The implementation of Electronic Medical Records (EMRs) may lead to improved quality of primary health care. To investigate this, we conducted a mixed methods study of eighteen Toronto family physicians who implemented EMRs in 2006 and nine comparison family physicians who continued to use paper records. We used a controlled before-after design and two focus groups. We examined five preventive services with Pay for Performance incentives: Pap smears, screening mammograms, fecal occult blood testing, influenza vaccinations and childhood vaccinations. There was no difference between the two groups: after adjustment, combined preventive services for the EMR group increased by 0.7% less than for the non-EMR group (p=0.55, 95% CI -2.8, 3.9). Physicians felt that EMR implementation was challenging.

Tissue engineering is limited by inability to create early and adequate blood supply. In-vivo DCE-MRI has imaged angiogenesis in soft tissues, yet has not been considered in hard tissues. Bilateral critical defects created in parietal bones of eighteen adult rabbits were left void, treated with haluronic acid acellular matrix (HA-ACM), or HA-ACM impregnated with vascular endothelial growth factor (VegF). DCE- MRI was acquired at weeks 1,2,3,6, and 12. Histologic analysis of HA-ACM treated defects demonstrated quantitatively greater immature bone formation, increased quantity and larger blood vessels compared to void. Statistically significant greater angiogenesis evidenced by quantitative perfusion on MRI supported histologic findings. DCE MRI is a novel means of imaging angiogenesis in grafted bone defects. DCE-MRI discerns physiologically important phases of angiogenesis: Initial vasoactive response, vessel network initiation, establishment, and pruning. DCE-MRI is adaptable to non-invasive study of candidate tissue engineered constructs and in evaluating scaffolds and treatments on angiogenesis.

Background: Parameters of carotid atherosclerosis dynamic contrast-enhanced MRI (DCE-MRI) are associated with stroke risk indices, but studies have only evaluated symptomatic arteries. I hypothesized that DCE-MRI parameters are different between carotid atherosclerotic plaques at high and low risk for precipitating ischemic stroke. Methods: High and low risk carotid plaques undergoing nonmodel-based DCE-MRI (n=18) were compared using two independent schema: 1) clinical standard (high risk defined as ipsilateral stroke/TIA <1 week old or stenosis >70%); 2) MRI standard (high risk defined as presence of intraplaque hemorrhage [IPH]). Results: IPH-positive plaques (n=9) exhibited greater area under the curve, early and late enhancement rate, and peak enhancement than IPH-negative plaques (n=9) (p<0.05 for all). High (n=8) and low (n=7) risk plaques defined by clinical criteria were not differentiated by any DCE-MRI parameters. Conclusions: Nonmodel-based DCE-MRI discriminates high versus low risk carotid plaque based on the presence of IPH, but not by clinical criteria.

Breast cancer is a growing international health epidemic, and patients in low and middle income countries (LMCs) have worse outcomes than those in high income countries. High quality, well-implemented guidelines help improve patient outcomes, but are often not resource-sensitive, and support therapies that may not be feasible in LMCs. A systematic review to address the content, quality, and resource-sensitivity of international breast cancer guidelines was completed. Also, a survey of global physicians evaluated the impact of resource setting on practice patterns and guideline use. Guideline use did not appear to be directed by quality (which was variable across guidelines) or resource-sensitivity (found in few guidelines). However, practice patterns were found to vary by resource setting and by continent, often due to the cost of certain therapies. In order for guidelines to better impact global breast cancer outcomes, they need to be of higher quality, more resource-sensitive, and better implemented.

Human immunodeficiency virus infection is a chronic condition causing significant changes in the immune system, which are reflected in the altered gene expression patterns of the immune cells. By studying these patterns through gene expression profiling it is possible to describe not only the current states the cells are in, but also to extrapolate the proximal signals that resulted in the observed patterns. In the studies described herein, we have applied this approach to better understand the alterations in the immune function that occur in HIV infection. First, we have obtained transcriptional profiles of CD4+ and CD8+ T cells from patients in early infection, in chronic infection, and in non-progressive infection, and we compared these profiles to each other and to the profiles from uninfected donors. The analyses of the profiles revealed no discernable changes in the T cells of the non-progressive patients when compared to the uninfected individuals. On the other hand, T cells from patients with progressive infection, both early and late, showed patterns characteristic of type I interferon (IFN) exposure. We next examined experimentally the possible proximal causes of the observed transcriptional profiles. We analyzed the gene expression patterns induced by TGFβ, 13 type I interferons, as well as recombinant HIV Tat protein, in T cells and peripheral blood mononuclear cells. The TGFβ responses were inconsistent with the transcriptional profiles seen in HIV-infected patients, whereas both type I IFNs and HIV Tat induced genes in patterns consistent with those seen in patients. In fact, the thirteen IFN-induced patterns were indistinguishable from each other. Tat treatments induced interferon-stimulated genes (ISGs) as well as other genes and the response was not dependent on the presence of plasmacytoid dendritic cells (pDCs), suggesting monocytes as the possible source of the interferon response. In the last study, we examined the responses of plasmacytoid dendritic cells (pDCs) to HIV and other stimuli in healthy and HIV-infected subjects. We observed induction of IFN genes in pDCs of all subjects in response to influenza virus and TLR7 agonist imiquimod, but not to HIV virus. In summary, HIV infection results in chronic induction of type I IFN response in cells of the immune system. The source of this response is likely to be type I IFNs produced by monocytes/macrophages rather than plasmacytoid cells. The monocytic production of type I IFN may be a Tat-dependent response.

This dissertation involved linking a clinical cystic fibrosis (CF) data registry with administrative databases to evaluate clinical, demographic, and geographical predictors of hospitalization in CF patients living in Ontario over a 10 year period. In addition, this work assessed the ability of administrative data to identify individuals with CF using the clinical registry as the reference standard. Sex was an independent predictor of hospitalization rates for individuals with CF. Females had a significantly higher hospitalization rate compared to males even after adjusting for important clinical factors suggesting that this finding is not simply due to worse CF disease. In those between 7 and 19 years of age, the adjusted hospitalization rate was 38% higher in females (rate ratio[RR] 1.38, 95% confidence interval [CI] 1.11-1.73). Similarly in those over the age of 19, females had a 30% higher hospitalization rate compared to males (RR 1.30, 95% CI 1.06-1.59). Other significant predictors associated with higher hospitalization rates in both age groups were lower lung function, worse nutritional status, pancreatic insufficiency, and the presence of CF-related diabetes. The presence of Burkholderia cepacia complex in the sputum was a significant predictor in those over the age of 19 years (RR 1.54, 95% CI 1.26-1.89). Distance to CF centre, community size and socioeconomic status were not significant predictors of hospitalization rates in either age group. There was no significant trend in hospitalization rates over time once rates were adjusted for markers of disease severity (p=0.08). Comparing administrative data with the CF registry data, administrative data captured hospitalizations more comprehensively. Despite CF being a specific diagnosis, health administrative databases alone were insufficient to reliably and accurately identify individuals with CF unless they had been hospitalized. The reason for the gender disparity seen within this dissertation is likely multifactorial. There may be differences in outpatient management between the sexes, hormonal influences may modulate disease severity causing higher hospitalization rates, and patient and provider-level influences may affect the decision to hospitalize a patient. Further research is needed in this area to elucidate the factors contributing to this gender gap.

Spinal cord injury (SCI) is uniquely devastating. Cellular transplantation strategies for SCI are showing promise. Little, however, is known about how transplanted neural precursor cells (NPCs) enhance functional recovery or the mechanisms by which they interact with the host spinal cord. Better understanding of these critical issues may lead to improved strategies to enhance recovery after SCI. Given this background, I hypothesized that NPCs mediate functional recovery by a number of mechanisms including trophin production, neuroprotection, modulation of the host inflammatory response or glial scarring, and/or remyelination. I thus endeavored to characterize trophin production by NPCs in vitro and in vivo in rats with clip compression SCI of the thoracic spinal cord, to determine if preservation of host cells and tissue contribute to functional recovery and to determine how NPC transplantation influences the host inflammatory response and glial scarring. Here I present unique and novel insights into NPC-host interactions following SCI. We show that NPCs are poised to provide trophic support to the injured spinal cord. We also show that the combination of NPCs, pharmacotherapy and trophin infusion is associated with sparing of grey and white matter, enhanced numbers of oligodendrocytes but not axons as well as an increased inflammatory response. To assess the potential impact of myelination as a mechanism underlying NPC-mediated functional recovery after SCI, experiments were undertaken using NPCs derived from shiverer mutant mice unable to produce central myelin. These experiments showed that while NPCs from wild-type mice generate myelin and mediate functional recovery after SCI; transplanted shiverer NPCs impede neurobehavioural recovery. In summary, my work provides unique insights into the functional effects of NPC transplantation after SCI. Of importance, this thesis provides novel evidence that remyelination is a key mechanism of action by which NPCs mediate recovery after SCI. Hence, this work has important implications for patients with SCI.

Corticobasal Syndrome (CBS) is a rare movement and cognitive disorder. There is significant heterogeneity observed in it clinical presentation, neuroimaging, pathology and genetics. Understanding this heterogeneity is a priority and may help to shed light on underlying pathogenic mechanisms. We first demonstrated that truncating mutations in the progranulin gene (PGRN) can cause familial CBS associated with frontotemporal lobar degeneration (FTLD)-ubiquitin pathology. This study identified a mutation in PGRN (Intervening Sequence 7+1 guanine > adenine [IVS7+1G>A]) that segregated with CBS in a family. The mutation was predicted to result in a shortened messenger RNA (mRNA) sequence and the absence of the mutant PGRN allele was confirmed in the reverse transcriptase-polymerase chain reaction (RT-PCR) product, which supported the model of haploinsufficiency for PGRN-linked disease. In a second familial study, clinical, radiological, genetic, and pathological studies were performed to contrast clinical features of the affected members. Sequencing PGRN revealed a novel, heterozygous cytosine-adenine dinucleotide deletion in exon 11 (g.2988_2989delCA, P439_R440fsX6). The proband`s clinical diagnosis was frontotemporal dementia and parkinsonism (FTDP). The proband’s brother with the same mutation presented initially as a progressive non-fluent aphasia (PNFA), and later evolved into a CBS. Pathological analysis revealed Frontotemporal Lobar Degeneration-Ubiquitin (FTLD-U)/ TAR DNA-binding protein 43 (TDP43) positive pathology. The next studies shift away from pathogenic mechanisms to focus on brain-behavioural correlations and phenotypic heterogeneity in a prospective sample of 31 CBS cases. We provide the first direct correlative analysis between the severity of ideomotor apraxia, a common sign in CBS, and cerebral SPECT perfusion imaging. Reductions in perfusion within the left inferior parietal lobule (t=5.7, p=0.03, Family-Wise Error [FWE] corrected), including the left angular gyrus (t=5.7, p=0.02, FWE corrected), were associated with more severe ideomotor apraxia. We stratified the sample into CBS presenting with early motor features (CBS-M; n=9) or early dementia (CBS-D; n=22), which identified that CBS-M were more likely to have cortical sensory loss than CBS-D (p=0.005). In contrast, the presence of aphasia was found to be more common and severe in CBS-D compared to CBS-M (p=0.02). CBS-M patients had significantly reduced perfusion in the right supplementary and premotor areas compared to CBS-D (p<0.05).

Gabapentin is an anticonvulsant that has become a treatment option for several indications that are not approved by Health Canada. Commonly, gabapentin is prescribed for neuropathic pain and anxiety disorders. The objective of this dissertation was to evaluate the efficacy of gabapentin for reducing pre-operative anxiety, post-operative pain and opioid consumption. The initial study examined regimens of pre-operative and post-operative gabapentin given to patients undergoing total knee arthroplasty. Patients that received gabapentin postoperatively used significantly less morphine at 24 hrs, 36 hrs and 48 hrs (p<0.05). Furthermore these patients had significantly better active-assisted knee flexion on postoperative day (POD) 2, POD 3, with a trend toward better flexion on POD 4. Next, we examined whether: 1) gabapentin administration reduces pain and opioid use after total hip arthroplasty using a multimodal analgesic regimen that included spinal anesthesia; and whether 2) preoperative administration of gabapentin is more effective than postoperative administration. Our results demonstrated that whether a 600 mg dose of gabapentin was given preoperatively or postoperatively, patients’ postoperative morphine consumption or pain scores were not reduced in hospital nor was there a reduction in pain 6 months after hip arthroplasty. The third study found that a single dose of 600 mg of gabapentin was not sufficient to reduce preoperative anxiety in patients prior to hip arthroplasty. In contrast, the final study demonstrated that 1200mg of gabapentin reduced pre-operative anxiety and pain catastrophizing in female patients with moderate to high levels of preoperative anxiety prior to major surgery, but also increased preoperative and early postoperative sedation. Our findings demonstrate the efficacy of perioperative gabapentin with respect to preoperative anxiety reduction and decreasing morphine consumption after surgery. Future studies that focus on the optimal dose and duration of perioperative gabapentin, with the aim of improving functional outcomes and decreasing the incidence and severity chronic post-surgical pain are warranted.

The implementation of Electronic Medical Records (EMRs) may lead to improved quality of primary health care. To investigate this, we conducted a mixed methods study of eighteen Toronto family physicians who implemented EMRs in 2006 and nine comparison family physicians who continued to use paper records. We used a controlled before-after design and two focus groups. We examined five preventive services with Pay for Performance incentives: Pap smears, screening mammograms, fecal occult blood testing, influenza vaccinations and childhood vaccinations. There was no difference between the two groups: after adjustment, combined preventive services for the EMR group increased by 0.7% less than for the non-EMR group (p=0.55, 95% CI -2.8, 3.9). Physicians felt that EMR implementation was challenging.