Barts C4TS autumn 2017 newsletter

C4TS Newsletter Autumn 2017 Issue 14 Welcome to the C4TS Autumn 2017 newsletter. In this edition, we outline our discoveries about how platelet function is affected by trauma. This work is increasing our understanding of the potential benefit of platelet transfusion for haemorrhage management. We also provide an update on our iTACTIC Randomised Control Trial, and discuss the effectiveness of the Rehabilitation Complexity Scale Extended to predict disability levels. Finally, as mentioned in the last edition, Barts Charity has launched a major appeal to increase funding for trauma research with support from high profile trauma survivors. We provide an update on campaign highlights thus far.

www.c4ts.qmul.ac.uk

(C4TS Research Assistant) The Dr Scarlett Gillespie

Platelet transfusions in trauma haemorrhage Background

by Dr Scarlett Gillespie and Dr Paul Vulliamy

Blood samples are taken when the patient is admitted to hospital (termed baseline), and then again after every time a patient receives 4 bags of red blood cells (termed 4, 8, 12 PRBC). The aim was to investigate whether giving patients platelets during transfusion helps platelets to aggregate and support the production of a more stable clot.

Platelets are small cells produced in bone marrow that get released into the blood stream and then circulate throughout the body. One of their primary roles is to seal holes in damaged blood vessels by producing a blood clot; another is to make proteins that support the production and stop the breakdown of this blood clot.

levels of tPA (Graph 2b), which is involved in blood clot breakdown.

These findings were also supported by an experiment that directly measures the size of blood clot formation, which found less blood clot breakdown (maximum lysis, (ML)) in those patients receiving a platelet transfusion (Graph 2c).

We found that receiving a platelet transfusion during bleeding did not improve the ability of platelets to aggregate (Graph 1). However, we noted that patients receiving platelet transfusion had increased levels of PAI-1 (Graph 2a), a protein which protects blood clots against being broken down, and decreased

Our previous research has found that following traumatic injury platelets do not function properly.

When compared to healthy people, trauma patients’ platelets appear less able to stick together – a process called aggregation. In a bleeding trauma patient, this decreased aggregation becomes worse if the patient receives a blood transfusion.

Implications Although platelet transfusion does not protect against the loss of platelet aggregation associated with traumatic injury and bleeding, transfusion supports blood clot stability through protecting clots from being broken down. Our ongoing research is using further techniques to understand how platelet function is altered by traumatic injury so that we are able provide the most efficient transfusion to a bleeding trauma patient. Read the full article here

The study We investigated what happened to platelet aggregation in patients who received platelet transfusions during their bleeding episode compared to those who did not. We also compared the levels of several proteins (PAI-1 and tPA) produced by platelets in these two patient groups Centre for Trauma Sciences

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Rehabilitation needs after injury

by Dr Karen Hoffman, Head of Trauma Rehabilitation Research The ability to predict rehabilitation needs and outcomes early after injury is valuable in terms of resource allocation and discharge planning. While injury severity scoring (ISS) is known to be a reasonably accurate predictor of mortality, it is unknown whether this translates into the rehabilitation needs of survivors. The objective of this study was to evaluate the effectiveness of an admission assessment using the Rehabilitation Complexity Scale Extended (RCS-E) to predict disability levels, discharge destination and health outcomes of major trauma patients, compared to standard injury scoring.

Methods A 12 month prospective cohort study at a major trauma centre in London collected data for patients with a length of stay (LOS) longer than 72 hours. The Rehabilitation Complexity Scale Extended (RCS-E) was used to measure rehabilitation needs and disability was measured using the 20-point Barthel Index (BI). Health outcome was measured using the European Quality of Life Scale (EQ5D-3L) prior to transfer or discharge. Patients were grouped into four rehabilitation categories depending on their rehabilitation need score. These were: ‘Low’ (1-6), ’Moderate’ (7-9), ’Heavy’ (10-13) and ‘Very Heavy’ (14-20) rehabilitation needs as measured with the 20 point RCSE. Patients continued to have rehabilitation needs despite improvements in dependency (Figure 1). Patients with higher rehabilitation needs had significantly longer LOS, more likely to be transferred to rehabilitation and worse outcomes compared to those with low rehabilitation needs. 40% of patients with mild to moderate injuries (ISS

≤15) had ‘Heavy’ or ‘Very Heavy’ rehabilitation needs, while 24% of severely injured (ISS >15) patients had only ‘Low’ or ‘Moderate’ rehabilitation needs.

Conclusions The ability to measure and predict rehabilitation needs and outcomes easily could potentially lead to improved allocation of rehabilitation resources. Early assessment of rehabilitation needs using the RCS-E better predicts the level of rehabilitation required, predicted length of stay and provides more relevant information than injury severity scoring alone. It is useful for discharge planning and able to identify patients at risk of poor health outcomes.

For more information about this study, contact Dr Karen Hoffman

C4TS Research Fellow wins prestigious scholarship C4TS Clinical Research Fellow Dr Paul Vulliamy has been awarded a one year research fellowship with the Royal College of Surgeons Dr Paul Vulliamy, C4TS (RCS).

Clinical Research Fellow The fellowship will provide funding to continue C4TS research into how trauma and blood loss affect platelet function. Platelets are cell fragments that are crucial to blood clotting, but our initial work has identified that platelets from trauma patients do not function properly in the face of sustained major bleeding. The fellowship will allow Paul to explore the mechanisms underlying this phenomenon in more detail, with the ultimate aim of finding new treatments to improve outcomes from traumatic haemorrhage.

Figure 1 – rehabilitation needs measured using the RCS-E compared to Barthel disability scores

In September, the patient and clinician focus group for the AfterTrauma recovery app met in London for the fourth time. The group is working with C4TS to coproduce the app which will assist trauma patients with rehabilitation and recovery challenges. For more information, contact Nicole Skeltys.

Centre for Trauma Sciences

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iTACTIC update

by Ms Claire Rourke, Clinical Trials Manager

Background Within the last decade, research focusing on Trauma Induced Coagulopathy (TIC) has led to improved resuscitation strategies, resulting in the early and more aggressive use of blood products and coagulation factors for the management of massively bleeding patients.

However, in spite of improved resuscitation strategies, current transfusion therapy still fails to correct coagulopathy during ongoing haemorrhage. iTACTIC is a European-wide Phase IIa randomised clinical trial investigating the effect of viscoelastic haemostatic assay (VHA)-guided resuscitation versus optimised conventional coagulation test (CCT) resuscitation support on outcomes in haemorrhaging trauma patients. Approximately 400 trauma patients will be recruited to the study at multiple sites across Europe over 2 years.

The EC funded trial opened to recruitment on 1st June 2016.

Progress As of 30th September 2017, six sites have been initiated and a total of 257 patients (66% of recruitment target) have been enrolled in the trial across all study centres (see graph below):

When complete, trial results will shed more light on how to optimise transfusion practices and save more lives that would otherwise succumb to TIC. More information about the iTACTIC trial.

Centre for Trauma Sciences

Newsletter Autumn 2017

The Transform Trauma concert to raise funds and awareness for trauma research was held at the Village Underground in London on 9 September. The concert, headlined by rap star Professor Green, was sold out, attracting 1200 attendees.

Videos showing trauma survivor stories were shown on the night, as were messages about the importance of trauma research. The Transform Trauma campaign, launched by Barts Charity on 16 July, is attracting an unprecedented level of UK media exposure about the need for increased investment in this area, which currently receives less than 1% of all medical research funding.

Our 2017 Trauma Sciences MSc Summer Session held over two weeks in August attracted 29 students who engaged in workshops with global leaders in trauma care. 36 students are graduating from the MSc in November, and 79 new students have just commenced their studies after a record number of applications.

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