17
C4TS RESEARCH NEWS AUTUMN 2018 Welcome to the Centre for Trauma Sciences (C4TS) Autumn 2018 newsletter. In this edition, we share our research into stabbings injuries in London’s youth. Media have sought commentary from C4TS leads on this disturbing rising trend. Media attention to civilian trauma survivors has also increased as a result of Barts Charity’s trauma appeal, and we give a summary of this coverage. We also give an overview of a pioneering study into the use of red blood cells and plasma in pre-hospital settings, which C4TS have helped design. Finally, we are happy to report on recent prestigious awards and public recognition bestowed on C4TS leads Professor Brohi and Professor Thiemermann.
Stab Injury Patterns in London’s Youth by Dr Paul Vulliamy, Clinical Research Fellow
C4TS study into London stabbings shows the need for a public health approach to youth violence. Background This year has seen a 15% increase in the number of knife crimes in Britain. There have been 119 murders in London, 74 of which were stabbings. In total, 117 people have been killed by knife crime across the UK. In response to this disturbing trend, C4TS have undertaken a study to better inform debate about how to tackle the growing problem.
Figure 1: Age-related variations in the pattern of stab injury. (A) Number of patients by age. (B) Time of injury. (C) Proportion of incidents occurring within 5km of home.
The study We looked at epidemiological data for 1824 people aged under 25 who were treated with emergency care for stab wounds at The Royal London Hospital’s major trauma centre from 2004 to 2014. Of these, 172 (around 9 per cent) were children under 16, and 861 (around 47 per cent) were aged 16-19. Seven hundred and ninety-one (around 44 per cent) were in their early twenties. We found the frequency of attacks in children aged under 16 spiked between 4pm and 6pm on school days. Almost half of the injuries (47 per cent) in children occurred within a 1-5 km radius from home, reflecting the average distance from home to school for children living in London (See Figure 1). Implications This work shows that children and young people in London are at risk of knife crime simply due to where they live and go to school. A long-term multi-agency and community approach is therefore needed if we are to change the culture of violence that now permeates deprived areas of London. Public health approaches to violence can show who is at risk and allow the community and police to respond effectively - through, for example, after school activities and targeted policing. We can reduce knife violence and unnecessary child deaths, but need more long term evidence-based interventions in education, policing, the community and at home. Study results have been published in the British Medical Journal.
C4TS Newsletter Autumn 2018
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Landmark UK study to test new pre-hospital blood product by Dr Ross Davenport, Senior Investigator
C4TS are co-investigators in a pioneering study that aims to improve pre-hospital blood transfusion outcomes. London’s Air Ambulance is now using a new blood product in roadside transfusions for severely bleeding critically injured patients. The new blood product will contain red blood cells and plasma as a single unit. London’s Air Ambulance previously used a product that contained only red blood cells. A team of senior doctors from Barts Health NHS Trust and C4TS identified the need for this study. This innovation will reduce the time for patients to receive effective therapy and aims to improve survival figures.
C4TS research informs the London Air Ambulance trial of a new blood product in prehospital transfusions
Experience from various military conflicts in the mid-20th century found whole blood to be a life-saving treatment for major bleeding, but in order to meet the needs of non-bleeding patients in civilian practice, blood was separated into its various components for individualised transfusion.
We now know that patients who bleed from trauma require all components of blood, and this product may offer a more effective way to stop bleeding. Further work is ongoing with NHS Blood & Transplant (NHSBT) to develop a complete whole blood product that contains platelets – the small clotting particles in the blood that plug holes in damaged blood vessels and support the blood clot. This study is the next step in the journey towards London’s Air Ambulance delivering whole blood transfusions, containing red blood cells, plasma and platelets, at the roadside. The aim is to further reduce deaths due to catastrophic bleeding. If successful, NHSBT hope to extend availability and practice across the UK to other providers, in order to deliver a clinical advantage to critically injured patients who otherwise would not survive. The trial has been supported by Barts Charity, Saracens, and The Henry Surtees Foundation. For more information, contact Dr Ross Davenport
The new transfusion product is a mixture of red blood cells and plasma
Trauma Lates! C4TS are hosting a new educational monthly forum series Trauma Lates: Improving Survival. The forum will have a different theme every month that will be tackled by speakers from academic, research and other backgrounds. The first Trauma Late is being held on Thursday 15 November, 6.00 – 8.00 pm, at the Perrin Lecture Theatre, Blizard Institute in Whitechapel. The forum will tackle multiple topics including: • • • •
What is Trauma? How to treat trauma? What is the trauma system, how does it work? How is trauma dealt with in major incidents?
There will also be an introduction to the Trauma Sciences Care of the Injured Patient Programme (TSCIPP) for Barts and the London School of Medicine (SMD) students interested in applying. TSCIPP is a new four-year integrated SMD Student Selected Component (SSC) in trauma.TSCIPP will educate students beyond Advanced Trauma Life Support, offering exclusive access to the Royal London Hospital Major Trauma Centre team, clinical research unit staff and C4TS research facilities. More information here.
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Traumatic brain injury: new preclinical discoveries in diet supplements by Dr Orli Thau-Zuchman, Research Fellow
Background Traumatic brain injury (TBI) is a leading cause of death and disability. Following the primary mechanical insult, TBI is associated with rapid progression of tissue injury and neuroinflammation. Overall, there is impaired glycolytic metabolism postinjury, which makes glucose a less favourable metabolic substrate (energy producer). High fat diets using ketogenic formulations (KDs) offer alternative energy substrates and support the formation of ketones bodies. A KD diet can have unique seizure-reducing properties, as is well documented in drug-resistant epilepsy, and it has also been shown to have potential for neuroprotection in the context of experimental TBI in juvenile animals. However, existing KDs have also shown drawbacks that have limited their effectiveness, and there is considerable scientific interest in developing improved formulations. Study objectives Towards that end, we tested a novel formulation of a KD diet that is different from the classic KD, and investigated its effects in an experimental model of TBI in adult mice. We wanted to see if the KD formulation could lead to an improved neurological outcome and have beneficial effects on the tissue. Method Three groups of mice were tested. Mice with TBI were fed either a control diet or the new KD diet. The third group had a craniotomy only. Mice were then assessed on a multitude of behavioural tasks for 70 days post-injury. On day 70 post-injury, brains were dissected and tissue blocks were subjected to histology and immunohistochemistry analyses. We observed behavioural improvements in the KD group compared to the control group as early as day 3 postinjury, and these improvements lasted for the duration of the study. We also noted a reduction in the lesion size and a reduction of neuroinflammation in the KD group (see Figure 2). Conclusions These results suggest that the new KD tested here has therapeutic potential in TBI. The new KD reduces some of the long-lasting neurological deficits (motor and cognitive) and promotes overall functional improvement after brain injury in adult mice. Further studies are required to fully characterise the mechanism of action underlying the observed neuroprotection. For more information, contact Dr Orli Thau-Zuchman
Craniotomy only
KD-control
New KD
Craniotomy only
KD-control
New KD
Figure 2. The new KD diet resulted in a significantly lower lesion size compared with the control groups, as shown in the stained tissue sections and graph above.
Opening our doors to the public! On 11 September, C4TS held a public event to showcase our research and encourage former patients and members of the public to get involved. The event was a great success, with over 60 attendees. Several talks were given by senior C4TS scientists, and Ngawai Moss and James Piercy talked about their positive experiences of being involved as lay advisors in research projects. If you would like to know more about how to help us with our research and how to join our Patient/Public Advisors for Injury Research (PAIR) group, then please contact Nicole Skeltys.
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AWARDS AND RECOGNITION Professor Karim Brohi and Professor Chris Thiemermann are honoured for their contributions to science and trauma care. C4TS lead Professor Karim Brohi has been named in the Evening Standard’s Progress 1000 list, which reocgnises the most influential people in the capital. The honor is recognition of Professor Brohi’s many contributions to trauma care in London, including his role as director of London’s major trauma network, set up in 2010 in response to the 7 July 2005 terror attacks. The network has led to a 20 per cent reduction in the capital’s mortality rate from major trauma, and was vital in saving many victims of the Westminster, London Bridge and Finsbury Park terror attacks and the Grenfell Tower fire. Commenting on the recognition, Professor Brohi said: “It is a great honour to be named in this list. It reflects the amazing trauma care delivered by all disciplines and specialities at the Royal London Hospital’s Major Trauma Centre, the commitment and drive of my research team, and the amazing institutional commitment to trauma care, innovation and research from both Queen Mary University of London and Barts Health.”
Professor Karim Brohi
In October 2018, Professor Chris Thiemermann, who is the discovery science lead for C4TS's organ dysfunction and protection research stream, received the prestigious Albert Nelson Marquis Lifetime Achievement Award. Established in 1898, the family of Marquis Who's Who publications present detailed biographical information about contemporary leaders and achievers from around the world, and from every significant field of endeavor. The prestigious Lifetime Achievement Award is recognition that an individual has achieved a very high level of accomplishments, visibility and prominence in their field. Professor Thiemermann has received this award in recognition of his global contributions as Scientist/ Educator and Business Leader.
Professor Chris Thiemermann
As a leading scientist and clinician, Professor Thiemermann has a strong research track record in cardiovascular disease (acute medicine, renal disease, shock) with specific expertise in target discovery, pharmacology and translational medicine. Since 2007 he has been Centre Lead for Translational Medicine at the William Harvey Research Institute and (since 2015) Deputy Director of the Barts Centre for Diabetic Kidney Disease. Recent successes have been phase II Randomised Control Trials evaluating the effects of pentoxiphylline in patients with chronic kidney disease (on dialysis) and the repositioning of the antimalarial drug artesunate for patients with severe haemorrhage and organ failure.
Professor Thiemermann said about his award: "I am of course delighted to have received this international recognition, from a publication with such global reach and influence. Ultimately for me my proudest moments are when I can translate science into therapies that can make a real difference to patient's lives, bringing discoveries from bench to bedside. For example, in preclinical trials on rats who experienced trauma haemorrhage, we found that artesunate helped protect their organs from damage. In the TOP-ART trial, we are testing whether this discovery can be translated to humans. A therapeutic agent that reduces the incidence and severity of multiple organ failure could have a major global impact on trauma patient outcomes".
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TRAUMA SURVIVORS IN THE NEWS Barts Charity trauma appeal puts the national media spotlight on trauma survivor experiences. Barts Charity’s Transform Trauma appeal was relaunched in September, and has put the UK media spotlight back on civilian trauma survivors. The Mirror Group are media partners for the appeal, which aims to raise £1m for C4TS trauma research and improved treatments for the severely injured. On 29 September, The Sunday Mirror published a moving piece on Evi Machova who had suffered severe injuries and scarring from a road traffic collision (RTC) in 2015. Evi talks about her loneliness and fears of intimacy that followed the accident, and how she eventually found a caring partner in Omar Agha who “thought my scars were beautiful because they are a part of me”. On 24 September, the Daily Express published a feature on elderly trauma, including an interview with Dr Elaine Cole and featuring 70 year old trauma survivor Renate. Dr Cole’s C4TS research aims to improve medical understanding of the impact of severe injury in older people. Dr Cole explained that “We used to call trauma the disease of the under-40s, but we realised there’s been a large increase in the proportion of elderly people - and not just over 60s, but over 75s and 80s - who are suffering severe injuries from falling during DIY, road-traffic crashes, and pedestrians or cyclists being hit by large vehicles”.
Trauma survivor Evi Machova and her partner Omar Agha
On 13 October, The Sunday Mirror featured Shan Martin, who spoke about working through her bucket list after being hit by a car. Shan was only given a 6% chance of survival after a RTC in 2015, and she attributes her remarkable recovery in part to the importance of setting life goals and the support of her family and friends.
C4TS research in the news On 1 October, Professor Brohi was featured in the Evening Standard discussing how advances in haemorrhage management, informed by C4TS research, have led to a dramatic drop in mortality for the most critically injured at the Royal London Hospital and other London Major Trauma Centres.
Some of the recent media coverage for trauma survivors and C4TS research
The Cryostat-2 trial was also mentioned in a Guardian article on 21 October which discussed knife crime and its treatment in UK trauma centres. Dr Ross Davenport explained that “with major blood loss a feature of many knife injuries, our research on bleeding at the Centre for Trauma Sciences at Queen Mary University of London has reduced mortality among the most critically injured”. On 7 November, the youth stabbings study that is summarised on page one of this newsletter and published in the BMJ was also front page news in The Guardian and The Metro. It was also picked up by eight other leading UK media including The Times.
Barts Charity’s Transform Trauma appeal seeks to raise community awareness of the impact of traumatic injury and the need for further investment in trauma research and treatments. You can help by sharing the Charity’s videos on social media, starting your own fundraising activity or simpy donate by visiting the appeal page: https://www.justgiving.com/campaigns/charity/blc/transformtrauma