Research has shown a strong correlation between oral and systemic disease; therefore, there is an increased need for collaboration between dental and medical professionals. The purpose of this study was to examine the current opportunities that exist for interprofessional education (IPE) at Nova Southeastern University (NSU), the perceived need for IPE for dental and health science/nursing students, the perceived advantages of an IPE program, the features that should be included in an IPE program, and the perceived administrative and financial barriers to increased interprofessional activities. This study surveyed graduate faculty and staff from NSU’s College of Health Care Sciences, College of Dental Medicine, and College of Nursing regarding their views on IPE. The study used the Health Professions IPE Survey. Responses were factor analyzed, which revealed two dimensions: Positive IPE Perception and NSU IPE. There was an overwhelmingly positive response to IPE for dental, health science, and nursing students as evidenced by component one (Positive IPE Perception); however, there was a more negative perception about IPE at NSU as evidenced by component two (NSU IPE), possibly due to financial and administrative considerations. Factor analysis of this data legitimizes the need for future survey development. Future research should examine enablers for IPE by eliciting faculty feedback. Faculty reluctance to engage in IPE activities can be addressed by designing faculty development programs based on Adult Learning Theory (ALT) concepts. Future IPE program development will need to include adequate institutional support, funding, faculty development, and faculty involvement in planning.

The purpose of this qualitative dissertation study was to examine the lived experience and meaning making of challenges, benefits, satisfaction, and professional sustainability for the advanced practice provider in the burn surgery specialty service. The problem addressed was the knowledge gap resulting from a lack of literature describing aspects of the advanced practice provider role in the burn specialty. An interpretive phenomenological analysis, informed by the philosophy of Dr. Martin Heidegger, was undertaken. Participants were solicited from the American Burn Association Advanced Practice Provider (APP) special interest group site. The results provided a thick description of the lived experience of the Burn APP offering, illuminating commonalities and distinctions to promote role gratification and fulfillment leading to professional success and prolonged engagement. Keywords: advanced practice provider, nurse practitioner, physician assistant, interpretive phenomenology, hermeneutics.

Objective: The purpose of this study was to investigate pneumonia readmissions of older adults with dementia. Readmission rates and predictive factors of older adults with and without dementia were compared in this study. Subjects: A nationally representative sample of 389,198 discharge records, representing 370,003 patients, was extracted from the 2013 Nationwide Readmission Database. Methods: Descriptive statistics were utilized to describe the demographics of the sample population. Differences between groups were analyzed using chi-square or t test statistics as appropriate. A generalized linear model was used to examine predictive factors for pneumonia readmissions. Results: Older adults with dementia had a readmission rate of 23.52% and were 2.9 times more likely to experience a pneumonia readmission than older adults without dementia. Significant differences in characteristics were found when comparing (a) older adults with and without dementia, (b) older adults with and without dementia who were readmitted, and (c) older adults with dementia who were and were not readmitted. Factors that significantly interacted with dementia included (a) discharge disposition, (b) number of chronic conditions, (c) risk of mortality, and (d) median household income. Conclusions: Classifying older adults with dementia as a high-risk group for pneumonia readmissions is supported by the findings of this study. More over, dementia diagnoses significantly affect discharge disposition, there are characteristic differences among older adults with dementia, and comorbidities and risk of mortality significantly affect pneumonia readmissions. Development of strategies to reduce pneumonia readmissions that are tailored to individuals with dementia should be considered.

One of the numerous complications of obesity is infertility. Leptin has been shown to reverse infertility; however, exact mechanism is poorly understood. Recent evidence indicates Ecadherin/ β-catenin complex, which is a structural constituent of adherens junction, is expressed in the rat ovary during folliculogenesis. We hypothesized that systemic leptin modulates the expression of E-cadherin and β-catenin in dietary-induced obese infertile rats to reverse infertility. Female Sprague-Dawley rats were fed either regular chow diet (RCD) (n=6) or high fat diet (HFD) (n=14). Oestrus cycles were monitored daily until their cycles became irregular. 100 ug/ml of leptin was given intraperitoneally to HFD-fed rats (n=5) with irregular cycles. The control rats HFD (n=9) and RCD received saline. Leptin treatment restored regular estrous cycle and increased the expression of E-cadherin and β-catenin in all the 5 rats (HFD+Leptin). This could represent the mechanism by which leptin reverses infertility in obese infertile rats.

Pseudomonas aeruginosa, a Gram-negative bacillus, commonly infects immunocompromised individuals and uses a variety of virulence factors to persist in these hosts. The posttranscriptional regulator, RsmA, plays a role in the expression of many virulence factors in P. aeruginosa. RsmA up regulates virulence factors used in colonizing hosts. However, regulation of rsmA is not well elucidated. Transposon mutagenesis was performed on P. aeruginosa containing a transcriptional rsmA-lacZ fusion to answer this question. Mutants were screened via β-galactosidase assay and transposon insertions identified via arbitrary PCR. A probable MFS transporter, we named mtpX, was one significant transposon mutant identified. A ΔmtpX mutant containing the rsmA-lacZ transcriptional fusion was constructed to confirm our results. Further analysis of rsmA, looking at RNA and protein levels, revealed varying results in nonmucoid versus mucoid backgrounds. Phenotypic assays were performed to characterize this unknown transporter and develop a putative mechanism as to how MtpX affects rsmA expression.

<p>The serpin α-1 proteinase inhibitor (API) normally only impacts the coagulation cascade through its ability to inactivate factor XIa. However, the point mutation (Met to Arg) at position 358 results in a potent thrombin inhibitor, API M358R. This mutation also enhances this serpin’s ability to inhibit the anticoagulant protein, activated protein C (APC) and hence this property limits its therapeutic potential. As a result, various modifications to this protein have been engineered in order to enhance its specificity towards thrombin. Previously, the Heparin Cofactor II (HCII) N-terminal tail, HCII 1-75, which binds exosite 1 of thrombin, was tethered to the N-terminus of API M358R, creating HAPI M358R. Although this change did not alter anti-APC activity, it did augment the anti-thrombin activity of API M358R. In addition, further changes in the reactive center loop, the region that interacts with the thrombin active site, resulted in a significant reduction in APC activity while maintaining antithrombotic activity similar to HAPI M358R; this variant was termed HAPI RCL5.</p> <p>Preliminary experiments were performed with the C-terminal tridecapeptide of Hirudin Variant 3 (HV3) to determine its exosite 1 binding capacity compared to HCII 1-75. Three different variants of this peptide were tested: one with a hexahistidine tag (H₆HV3_54-66), another that also had a hexa-glycine C-terminal addition (H₆HV3_54-66G₆) and a third without either addition. All were found to bind exosite 1 with a greater affinity than HCII 1-75. Thus, the H₆HV3_54-66G₆peptide was fused to API M358R and API RCL5 in hopes of creating an inhibitor with heightened specificity compared to HAPI M358R and HAPI RCL5, respectively.</p> <p>HV3API M358R and HV3API RCL5 were expressed in a bacterial system and purified by nickel-chelate and ion exchange chromatography. Second order rate constants for the inhibition of thrombin and APC by the API variants and fusion proteins were determined. The K₂ values for α-thrombin inhibition ranged from 186 M^-1min^-1 to 22 M^-1min^-1 with an order of inhibitory potency observed as follows: HAPI M358R > HAPI RCL5 > HV3API M358R > HV3API RCL5>API RCL5 > API M358R.</p> <p>The ability of recombinant chimeric serpins to bind thrombin exosite 1 in a manner independent of RCL-thrombin active site interactions was also investigated through competitive inhibition of the binding of active site-inhibited thrombin to immobilized HCII 1-75. It was found that the order of exosite 1 binding affinity was HV3API RCL5 > H₆HV3_54-66G₆> HCII 1-75 > HAPI RCL5. Our results indicate that fusing the C-terminal tridecapeptide of HV3 to API variants enhanced their ability to inhibit thrombin, but to a lesser extent than fusing the N-terminal 75 residues of HCII. This finding likely reflects a requirement for the exosite 1-binding motif of the fusion protein to bind exosite 1 in a way that allows for subsequent optimal active site attack on the RCL by the serpin moiety of the fusion protein. In general, this work provides a second novel example of how the activity of a thrombin-inhibitory serpin can be enhanced by fusion to an exosite-1 binding motif.</p> / Master of Health Sciences (MSc)

<p>Introduction: Palliative care in Canada is an under-funded service for all Canadians, but for Aboriginal people in Canada, the level of access to such care is significantly lower. This study examined the system of palliative care delivery at Six Nations of the Grand River. The overall aim of the project was to identify ways on how the system of care could be improved.</p> <p>Methods: A qualitative case study approach was used. Interviews were held with Elders and family caregivers to identify the priorities in care delivery from their perspective. Focus groups were held with representatives from palliative care service provider agencies in an effort to identify the strengths and challenges within the system and to determine how palliative care services provided to the members of Six Nations could be improved.</p> <p>Findings: Themes identified in the interviews included: personable, caring care; culturally-competent care; open two-way communication; support for family caregivers; palliative home care should be available; meeting comfort needs of the person; and the need for a hospice in the community. The main theme identified in the focus groups with care providers included: relationship/rapport issues between provider organizations; within-program strengths and challenges; cultural considerations in care; and broader system factors that influence care.</p> <p>Discussion: Relationship/rapport issues were identified as a challenge, and it appeared that the focus groups provided an opportunity for communication between the organizations to improve. Identification of within-program challenges – and ways to address these challenges - may provide opportunities for each organization to improve how palliative care services are delivered at Six Nations. Identification of broader system factors that influence care may also benefit patients in need of palliative care.</p> / Master of Science (MSc)

Older adults, especially older women, produce less muscular power than young adults, due primarily to slower maximal contractile velocity. These decrements may lead to increased fall risk in older women and can be exacerbated by fatigue. Recently, a 32 min walking task (32MWT) was shown to elicit fatigue in older women. The purpose of this study was to determine whether knee extensor (KE) maximal velocity is related to dynamic stability (margin of stability, MoS) in young and older women pre- and post-32MWT. METHODS: Nine young (Y; 24.3+1.1years, mean±SE) and 17 older (O; 71.1±1.1years) healthy women completed 2 testing sessions on separate days: 1) electrically-stimulated and voluntary KE muscle characteristics were measured to determine rates of force development and relaxation (RFD, RFR) and half-relaxation times (T1/2) as well as peak isometric torque, power generated at 270 deg∙s-1, and maximal contractile velocity of the dominant leg; 2) MoS was measured using a forward fall test at 25% body weight; 10 baseline trials were performed. On both testing days, the 32MWT was performed following baseline measures. All variables of interest were then collected during 30 min of recovery. RESULTS: MoS was higher in young than older women (Y: 0.044±0.021m, O: -0.130±0.033m, p=0.001) and increased over the 10 baseline trials in both groups (p=0.01). Post-32MWT, both groups showed decreased isometric torque (Y: p=0.04, O: p-1 (Y: p=0.05, O: p=0.01), and unaltered MoS (Y: p=0.34, O: p=0.52) and maximal velocity (Y: p=0.22, O: p=0.54). Additionally, T1/2 was lower post-32MWT in older (p20.32) or post-32MWT (r20.22) in either group. CONCLUSIONS: The 32MWT elicited fatigue in some contractile variables, but improved or had no effect on others. Maximal KE contractile velocity was not associated with MoS in young or older women. Future studies are needed to determine other potential mechanisms of lower MoS in older than young women. The increase in MoS over 10 baseline trials should be considered by researchers when using the forward fall test to evaluate real-world fall risk.

Deformable image registration (DIR) is an essential tool in medical image processing. It provides a means to combine image datasets, allowing for intra-subject, inter-subject, multi-modality, and multi-instance analysis, as well as motion detection and compensation. One of the most popular DIR algorithms models the displacement vector field (DVF) as B-splines, a sum of piecewise polynomials with coefficients that enable local shape control. B-splines have many advantageous properties in the context of DIR, but they often struggle to adequately model steep local gradients and discontinuities. This dissertation addresses that limitation by proposing the replacement of conventional B-splines with a generalized formulation known as a Non-Uniform Rational B-Splines (NURBS). Beginning with the 1D fitting, heuristic rules are developed to determine the values of the additional free parameters introduced by NURBS. These rules are subsequently modified and extended to the 2D and 3D fitting of anonymized and publicly available patient DVFs. Based on the lessons learned from these increasingly complex test cases, a 2D DIR scheme is developed and tested on slices from a thoracic computed tomography (CT) scan. Finally, an automatic, non-uniform scheme is presented, and its registration performance is compared to the conventional uniform methods.

The purpose of this study is to explore differences in quality between Medicare Accountable Care Organizations (ACO) and Health Maintenance Organizations (HMO). Three outcomes measures reported by these plans use different methodologies but possess enough alignment to permit comparison: percent of diabetic patients with last HbA1c > 9.0%, colon cancer screening rate and ER visits per 1,000. These outcomes are the dependent variables (DV). A secondary purpose is to explore differences in quality based on the size of the beneficiary population served, using the same measures. As the Medicare program faces threats to its solvency in coming decades, with 10,000 baby boomers becoming eligible every day, and the ongoing national conversation about healthcare more generally, approaches to Value-Based Purchasing (VBP) are becoming more common. Organizations seeking to identify the types of VBP arrangements in which they should enter have precious little information on the comparative performance of VBP approaches relative to outcomes measures. Different structures create different incentives through the plan design and risk/reward. The convergence or dissipation of the plan incentives at the level of the provider, particularly in primary care, may be a source of variance. This study is retrospective, non-experimental, and uses publicly available data on the performance of Medicare ACO and HMO plans in calendar year 2015, for the identified measures. Using the Donabedian Structure-Process-Outcome framework, this study explores the impact of structure by type of plan and size of population served, relative to the outcomes. Race, average Hierarchical Condition Category (HCC) risk score and duration of operations are control variables. The analysis uses multiple hierarchical regression to better understand the relationship between the independent variables (IV) and DVs, after the impact of the control variables (CV). After controls, the IVs did offer some explanation of variation in outcomes. The ACO plans fared better on HbA1c control, while HMO plans had fewer ER visits per 1,000. No discernable difference existed between the HMO and ACO plans with regard to colon cancer screening rate. Serving larger populations led to better performance on all three measures. In general performance was worse on each measure in both models when the percent of not-White patients or average HCC risk score increased. A longer duration of operations also associated to better performance on the outcome measures.