High mobility group box 1 (HMGB-1) protein is a non-histone chromosomal protein. As a DNA binding protein, HMGB-1 is involved in the maintenance of nucleosome structure, regulation of gene transcription and it is active in DNA recombination and repair. It has been known that HMGB-1 is a late mediator of endotoxemia and sepsis. HMGB-1 is released from activated macrophages, induces the release of other proinflammatory mediators, and mediates cell death when overexpressed. We speculated that the course of sepsis maybe different without the involvement of HMGB-1. The aims of this study are to investigate the role of HMGB-1 in mediating sepsis and to observe the effects by using RNAi to affect the production of HMGB-1. Lipopolysaccharide (LPS) was used to simulate sepsis in culture as well as stimulate the release of HMGB-1 from RAW 264.7 cells. Levels of HMGB-1 in the culture medium were subsequently measured by Western blot. Other proinflammatory cytokines (TNF-£\, IL-6 and TGF-£]) were measured by ELISA. HMGB-1 could not be detected in the culture medium in the absence of LPS stimuli, but after 0.5 £gg/ml LPS treatment HMGB-1 release could be detected. HMGB-1 the amount of released from LPS activated RAW 264.7 cells was in a time- and dose-dependent manner. The present study demonstrated that RNAi in the treatment of LPS-stimulated RAW264.7 cells resulted in the blockade of HMGB-1 and decreased LPS-induced inflammatory response. The results demonstrated that HMGB-1 plays a pivotal role in macrophage inflammatory responses by modulating the production of inflammatory mediators.

Severe sepsis and septic shock comprise a significant number of emergency department (ED) admissions annually. With the advent of early goal directed therapies, early identification and intervention have become paramount in this population. Few studies, however, have examined the role of serum lactate as a predictor of mortality or endpoint to resuscitation among this population. We aimed to show that improved lactate clearance is associated with decreased 28-day in-hospital mortality. We retrospectively examined data from the Yale Sepsis Registry for patients with severe sepsis or septic shock who had lactate levels that were measured initially in the ED and subsequently when the patient arrived on the floor. This study received institutional review board approval. Lactate clearance was calculated as a percentage, and comparison between patients who cleared lactate and those who did not were made for mortality data as well as baseline characteristics and interventions required between the two groups. 207 patients (110 male) with mean age and standard deviation (SD) of 63.17 ± 17.9 years were examined. 136 patients (65.7%) were diagnosed with severe sepsis and 71 patients (34.3%) had septic shock. Of those with identified sources of infection, pneumonia was the most common (54 patients, 26.1%). There were 171 patients in the clearance group and 36 patients in the non-clearance group, all of whom had a mean time of 9 hours 8 minutes ± 4 hours 6 minutes between lactate measurements. 28-day mortality rates were 15.2% (26 patients) in the lactate clearance group and 36.1% (13 patients) in the non-clearance group (p<0.01). Vasopressor support within 72 hours of admission was initiated among 61.1% (22 patients) in the non-clearance group compared with 36.8% (63 patients) in the clearance group (p<0.01). Mechanical ventilation was required for 36.3% (62 patients) in the clearance group and 66.7% (24 patients) in the non-clearance group (p=0.001). Rates of severe sepsis, mean number of SIRS and organ dysfunction criteria, and initial creatinine were similar between the two groups; however, only 86.1% (31 patients) in the non-clearance group received intravenous fluids in the ED compared with 98.8% (169 patients) in the clearance group (p=0.002). 33.3% (12 patients) in the non-clearance group had chronic obstructive pulmonary disease (COPD) compared with 15.2% (26 patients) in the clearance group (p<0.05). The mean Mortality in Emergency Department Sepsis (MEDS) scores were 8.78 ± 3.96 for the clearance group and 10.4 ± 4.48 for the non-clearance group (95% CI, -3.1 to -.14, p<0.05). These results show significantly higher mortality rates among patients who do not clear their lactate in the ED. Additionally, these patients require vasopressor support and mechanical ventilation more often. Lactate clearance was significantly associated with receipt of fluids and may also reflect lower MEDS score. Our findings suggest lactate clearance could be used as an endpoint for ED resuscitation and in stratifying mortality risk among patients with severe sepsis or septic shock. Future studies might seek to prospectively validate these findings and incorporate multivariate analysis to determine factors affecting lactate clearance.

Microfluidics promises to re-shape the current health-care system by transferring diagnostic tools from central laboratories to close vicinity of the patient (point-of-care). One of the most important operational steps in any diagnostic platform is sample preparation, which is the main subject in this thesis. The goal of sample preparation is to isolate targets of interest from their surroundings. The work in this thesis is based on three ways to isolate bacteria:  immune-based isolation, selective cell lysis, size-based separation. The first sample-preparation approach uses antibodies against lipopolysaccharides (LPS), which are surface molecules found on all gram-negative bacteria. There are two characteristics that make this surface molecule interesting. First, it is highly abundant: one bacterium has approximately a million LPS molecules on its cell-wall. Second, the molecule has a conserved region within all gram-negative bacteria, so using one affinity molecule to isolate disease-causing gram-negative bacteria is an attractive option, particularly from the point of view of sample preparation. The main challenge, however, is antigen accessibility. To address this, we have developed a treatment protocol that improves the capturing efficiency. The strategy behind selective cell lysis takes advantage of the differences between the blood-cell membrane and the bacterial cell-wall. These fundamental differences make it possible to lyse (destroy) blood-cells selectively while keeping the target of interest, here the bacteria, intact and, what is more important alive. Viability plays an important role in determining antibiotic susceptibility. Difference in size is another well-used characteristic for sample- separation. Inertial microfluidics can focus size-dependent particle at high flow-rates. Thus, particles of 10 µm diameter were positioned in precise streamlines within a curved channel.  The focused particles can then be collected at defined outlets.  This approach was then used to isolate white blood cells, which account for approximately 1% of the whole blood.  In such a device particles of 2µm diameter (size of bacteria) would not be focused and thereby present at every outlet. To separate bacteria from blood elasto-inertial microfluidics was used. Here, e blood components are diverted to center of the channels while smaller bacteria remain in the side streams and can subsequently be separated. / <p>QC 20141212</p>

The ROx is a retinal oximeter under development with the purpose of non-invasively and accurately measuring oxygen saturation (SO₂) in vivo. It is novel in that it utilizes the blue-green oximetry technique with on-axis illumination. ROx calibration tests were performed by inducing hypoxia in live anesthetized swine and comparing ROx measurements to SO₂ values measured by a CO-Oximeter. Calibration was not achieved to the precision required for clinical use, but limiting factors were identified and improved. The ROx was used in a set of sepsis experiments on live pigs with the intention of tracking retinal SO₂ during the development of sepsis. Though conclusions are qualitative due to insufficient calibration of the device, retinal venous SO₂ is shown to trend generally with central venous SO₂ as sepsis develops. The novel sepsis model developed in these experiments is also described. The method of cecal ligation and perforation with additional soiling of the abdomen consistently produced controllable severe sepsis/septic shock in a matter of hours. In addition, the ROx was used to collect retinal images from a healthy human volunteer. These experiments served as a bench test for several of the additions/modifications made to the ROx. This set of experiments specifically served to illuminate problems with various light paths and image acquisition. The analysis procedure for the ROx is under development, particularly automating the process for consistency, accuracy, and time efficiency. The current stage of automation is explained, including data acquisition processes and the automated vessel fit routine. Suggestions for the next generation of device minimization are also described.

Septic shock is frequently seen in intensive care units and is associated with significant mortality. Endotoxin – a major mediator of the pathophysiologic responses – is released during lysis of Gram-negative bacteria. These responses can be mimicked in the endotoxaemic pig. This thesis focuses on the following topics: the inflammatory and pathophysiological responses to various endotoxin doses and infusion patterns; covariations between endotoxin induced inflammatory and pathophysiological responses; whether the biological effects of endotoxin can be modulated by clopidogrel and whether tobramycin or ceftazidime reduce plasma cytokine levels. Endotoxin induced linear log-log cytokine and F2-isoprostane responses. Leukocyte and platelet responses, pulmonary compliance, circulatory variables as well as indicators of plasma leakage and hypoperfusion exhibited log-linear responses to the endotoxin dose. Biological responses to endotoxaemia such as inflammation, hypotension, hypoperfusion and organ dysfunction were more expressed when the organism was exposed to endotoxin at a higher rate. These results may facilitate the possibility to choose relevant endotoxin administration, when experiments are set up in order to evaluate certain responses to endotoxaemia. Correlation studies between cytokines, leukocytes, platelets and the endotoxin dose were in agreement with the well-known ability of endotoxin to induce cytokine expression and to activate both primary haemostasis and leukocytes. Free radical mediated lipid peroxidation and COX-mediated inflammation correlated to cytokine expression and organ dysfunction in endotoxaemic shock. Endotoxaemic pigs pretreated with clopidogrel, exhibited a trend towards less expressed deterioration of renal function, although blocking of ADP-induced primary haemostasis is not a key mediator of endotoxin induced deterioration of renal function. Tobramycin did not neutralise the biological effects of endotoxin or the plasma levels of endotoxin, suggesting that these antibiotics do not bind to endotoxin. Reduction in IL-6 was greater in pigs treated with ceftazidime and tobramycin as compared with those given saline, indicating a possible anti-inflammatory effect of both antibiotics.

Septic shock is a leading cause of death in intensive care units. As part of the septic process, the endothelium becomes activated and propagates the septic condition. It has become evident that reactive oxygen species (ROS) are involved in the signaling of mediators of sepsis, such as tumor necrosis factor-alpha (TNF-alpha) and the lipopolysaccharide coating of gram-negative bacteria (LPS). An important source of these ROS is NADPH oxidase, which is a ubiquitously expressed enzyme complex that also exists in endothelial cells (EC). We showed that O2- from NADPH oxidase was important for LPS, as well as TNF-alpha, induction of two markers of an activated endothelium, interleukin-8 (IL-8) and intercellular adhesion molecule-1 (ICAM-1) in human umbilical vein endothelial cells (HUVEC). / Expression of a gene can be increased by a rise in transcription as well as post-transcriptional changes, such as mRNA stability modifications. We assessed the role of NADPH oxidase in this process and found a complex interaction. Although LPS increases IL-8 transcription, it also destabilizes IL-8 mRNA in a p38 and extracellular signal-regulated kinase (ERK) MAPK dependent manner, which was only evident after blocking NADPH oxidase. This regulation involved the mRNA de-stabilizing factor tristetraprolin (TTP). In contrast, TNF-alpha enhanced the stability of IL-8, IL-6 and ICAM-1 mRNA in a p38 MAPK dependent, but NADPH oxidase independent manner. Furthermore, LPS did not have an effect on mRNA stability of IL-6 or ICAM-1 in our system. Thus, we conclude from our studies that the NAPDH oxidase is important for the induction of inflammatory molecules in LPS and TNF-alpha treated EC and is also involved in mRNA stability regulation of these molecules in a signal and gene specific fashion.

Grâce à l’échocardiographie au chevet, il est maintenant reconnu que la dysfonction myocardique a une forte prévalence et coexiste avec le choc distributif tôt dans le sepsis sévère. Dans les deux cas, la réanimation liquidienne représente la première ligne de traitement qui permet de sauver des vies. À ce jour, aucun liquide spécifique n'a pu être déclaré supérieur ou ayant un impact clair sur l’issue du choc septique. L’objectif est donc d'évaluer les impacts moléculaires de la perfusion isovolémique de différents liquides de réanimation sur la dysfonction myocardique induite par l'endotoxine. Des rats adultes se sont fait équiper de voies centrales, injecter en intrapéritonéale avec de l’endotoxine (lipopolysaccharide [LPS], provenant d'E. coli) ou du normal salin (0,9 %; contrôle) et, subséquemment, perfuser (ou non) avec une quantité isovolémique de liquide de remplissage vasculaire (normal salin [NS], albumine [ALB], solution de salin hypertonique [HTS]) pour une période de 6 à 24 heures, suivie d'un monitorage échocardiographique ainsi que d'une évaluation biochimique et histopathologique. Résultats : l’albumine améliore la dysfonction myocardique induite par le LPS en : i) réduisant l’épaisseur relative du ventricule gauche en diastole (LVRWD) (élargissement de l’espace interstitiel et de la teneur en albumine endogène); ii) limitant l'apoptose cardiaque tout en maintenant et en régulant le signal extracellulaire d’activation de la protéine kinase mitogène activée [ERK1-2 MAPK]; iii) favorisant les voies d'expression de l’hème oxygénase-1 [HO-1] et de la NO synthase inductible [iNOS]. La solution saline hypertonique [HTS] a été la seule à permettre une prévention hâtive de la dysfonction myocardique, en plus de réduire l'apoptose cardiaque grâce à une augmentation de l’expression de HO-1. Conclusion : les perfusions isovolémiques de liquides ont des impacts moléculaires distincts sur la dysfonction myocardique induite par l’endotoxine. L’albumine et le salin hypertonique présentent de potentielles propriétés antioxydantes, anti-apoptotiques et anti-oedémateuses. Cependant, d’autres recherches seront nécessaires afin d'approfondir les mécanismes sous-jacentes de ces impacts, afin d'éventuellement modifier certaines pratiques cliniques et d'améliorer la survie des patients atteints de dysfonction myocardique d'origine septique.

Introduction: Currently, there are no specific pharmacological treatments for sepsis-induced acute respiratory distress syndrome (ARDS). And mesenchymal stem cells (MSCs) have shown reparative potential in both sepsis and ARDS. Objectives: To determine the role of MSC administration in the modulation of pulmonary host-responses to sepsis via differential regulation of regulatory microRNAs (miRNAs/miRs). Methods: MicroRNA and mRNA profiling was performed to identify differential expression. Quantitative real time polymerase chain reaction (qRT-PCR), trans-endothelial electrical resistance (TEER) measurements, and luciferase activity assay were used. Results: MicroRNA expression was examined in Human Pulmonary Microvascular Endothelial Cells (HPMECs). One miRNA – miR-193b-5p, targets occludin, a tight junction protein associated with endothelial leakage. A specific regulatory relationship between miR-193b-5p and occludin was identified. The loss in endothelial integrity was rescued when miR-193b-5p inhibitor was transfected. Conclusion: miR-193b-5p is a suppressor of occludin. Studying transcriptional changes allows identification of therapeutically relevant mediators for ARDS/ALI treatment.

Introduction: Currently, there are no specific pharmacological treatments for sepsis-induced acute respiratory distress syndrome (ARDS). And mesenchymal stem cells (MSCs) have shown reparative potential in both sepsis and ARDS. Objectives: To determine the role of MSC administration in the modulation of pulmonary host-responses to sepsis via differential regulation of regulatory microRNAs (miRNAs/miRs). Methods: MicroRNA and mRNA profiling was performed to identify differential expression. Quantitative real time polymerase chain reaction (qRT-PCR), trans-endothelial electrical resistance (TEER) measurements, and luciferase activity assay were used. Results: MicroRNA expression was examined in Human Pulmonary Microvascular Endothelial Cells (HPMECs). One miRNA – miR-193b-5p, targets occludin, a tight junction protein associated with endothelial leakage. A specific regulatory relationship between miR-193b-5p and occludin was identified. The loss in endothelial integrity was rescued when miR-193b-5p inhibitor was transfected. Conclusion: miR-193b-5p is a suppressor of occludin. Studying transcriptional changes allows identification of therapeutically relevant mediators for ARDS/ALI treatment.

<p><bold>Background</bold> The diagnosis of sepsis is challenging because the infection can be caused by more than 50 species of pathogens that might exist in the bloodstream in very low concentrations, e.g., less than 1 colony-forming unit/ml. As a result, among the current sepsis diagnostic methods there is an unsatisfactory trade-off between the assay time and the specificity of the derived diagnostic information. Although the present qPCR-based test is more specific than biomarker detection and faster than culturing, its 6 ~ 10 hr turnaround remains suboptimal relative to the 7.6%/hr rapid deterioration of the survival rate, and the 3 hr hands-on time is labor-intensive. To address these issues, this work aims to utilize the advances in microfluidic technologies to expedite and automate the ``nucleic acid purification - qPCR sequence detection'' workflow.</p><p><bold>Methods and Results</bold> This task is evaluated to be best approached by combining immiscible phase filtration (IPF) and digital microfluidic droplet actuation (DM) on a fluidic device. In IPF, as nucleic acid-bound magnetic beads are transported from an aqueous phase to an immiscible phase, the carryover of aqueous contaminants is minimized by the high interfacial tension. Thus, unlike a conventional bead-based assay, the necessary degree of purification can be attained in a few wash steps. After IPF reduces the sample volume from a milliliter-sized lysate to a microliter-sized eluent, DM can be used to automatically prepare the PCR mixture. This begins with compartmenting the eluent in accordance with the desired number of multiplex qPCR reactions, and then transporting droplets of the PCR reagents to mix with the eluent droplets. Under the outlined approach, the IPF - DM integration should lead to a notably reduced turnaround and a hands-free ``lysate-to-answer'' operation.</p><p>As the first step towards such a diagnostic device, the primary objective of this thesis is to verify the feasibility of the IPF - DM integration. This is achieved in four phases. First, the suitable assays, fluidic device, and auxiliary systems are developed. Second, the extent of purification obtained per IPF wash, and hence the number of washes needed for uninhibited qPCR, are estimated via off-chip UV absorbance measurement and on-chip qPCR. Third, the performance of on-chip qPCR, particularly the copy number - threshold cycle correlation, is characterized. Lastly, the above developments accumulate to an experiment that includes the following on-chip steps: DNA purification by IPF, PCR mixture preparation via DM, and target quantification using qPCR - thereby demonstrating the core procedures in the proposed approach.</p><p><bold>Conclusions</bold> It is proposed to expedite and automate qPCR-based multiplex sparse pathogen detection by combining IPF and DM on a fluidic device. As a start, this work demonstrated the feasibility of the IPF - DM integration. However, a more thermally robust device structure will be needed for later quantitative investigations, e.g., improving the bead - buffer mixing. Importantly, evidences indicate that future iterations of the IPF - DM fluidic device could reduce the sample-to-answer time by 75% to 1.5 hr and decrease the hands-on time by 90% to approximately 20 min.</p> / Dissertation