Acute kidney injury (AKI) induced by renal ischaemia reperfusion injury (IRI) is characterised by renal failure, acute tubular necrosis (ATN), inflammation and microvascular congestion. Apoptotic cell administration reduces inflammation in experimental models of acute inflammation in the lung, joints and peritoneum. Preliminary data suggested that administration of 20x106 apoptotic thymocytes to mice 24-hours prior to renal IRI ameliorated renal function without affecting ATN 24-hours following IRI. This thesis attempted to validate these finding and explore underlying hypothetical mechanisms. These studies examined if functional protection was conferred by apoptotic cell modulation of (a) circulating IgM antibodies or (b) coagulation status leading to improved intrarenal microvascular blood flow. Pathogenic IgM antibodies bind ischaemic cardiac or skeletal muscle and the intestine leading to complement activation and worse injury. We examined IgM binding to human renal (HK-2) cells by flow cytometry and to ischaemic murine kidney tissue. H2O2 or Antimycin A treated HK-2 cells incubated with human serum (IgM source) exhibited no IgM binding. Medullary IgM deposition assessed by immunofluorescence was minimal following IRI. We also assessed IgM deposition by immunohistochemistry following hepatic IRI and discovered dramatic deposition. These data suggest that IgM antibodies exhibit differential binding to injured tissues and are not directly involved in renal IRI, but may have a role in hepatic IRI. To support our second hypothesis we studied apoptotic cell modulation of coagulation. A thrombin generation assay revealed that early apoptotic cell-treated mice exhibited delayed thrombin generation. Furthermore, in vitro studies confirmed direct apoptotic cell-platelet binding. To replicate apoptotic cell derived functional protection Balb/c mice underwent 20, 24 or 25-minutes of ischaemia to induce mild, moderate or severe kidney dysfunction. Renal function and injury was determined 24-hours following IRI by plasma creatinine measurement and ATN scoring. Unexpectedly, intravenous pretreatment of mice with apoptotic thymocytes conferred no protection. Indeed, apoptotic thymocytes further impaired renal function depending upon injury severity. Impairment of renal function was not secondary to increased microvascular congestion, inferred by fibrin and platelet deposition, neither increased ATN nor inflammation, assessed by neutrophil infiltration. These data indicate that apoptotic cell administration does not protect from subsequent renal IRI and that apoptotic cells are thus not inherently anti-inflammatory in all models of acute inflammation. Unable to replicate apoptotic cell derived functional protection we explored the binding of IgM antibodies to apoptotic cells which acts to facilitate dead cell clearance. We characterised IgM binding to non-apoptotic and apoptotic murine thymocytes and human Jurkat cells using flow cytometry, confocal and electron microscopy. We demonstrated specific IgM binding to a subset of late apoptotic cells. Electron microscopy indicated that IgM+ apoptotic cells exhibited marked plasma membrane disruption, suggesting that access to intracellular epitopes was required for IgM binding. Binding of IgM to permeabilised non-apoptotic and apoptotic cells suggested that IgM bound epitopes are ‘apoptosis independent’ such that IgM may bind any cell with profound plasma membrane disruption. Interestingly, permeabilised erythrocytes exhibited significant IgM binding thus supporting the importance of cell membrane epitopes. These data suggest that IgM may recognise and tag damaged nucleated cells or erythrocytes that exhibit significant cell membrane disruption.

Class of 2014 Abstract / Specific Aims: To determine the cost of treatment of oral and intravenous n-acetylcysteine (IV NAC) in acute acetaminophen (APAP) toxicity using the length of treatment and length of hospital stay. Methods: A retrospective chart review of Arizona Poison and Drug Information Center electronic records from 2009-2012 and January-June 2013 were evaluated. The following information was collected: age, sex, use oral or intravenous NAC, length of treatment, length of hospital stay (intensive care unit (ICU) and non-ICU) and use of antiemetic. The mean length of stay (MLOS) was calculated for each group as well as the cost of IV and oral NAC. These means were then compared using t-test for independent groups to test for significance. The average total cost of IV and oral NAC treatment was calculated by using monetary values from primary literature. A sensitivity analysis was performed to test the possible effects of an increase or decrease of the final costs by 5 to 10%. Main Results: Patients (≥18 yrs) being treated with IV or oral NAC for acute APAP toxicity (≤8 hours prior to ingestion) were included in this study. A total of 47 patients met the inclusion criteria. Length of hospital stay was shorter in patients receiving IV NAC (42.5% 24-24hr; 37.5% 48-72hr) compared to patients receiving oral NAC (28.6% 48-72hr, 71.4% >72hrs; p<0.001). Total cost of ICU/non-ICU stay in patients receiving IV NAC ($8,720/$3010) was less than patients receiving oral NAC ($12,321/$4703); however, cost of IV NAC-extended (37hrs) in ICU/non-ICU ($13,153/$5535) was greater than oral NAC. The sensitivity analysis performed demonstrated that an increase or a decrease by 5 to 10% in change of cost does not affect our final conclusion. Conclusion: The cost of treatment of IV NAC is lower due to shorter LOS of patients treated with IV NAC (p<0.001). However, when an extended course of treatment is medically necessary for patients on IV NAC then the cost of treatment with IV NAC exceeds the cost of treatment with oral NAC.

Class of 2014 Abstract / Specific Aims: Clostridium difficile associated diarrhea (CDAD) frequently occurs in patients exposed to broad-spectrum antibiotics which can result in a life threatening illness. The role of probiotics in the prevention of CDAD is not well established and many medical centers across the United States are opting to remove probiotics from common CDAD prophylaxis. We aim to evaluate the efficacy of lactobacillus probiotics during the use of broad-spectrum antibiotic therapy in the acute care setting for the prophylaxis of CDAD at Kindred Hospital. Methods: We performed a single center, retrospective data analysis efficacy trial of inpatients receiving beta-lactam, fluoroquinolone or clindamycin antibiotics from the Kindred Hospital database. Two study groups will be compared: patients who received lactobacillus probiotic therapy based on protocol since May 2011 and patients who did not receive probiotic therapy. The presence or absence of CDAD will be used to evaluate probiotic efficacy. Main Results: Of the ### patients screened, ## were assigned to the treatment group and ## were assigned to the non-treatment group, a total of ## patients were analyzed for the primary endpoint. CDAD occurred in ## patients (xx%) receiving probiotic therapy while CDAD occurred in ## patients (xx%) not receiving probiotic therapy (relative risk [RR]: xx.x; p=0.xxx). Conclusion: [Anticipated] We identified no statistically significant evidence that the use of lactobacillus was effective in the prevention of CDAD. Further knowledge of the pathophysiology of CDAD and proper antibiotic use is needed for future studies.

Magister Artium (Child and Family Studies) - MA(CFS) / Introduction: Malnutrition is the immediate result of inadequate dietary intake, the presence of disease or the interaction between these two factors. It is a complicated problem, an outcome of several etiologies. SAM is one of the leading causes of morbidity and mortality among children under the age of five in developing countries. Although studies in Botswana show some improvement in child malnutrition since the 1980s, severe acute malnutrition still remains a cause for concern in many parts of the country. There is little information on undernourishment situation of children under the age of five years in the urban areas of the country. Aim: The purpose of this study was to determine the risk factors to severe acute malnutrition among children under the age of five years in Francistown, Botswana. The UNICEF conceptual framework was used as a guide in assessing and analysing the causes of the nutrition problem in children and assisted in the identification of appropriate solutions. Methods: The study was conducted on cases who had been admitted and referred at any time between March and July 2015. A quantitative research methodology was used to conduct the study. A case-control study design was utilised. Random selection of cases and controls was done on a ratio of 1:2 case per control. Cases included children under the age of five years admitted to Nyangabgwe Referral Hospital and those referred to the Nutritional Rehabilitation Centre within the hospital in Francistown-Botswana with a diagnosis of severe acute malnutrition. Controls were children of the same age, gender and attending the same Child welfare clinic as the case and with good nutritional status. Data was collected through face-to-face standardised interviews with care-givers. Results: Data collection was done using a combination of a review of records (child welfare clinic registers, and child welfare clinic cards) and structured questionnaires. 52 cases and 104 controls were selected with the primary or secondary care-giver as the respondent. (N=156). Data was collected using a self-developed structured questionnaire and the review of documents. Of all the cases 36.5% (n=19) were diagnosed with MAM, 46.2% (n=24) with SAM, 1.9% (n=1) with moderate PEM and 7.7% (n=4) each for PEM and Severe PEM. All the cases had presented with clinical signs and symptoms of severe acute malnutrition and/or the weight-for-height Z-score of ≤ -3 SD. Following placement of the data in regression models, the factors that were found to be significantly associated with child malnutrition were low birth weight (AOR = 0.437; 95% CI = 0.155-1.231) , exclusive breastfeeding (AOR = 2.741; 95% CI = 0.955-7.866), child illness (AOR = 0.383; 95% CI = 0.137-1.075), growth chart status (AOR =7.680; 95% CI = 1.631-36.157), level of care-giver’s education (AOR = 0.953; 95% CI = 0.277-3.280), breadwinner's work status (AOR = 1.579; 95% CI = 0.293-8.511), mother’s HIV status (AOR = 0.777; 95% CI = 0.279-2.165), alcohol consumption (AOR = 0.127; 95% CI = 0.044-0.369), household having more than one child under the age of five (AOR = 0.244; 95% CI = 0.087-0.682), household food availability (AOR = 0.823; 95% CI = 0.058-11.712), living in a brick type of house (AOR = 13.649; 95% CI = 3.736-49.858), owning a tap (AOR = 1.269; 95% CI = 0.277-5.809) and refuse removed by the relevant authority (AOR= 2.095; 95% CI = 0.353-12.445) were all statistically significantly associated with severe acute malnutrition (p < 0.05). Therefore, all these variables were included in the binary stepwise regression where living in a mud house type was the most significant factor and not being breastfed for at least three months was the least significant. Conclusion: The findings of this study suggested that immediate determinants to SAM were; child born with a low birth weight, appetite and child illness. Underlying contributing factors were; the child not exclusively breastfed for at least three months, growth chart not up to date, care-givers education level, employment status, alcohol consumption, household food availability, type of housing, owning a tap and number of children under the age of five year. Therefore, increasing household food security and strengthening educational interventions for women could contribute to a reduction in the prevalence of SAM in Francistown, Botswana.

Class of 2005 Abstract / Objectives: To develop a decision analytic model to compare the clinical and economic outcomes of enteral nutrition (EN) and total parenteral nutritional (TPN) support in acute pancreatitis patients. Methods: All randomized clinical trials comparing EN and TPN in acute pancreatitis patients published in the medical and pharmacy literature were identified. Six trials were identified by searching MEDLINE, Web of Science, Cochrane Controlled Trials Register, International Pharmaceutical Abstracts, HealthStar, Cumulative Index to Nursing & Allied Health Literature, and citation review of applicable literature. The costs used for the decision tree were from the perspective of a hospital. A literature based decision tree was formed based from these costs and the probabilities of events from the six identified clinical trials. The TreeAge Pro computer program (TreeAge Software, Inc.; Williamstown, MA) was used to conduct the cost effectiveness analysis. Therapeutic success was considered, for the purposes of the trial, as having no complications. Results: EN was associated with a lower risk of infections, a reduced length of hospital stay, and fewer surgical interventions. There was no statistical difference in the risk of mortality, adult respiratory distress syndrome or multiple organ failure between groups treated with EN or TPN. The results found that EN dominated TPN by being both less costly and more effective. The average costs for EN and TPN were $46,345 and $73,878, respectively. The success rates were 0.652 and 0.358 for EN and TPN, respectively. Conclusion: Enteral nutrition was the dominant route of administration for nutritional support, when compared to total parenteral nutrition both clinically and economically for acute pancreatitis patients.

Although the impact of cannabinoids (CBs) on anxiety has been thoroughly studied, current research paradigms fail to incorporate acute stressors. The present study investigated the synthetic CB HU-210’s anxiolytic potential in an acute stress CD1 male mouse model, where the animals were subject to a 10-minute Forced Swimming (FS) test between treatment and behavioral tests. Surprisingly, HU-210 did not show anxiolytic action in the Open Field (OFT) and Elevated-Plus Maze (EPM) stressed mice as previously reported in the naïve model literature. The combination of acute stress and high HU-210 doses produced severe locomotor impairments in ambulatory movement that were not previously observed in unstressed mice. It is hypothesized that this anxiogenic phenotype results from the summation of exogenous CB treatment and stress-induced endocannabinoid (eCB) release. Subsequently, the impact of the eCB signaling on anxiety behaviors was examined. Systemic administration of KML29, the selective inhibitor of 2-AG degradative enzyme, returned stress-induced anxiety-like behaviors to baseline levels, without significantly affecting locomotion. KML29’s anxiolyticism was abolished when combined with the cannabinoid receptor antagonist AM281, implying this is a CB receptor-mediated process. A GABAA receptor agonist muscimol was co-administered with KML29 in order to pharmacologically investigate the role of GABAergic neurotransmission in this anxiolytic phenomenon, but it did not alter KML29’s effects. Collectively, these findings suggest that exogenous CBs and acute stress act synergistically in an anxiogenic manner, but that enhanced 2-AG signaling in response to stress demonstrates anxiolytic potential.

Acute kidney injury (AKI), characterized by an abrupt loss of kidney function with retention of nitrogenous waste products, is common in the months to years following kidney transplantation and is associated with an increased risk of transplant failure (graft loss). Kidney transplant patients who experience graft loss and return to dialysis have an increased mortality risk and a lower quality of life. Research involving kidney transplant patients can prove challenging, as they are relatively small in number. To increase statistical power, researchers may utilize administrative databases. However, these databases are not designed primarily for research, and knowledge of their limitations is needed, as significant bias can occur. When using administrative databases to study AKI in kidney transplantation, the method used to define AKI should be carefully considered. The power of a study may be greatly increased if AKI can be accurately defined using administrative diagnostic codes because data on AKI will be universally available for all patients in the database. However, the methods by which diagnostic codes are assigned to a patient allow for error to be introduced. We confirmed that, when compared to the gold standard definition for AKI of a rise in serum creatinine, the diagnostic code for AKI has low sensitivity but high specificity in the kidney transplant population (the best performing coding algorithm had a sensitivity of 42.9% (95% CI 29.7, 56.8) and specificity of 89.3% (95% CI 86.2, 91.8) (Chapter 3). We therefore determined that for the study outlined in Chapter 4, defining AKI using diagnostic codes would significantly under-­capture AKI and misclassify patients. We decided to define AKI using only serum creatinine criteria even though this would limit our sample size (creatinine data was only available for a subset of patients in the administrative databases). In Chapter 4, we derived an index score to predict the risk of graft loss in kidney transplant patients following an admission to hospital with AKI. The index includes six readily available, objective clinical variables that increased the risk of graft loss: increasing age, increased severity of AKI (as defined by the AKIN staging system), failure to recover from AKI, lower baseline estimated glomerular filtration rate, increased time from kidney transplant to AKI admission, and deceased donor. The derived index requires validation in order to assess its utility in the clinical realm.

Acute myeloid leukemia (AML) often remains refractory to current chemotherapy and transplantation approaches despite many advances in our understanding of mechanisms in leukemogenesis. The bone marrow “niche” or microenvironment, however, may be permissive to leukemia development and studying interactions between the microenvironment and leukemia cells may provide new insight for therapeutic advances. Mesenchymal stem cells (MSCs) are central to the development and maintenance of the bone marrow niche and have been shown to have important functional alterations derived from patients with different hematological disorders. The extent to which MSCs derived from AML patients are altered remains unclear. The aim of this study was to detect changes occurring in MSCs obtained from human bone marrow in patients with AML by comparing their function and gene expression pattern with normal age-matched controls. MSCs expanded from patients diagnosed with acute leukemia were observed to have heterogeneous morphological characteristics compared to the healthy controls. Immunohistochemistry and flow data confirmed the typical cell surface immunophenotype of CD90+ CD105+ CD73+ CD34- CD45-, although MSCs from two patients with AML revealed reduced surface expression of CD105 and CD90 antigens respectively. Differentiation assays demonstrated the potential of MSCs from AML patients and healthy donors to differentiate into bone, fat and cartilage. However, the ability of MSCs from AML samples to support hematopoietic function of CD34+ progenitors was found to be impaired while the key hematopoietic genes were found to be differentially expressed on AML-MSCs compared to nMSCs. These studies indicate that there exist differences in the biologic profile of MSCs from AML patients compared to MSCs derived from healthy donors. The results described in the thesis provide a formulation for additional studies that may allow us to identify new targets for improved treatment of AML.

The objective of the dissertation is analysis of costs that are connected with acute myocardial infarction in the Znojmo Hospital. It is about the bill of costs of this diagnosis with the use of analysis "Cost of Illness". Cost of Illness is one of many kinds of analysis examining the costs of illnesses. At work, I have tried to capture all relevant costs of this diagnosis, especially the cost of diagnosis, therapy and hospitalization of patients with the diagnosis of acute myocardial infarction.

The spectrum of acute pancreatitis (AP) affects between 4.9 and 73.4 patients out of 100,000 worldwide annually (Tenner, Baillie, DeWitt, & Vege, 2013). AP uses the Atlanta classification system to establish a diagnosis of mild, moderate, or severe. The American College of Gastroenterology (ACG) has established comprehensive clinical practice guidelines (CPG) for the management of AP, the most recent version published in 2013 (Tenner et al., 2013). There have been similar CPGs published internationally that integrate current evidence-based research into recommendations for practice. These guidelines along with the ACG's guidelines recommend initiating a diet for mild acute pancreatitis patients due to research findings of improved patient outcomes (i.e. reduced length of hospital stay, decreased rate of infections, and reduced mortality) (Horibe et al., 2015; Lariño-Noia et al., 2014). There is an international awareness of the need for increased CPG nutrition recommendation compliance in the practice setting as many studies have found providers prefer to keep patients nil per os (NPO) and do not adhere to CPGs (Andersson, Andrén-Sandberg, Nilsson, & Andersson, 2012; Greenberg et al., 2016; Sun et al., 2013). The purpose of this doctor of nursing practice (DNP) project is to assess providers' current nutrition therapy practice and knowledge of the ACG’s CPG nutrition recommendations for mild AP patients. The researcher conducted the assessment with a hospitalist practice at Banner University Medical Center in Phoenix, Arizona. The results of the project contribute to the current body of research on national adherence to CPGs for AP and act as a needs assessment for future projects where a nutrition protocol order set may be established. The investigation of nutrition therapy for AP patients seeks to improve and standardize the care this patient population receives while in the acute care setting.