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<p>Sepsis is a major cause of morbidity and mortality in the United States, and Staphylococcus aureus (S. aureus) is the bacteria most commonly cultured from septic patients. In severe sepsis, the relationship between the systemic inflammatory response and the resulting mitochondrial and metabolic dysfunction is not fully understood, especially with respect to the mechanisms of mitochondrial damage resolution. The process of mitochondrial biogenesis, which leads to the restoration of metabolic and anti-oxidative functions in damaged or stressed cells and tissues, is pro-survival and is a critical protective response in sepsis. Mitochondrial biogenesis requires the coordinated expression of multiple regulatory proteins, including the PPARgamma-coactivator (PGC) family of proteins. Previous work in sepsis has focused on mitochondrial biogenesis in response to late signals of mitochondrial damage; however, for acute sepsis, we have hypothesized a direct and early link between the innate immune response and the transcriptional activation of mitochondrial biogenesis. Since the Toll-like receptors (TLRs) are a major part of the innate immune response, we hypothesized that they could activate mitochondrial biogenesis in bacterial sepsis. Earlier work showed that TLR4 (which responds to components of Gram-negative bacteria) was necessary for mitochondrial biogenesis induction in response to heat-killed E. coli challenge. For this work, the objective was to investigate whether signaling by TLR2 (which responds to components of Gram-positive bacteria) would activate mitochondrial biogenesis in response to S. aureus sepsis in mice. The sepsis model was initially characterized in wild-type (WT) mice by PCR analysis of hepatic RNA, in which the up-regulation of several regulatory proteins for mitochondrial biogenesis, including all three PGC family members, was observed. In contrast, in both TLR2-/- and TLR4-/- mice, the mitochondrial biogenesis response was deficient and delayed. In addition, PGC-1alpha and PGC-1beta were differentially regulated in WT, TLR2-/-, and TLR4-/- mice. To identify the mechanisms involved in this induction pattern, the known TLR signaling pathways were systematically probed for activation using several strains of genetic knockout mice. These data demonstrated that the differential regulation of the PGC family is independent of the MyD88 adapter protein and is caused in part by IRF7 signaling. IRF7 is a pro-inflammatory transcription factor that is normally involved in the interferon response; in this case, IRF7 was found to be necessary but not sufficient for PGC-1alpha/beta induction. In addition, a second level of regulation was identified in the microRNA mmu-mir-202-3p, which is inversely correlated with the expression of PGC-1alpha and PGC-1beta mRNA in WT, TLR2-/-, and TLR4-/- mice and was shown to functionally decrease PGC-1alpha mRNA. If these observations are confirmed in humans, IRF7 and mir-202-3p may be potential therapeutic targets for the up-regulation of PGC-1alpha/beta levels in the clinical setting of sepsis and impaired mitochondrial biogenesis.</p> / Dissertation

<p>Although various proof-of-concept studies have demonstrated the eventual potential of a multifunctional SERS-active metallic nanostructures for biological applications such as single cell analysis/measurement and drug delivery, the actual development and testing of such a system in vitro has remained challenging. One key point at which many potentially useful biomethods encounter difficulty lies in the translation of early proof-of-concept experiments in a clean, aqueous solution to complex, crowded, biologically-active environments such as the interior of living cells. The research hypotheses for this work state that multifunctional nanoconstructs can be fabricated and used effectively in conjunction with surface-enhanced Raman scattering (SERS) spectroscopy and other photonics-based methods to make intracellular measurements in and deliver treatment to single cells. The results of experimental work address the specific research aims, to 1) establish temporal and spatial parameters of nanoprobe uptake and modulation, 2) demonstrate targeting of functionalized nanoparticles to the cytoplasm and nucleus of single cells, 3) deliver to and activate drug treatment in cells using a multifunctional nanosystem, and 4) make intracellular measurements in normal and disease cells using external nanoprobes,</p><p>Raman spectroscopy and two-dimensional Raman imaging were used to identify and locate labeled silver nanoparticles in single cells using SERS detection. To study the efficiency of cellular uptake, silver nanoparticles were functionalized with three differently charged SERS/Raman labels and co-incubated with J774 mouse macrophage cell cultures for internalization via normal cellular processes. The surface charge on the nanoparticles was observed to modulate uptake efficiency, demonstrating a dual function of the surface modifications as tracking labels and as modulators of cell uptake. </p><p>To demonstrate delivery of functionalized nanoparticles to specific locations within the cell, silver nanoparticles were co-functionalized with the HIV-1 TAT (49-57) peptide for cell-penetrating and nuclear-targeting ability and p-mercaptobenzoic acid (pMBA) molecules as a surface-enhanced Raman scattering (SERS) label for tracking and imaging. Two-dimensional SERS mapping was used to track the spatial and temporal progress of nanoparticle uptake in PC-3 human prostate cells and to characterize localization at various time points, demonstrating the potential for an intracellularly-targeted multiplexed nanosystem. Silver nanoparticles co-functionalized with the TAT peptide showed greatly enhanced cellular uptake and nuclear localization as compared with the control nanoparticles lacking the targeting moiety. </p><p>The efficacy of targeted nanoparticles as a drug delivery vehicle was demonstrated with development and testing of an anti-cancer treatment in which novel scintillating nanoparticles functionalized with HIV-1 TAT (49-57) for cell-penetrating and nuclear-targeting ability were loaded with tethered psoralen molecules as cargo. The experiments were designed to investigate a nanodrug system consisting of psoralen tethered to a nuclear targeting peptide anchored to UVA-emitting, X-ray luminescent yttrium oxide nanoparticles. Absorption of the emitted UVA photons by nanoparticle-tethered psoralen has the potential to cross-link adenine and thymine residues in DNA located in the nucleus. Such cross-linking by free psoralen following activation with UVA light has previously been shown to cause apoptosis in vitro and an immunogenic response in vivo. Experimental results using the PC-3 human prostate cancer cell line demonstrate that X-ray excitation of these psoralen-functionalized Y2O3 nanoscintillators yields concentration-dependent reductions in cell number density when compared to control cultures containing psoralen-free Y2O3 nanoscintillators. </p><p>The development and demonstration of a small molecule-sensitive SERS-active fiber-optic nanoprobe suitable for intracellular bioanalysis was demonstrated using pH measurements in single living human cells. The proof-of-concept for the SERS-based fiber-optic nanoprobes was illustrated by measurements of intracellular pH in MCF-7 human breast cancer, HMEC-15/hTERT immortalized normal human mammary epithelial, and PC-3 human prostate cancer cells. Clinical relevance was demonstrated by pH measurements in patient biopsy cell samples. The results indicated that that fiber-optic nanoprobe insertion and interrogation provide a sensitive and selective means to monitor biologically relevant small molecules at the single cell level.</p> / Dissertation

Thesis (Ph.D.)--Lehigh University, 2009. / Adviser: Shin-Yi Chou.

Two of the major infectious complications of cardiac surgery are pneumonia and surgical site infections of the sternum and graft harvest site. These postoperative adverse events significantly increase patient morbidity, mortality and cost associated with coronary artery bypass graft operations. Pre-existing diabetes mellitus is commonly considered one of the primary risk factors for development of these major infections. However, most of the previous cardiac surgery risk factor studies have not considered the role perioperative stress hyperglycemia may play in initiating these complications. The primary hypothesis of this retrospective descriptive cohort study was that perioperative stress hyperglycemia (defined as either perioperative serum glucose threshold ≥250 mg/dL or perioperative serum glucose change ≥50 mg/dL) is an independent risk factor for the composite outcome of postoperative infections, including pneumonia and surgical site infections of the sternum and harvest site. The relationship of stress hyperglycemia to the individual infection outcomes was also examined. The secondary study hypothesis was that stress hyperglycemia increases resource utilization as excess days of care. The setting was a tertiary care federal medical facility in the southwestern United States, and the study cohort involved 1285 male military veterans.

Almost everyone agrees that doctors' handwriting is not the only indecipherable and alienating communication practice in healthcare. The oral communication between doctors and patients is equally problematic. Few scholars in the field of rhetoric have attempted to analyze why and how these discursive practices have come about. Equally absent from the medical and rhetorical fields are alternative models that construct a better discourse between doctors and patients. My dissertation, Look Who's Not Talking: Recovering the Patient's Voice in the Clinique, not only examines how doctors talk to patients, but also begins an effort to change present discursive practices in healthcare. Michel Foucault began an academic conversation in The Birth of the Clinic and in Power/Knowledge that deconstructed certain institutionalized discourses. While his study went a long way toward analyzing the discourse of medicine, his language and theories have not moved into medical journals or patient rooms. My dissertation acts as a bridge between "high" rhetorical theory and the "marketplace" of medicine (an unfortunately apt metaphor for healthcare in this country). Foucault supplies one of the lenses I use to look at the discourse. Other lenses include those of Kenneth Burke and Lloyd Bitzer. One underlying assumption in the dissertation is that practices are more easily changed once they have been analyzed. I place the analysis within history and within current contexts. This strategy enacts a model opposing the usual acontextualized, ahistoric doctor/patient discourse. Both chapters 3 and 4 look at how doctor/patient discourse was constructed in Europe and America. In addition to making a contribution to the medical field, this dissertation breaks new ground within rhetoric and lays the basis for further explorations. Because of my extensive work in the healthcare field as cardio-pulmonary technician and special procedures nurse, I was able to draw on my own experience to use as examples of the particular problems within the discourse I isolate and propose alternatives to. The fifth chapter features a two-semester course I designed for first-year medical students. This course is rhetorically based and teaches doctors-to-be why the language they use with patients is important and how to effectively address patients.

The healthcare marketplace is rapidly changing how we finance medical education, how we train physicians, and the interrelationships within an academic institution. This case study examined the historical development of the Department of Family and Community Medicine and the impact of growing financial constraints on the training of medical students and residents, the clinical practice, faculty workload, and departmental organization. The theoretical frameworks of resource dependence, culture, and professionalization theory were employed to understand how different groups within the context of an academic health center co-exist to meet the core missions of teaching, research, and service. Data collection was conducted over a two-year period and utilized the triangulation of interviews, document analysis, and participant observation methods. The study's findings indicated that the Department of Family and Community Medicine continually faced the challenge of being a primary care department in an academic medical culture that placed more emphasis on specialized care and specialty departments. Over a period of time, the Department went from a profit-center to a cost-center where faculty's ability to teach and conduct research revolved around the success or failure of the clinical care enterprise. Faculty productivity was increasingly emphasized and its definition was dependent on the healthcare marketplace and the availability of resources. The competitive health care market encroached on faculty workload and manifested itself in part through the loss of a major patient care contract, the receivership of the Department, and the splitting of the Department and its resources. During the period of time analyzed, the department was in a no-win situation because the success of the department was determined by more powerful coalitions that had decision making ability and controlled the necessary resources. The department's power lay in the provision of teaching resources and its alignment with the state's goal of training primary care physicians to work in rural and underserved communities. Conflict arose as departments tried to defend and protect their declining resources and jurisdictions. The study findings emphasized the importance of understanding departmental jurisdictions and how resource allocation decisions are made in the context of the academic setting and culture.

Multidrug resistance protein-1 (mdr1) is a well characterized membrane protein, expressed in a variety of cell types. In cancer cells, an overexpression of mdr1 has the function of conferring drug-resistance. The exact physiological function of mdr1 constitutively expressed in normal cells still remains unclear. A goal of this work was to determine if there is an increase in expression of mdr1, above constitutive levels, on CD4+ and CD8+ T-lymphocytes, following cardiac transplantation. The expression of mdr1 was correlated with episodes of acute cardiac rejection in order to determine if mdr1 has the functional ability to confer immunosuppressive drug resistance. Drug resistant CD4+ and CD8+ T-lymphocytes could explain episodes of acute allograft rejection observed in a number of immunosuppressed patients. Immunochemical techniques measuring mdr1 were performed on endomyocardial biopsy specimens and peripheral blood mononuclear cells (PBMCs) isolated from cardiac transplant patients. Functional mdr1 assays and flow cytometry were performed on PBMCs isolated from cardiac transplant patients prior to transplantation and at longitudinal time points post-transplantation. The expression and function of mdr1 was correlated to the histological diagnosis of acute rejection. Immunochemical analysis of endomyocardial biopsy samples showed mdr1 expression localized on the plasma membrane of graft infiltrating mononuclear cells. Immunochemical analysis of PBMC samples showed a constitutive mdr1 expression on normal volunteer PBMCs and a increased expression of mdr1 on cardiac transplant PBMCs during episodes of acute rejection. Doxorubicin cytotoxicity assays showed an increased drug resistance profile in transplant patients compared to normal individuals. An mdr1 efflux assay demonstrated an increase efflux function in PBMCs during episodes of acute rejection. Flow cytometric analysis showed significant increases in the intensity of mdr1 expression on CD4+ and CD8+ T-lymphocytes in transplant patients compared to normal individuals. Flow cytometry also confirmed a significant increase in both the number of CD4+ and CD8+ T-lymphocytes expressing mdr1 and the intensity of mdr1 on these subtypes for those patients that had an episode of acute rejection compared to those transplant patients with no episodes of acute rejection. Thus, this study demonstrates an overexpression of a functionally active multidrug resistant protein-1 during episodes of acute rejection.

The Remote Consultation and Diagnosis (RCD) in Global Picture Archiving and Communication System (Global PACS) is a unique suite of multimedia telemedicine applications developed at the University of Arizona. The applications support real-time patients' data, image files, audio and video consultation and diagnosis annotation exchanges. The RCD enables joint collaboration between pathologists, radiologists, or physicians while they are at distant geographical locations. This project provides four RCD scenarios, i.e., Case Review, Case Acquire, Store and Forward Analysis, as well as Interactive Diagnosis and Consultation. The RCD Global PACS environment consists of heterogeneous, autonomous, and legacy resources. The Common Object Request Broker Architecture (CORBA), Java Database Connectivity (JDBC), and Java language provide the capability to combine the RCD Global PACS resources into an integrated, interoperable, and scalable system. The underneath technology, including IDL, ORB, Event Service, IIOP, JDBC/ODBC, legacy system wrapping and Java implementation are explored. This distributed collaborative CORBA/JDBC based framework will challenge the advanced, medical information management requirements. It also makes the RCD Global PACS both hardware and software technologically independent. As our research and development extend, we will continue to incorporate the latest advances in computer technology. RCD Global PACS is not another new tool in telemedicine, but rather a new paradigm for the delivery of health services that requires process reengineering, cultural changes, as well as organizational changes. It is a whole new way of practicing in telemedicine. We ensure that the RCD Global PACS project has long-term, comprehensive solutions for today and tomorrow's healthcare needs.

The primary purpose of this study was to evaluate the effectiveness and the costs of a community based nursing intervention for Hispanic women undergoing treatment for breast cancer. The purposes were: (1) Determine if the self-help nursing intervention resulted in significant improvements in the outcome variables of self-care, symptom burden, functional status, and productivity; and (2) describe the costs of each component of the SHIP II project; and (3) describe the average costs per woman participating in SHIP II; and (4) estimate the cost-effectiveness of SHIP II. Data from the Self-Help Intervention Project (SHIP II), an experimental, randomized block, repeated measures design study of women undergoing treatment of breast cancer were analyzed using growth curve analysis and path analysis in EQS. Results revealed that a woman's initial status upon entering the project subsequently affected her outcomes of self-care, symptom burden, productivity, and functional status. The nursing intervention did not affect the outcomes of the women in this sample. An economic analysis revealed that the most expensive program component was that of personnel salaries and represented 91% of the total intervention costs. Recommendations include: (1) exploration of the functional relationships between the nursing intervention and the outcome variables; and (2) exploration of mediating and moderating variables; and (3) further instrumentation work on the outcome variables.