<p><italic>Kingella kingae</italic> is an emerging bacterial pathogen that is being recognized increasingly as an important etiology of septic arthritis, osteomyelitis, and bacteremia, especially in young children. The pathogenesis of <italic>K. kingae</italic> disease begins with bacterial adherence to respiratory epithelium in the posterior pharynx. Previous work identified type IV pili as a critical factor for adherence to human epithelial cells. However, the finding that a significant percentage of pharyngeal isolates are non-piliated suggests that <italic>K. kingae</italic> expresses additional surface factors that modulate interactions with host cells and likely play key roles in the pathogenesis of <italic>K. kingae</italic> disease. The purpose of this work was to increase our understanding of <italic>K. kingae</italic> virulence determinants, specifically focused on defining the surface factors and the mechanism involved in <italic>K. kingae</italic> adhesive interactions with epithelial cells. Additionally, this work aimed to further characterize components of the <italic>K. kingae</italic> type IV pilus system, namely the PilC proteins and PilA2. </p><p>We first set out to identify non-pilus factors that influence <italic>K. kingae</italic> interactions with human epithelial cells. Using targeted genetic approaches, we found that insertional inactivation of the gene encoding a predicted trimeric autotransporter protein called Knh (Kingella NhhA homolog) resulted in reduced adherence to human epithelial cells. In addition, using a variety of techniques, including morphological analysis, cationic ferritin staining, and thin section transmission electron microscopy, we established that <italic>K. kingae</italic> elaborates a surface-associated polysaccharide capsule that requires a predicted ABC-type transporter export operon called <italic>ctrABCD for surface presentation. Furthermore, using quantitative human epithelial cell adherence assays, we discovered that the presence of surface capsule interferes with Knh-mediated adherence by non-piliated organisms and that maximal adherence in the presence of capsule requires the predicted type IV pilus retraction machinery, PilT/PilU. Based on the data presented here, we propose a novel adherence mechanism that allows <italic>K. kingae</italic> to adhere efficiently to human epithelial cells while remaining encapsulated and more resistant to immune clearance. </p><p>Having established that <italic>K. kingae</italic> produces a capsule, a large-scale polysaccharide purification technique was developed for capsule analysis of strain 269-492. Biochemical assays determined that the purified material contained thiobarbituric and phenol-sulfuric acid reactive glycosyl residues. In collaboration with the University of Georgia Complex Carbohydrate Research Center (CCRC), mass spectrometry identified galactose, N-acetyl-galactosamine, and Kdo as the major glycosyl components of the polysaccharide preparation. NMR spectroscopy revealed that the purified material contained two distinct polysaccharides with the structures of &rarr;5)&ndash;&beta;&ndash;Gal<italic>f</italic>&ndash;(1&rarr; and &rarr;3)&ndash;&beta;&ndash;GalNAc<italic>p</italic>&ndash;(1&rarr;5)&ndash;&beta;&ndash;Kdo<italic>p</italic>&ndash;(2&rarr;. Further characterization of the polysaccharides expressed by <italic>K. kingae</italic> may have implications for disease prevention strategies. </p><p>Previous work in our lab found that two PilC-like proteins called PilC1 and PilC2 influence type IV pili expression and pilus-mediated adherence. Production of either PilC1 or PilC2 is necessary for <italic>K. kingae</italic> piliation and bacterial adherence. We set out to further investigate the role of PilC1 and PilC2 in type IV pilus-associated phenotypes. We found that PilC1 contains a functional nine amino acid calcium-binding (Ca-binding) site with homology to the <italic>Pseudomonas aeruginosa</italic> PilY1 Ca-binding site and that PilC2 contains a functional 12 amino acid Ca-binding site with homology to the human calmodulin Ca-binding site. Using targeted mutagenesis to disrupt the Ca-binding sites, we demonstrated that the PilC1 and PilC2 Ca-binding sites are dispensable for piliation. Interestingly, we show that the PilC1 site is necessary for twitching motility and adherence to Chang epithelial cells, while the PilC2 site has only a minor influence on twitching motility and no influence on adherence. These findings establish key differences in PilC1 and PilC2 function in <italic>K. kingae</italic> and provide insights into the biology of the PilC-like family of proteins.</p><p>Lastly, we set out to define the role of the PilA2 minor pilin in <italic>K. kingae</italic> strain 269-492. While previous studies indicated that PilA2 is not essential for pilus expression or adherence to epithelial cells, analysis of the pilin locus in a diverse set of clinical isolates revealed that the <italic>pilA2</italic> gene sequence is highly conserved, suggesting it serves an important function. Using targeted mutagenesis we showed that PilA2 is not essential for twitching motility and may or may not be involved in natural competence. Western blot analysis was unable to detect PilA2 in wild type pilus preparations, indicating that it is expressed at a level beneath the assay detection limit or does not localize to the pilus. Additionally, site-directed mutagenesis was used to place <italic>pilA2</italic> under control of the highly active <italic>pilA1</italic> promoter and showed that PilA2 is able to be assembled into fibers that mediate intermediate adherence to epithelial cells. </p><p>Taken together, this work expands our knowledge of the <italic>K. kingae</italic> surface factor repertoire and provides insights into the roles of type IV pilus components. The mechanism of<italic> K. kingae</italic> adherence to epithelial cells is beginning to emerge. These contributions may lead to novel strategies for the prevention of invasive <italic>K. kingae</italic> disease in young children.</p> / Dissertation

Background - Communicable respiratory illness is a serious occupational threat to healthcare workers. A key reason for occupational transmission is failure to implement appropriate barrier precautions. Facial protective equipment, including surgical masks, respirators and eye/face protection, is the least adhered to type of personal protective equipment used by healthcare workers, yet it is an important barrier precaution against communicable respiratory illness. Objectives - To describe nurses’ adherence to recommended use of facial protective equipment and to identify the factors that influence adherence. Methods - A two-phased study was conducted. Phase 1 was a cross-sectional survey of nurses in selected units of six acute care hospitals in Toronto, Canada. Phase 2 was a direct observational study of critical care nurses. Results – Of the 1074 nurses who completed surveys (82% response rate), 44% reported adherence to recommended use of facial protective equipment. Multivariable analysis revealed four organizational predictors of adherence: ready availability of equipment, regular training and fit testing, organizational support for health and safety, and good communication. Following the survey, 112 observations in 14 intensive care units were conducted that showed a 44% competence rate with proper use of N95 respirators. Common gaps included failure to verify the seal and touching the face piece. Multivariable analysis revealed knowledge of recommended use of facial protective equipment as a significant predictor of competence. Discussion – Despite the SARS experience and the resulting investment in our public health system, nurses’ adherence to recommended use of facial protective equipment and competence in effective use of N95 respirators remains suboptimal. To improve adherence, organizational leaders should focus on equipment availability, training and fit testing, organizational support for health and safety, and positive communication. To improve competence in effective use of N95 respirators, strategies to increase knowledge should be implemented. These efforts should assist to reduce occupational transmission of communicable respiratory illness and foster a healthier and safer working environment for nurses.

Disparities in medication adherence (MA) associated with African American (AA) adults may be related to a dynamic interplay between personal factors, behavioral capability, and environmental factors. The purpose of the study was to examine this relationship in AA adults with metabolic syndrome (MetS). A cross-sectional, correlational analysis was conducted from baseline data from a larger intervention study. Constructs from the Social Cognitive Theory were used to predict MA. The sample of 91 AA adults with MetS was primarily middle-aged (age range 45-70 years old; M 53, SD 6.3), female (79%), relatively well-educated, and married. Despite being on antihypertensive medications, 53% of the participants presented with uncontrolled high blood pressure (≥130/90 mmHg). Although the vast majority (95%) of the sample displayed adequate health literacy (HL), 30% of the sample was non-adherent to their medication regimen. A positive significant relationship was found between age and MA [χ2 (1, n = 90) = 6.71, p = .01)]. Stress [χ2 (1, n = 90) = 6.28, p = .012)] and social support (SS) [χ2 (1, n = 90) = 4.10, p = .04)] were the only significant relationships among environmental factors, barriers and hypertension MA. Highly stressed AA adults were significantly more likely to be non-adherent or had a 15% reduction in the odds of hypertension MA. Similarly, adults with a low income were 5.8 times more likely to be non-adherent (OR 5.828, 95% CI, 1.014-33.493, p= .0482), while those with low SS had a 9% reduction in the odds of MA; SS trended toward significance (OR.914. 95% CI .823-1.016, p =.09). With increasing age, AA adults were more likely to be non-adherent (OR 1.12, 95% CI 1.028-1.220, p =.0096). Most of the participants reported a high degree of autonomy, satisfaction with their health care climate, and the availability of SS. Although increasing age, adequate SS, high stress, and adequate HL appeared to influence MA in AA adults with MetS, the research questions were only partially answered. Further investigation of the relationships and potential mediating pathways between personal characteristics, environmental factors, behavioral capability and hypertension MA in AA adults with MetS is needed.

SAMMANFATTNING Bakgrund: Antipsykotika utgör grunden i behandling av psykossjukdomar. Bristande följsamhet till läkemedelsbehandlingen är dock vanligt förekommande och en stor anledning till att patienter återinsjuknar i psykos och behöver vårdas inom slutenvård. Syfte: Dels att beskriva hur patienter som vårdas inom sluten psykiatrisk psykosvård uppfattar läkemedelsadministrering och dels att beskriva om patienterna uppfattar att sjuksköterskors bemötande i samband med läkemedelsadministrering har betydelse för deras inställning till att medicinera. Metod: Kvalitativ ansats. Intervjustudie med fenomenografi som metod i datainsamling och analys. Resultat: Tio beskrivningskategorier identifierades: Läkemedel befogat och bra, tar läkemedel trots ambivalens/motstånd, läkemedelsadministrationen – ett odramatiskt moment, tvångsmedicinering, behov av information om läkemedel, att vilja ha kontroll eller överlåta ansvar, en stressig situation, belöning för medverkan i medicinering, bemötandet spelar ingen roll och bemötandet spelar stor/viss roll.  Slutsats: Patienter som vårdas inom sluten psykiatrisk psykosvård uppfattar medicinering med antipsykotika och momentet läkemedelsadministration olika. Dessa individuella uppfattningar skulle troligtvis kunna identifieras om rutiner för samtal med patienter kring dessa frågor utarbetas på avdelningar där sådan vård bedrivs. Sannolikheten för att frivilliga lösningar och en bättre individuellt anpassad vård lättare skulle kunna bedrivas borde då öka. Strävan måste vara att så långt det är möjligt undvika tvångsmedicinering och situationer och bemötande som i denna studie identifierats som mindre positiva då de kan utgöra en risk att patienter blir negativt inställda till att medicinera. Ambitionen måste vara att hitta arbetssätt som syftar till långvarig följsamhet. / ABSTRACT Background: Antipsychotics are the basis of the treatment of psychotic illnesses. Lack of adherence to medication is common and a major reason why patients recurrence of psychosis and need to be cared for in hospital. Purpose: To describe how patients with psychosis, cared for in inpatient psychiatric wards, understand medication administration and also to describe if the patients perceive that nurses treatment in the moment of medication administration has an impact on their attitudes to medicate. Method: Qualitative approach. An interview study with phenomenography as a method of data collection and analysis.  Results: Ten categories were identified: medicines justified and well, take medicine despite ambivalence/resistance, administration of medicine – an undramatic moment, coerced medication, need for information about medicines, want to have control or assign responsibility, a stressful situation, reward for participation in the medication, treatment don´t  matter and treatment play a major/some role. Conclusion: Patients with psychosis, who are cared for in inpatient psychiatric wards, understand medication with antipsychotics and the moment of drug administration different. These individual understandings would likely be identified if routines for dialogue with patients about these issues were developed at wards where such care is conducted. The probability of voluntary solutions and better individualized care should then be increased. The ambition must as far as possible be to avoid forced medication and situations identified as less positive in this study as they may pose a risk to cause negative attitudes to medication among patients.  The ambition must be to find ways of working aimed at long-term adherence.

Heart failure is a chronic condition that increases the risk for death and disability. Beta blockers and ACE inhibitors have become standard treatments in heart failure because clinical trials have demonstrated their beneficial effect on mortality and morbidity in these patients. As not much is known about adherence to these medications, the main objectives of this project were to determine long term adherence to ACE inhibitors and beta blockers and determine how various degrees of adherence to a beta blocker can affect major health outcomes in patients with heart failure.<p> Data was obtained from Saskatchewan health from January 1, 1994 to December 31, 2003 for all heart failure patients from their first hospitalization for heart failure. Adherence was calculated using the fill frequency measure of adherence, and all survival analyses were completed using the Cox proportional hazards model.<p>Although 14, 000 patients were admitted to hospital for a first admission for heart failure, only 1143 subjects started a beta blocker and 5084 subjects started an ACE inhibitor within 3 months of the index hospitalization. Within the first year, adherence was excellent for both beta blockers (80.8 percent) and ACE inhibitors (82.5 percent). The proportion of patients remaining adherent slowly decreased to reach approximately 60 percent, for both medication classes, after 4 years. There was no significant difference in all-cause mortality between patients with high adherence and low adherence, but there appeared to be a trend towards decreased survival time in those remaining adherent throughout the study period [HR = 1.18 (95% CI: 0.98 to 1.43; p=0.07)].<p>Since the overall rate of adherence to beta blockers was excellent in most patients during the first year, it is possible that non-adherence is not responsible for a significant burden of mortality in Saskatchewan heart failure patients, and perhaps and the focus of quality improvement should be optimal prescribing of evidence-based therapies, and continued adherence over time.

<p>Cardiovascular disease is a leading cause of death and hospitalizations in Canada. Most risk factors for cardiovascular disease are known, and many are modifiable. One such risk factor that often goes unrecognized is non-adherence. Pharmacists are ideally positioned to have an influence on cardiovascular risk reduction, including supporting medication adherence; however it is still unknown whether typical (non-specialist) pharmacists can provide strategies that are effective and sustainable in todays health care system. Thus, the overall objective of this research project was to determine what interventions typical pharmacists can adopt to effectively facilitate cardiovascular risk reduction within the constraints of the current practice environment. This objective was accomplished through 4 related studies: 1) a randomized controlled trial involving a pharmacist-directed cardiovascular risk reduction collaboration within a family physician practice; 2) a systematic review identifying and evaluating published interventions by community pharmacists for cardiovascular disease or diabetes; 3) the design of a pilot study evaluating a novel community pharmacy intervention aimed at cardiovascular risk reduction and; 4) the examination of adherence patterns among antihypertensive medication users to identify associated factors and high-risk periods for non-adherence.</p> <p>Although the randomized controlled trial did not show a statistically significant benefit of the pharmacist intervention on cardiovascular risk, it did demonstrate the feasibility of incorporating a pharmacist into a collaborative role, without the need for an advanced or specialized degree. Results from the systematic review yielded several studies involving community pharmacists and cardiovascular disease or diabetes. However, the majority of these studies were of poor quality, evaluated complex and intensive interventions, and provided questionable clinical benefits. The design of the pilot study demonstrated the feasibility of developing high quality, robust research involving community pharmacists. Finally, the observational study examining adherence patterns to antihypertensive agents revealed two important findings that can guide the development of future strategies to support adherence: the first year of therapy, and particularly the first dispensation, is a critical time for the development of non-adherence and, contrary to previously published studies, adherence is similar between all classes of antihypertensive medications.</p> <p>This program of research did not identify one particular pharmacist intervention as being superior for cardiovascular risk reduction in todays practice environment. However, it did highlight the need for improved study quality and the development of interventions that are practical and can be realistically implemented by pharmacists in todays practice environment.</p>

Syfte: Syftet med denna studie är att beskriva patienters inställning till sin antipsykotiska medicinering och orsaker till varför läkemedelsordinationer inte följs. Metod: Enkätstudie med kvalitativ innehållsanalys. Resultat: Två teman och 13 kategorier framkom för att beskriva patienters inställning till läkemedlet. Dessa teman är Läkemedel som hjälp och Läkemedel som belastning. Antalet kategorier under temat läkemedel som hjälp är nio stycken och antalet kategorier under temat läkemedel som belastning är fyra. För att beskriva varför ordinationer inte följts framkom fyra kategorier. Slutsats: Huvudresultaten i denna studie är de två teman som framkom, Läkemedel som hjälp och Läkemedel som belastning. Deltagarna i denna studie uppgav både positiva och negativa attityder till sin antipsykotiska medicin. Medicinen förbättrade sjukdomsbilden och ökade deras välbefinnande, men den var också förknippad med biverkningar och att man var bunden till att äta ett läkemedel. Inställningen till antipsykotiska läkemedel var dock övervägande positiv i denna studie. Deltagare som någon gång valt att sluta med medicinen uppgav att de gjort det på grund av glömska, biverkningar och en önskan om att få vara frisk. / Objective: The purpose of this study is to describe patients’ attitude to their medication and reasons why they may not be compliant to the medical treatment. Method: Data was collected using questionnaires and the data was analysed using qualitative content analysis. Results: Two themes and 13 categories emerged to describepatients’ attitude to their medication. The themes are Medication as an aid and Medication as a burden. There were nine categories describing the theme Medication as an aid and four to describe Medication as a burden. For reasons why patients did not adhere to medication treatment four categories emerged. Conclusion: The main results in this study are the two themes that emerged, Medication as an aid and Medication as a burden. The participants in this study expressed both positive and negative attitudes towards their antipsychotic medication. The medicine improved the clinical picture and their well-being, but it was also associated with side effects and that they were tied to a drug. Participants who stated that they had quit taking their medication one time or another had done so because of forgetfulness, side effects and a desire to be healthy.

IgA1 (immunoglobulin A1), a predominant immunoglobulin, is at the first defense line against microbial pathogens infection and invasion, to neutralize pathogenic antigens. Some bacterial pathogens, such as Neisseria meningitidis and Haemophilus influenzae, however, secrete site-specific IgA1 proteases to counteract with the human defense system. The protease is capable of cleaving at the hinge region of immunoglobulin A1 to destroy the structure and function of human IgA1, impairing the role of the immunoglobulin from the host defense. The protease has therefore been implicated as a putative virulence factor that contributes to bacterial colonization, but bacterial isolates from patients with invasive diseases contain both positive and negative IgA1 proteases. To clarify the role of IgA1 protease in bacterial infection, this project is designed to reveal the molecular mechanism of the protease in bacterial infection and colonization. To do this, iga genes encoding non-typable H. influenzae type 1, type 3 and Neisseria meningitidis type 3 IgA1 proteases were isolated, sequenced and then expressed in IgA1 protease-negative E. coli BL21 (DE3). The recombinant proteases have been purified to homogeneity using ion exchange chromatography. Comparison of the deduced amino acid sequences from non-typable H. influenzae IgA1 proteases with other published H. influenzae IgA1 protease revealed a high degree of homology. Sequence analysis indicates that both type 1 and type 3 non-typable H. influenzae IgA1 proteases lack £\-protein in comparison with the iga from N. meningitidis. The role of IgA1 protease in relation to deposition and invasion has also been evaluated in human lung carcinoma cell (A549) model. The results suggest that the IgA1 protease plays a role in the adherence of H. influenzae on epithelial cell surface though the best effectiveness varies upon different pathogenic bacterial strains at different concentrations.

Title: “Effects of Power Toothbrushing on Oral Inflammation, Caregiver Adherence, and Systemic Inflammation in a Sample of Nursing Home Residents” Objectives: The aims of this study were to investigate whether twice daily use of a rotating–oscillating power toothbrush (Oral-B Professional Care 1000 ™) in nursing home (NH) residents over a six-week period of time, as compared to usual care, would: (1) reduce oral inflammation; (2) increase caregiver adherence with oral care; and (3) reduce systemic inflammation. Methods: In this repeated measures single-blinded randomized controlled trial, 59 residents of one nursing home in Winnipeg, Canada, were randomized to receive either twice daily tooth brushing with a rotating-oscillating power toothbrush (PB) or usual care (UC) by caregivers. Consent was obtained from residents directly or from their proxies. Participants had some natural teeth; oral inflammation; non- aggressive behaviour; no communicable diseases; were non-smokers; and were non-comatose. Outcomes were recorded at baseline and 6 weeks, which included oral inflammation (MGI, Lobene), bleeding (PBI, Loesche), and Plaque (Turesky); systemic inflammation (hsC-reactive Protein, hsCRP) and caregiver adherence (self-reported twice daily toothbrushing). Caregivers completed a survey at study end regarding their oral care delivery preference. Group specific changes in oral outcomes and caregiver adherence were analyzed using a General Linear Model with a repeated measure. Changes in hsCRP were analyzed using non-parametric statistical tests, given challenges with the variance in these data. Survey results were analyzed using descriptive statistics. Results: Of the 59 original study participants, one withdrew and one died prior to initial data collection, and three individuals died before study completion. Oral health parameters improved significantly for the remaining 54 residents over time, (p< 0.0001) however equally for residents in each study group. HsCRP did not change significantly over time, overall or between residents in either study group. During all weeks combined, caregiver adherence was similar between study groups (40% for UC, 42% for PB). Caregiver adherence reduced significantly, from week 1 (48.6%) to week 6 (37.4%), with no significant differences between groups. Caregivers stated a preference for the power toothbrush (69%), and 78% reported it was easier to use than a regular brush. Conclusions: This study provides unique evidence about NH caregiver adherence to providing oral care for a sustained period of time. Despite this however, using as outcomes direct measures of inflammation, the oral health of NH residents improved significantly, albeit equally in both study groups. Given this disjoint in results, further studies are required to investigate improved methods for measuring caregiver adherence to the provision of daily oral care for NH residents.

This study evaluated the epidemiological relationship between diabetes and incident depression, as well as antidepressant medication utilization among indigent care patients diagnosed with diabetes. Medical data for 2,886 subjects receiving care in a public indigent care provider network were utilized for this study. Diagnoses of diabetes, depression, and other comorbid medical conditions were identified from the electronic medical record. Prescription claims data from the clinic pharmacy network were used to evaluate medication-taking behaviors. Clinical laboratory data were extracted, as available, from the electronic clinic records. After controlling for the influence of age, gender, race/ethnicity, marital status classification, and Charlson score, a diagnosis of diabetes was associated with a 42 percent reduction in odds of new-onset depression (p = 0.021). In the a priori analysis of factors associated with new-onset depression among diabetic patients, none of the risk factors evaluated were associated with incident depression at a statistically significant level. Post-hoc exploratory analyses revealed that female gender and White non-Hispanic race/ethnicity were associated with increased odds of a prevalent diagnosis of depression among diabetic patients. Patients with diabetes were more likely to be prescribed selective serotonin reuptake inhibitors (SSRIs) as their initial antidepressant medication compared to non-SSRIs. Diagnosis of diabetes was not associated with antidepressant switch, discontinuation, or 6-month antidepressant adherence; however, diagnosis of diabetes was associated with a higher level of 12-month antidepressant adherence (p = 0.024). Diagnosis of diabetes was also associated with a higher level of 3-month antidepressant persistence (p = 0.004), but not 12-month persistence. There were no statistically significant relationships observed between initial class of antidepressant medication prescribed and any of the medication-taking behaviors evaluated. For subjects with available data (n = 106), glycemic control was evaluated in terms of hemoglobin A1c. Increased antidepressant medication adherence was associated with higher hemoglobin A1c values during follow-up. Results suggest that prevalent diabetes is associated with a reduced risk of diagnosis of new-onset depression in indigent care patients. Further research is necessary to evaluate the effect that chronic comorbid medical conditions such as diabetes may have on antidepressant medication-taking behaviors, and the relationship between antidepressant exposure and glycemic control. / text