The recombinant Hepatitis B surface antigen vaccine inadequately protects those living with HIV from Hepatitis B virus infection. This study utilized saved serum samples from a retrospective cohort of persons with HIV and documented vaccine-induced HBsAb seroconversion to determine factors associated with persistence of protective levels of HBsAb (≥10mIU/ml). HBsAb levels fell below 10mIU/ml in 27% of the cohort after a median follow-up of 43 months. HIV viral load suppression (<50copies/ml) at the time of vaccination was the major factor associated with persistence of protective levels of HBsAb (OR 3.83, p <0.01). Among individuals who lost protective levels of HBsAb, booster doses of vaccine re-instated the development of protective levels of HBsAb. Delaying or repeating HBV vaccination until after suppression of HIV viral load is achieved should be considered HBV antibody levels should be followed over time and boosters given with loss of protective levels of HBsAb.

Endogenously, VEGF initiates angiogenesis, then later Angiopoietin (Ang)-1 matures vessels. We hypothesized that multigene therapy of VEGF before Ang1 to ischemic hindlimb tissue would result in persistent angiogenesis. At 2, 4 and 8 wks after inducing ischemia, blood flow was assessed by contrast-enhanced ultrasound. Animals were treated with VEGF at 2 wks, VEGF/Ang1 at 2 wks, or VEGF at 2 wks and Ang1 at 4 wks. In untreated controls, blood flow remained reduced. After VEGF delivery, resting flow and vessel density increased; however, flow reserve remained reduced, and vasculature was capillary-rich and eventually regressed. After VEGF/Ang1 co-delivery, flow increased marginally, flow reserve improved and vascular architecture remained normal. After separated VEGF and Ang1 delivery, flow, vessel density and flow reserve increased and were sustained, while vascular architecture remained normal. In conclusion, temporally separated VEGF and Ang1 delivery promotes sustained angiogenesis and improved vessel functionality.

Airway hyperresponsiveness (AHR) is a cardinal feature of asthma that is aggravated by environmental air pollution (EAP). Splenocyte tyrosine kinase Syk has been associated with asthma pathogenesis. Therefore, we sought to investigate the effect of Syk inhibition on AHR and its exacerbation by EAP. For this purpose, we examined Syk protein expression in lung homogenates from three murine models of ovalbumin (OVA)-induced asthma expressing different pathophysiological features of the disease: airway inflammation, AHR and remodeling. Increased Syk expression was observed only in the chronic model of airway inflammation and remodeling. In vivo Syk inhibition attenuates AHR in this model, and further augmentation induced by EAP without affecting the underlying airway inflammation. We demonstrated, for the first time, that Syk inhibition effectively reverted AHR in an already established chronic model of asthma. These findings highlight the therapeutic potential of targeting Syk for the treatment of asthma and its exacerbations by EAP.

It is well recognized that a certain component of surgical residency training has transitioned from the operating room to the surgical skills lab. Although a significant amount of important work has validated simulators as viable systems for teaching technical skills outside the operating room, the next step is integrating simulators into a comprehensive curriculum. Several frameworks for curricular design have been described in the literature; however, few curricula have been described or validated for minimally invasive surgical procedures. This study describes the design and validation of a comprehensive technical skills curriculum for laparoscopic colorectal surgery, an advanced laparoscopic procedure. The initial step in this project utilized the Delphi consensus methodology to develop a procedure-specific evaluation tool for laparoscopic colorectal surgery. This evaluation tool demonstrated reliability and validity in the context of expert and novice performance in the operating room. The next phase of the project also used the Delphi method to develop international consensus on a proficiency-based virtual reality program designed to teach the technical skills necessary to perform laparoscopic colorectal surgery. This virtual reality training program was then integrated into a comprehensive curriculum consisting of psychomotor training on the virtual reality simulator, as well as cognitive training and a cadaver lab. The final component of this project was a randomized single-blinded controlled trial that demonstrated that surgical residents who participated in the comprehensive curriculum exhibited superior technical skills in the operating room, and superior cognitive knowledge relating to laparoscopic colorectal surgery, compared to residents who received only conventional residency training.

Background: The incidence of inadequate empiric antibiotic therapy (IET) and its clinical importance as a risk factor for hospital mortality in Canadian solid-organ transplant patients remains unknown. Methods: This retrospective cohort study evaluated all patients admitted to a transplant unit from May/2002-April/2004. Therapy was considered adequate when the organism cultured was found to be susceptible to an antibiotic administered within 24 hours of the index sample collection time. Univariate and multivariate regression analyses were conducted to determine associations between potential determinants, IET, and mortality. Results: IET was administered in 169/312 (54%) transplant patients. Regression analysis demonstrated that an increasing duration of IET (adjusted OR at 24h, 1.33; p < 0.001), ICU-associated infections (adjusted OR, 6.27; p < 0.001), prior antibiotic use (adjusted OR, 3.56; p = 0.004), and increasing APACHE-II scores (adjusted OR, 1.26; p < 0.001), were independent determinants of hospital mortality. Conclusions: IET is common and appears to be an important determinant of hospital mortality in the Canadian transplant population.

Accumulating evidence suggests that volume overload in drug-resistant hypertension (RH) may contribute to the high prevalence of obstructive sleep apnea-hypopnea (OSAH). Upon recumbency, leg fluid volume moves rostrally causing an increase in nuchal and peripharyngeal fluid content, subsequently obstructing airflow. Rostral fluid displacement following lower body positive pressure (LBPP) application and occurring spontaneously overnight were evaluated in subjects with RH (n = 25) and controlled hypertension (n = 15). In both groups, the reduction in mean upper airway cross-sectional area with LBPP strongly related to the amount of fluid displaced from the legs (R2 = 0.41; p<0.0001), although its magnitude was greater in the RH group (p=0.001; adjusted for propensity score). In both groups, the apnea-hypopnea index strongly related to the amount of fluid spontaneously displaced from the legs during sleep (R2 = 0.56; p<0.0001), although its magnitude was greater in the RH group (p=0.01; adjusted for propensity score).

We conducted a retrospective review of discordant pathology for lymphoma patients treated at the Princess Margaret Hospital between 2000 and 2003. We identified 2818 lymphoma patients of which 1567 (38%) met inclusion criteria with 167 discordant cases (discordance rate 15.7%). Six reviewers blinded to clinical management rated potential for harm on a minimal to severe scoring. The majority (67.6%) received a rating of moderate to severe. Review of actual clinical management revealed unnecessary surgical procedures, incorrect chemotherapy and under or over treatment of patients. For discordant cases, 8.4% were identified as having severe actual harm. This means that 1/6 patients diagnosed with lymphoma may have a change in diagnosis after pathologic review, 1/9 will have discordance with the potential to cause moderate to severe consequences, and 1/75 will experience significant clinical harm. We conclude that pathologic discordance in lymphoma is common and can lead to patient harm.

Endothelial progenitor cells (EPCs) have reduced neovascularization capacity in the context of coronary artery disease (CAD) or cardiac risk factors (RFs). Since, endothelial NO synthase (eNOS) is critical to normal EPC function, we hypothesized that bone marrow cells (BMCs) from rats with RFs and EPCs from humans with CAD and/or RFs show dramatically reduced neovascularization capacity in vitro and in vivo, which can be reversed by eNOS overexpression. BMCs were isolated from rat models of type II diabetes and the metabolic syndrome, and we showed a significant reduction in their ability to stimulate neovascularization in vitro and in vivo. In humans, we isolated circulating ‘early EPCs’ from healthy subjects and patients with CAD and RFs, and transduced them using lentiviral vectors containing either eNOS or GFP (sham). EPCs from patients had reduced in vitro migration in response to SDF-1 or VEGF, which was reversed by eNOS-transduction. In co-culture with human umbilical vein endothelial cells (HUVECs) on Matrigel, eNOS-transduced EPCs contributed to increased and more complex angiogenic tube formation compared to sham-transduced cells. Human EPCs from patients were ineffective in enhancing ischemic hind limb neovascularization and perfusion in a nude mouse, whereas eNOS-transduced EPCs resulted in a significant improvement compared to sham-transduced cells. In a swine model of acute myocardial infarction (MI), eNOS- and non-transfected BMCs both increased left ventricular function compared to sham. However, there was no benefit to eNOS overexpression in this model. Various differences in the models and procedures may explain the incongruous results obtained. Taken together, these results show that eNOS overexpression significantly improves the neovascularization capacity of EPCs of human subjects with CAD and RFs and could represent an effective adjunctive approach for the improvement of autologous cell therapies for cardiovascular disease.

Anthracycline- and taxane-based regimens have been the mainstay in treating breast cancer patients using chemotherapy. Yet, the genetic make-up of patients and their tumors may have a strong impact on tumor sensitivity to these agents and to treatment outcome. This study represents a new paradigm assimilating bioinformatic tools with in vitro model systems to discover novel genetic variations that may be associated with chemotherapy response in breast cancer. This innovative paradigm integrates drug response data for the NCI60 cell line panel with genome-wide Affymetrix SNP data in order to identify genetic variations associated with drug resistance. This genome wide association study has led to the discovery of 59 candidate loci that may play critical roles in breast tumor sensitivity to doxorubicin and paclitaxel. 16 of them were mapped within well-characterized genes (three related to doxorubicin and 13 to paclitaxel). Further in silico characterization and in vitro functional analysis validated their differential expression in resistant cancer cell lines treated with the drug of interest (over-expression of RORA and DSG1, and under-expression of FRMD6, SGCD, SNTG1, LPHN2 and DCT). Interestingly, three and six genes associated with doxorubicin and paclitaxel resistance, respectively, are involved in the apoptotic process in cells. A constructed interactome suggested that there is cross-talk at the Nrf-2 oxidative stress pathway between genes associated with resistance to doxorubicin and paclitaxel. This unique GWA approach serves as a proof-of-principle study and systematically investigates targets responsible for variable response to chemotherapy in breast tumor cells and possibly the tumors of breast cancer patients. Overall, the model discovered novel candidate genes that have not been previously associated with doxorubicin and paclitaxel cytotoxicity. Future studies will be directed at illustrating a causative relationship between the observed genomic changes and drug resistance in breast cancer patients undergoing doxorubicin and paclitaxel chemotherapy.

The brain is a complex dynamic and self-organizing system. Normal brain function emerges from synchronized neuronal firing between local neurons which are integrated into large scale networks via white matter tracts. Normal brain function and consciousness arise from the continual integration and dissolution of neuronal networks, and this fluctuation in synchronization is termed variability. Brain electrical activity is recorded as local field potentials using electroencephalography (EEG). The phase synchrony and variability of EEG waveforms can be quantified. The healthy brain exhibits a relatively low degree of phase synchrony and a high degree of variability. Clinicians are interested in using a complex system approach to brain function to provide dynamic information on neuronal physiology and pathology not available by other evaluation methods. A common challenge in paediatric critical care is evaluation of the comatose child post brain injury. Coma and medical interventions confound the clinical examination making monitoring and prognostication of outcome difficult. Brain cells and white matter tracts are disrupted post injury altering the phase synchrony between neuronal networks. It is proposed in this thesis that the estimation of the variability in EEG phase synchrony can evaluate paediatric brain function. The EEG recordings of normal children and patients in coma post brain injury are used, in a series of studies, to test the main hypothesis that slow EEG wave brain states associated with brain injury have higher magnitudes of EEG phase synchrony and lower variability values than those of EEG waves associated with consciousness. Further, the effects of age, brain development brain and the effect of a conscious slow wave EEG state (hyperventilation) on phase synchrony and variability are evaluated. Results of the studies showed that EEG phase synchrony is increased in all slow wave states and is highest in comatose children with poor neurological outcome. Younger children’s brains have higher phase synchrony than older children. The variability of the EEG phase synchrony differentiates between the awake (higher values) and unconscious states (lower values). Physiologic models underlying EEG phase synchrony are discussed. The EEG phase synchrony and variability measures provide new insight into paediatric brain function.