Irradia AB tillverkar och säljer terapeutiska, kirurgiska och kosmetiska lasrar. Företaget har hittills inte lyckats skapa utbyte med den offentliga sjukvårdsmarknaden. Syftet med undersökningen var därför att analysera och utvärdera hinder för Irradia AB:s introduktion på den offentliga svenska sjukvårdsmarknaden. Fokus lades på de terapeutiska lasrarna. På grund av undersökningsområdets natur gjordes en separation av mega- och marknadsnivå. På meganivån undersöktes ett expertnätverk, som skall acceptera nya medicinsktekniska produkter inom sitt verksamhetsområde, och på marknadsnivån undersöktes Irradia AB och den offentliga sjukvårdsmarknaden. Författarna valde fallstudien som metod. För att samla in primärdata ansåg författarna att intervjuer var den mest relevanta metoden. På marknadsnivån intervjuades Lars Hode, VD för Irradia AB, och Jan Svenonius, tidigare upphandlingschef på Huddinge sjukhus och Mikael Wickström, upphandlingschef, Karolinska Universitetssjukhuset. På meganivån fick Audio Laser-Kliniken representera Irradia, då företagets produkter används till behandling av hörselsjukdomar på kliniken. Med hjälp av ett anvisningsurval lyckades författarna snabbt identifiera och intervjua respondenter som varit kritiska till behandlingsformen som tillämpas på kliniken. Analysen på meganivån genomfördes utifrån nätverksteorin, teorin om idésystem och socialpsykologi. I analysen på marknadsnivån tillämpades konkurrensstrategier, involveringsteorin, faktorer som påverkar köpbeslut och nätverksteorin. Resultatet visar att Irradia möter hinder på marknadsnivån, framför allt när det gäller relationers betydelse i upphandlingsprocessen. Irradia AB har goda förutsättningar för att bemästra de flesta hindren, men relativt lite nätverkande har varit svagheten i den strategi som tillämpats hittills. Resultatet på meganivån visar att aktörerna anser att Mikael Bäckmans verksamhet på Audio Laser-Kliniken inte svarar mot vetenskap och beprövad erfarenhet. Därmed har experterna kunnat förklara laserbehandling av hörselsjukdomar som illegitim. Undersökningen visar dock att andra behandlingsmetoder på hörselområdet inte möter samma krav utifrån vetenskap och beprövad erfarenhet. Resultatet visar framför allt att liten tilltro till produkterna i expertnätverket sänker möjligheten till utbyte med den offentliga sjukvården. Frågeställningen hade fokus på faktorer som är viktiga för nyetablerare på sjukvårdsmarknaden. Slutsatserna är att differentiering kan vara en lämplig strategi för företag med små resurser, och att utbildning som mervärde kan vara lämpligt om produkterna är komplexa. Nyetablerare bör satsa på löpande bearbetning av aktörer både på mega- och marknadsnivå. Undersökningen tyder dock på att bearbetningen på meganivå bör ske i första hand, för att nyetablerare skall kunna sälja nya produkter på den offentliga sjukvårdsmarknaden. / Irradia AB is a manufacturer and seller of medical, surgical and cosmetical laser instruments. So far the company has failed in establishing exchange with the public health services in Sweden. The purpose of this studie was to analyse and evaluate obstacles in the way of Irradias introduction on the public health service market. The medical lasers were chosen as the primary products to study. Due to the nature of the area of investigation, mega level marketing was separated from the market level. On the mega level, new and complex medical products must be approved by experts. On the market level, a comparison was made between Irradia and the public health service market. The case study was chosen as a main method. Qualitative primary data was collected by interviewing. On the market level, interviews were conducted with Lars Hode, managing director of Irradia AB, Jan Svenonius, former director of purchasing at Huddinge Sjukhus and Mikael Wickström, director of purchasing at Karolinska Sjukhuset. On the mega-level, Audio Laser-Kliniken was chosen to represent Irradia, since their medical lasers are used for treatment of hearing disorders at the clinic. By using directive selection, the authors could quickly identify and interview persons who are negative when it comes to laser treatment of hearing disorders. Competitive strategies, the involvement theory, network theory and factors influencing buyer behavior were applied in the market level analysis. The mega level analysis is based on the network theory, the theory of dominant ideas and social psychology. Results of the market level analysis show that relations are of great importance in public health service purchasing processes. Irradia meets most of the basic conditions that are required for establishing exchange with the public health service market, but a relatively low degree of networking has been a flaw in the strategy that Irradia has had so far. Results of the mega level analysis show that the laser treatment of hearing disorders at Audio Laser-Kliniken does not comply with the requirements for an evidence-based medicine, according to the interviewees. Therefore laser treatment of hearing disorders has been announced illegitimate by the experts. The results also show that other treatment forms of hearing disorders can be difficult to evaluate regarding to the requirements of an evidence-based medicine. The results show, above all, that any possible distrust to the products among experts will have a negative impact on the possibility to establish exchange with the public health service market. The question at issue focused on factors that are of importance for companies trying to establish exchange with the public health service market. Conclusions of the study show that differentiation can be a suitable strategy for establishers with new products, and that customer academies can be a relevant way to reduce risks if the products are complex. New companies should try to create relations on both the mega level and market level. The study shows that relations with experts on the mega level are critical for companies trying to sell new products to the public health service market.

B cell lymphomas and leukemias are heterogeneous tumors with different cellular origins. Analysis of immunoglobulin (Ig) genes enables insight into the B cell progenitor, as Ig somatic hypermutation correlates with antigen-related B cell transit through the germinal center (GC). Also, restricted Ig variable heavy chain (VH) gene repertoires in B cell malignancies could imply antigen selection during tumorigenesis. The length of telomeres has been shown to differ between GC B cells and pre/post-GC B cells, possibly representing an alternative angle to investigate B cell tumor origin. Mantle cell lymphoma (MCL), previously postulated to derive from a naïve, pre-GC B cell, was shown to have an Ig-mutated subset (18/110 MCLs, 16%), suggestive of divergent cellular origin and GC exposure. Another subset of MCL (16/110, 15%), characterized by VH3-21/Vλ3-19 gene usage, alludes to a role for antigen(s) in pathogenesis, also possible for hairy cell leukemia (HCL) in which the VH3-30 gene (6/32, 19%) was overused. HCL consisted mainly of Ig-mutated cases (27/32, 84%) with low level intraclonal heterogeneity, contrasting with the proposed post-GC origin, for both Ig-mutated and Ig-unmutated HCLs. For MCL and HCL, derivation from naïve or memory marginal zone B cells which may acquire mutations without GC transit are tempting speculations, but currently little is known about this alternative immunological pathway. Heavily mutated Ig genes without intraclonal heterogeneity were demonstrated in lymphoplasmacytic lymphoma/Waldenström’s macroglobulinemia (13/14, 93%), confirming that the precursor cell was transformed after GC affinity maturation. Telomere length analysis within 304 B cell tumors revealed variable lengths; shortest in the Ig-unmutated subset of chronic lymphocytic leukemia, longest in the GC-like subtype of diffuse large B cell lymphoma, and homogeneous in MCL regardless of Ig mutation status. However, telomere length is complex with regard to GC-related origin. In summary, this thesis has provided grounds for speculation that antigens play a role in MCL and HCL pathogenesis, although the potential antigens involved are currently unknown. It has also enabled a more informed postulation about the cellular origin of B cell tumors, which will ultimately enhance understanding of the biological background of the diseases.

The aims of this study were to document the levels of cobalamin, folate, methylmalonic acid (MMA) and total homocysteine (tHcy) in serum and their relations to symptoms, clinical findings, and other factors in order to improve the possibilities of detecting early deficiency of vitamin B12 or folate, and to study the effects of cobalamin and folic acid treatment over a three-year period. The study population consisted of a 20% random sample of persons 70 years or older living in Älvkarleby in mid-Sweden. They were invited to a survey and 224 (88.4%) persons responded. Data were obtained by questionnaire, laboratory investigations and physical examination for the period 1993 – 1999. In a multivariate analysis performed at baseline, serum MMA and tHcy were significantly and independently correlated to age, serum cobalamin, and creatinine levels, and tHcy also to sex and serum folate. Neither serum cobalamin, folate, MMA nor tHcy had any significant correlation to haemoglobin or mean red cell volume. Almost half of the study population had signs of low tissue levels of vitamin B12 or folate. Among those who took multivitamin preparations, the proportion was much lower, 25%. Among traditional symptoms and clinical findings that have been linked to vitamin B12 or folate tissue deficiency, only changes in the tongue mucosa and mouth angle stomatitis were significantly associated with abnormal serum folate and tHcy levels. Traditional symptoms of vitamin deficiency may appear later in the course. 69 persons who had laboratory indications of early or overt tissue deficiency of vitamin B12 or folate and who had no ongoing vitamin treatment were given cobalamin for six months. Those whose MMA or tHcy levels did not normalise were given folic acid in addition to cobalamin. After further treatment for three months, all persons but one had normal levels. The laboratory effect still remained after three years of treatment. There was a tendency towards improvement of vibration sense, especially in the long nerve paths, and improvement of neurological symptoms and oral mucosa findings. Conclusion: A substantial proportion of elderly persons have laboratory signs of incipient tissue deficiency of vitamin B12 and folate. Treatment normalises lab parameters and some symptoms.

Treatment results and clinical characteristics in adult acute lymphoblastic leukaemia (ALL) were evaluated regarding three issues: a new treatment with cytarabine up-front, stem cell transplantation and a comparison between adult and paediatric treatment protocols. All studies were conducted on a national basis. Furthermore, activity of imatinib was investigated by in vitro cytotoxicity assay. The national protocol was evaluated in 153 adult ALL patients. A high complete remission rate, 86%, was achieved with 29% overall survival at 3-years. Favourable outcome was identified in patients < 40 years with precursor B phenotype and continuous complete remission was higher for precursor B compared to T-ALL. Stem cell transplantation was evaluated in 187 patients. No differences in outcome between allogeneic and autologous transplantation were found, with the exception of Philadelphia-positive ALL, in which allogeneic transplantation was preferable. Limited chronic graft-versus-host disease (compared to none) resulted in superior disease free survival. The paediatric NOPHO-92 and the Adult protocols were evaluated for 243 ALL-patients. Superior remission rate and survival were achieved for 10-18 year-olds treated according to the Paediatric protocol compared to both 15-25 and 25-40 year-olds treated according to the Adult protocol. Treatment protocol was a significant prognostic factor for patients aged 15-20 years. Fluorometric Microculture Cytotoxicity Assey was used to analyze 15 tumour cell samples from ALL patients. High concordance was determined between in vitro sensitivity to imatinib and presence of BCR-ABL. Daunorubicin, prednisolone and cytarabine had the greatest benefit from a combination with imatinib. The national adult treatment protocol’s results were consistent with international trials regarding precursor B ALL but may be under performing for T-ALL. Adolescents may benefit from treatment according to the Paediatric protocol. No difference in outcome between allogeneic and autologous stem cell transplantation was determined except for Philadelphia-positive patients, despite the indication of a graft-versus-leukaemia effect.

The aims of the thesis were (i) to investigate the impact of repetitive low-intensity work exposure on proprioception and (ii) to examine effects of muscle stretching (especially sensory effects and effects on muscle nociception) and to relate its application to the prevention, alleviation and/or treatment of work-related neuromuscular disorders. The effects of low-intensity repetitive work on the shoulder proprioception were tested in healthy subjects. The effect of working time on the retention of subjective fatigue and their relation to changes in proprioception, and the immediate effect of stretching on shoulder proprioception were investigated. A new method to test the stretchability of the rectus femoris muscle was investigated for reliability and validity and used to assess the effects of a two-week stretching regimen on range of motion and on subjective stretch sensation. Finally, the interactions between innocuous muscle stretch and nociceptive chemical stimulation on discharge behavior of nociceptive dorsal horn neurons in the feline spinal cord were explored. The main findings were as follows: 1) The repetitive low-intensity work to fatigue diminished the shoulder proprioception; the working time as well as the retention of subjective fatigue were partly related to the extent of changed proprioception. 2) There was no effect of acute muscle stretching on the proprioception. 3) The new method for testing muscle stretchability proved valid and reliable. A two-week stretching regimen increased the tolerance to stretch torque, but the range of motion remained unchanged. 4) Half of the nociceptive dorsal horn neurons that responded to close arterial injections of bradykinin were modulated by muscle stretching applied directly after the injections. Altogether, the results give credence to the hypothesis of an involvement of sensory information distortion due to repetitive low-intensity work exposure in the development of work-related neuromuscular disorders. Increased tolerance to stretch torque may be an important mechanism in explaining improvements following stretch treatment. The spinal interactions between innocuous stretch and nociceptive muscle afferent inputs indicate a possible mechanism involved in stretching-induced pain alleviation.

Mantle cell lymphoma (MCL) and chronic lymphocytic leukemia (CLL) both belong to the group of mature B-cell malignancies. However, MCL is typically clinically aggressive while the clinical course of CLL varies. CLL can be divided into prognostic subgroups based on IGHV mutational status and into multiple subsets based on closely homologous (stereotyped) B-cell receptors. In paper I we investigated 31 MCL cases using high-density 250K single-nucleotide polymorphism arrays and gene expression arrays. Although most copy-number aberrations (CNAs) were previously reported in MCL, a novel deletion was identified at 20q (16%) containing the candidate tumor suppressor gene ZFP64. A high proliferation gene expression signature was associated with poor prognosis, large CNAs, 7p gains and 9q losses. Losses at 1p/8p/13q/17p were associated with increased genomic complexity. In paper II we sequenced exons 4 to 8 of the TP53 gene in 119 MCL cases. 17p copy-number status was known from previous studies or determined by real-time quantitative polymerase chain reaction. TP53 mutations were detected in 14% of cases and were strongly associated with poor survival while 17p deletions were more common (32%) but did not predict survival. In papers III and IV we applied high-resolution genomic 27K methylation arrays to 20 MCL and 39 CLL samples. In paper III MCL displayed a homogenous methylation profile without correlation with the proliferation signature whereas MCL was clearly separated from CLL. Gene ontology analysis revealed enrichment of developmental genes, in particular homeobox transcription factor genes, among targets methylated in MCL. In paper IV we compared three different stereotyped CLL subsets: #1 (IGHV unmutated), #2 (IGHV3-21) and #4 (IGHV mutated). Many genes were differentially methylated between each two subsets and immune response genes (e.g. CD80 and CD86) were enriched among genes methylated in subset #1 but not in subsets #2/#4. In summary, CNAs were frequent and not random in MCL. Specific CNAs correlated with a high proliferation gene expression signature or genomic complexity. TP53 mutations predicted short survival whereas 17p deletions did not. A high proliferation signature was not associated with differential DNA methylation in MCL, which demonstrated a homogeneous methylation pattern. In contrast, genomic methylation patterns differed between MCL and CLL and between stereotyped CLL subsets.

Cette étude pilote vise à développer une méthode d'analyse intégrative qui permet d'augmenter le taux de réussite du diagnostic clinique des mutations génétiques rares. De plus, l'identification de nouveaux gènes associés à l'ataxie épisodique (EA) et l'évaluation de nouveaux algorithmes de prédiction, pour un examen de variants plus robuste, découleront de l'enquête. Caractérisé par une perte sporadique de la coordination des mouvements volontaires, l'EA se manifeste généralement tardivement, avec une hétérogénéité clinique et génétique élevée, compliquant largement l’obtention d’un diagnostic précis. Alors que quatre gènes ont été liés aux huit sous-types d'EA, de nombreux patients demeurent sans diagnostic moléculaire dû aux limites des méthodes de séquençage d’ADN. Ces lacunes accentuent l’intérêt d’implanter le séquençage de l’ARN en milieu clinique, afin d’obtenir l’information fonctionnelle offerte par l’approche. Des patients atteints d’EA, sans diagnostic moléculaire malgré un examen approfondi, ont été recrutés à Montréal. Le séquençage du génome entier (WGS) et de l'ARN a été effectué sur des échantillons de sang pour identifier les variants nucléotidiques, l'expression différentielle, les événements d'épissage ainsi que les expansions de microsatellites. Plusieurs algorithmes de prédiction de la pathogénicité récents ont été choisis pour être testés parallèlement aux algorithmes standard. Des données WGS provenant d’un trio familial atteint de pathologies neurologiques ont également été soumises au pipeline génomique développé pour la cohorte EA. Des variants candidats ont été identifiés pour chaque patient en fonction des scores de pathogénicité, de la rareté des événements génétiques et des informations fonctionnelles et cliniques connues pour un gène altéré donné. Parmi les découvertes figurent des mutations non-sens, des faux-sens, de l'épissage alternatif ainsi que des expansions nucléotidiques dans des gènes associés aux ataxies spinocérébelleuses ou aux paraplégies spastiques. En plus d'être présents dans les ensembles de données de séquençage disponibles pour chaque patient, les événements génomiques ont été vérifiés par séquençage Sanger de l'ADN et de l'ARN lorsque possible. Les effets fonctionnels potentiels, prédits principalement à partir du RNA-seq et suggérant une expression anormale de l'ARNm, ont également été évalués par amplification PCR et qPCR traditionnelle. À ce jour, quatre des dix patients ont reçu ou sont en voie de recevoir un diagnostic clinique, et quatre autres présentent d’excellents candidats moléculaires pour expliquer une pathologie ataxique. Ce projet devrait permettre un diagnostic mieux défini, conduisant à une meilleure qualité de vie, une meilleure évaluation du pronostic et une meilleure prise en charge des patients. L’identification de modulateurs génétiques chez certains d’entre eux devrait également permettre une meilleure caractérisation clinique des conditions rapportées, bénéficiant les évaluations symptomatiques futures. De plus, la méta-analyse des données RNA-seq offre le potentiel de découvrir des régulateurs de pathogenèse communs à l’EA. Il favorisera également l'approche intégrative pour un plus large éventail de troubles et pourrait éventuellement conduire à de nouvelles stratégies thérapeutiques. / This pilot study aims to develop an integrative analysis method that allows for an increased diagnosis success rate of rare genetic mutations. Moreover, identification of novel genes associated with Episodic Ataxia (EA) and evaluation of new AI-generated prediction algorithms, for a more robust variant examination, will ensue from the investigation. Characterized by sporadic loss of voluntary movement coordination, EA typically manifest with a late onset as well as high-clinical and genetic heterogeneity, setting additional hurdles to diagnosis. While four genes have been linked to the eight subtypes of EA, many patients are left without molecular diagnosis due to the limitations of individual DNA-sequencing methods, which can be mitigated by the functional overview that RNA sequencing (RNA-seq) offers. EA patients, lacking molecular diagnosis despite in-depth examination, were recruited in Montreal. Whole-Genome sequencing (WGS) and RNA-seq were performed on blood samples to identify single nucleotide variants, differential expression, splicing events, structural variants and repeat expansions. Multiple recent pathogenicity prediction algorithms were chosen for testing concurrently to standard ones, in order to evaluate their performance and potential for clinical pipelines integration. WGS data of a family trio from France, in which the father and the daughter present neurologic pathologies, were also processed through the genomic pipeline that was developed for the EA cohort in order to identify the cause of their disorder. Candidate variants were identified for each patient according to pathogenicity scores, rarity of genetic events, and known functional as well as clinical information for a given altered gene. Among the findings are truncations, missenses, alternative splicing, and repeat expansions in genes already associated to either spinocerebellar ataxia or spastic paraplegia. In addition to being present in both datasets when available, validation of these interesting genomic events has been performed through Sanger Sequencing of both DNA and RNA when feasible. For strong candidates where the available functional information from RNA-seq suggests abnormal mRNA expression, validation includes PCR amplification as well as a traditional qPCR to support effects on transcripts. To this day, four out of ten patients have received or are on the verge of receiving a diagnosis, and four others are carrying excellent molecular candidates requiring further validation to explain their ataxic pathologies. This project should provide more defined diagnosis, leading to better quality of life, better evaluation of prognosis and better management of care for patients. Identification of genetic modifier in some of them should also allow for a better clinical characterization of the reported conditions, benefiting future patient examinations. A meta-analysis of our patients’ transcriptomic profiles could also uncover commonly affected pathways in EA development. It will also promote the integrative approach for a larger spectrum of disorders and might eventually lead to new therapeutic strategies.

Preimplantation genetic diagnosis (PGD) refers to the testing of embryos produced through in vitro fertilization (IVF) in order to identify those unaffected by a specific genetic disorder or chromosomal abnormality. In this study, different methodologies were examined and developed for performance of PGD. Investigation of various whole genome amplification (WGA) methods identified multiple displacement amplification as a reliable method for genotyping single cells. Furthermore, this technology was shown to be compatible with subsequent analysis using single nucleotide polymorphism (SNP) microarrays. Compared to conventional methods used in this study to perform single cell diagnosis (e.g. multiplex PCR), WGA techniques were found to be advantageous since they streamline the development of PGD protocols for couples at high risk of transmitting an inherited disorder and simultaneously offer the possibility of comprehensive chromosome screening (CCS). This study also aimed to develop a widely applicable protocol for accurate typing of the human leukocyte antigen (HLA) region with the purpose of identifying embryos that will be HLA-identical to an existing sibling affected by a disorder that requires haematopoietic stem cell transplantation. Additionally, a novel microarray platform was developed that, apart from accurate CCS, was capable of reliably determining the relative quantity of mitochondrial DNA in polar bodies removed from oocytes and single cells biopsied from embryos. Mitochondria are known to play an important role in oogenesis and preimplantation embryogenesis and their measurement may therefore be of clinical relevance. Moreover, real-time PCR was used for development of protocols for CCS, DNA fingerprinting of sperm samples and embryos and the relative quantitation of telomere length in embryos (since shortened telomeres might be associated with reduced viability). As well as considering the role of genetics in terms of oocyte and embryo viability assessment and the diagnosis of inherited genetic disorders, attention was given to a specific gene (Phospholipase C zeta) of relevance to male infertility. A novel mutation affecting the function of the resulting protein was discovered highlighting the growing importance of DNA sequence variants in the diagnosis and treatment of infertility.

My thesis aims at identifying both genetic and environmental causes of major depressive disorder (MDD), using a large case-control study: 6,000 Chinese women with recurrent MDD and 6,000 controls. One of the major challenges for conducting genetic research on MDD is disease heterogeneity. The first question addressed is how different MDD is from highly comorbid anxiety disorders. I examine how anxiety disorders predict clinical features of depression and the degree of heterogeneity in their predictive pattern. The second question addressed is whether clinically defined MDD is a single disorder, or whether it consists of multiple subtypes. Results are then compared with and interpreted in the context of Western studies. Furthermore, latent class analysis and factor analysis results are also used in association analysis to explore more genetically homogeneous subtypes. Genetic data were derived using a novel strategy, low pass whole genome sequence analysis. Using genotypes imputed from the sequence data, I show that a cluster of single nucleotide polymorphisms (SNPs) is significantly associated with a binary disease phenotype including only cases with = 4 episodes of MDD, suggesting that recurrence might be an indication of genetic predisposition. The third issue examined is the contribution of rare variants to disease susceptibility. Again using sparse sequence data, I identified exonic sequence variants and performed gene-based analysis by comparing the number of variants between cases and controls in every gene. Furthermore I performed gene enrichment test by combining P values of SNP association tests at different minor allele frequency ranges. Overall, I did not find convincing evidence that rare variants aggregately contribute to disease susceptibility. However, the gene-based analysis resulted in an unexpected finding: cases have an excess of variants in all thirteen-protein coding mitochondrial genes, which was due to copy number differences in the mitochondrial genome. Both human phenotypic data as well as mice experimental data show that the increase in the mitochondrial copy number in cases is due to chronic stress.

Against the background of a dilemma experienced by researchers during a genomics study at an established biomedical research centre in Kenya, the broad aims of this thesis are to develop appropriate responses to important ethical questions on sharing information on a common and serious genetic condition, sickle cell disorder, and assess the responsibilities of researchers in this regard. Using an empirical approach to normative reflection across two phases of qualitative research, I explore the nature of important moral concerns related to sharing sickle cell disease information from researchers’ and community members’ points of view; and develop a bottom-up normative analysis around the questions generated. This analysis interweaves community experiences, processes of community reasoning and ex situ normative reflection; placing community views and values centrally while referencing these to wider ethical debates, commentaries and guidelines in the literature. Two main outputs of this thesis are to provide recommendations for information sharing on SCD findings in the genomics study in Kilifi; and to propose a set of key issues to consider for this type of information in other studies and geographic settings. I conclude that researchers have a strong responsibility to share SCD information on affected children with families as a form of ancillary service (validating tests, counselling and care); but less responsibility to actively share carrier information. Concurrent responsibilities are working collaboratively with the Ministry of Health/District General Hospital to plan and implement services for SCD; ensuring counselling services support family stability as far as reasonably possible; and to build forms of community engagement and informed consent that counter risks of diagnostic interpretations of research.