Introduction Following polytrauma and major surgery patients experience a period of immunosuppression, which can predispose them to the development of nosocomial infections. This thesis examines how polytrauma and surgery influences T-helper (Th) cell differentiation and antigen presentation, whilst exploring how the detrimental immunomodulatory effects of these insults may be reversed. Methods Serial blood samples were drawn from two cohorts of patients at The Royal London Hospital; following severe polytrauma (n=112) or major abdominal surgery (n=119). mRNA levels of candidate cytokines and transcription factors were assayed, along with protein levels of key cytokines IL-10 and IL-6. Associations between these data, acquisition of nosocomial infection and outcome were described. As a validated surrogate of immune competence CD14+HLA-DR levels were quantified. In vitro models explored the reversibility of tissue damage induced immunosuppression and determined the role of individual circulating mediators in altering host immune function. Results A consistent up-regulation in gene expression of prototypical anti-inflammatory pathways in conjunction with features of depressed pro-inflammatory Th cell pathways was detected across both cohorts. This was accompanied by early down-regulation of CD14+HLA-DR. Gene expression changes were quantitatively associated with the subsequent acquisition of nosocomial infections. Allogeneic blood transfusion exacerbated these findingsand was independently associated with an increased risk of nosocomial infection. Culture experiments determined that postoperative decreases in antigen presentation were IL-10 dependent and reversible in the presence of Interferon-Gamma and Granulocyte Monocyte- Colony Stimulating Factor. Conclusions This thesis describes a significant host immune response immediately following significant tissue damage which is dominated by features of immune suppression. Blood transfusion appears to have a distinct, additive effect. These data identify a potential role for targeted treatment with currently licenced immune stimulants (IFN-γ and GM-CSF). In addition exploitation of the IL-10 signalling pathway may be of importance as a strategy to reduce the incidence of nosocomial infections.

There is ample evidence of the crucial role of PI3K/Akt dependent signalling in cardiac function, cellular growth and cell apoptosis. The PI3K/Akt pathway mediates cardioprotective effects in experimental models of cardiovascular disease. For example, activation of this pathway ameliorates the sepsis-induced cardiac dysfunction, whereas its activation in myocardial ischaemia/reperfusion (I/R) limits cardiac injury. This thesis investigates the role of two drugs, which activate the PI3K/Aktpathway, namely the haematopoietic cytokine erythropoietin and the anti-malarial drug artesunate, in a mouse animal model of experimental sepsis-induced cardiac dysfunction and in a rat model of regional myocardial I/R injury, respectively. Using a clinically relevant model of caecal ligation and puncture in mice, I demonstrated that aged (8 months) C57BL/6 mice (receiving fluid resuscitation and antibiotic therapy) developed significant cardiac dysfunction (within 24 h), while younger mice (2 months) did not. Erythropoietin attenuated the impaired systolic contractility (in vivo and ex vivo) caused by endotoxaemia (lipopolysacchride 9 mg kg-1; young mice) and sepsis (aged mice). These beneficial effects were associated with activation of Akt and endothelial nitric oxide synthase survival pathways and inhibition of the glycogen synthase kinase 3β, nuclear factor-κB and interleukin 1β pro-inflammatory pathways, secondary to activation of the β-common receptor. A single bolus administration of artesunate at the start of reperfusion in a rat model of myocardial I/R significantly attenuated the infarct size. This effect was mediated via activation of pro-survival pathways (PI3K/Akt and ERK 1/2 and STAT-3) and inhibition of the glycogen synthase kinase 3β and nuclear factor-κB pro-inflammatory pathways. Thus, in this thesis I have demonstrated that pharmacological activation of the PI3K/Akt pathway by erythropoietin and artesunate in sepsis and myocardial I/R, respectively, plays a vital role in the amelioration of cardiac dysfunction and injury.

Diabetes is a complex disease characterised by hyperglycaemia, which often leads to microvascular complications including diabetic nephropathy and cardiomyopathy. In this thesis, I have investigated the role of Annexin-A1 (ANXA1), an endogenous anti-inflammatory peptide, in two experimental murine models of diabetes caused by streptozotocin (STZ) or high-fat high-sugar diet (HFD), which mimic type-1 (T1DM) and type-2 diabetes (T2DM) respectively. I have also investigated the levels of ANXA1 in patients with either T1DM or T2DM. Patients with T1DM have increased plasma ANXA1 levels. In a murine models of type 1 diabetes loss of endogenous ANXA1 aggravates both cardiac and renal dysfunction in mice. Specifically, I have shown that key mediators of the MAPK pathway (p38, JNK and ERK1/2) are constitutively activated in ANXA1-/- mice, and activation of these pathways is exacerbated in diabetic ANXA1-/- mice. Administration of human recombinant (hr) ANXA1 did not alter the diabetic phenotype in diabetic WT mice, but attenuated the cardiac and renal dysfunction caused by STZ. Interestingly, late administration of ANXA1 (after significant cardiac and renal dysfunction had already developed) halted the progression of both cardiac and renal dysfunction. Patients with T2DM have increased plasma ANXA1 levels. HFD-fed ANXA1-/- mice have a more severe diabetic phenotype compared to HFD-fed WT mice. Therapeutic administration of hrANXA1 prevented the development of a diabetic phenotype. Specifically, I have shown that the insulin signalling pathway is further perturbed in diabetic mice resulting in severe insulin resistance, and that these signalling abnormalities were prevented by therapeutic administration of hrANXA1. In addition, loss of endogenous ANXA1 aggravates both cardiac and renal dysfunction in mice with experimental T2DM. The GTPase RhoA is constituently activated in ANXA1-/- mice leading downstream activation of MYPT1. Feeding a HFD also activated the small GTPase RhoA, leading to increased MYPT1 activity, which could be attenuated with treatment with hrANXA1. Mice subjected to HFD for 12 weeks had a more 'leaky' blood brain barrier (BBB), which is further exacerbated in ANXA1-/- mice fed a HFD. Compared to mice fed a chow diet, mice fed a HFD had an augmented CD4+ T-cell profile; with a clear decline in CD4+FoxP3+ (anti-inflammatory) and increase in CD4+RORgt+ (pro-inflammatory) cells. Administration of hrANXA1 to mice fed on HFD restored BBB integrity and CD4+ T-cells profile similar to mice fed on normal chow diet. Mice fed a HFD also had more activated CD4+ T-cells, which adhered more readily and transmigrated through a brain endothelial mono-layer ex vivo. In contrast, administration of hrANXA1 to mice fed on HFD reduced re-activity of CD4+ T-cells, reducing the number of adherent CD4+ T-cells to the brain endothelial mono-layer.

Sepsis is the leading cause of death in ICU patients. Patients with sepsis may develop sepsis-related cardiac dysfunction. The presence of this cardiac dysfunction can increase the mortality rate from 40% to 70%. Diabetes is a chronic disease that manifests as an elevation in blood glucose. Patients with diabetes are more susceptible to, and at increasing risk of developing, infections and subsequently sepsis. Activation of the NF-ĸB pathway plays a crucial role in the pathophysiology of sepsis-associated cardiac dysfunction and diabetic cardiomyopathy. The effect of diabetes on outcomes in patients with sepsis is highly controversial and it is still unclear whether pre-existing T2DM augments the cardiac dysfunction associated with sepsis and whether activation of NF-ĸB drives the cardiac dysfunction in T2DM/sepsis patients. In this thesis, I have first developed two models of high fat diet (HFD)-induced diabetes and diabetic cardiomyopathy in mice. Then, I developed two models of sepsis associated cardiac dysfunction using lipopolysaccharide (LPS) or caecumligation and puncture (CLP) in diabetic mice. I have demonstrated that mice with pre-existing T2DM exhibit a significantly greater cardiac (organ) dysfunction after challenge with either (low dose) LPS or mild CLP surgery. The exacerbated cardiac dysfunction was accompanied by an increase in NF-ĸB activation and reduction in Akt phosphorylation in the heart and an increase in the serum levels of proinflammatory cytokines. The increase in cardiac dysfunction, as well as the increase in the activation of NF-ĸB, caused by sepsis in animals with T2DM was largely attenuated by treatment with a selective IĸB kinase inhibitor (IKK-16) or a DPP-4 inhibitor (linagliptin). Thus, excessive activation of NF-ĸB in animals with diabetes/sepsis drives the observed excessive cardiac dysfunction, and that inhibition of NF-ĸB may be a useful target to treat the excessive inflammation and sepsis associated cardiac (organ) dysfunction in patients with T2DM and sepsis.

BACKGROUND:Translational medicine is attracting much attention worldwide and many translational research organizations (TROs) have been established. In China, translational medicine has developed rapidly, but faces many challenges. This study was aimed at exploring these challenges faced by emerging TROs in China.METHOD:A qualitative, multiple case study approach was used to assess the challenges faced by TROs in China. Data were collected between May and August 2012.RESULTS:Eight cases were identified. Overall, four themes that characterized TROs in China emerged from analyses: 1. objectives, organizer, and funding resources, 2. participating partners and research teams, 3. management, and 4. achievements. All TROs had objectives related to translating basic discovery to clinic treatment and cultivating translational researchers. In terms of organizer and funding resources, 7 out of 8 TROs were launched only by universities and/or hospitals, and funded mostly through research grants. As for participating partners and multidisciplinary research teams, all but one of the TROs only involved biomedical research institutions who were interested in translational research, and characterized as clinical research centers / 7 out of 8 TROs involved only researchers from biomedicine and clinical disciplines and none involved disciplines related to education, ethnicity, and sociology, or engaged the community. Current management of the TROs were generally nested within the traditional research management paradigms, and failed to adapt to the tenets of translational research. Half of the TROs were at developmental stages defined as infrastructure construction and recruitment of translational researchers.CONCLUSIONS:TROs in China face the challenge of attracting sustainable funding sources, widening multidisciplinary cooperation, cultivating multi-disciplinary translational researchers and adapting current research management to translational research. Greater emphasis should be placed on increasing multidisciplinary cooperation, and innovating in education programs to cultivate of translational researchers. Efforts should be made to reform research management in TROs, and establish sustainable funding resources.

C-type natriuretic peptide (CNP) is synthesised and released by the endothelium and plays a vital role in the maintenance of vascular homeostasis (Moyes et al., 2014). However, a similar regulatory role of endogenous CNP in the heart has yet to be elucidated. Therefore, I have used three unique mouse strains with endothelium (Tie2-Cre), cardiomyocyte (αMHC-Cre) and fibroblast (Col1α2-Cre)-restricted deletion of CNP to investigate if the peptide modulates coronary vascular reactivity and cardiac function. Methods: Langendorff isolated hearts were used to investigate the effect of CNP deletion on coronary vascular reactivity in response to the endothelium-dependent vasodilators bradykinin (10nmol) and acetylcholine (0.1-1nmol). Vasodilatation associated with reperfusion was investigated by transient cessation of flow (20-80 seconds). Ischaemia reperfusion (IR) injury (35 minutes ischaemia followed by 60 minutes reperfusion) was also investigated in cell-specific knockout (KO) animals. Isoprenaline (ISO; 20mg/kg/day, 7days)- and pressure overload (abdominal aortic constriction [AAC]; 6 weeks)-induced heart failure were used to study the effect of CNP deletion during cardiac stress, with cardiac function assessed by echocardiography. Cardiac fibrosis and hypertrophy were determined by picro-sirius red and wheat-germ agglutinin fluorescence staining, respectively. A subset of experiments was repeated in mice with global deletion of natriuretic peptide receptor-C (NPR-C) to delineate the signalling pathway triggered by CNP. Real time qPCR was used to determine hypertrophic and fibrotic gene expression in left ventricles isolated from mice subjected to AAC or sham. Neonatal cardiomyocytes were isolated to investigate angiotensin (Ang)II-induced hypertrophy. Results: Coronary endothelial reactivity was reduced in endothelial CNP (ecCNP) KO mice compared to wild type (WT) in response to bradykinin, acetylcholine and reperfusion-induced vasodilatation. These observations were paralleled in NPR-C KO animals. ecCNP KO did not exacerbate IR injury, whilst mice with cardiomyocyte-restricted deletion of CNP (cmCNP KO) and NPR-C KO animals exhibited a larger infarct size compared to WT. cmCNP KO mice also displayed greater cardiac dysfunction and fibrosis after ISO infusion or AAC compared to WT; similar results were observed in fbCNP KO and NPR-C KO animals. Infusion of CNP (0.2mg/kg/day; osmotic mini-pump, s.c.) in WT, but not NPR-C KO, animals rescued the decline in cardiac function. CNP (1μM) administration in isolated cardiomyocyte also blunted Ang II-induced hypertrophy. Pro-hypertrophic and pro-fibrotic gene expression (ANP, β-MHC and MMP-2) was augmented in cmCNP KO and NPR-C KO mice compared to littermate controls following AAC. Conclusions: Endothelial, cardiomyocyte and fibroblast-derived CNP have distinct, complementary roles in the heart, modulating cardiac function by influencing coronary vascular tone and protecting against heart failure and IR injury. These protective effects of CNP are mediated, at least in part, via NPR-C activation. Developing CNP mimetics or selective NPR-C agonists could be a novel therapeutic intervention in cardiovascular disease.

A massificação dos estudos da medicina translacional permite aos pesquisadores que usufruam de fontes de dados das mais diversas áreas. Uma área de suma importância e a bioinformatica, que agrega o alta capacidade de processamento computacional disponível atualmente, com a infindável quantidade de dados gerada por métodos de sequenciamento de ultima geração, para entregar aos pesquisadores uma quantidade rica de dados para serem analisados. Apesar da disponibilidade desses dados, a expertise necessária para analisa-los dificulta que profissionais com pouco conhecimento em bioinformatica, estatística e ciência da computação possam realizar pesquisas e analises com estes dados. Dada esta situação, este trabalho consistiu em criar uma ferramenta que tira proveito da integração de múltiplas bases de dados proporcionada pelo framework IPTrans, permitindo que usuários da área biomédica realizem analises com os dados contidos nessas bases. Com base em outras ferramentas existentes e em um levantamento de requisitos junto a potenciais usuários, foram identificadas as funcionalidades mais importantes e assim foi projetada e implementada a IPTrans Advanced Analysis Tool (IPTrans A2Tool). Esta ferramenta permite que usuários façam analises de expressão diferencial mais comuns como heatmaps, volcano plots, consenso de agrupamentos e blox-plot. Além disso, a ferramenta proporciona um algoritmo de mineração de dados baseado na extração de regras de associação entre dados clínicos e biomoleculares, que permite ao usuário descobrir novas associações entre a expressão dos genes dados clínicos e fenotípicos. Adicionalmente a este trabalho, foi criado também o BioBank Warden, um sistema de controle de dados clínicos e amostras biomoleculares, que foi utilizado como uma das fontes de dados para o IPTrans A2Tool. Este sistema permite que usuários adicionem informações clinicas de pacientes e também das amostras extraídas para a realização de estudos. Uma avaliação preliminar de usabilidade, realizada junto a profissionais da área biomédica, mostrou que as ferramentas possuem potencial para serem utilizadas no contexto da medicina translacional. / The great number of translational medicine studies allows researchers to make benefit of data sources from various fields. An area of great importance is bioinformatics, which combines the high computational processing capabilities found nowadays with the endless amount of data generated by next-generation sequencing methods, to give researchers a rich amount of data to be analyzed. Despite the availability of such data, the expertise required to analyze it makes difficult for professionals with little knowledge in bioinformatics, statistics or computer science, to conduct research and analysis on this data. Given this situation, this work was intended to create a tool that takes advantage of multiple databases integration capabilities provided by IPTrans and that allows users to perform analysis on the data contained in these databases. To accomplish that other tools were studied in order to observe which features our framework should aggregate and thus was created the IPTrans A2Tool (IPTrans Advanced Analysis Tool). This tool allows users to perform differential expression analysis and generate output as heatmaps, volcano plots, consensus clustering and blox-plots. In addition, the tool provides an association rule extraction algorithm between clinical and biomolecular data, allowing the user to discover hidden associations between the expression of analyzed genes and clinical data. As a by-product of this work was also created the BioBank Warden a clinical data and biomolecular samples management system that was used as one of the data sources for IPTrans A2Tool. This system allows users to add patients clinical information and also of samples taken for carrying out studies. In addition, the system provides a strong research group and project permission management that ensures only authorized people to have access to patients data.

Collaboration between academia and industry has been the focus of numerous government reports and initiatives over the past 15 years, and is increasingly recognized as an effective way to capitalize on the UK's world-class research base. However, there is a need to further understand the role of such collaborations in the field of translational medicine, where the path to market is particularly lengthy, expensive, and risky, due to complexities associated with the clinical trial process. This research uses a mixed methods approach to investigate collaboration in translational medicine at the University of Oxford. The project comprises three principal stages. First, a broad understanding of the current landscape of academia-industry collaboration in translational medicine was obtained by administering a questionnaire to academics who had received industry funding. Next, a deeper understanding of the barriers to collaboration was sought through semi-structured interviews with 27 academics. Finally, potential strategies to reduce practical barriers to the collaboration process were investigated through interviews with members of three groups within the university who interact directly with industry: Research Services, Oxford University Innovation, and Business Development. This research constitutes the first empirical study on university-industry collaboration in translational research in the United Kingdom. It contributes to existing theory through the development of a new theoretical framework for the evaluation of barriers in terms of a) the practicalities of the collaboration process, b) the institutional environment and c) presiding cultures. Through these analyses, differences in experiences of barriers to collaboration emerged for clinical and non-clinical researchers. Furthermore, industry was seen as playing a crucial role in the translation of new therapeutics, especially in the funding of research that was perceived as being ‘too risky’ for Research Councils. Thus, reducing barriers to university-industry collaboration was seen as important to the realisation of public benefit from university research. Barriers were seen as being overcome, or avoided, via the formation of relationships between academics and companies at several different levels; while systems exist within the university to facilitate this, awareness and uptake of these systems was poor amongst the study population. Finally, if universities are to deliver impact as a key metric of performance, incentives within the university need to reward academics for commercialisation activities, in addition to publication. Through the suggestion of long and short-term strategies and a detailed analysis of industrial collaboration in this setting, this research has implications for both university and government policy.

A massificação dos estudos da medicina translacional permite aos pesquisadores que usufruam de fontes de dados das mais diversas áreas. Uma área de suma importância e a bioinformatica, que agrega o alta capacidade de processamento computacional disponível atualmente, com a infindável quantidade de dados gerada por métodos de sequenciamento de ultima geração, para entregar aos pesquisadores uma quantidade rica de dados para serem analisados. Apesar da disponibilidade desses dados, a expertise necessária para analisa-los dificulta que profissionais com pouco conhecimento em bioinformatica, estatística e ciência da computação possam realizar pesquisas e analises com estes dados. Dada esta situação, este trabalho consistiu em criar uma ferramenta que tira proveito da integração de múltiplas bases de dados proporcionada pelo framework IPTrans, permitindo que usuários da área biomédica realizem analises com os dados contidos nessas bases. Com base em outras ferramentas existentes e em um levantamento de requisitos junto a potenciais usuários, foram identificadas as funcionalidades mais importantes e assim foi projetada e implementada a IPTrans Advanced Analysis Tool (IPTrans A2Tool). Esta ferramenta permite que usuários façam analises de expressão diferencial mais comuns como heatmaps, volcano plots, consenso de agrupamentos e blox-plot. Além disso, a ferramenta proporciona um algoritmo de mineração de dados baseado na extração de regras de associação entre dados clínicos e biomoleculares, que permite ao usuário descobrir novas associações entre a expressão dos genes dados clínicos e fenotípicos. Adicionalmente a este trabalho, foi criado também o BioBank Warden, um sistema de controle de dados clínicos e amostras biomoleculares, que foi utilizado como uma das fontes de dados para o IPTrans A2Tool. Este sistema permite que usuários adicionem informações clinicas de pacientes e também das amostras extraídas para a realização de estudos. Uma avaliação preliminar de usabilidade, realizada junto a profissionais da área biomédica, mostrou que as ferramentas possuem potencial para serem utilizadas no contexto da medicina translacional. / The great number of translational medicine studies allows researchers to make benefit of data sources from various fields. An area of great importance is bioinformatics, which combines the high computational processing capabilities found nowadays with the endless amount of data generated by next-generation sequencing methods, to give researchers a rich amount of data to be analyzed. Despite the availability of such data, the expertise required to analyze it makes difficult for professionals with little knowledge in bioinformatics, statistics or computer science, to conduct research and analysis on this data. Given this situation, this work was intended to create a tool that takes advantage of multiple databases integration capabilities provided by IPTrans and that allows users to perform analysis on the data contained in these databases. To accomplish that other tools were studied in order to observe which features our framework should aggregate and thus was created the IPTrans A2Tool (IPTrans Advanced Analysis Tool). This tool allows users to perform differential expression analysis and generate output as heatmaps, volcano plots, consensus clustering and blox-plots. In addition, the tool provides an association rule extraction algorithm between clinical and biomolecular data, allowing the user to discover hidden associations between the expression of analyzed genes and clinical data. As a by-product of this work was also created the BioBank Warden a clinical data and biomolecular samples management system that was used as one of the data sources for IPTrans A2Tool. This system allows users to add patients clinical information and also of samples taken for carrying out studies. In addition, the system provides a strong research group and project permission management that ensures only authorized people to have access to patients data.

XMARCUS: A Pathway Towards Remote Robotic Surgery Training}, is a compilation work of human-robot, human-artificial intelligence, and human-computer interaction. The thesis provides a technical overview of the history of robotic surgery, present innovation, and future impacts. We present a behaviorist overview and describe our view of the overall direction of robotic surgery to enhance surgical training. We also discuss application towards future directions of translational medicine, adoption of surgical tools, and innovation within medicine. XMARCUS indicates the possibility of another artificial intelligence winter within surgery domain and presents a direction towards surgical training. Our macroscopic perspective and development of demo applications on third-party consoles demonstrates how to enhance robotic surgery training, provide future directions of minimally invasive surgery, and further enhance medical education. We also present the argument for a definitive direction of applications of artificial intelligence, the breakdown of its very definition, along with its proper application, in order to connect both the surgical and software communities for further steps in translational medicine. XMARCUS is not only a pathway towards applicable accessibility for surgical training, but also is a framework to allow further innovation in translational medicine for robotic surgery. The thesis consists of 14 chapters divided into 3 parts. Part 1 provides a technical history background focused on the history of robotic surgery, the present hardware breakdown, applications and advancement of artificial intelligence and computer vision practices within the field. Part 2 highlights the disconnect between both surgical and software communities, and a pathway to integrating both fields towards translational medicine, specifically focusing on artificial intelligent practices by integrating machine learning for computer vision in the endoscopic space. Part 3 presents future research directions and important research questions to address, highlighting the future of surgery with the lack of physician accessibility to implementing artificial intelligence practices, focuses on providing an integration of remote robotic surgery training. / Master of Science / XMARCUS: A Pathway Towards Remote Robotic Surgery Training} is an avocation, proof of concept, and general overview of robotic surgery, its present predicament, and future impact of software engineering. There is an ever pressing need to integrate artificial intelligence practices within robotic surgery and minimally invasive surgery procedures. However, computing has faced a number of artificial intelligence winters with no viable means of application. Due to the lack of available data and machine learning models trained on such data, there is another permanence of an artificial intelligence winter, especially surgical applications. We also present the XMARCUS dataset, with over 12,000 images and a walk-through for crowdsource annotation process using Intel's OpenVino framework, where there has been less viable data. The focus is on the general overview of artificial intelligence, within the domain of machine learning for computer vision practices. This includes a discussion of virtual coaching and remote surgical training, specifically methods to further develop robotic surgery simulation software, in order to advance not solely the endoscopic space, but also the surgical training. Human-computer interaction models and theories, such as the Diffusion of Innovation, showcase the adaptation and timing of certain technologies, for viable application. We also present another concept focusing on the timing of technology to be introduced to help with translational medicine. Finally, we show an application in a series of proof concepts of remote virtual coaching for remote robotic surgical training including the psychomotor skills and FDA policy overview for implementing novel software practices to advance robotic surgery. With consideration towards remote surgery training and the universal push for creating credentialing and guidelines in robotic surgery, we discuss further disparities to showcase an ethical framework to enhance surgical training and implement novel software engineering practices.