Unilateral cortisol producing adenoma (CPA) is the most common cause of ACTH-independent Cushing’s syndrome and is surgically curable. On the other hand, adrenocortical carcinomas (ACCs) are rare and aggressive tumours. Although the overall survival of the patients with ACC is very poor, the outcome can be heterogeneous and vary significantly between the patients. This thesis comprises studies showing genetic and genomic events occurring in CPAs and ACCs, their functional impact and clinical correlations. The Wnt/β-catenin and cAMP/PKA signalling pathways are crucial in adrenal homeostasis and frequent mutations in members of these pathways (CTNNB1, GNAS, and PRKACA) are found in CPAs. Mutational analysis revealed that ~60% of the CPAs harboured mutations in either of these genes. Transcriptome signature exhibited increased expression of genes involved in steroidogenesis in PRKACA/GNAS mutated (Cluster1) tumours in comparison to CTNNB1 mutated /wildtype (Cluster2) tumours. In addition we have also observed that gain of chromosome arm 9q was the most frequent arm level copy number variation (CNV) occurring in CPAs and were exclusively present in Cluster2 tumours. We also discovered novel PRKACA mutations occurring in ACCs, causing activation of cAMP/signalling pathway.    Comprehensive analysis of Wnt/β-catenin signalling pathway in ACCs revealed novel interstitial deletions occurring in CTNNB1 leading to deletion of the N-terminus of β-catenin. This is a novel and yet another frequent event leading to activated Wnt/β-catenin signalling and downstream targets in ACCs. Both, mutations occurring in CTNNB1 and nuclear expression of its protein were associated with poor overall survival. Through multiregional sampling approach we discovered intra-tumour heterogeneity in ACC tumours. Although all the multiregions within a tumour showed presence of shared basal CNVs, they encompassed private CNVs, different ploidy levels and private mutations in known driver genes. We found intra-tumour heterogeneity in CTNNB1, PRKACA, TERT promoter and TP53 mutations as well as ZNRF3 and CDKN2A/2B homozygous deletions.

Diabetes is a condition that is primarily self-managed and lifestyle modifications such as diet, exercise, and weight management are necessary to reduce morbidity and mortality. Motivation to implement lifestyle modifications through self management is an integral part of disease management and studies have shown group medical visits are more effective than individual appointments in this patient population. The purpose of this project was to develop, implement and evaluate an evidencebased group medical visit program for up to a maximum of 8 adult patients with type 2 diabetes in a family practice setting for six months. Seven participants with abnormal A1C results accepted the invitation to attend group medical visits. Here surrounded by peers with the same diagnosis, they were able to learn and discuss methods to self manage their type 2 diabetes. At the conclusion post survey results indicate positive change in some lifestyle behaviors and improvement with hemoglobin A1C. However there was no improvement in weight management. A cost analysis reveals group medical visits may generate a small profit when compared to individual visits. Group medical visits may offer an effective means to motivate patients to make lifestyle change to reduce risk.

The Asian elephant (Elephas maximus), a charismatic ‘flagship species’, is threatened by extinction in the wild, and the development of self-sustainable captive populations is a key conservation challenge. A third of the Asian elephant population is presently in captivity and information on the reproductive status, especially in females, is still lacking to a large extent. The onset of estrus in female Asian elephants is not associated with any visible physical signs, thus making the assessment of the reproductive status rather difficult. One approach to understanding reproductive cyclicity of animals is through generating profiles of reproductive hormones in blood (Wiseman et al. 1983; Brown et al. 1999, 2004). Profiles of reproductive hormones such as progesterone (P4), estrogen, luteinizing hormone and follicle stimulating hormone have already being demonstrated in Asian elephants (Brown et al. 1999, 2004; Brown 2000). In these studies, the reproductive status of females, maintained in zoos/captivity, was characterized based on circulating levels of hormones in blood samples. This is difficult to implement in the case of semi-captive or wild populations of elephants due to practical, legal and ethical considerations. In order to overcome this problem and to better understand the estrous status of female elephants, it is important to develop and validate non-invasive methods to monitor the reproductive status of female Asian elephants. An alternative approach to evaluating the reproductive status of females is to consider behavioral responses shown by males towards chemical signals produced by females to advertise their reproductive status. In order to understand the reproductive status of the individual belonging to the opposite sex, studies have shown that elephants rely on a variety of chemical signals produced in biological fluids such as urine, temporal gland secretion, inter-digital gland secretion, etc. (Krishnan 1972; Rasmussen & Schulte 1998). Chemical signaling is one of the prominent modes of communication in elephants, especially with respect to locating potential mates (Sukumar 2003). Thus, in most cases, elephants usually employ specific behavioral responses, for example sniff, check and place behaviors of trunk, for investigating the reproductive status of the conspecific individual, belonging either to the same or the opposite sex (Rasmussen et al. 1996; Schulte & Rasmussen 1999; Bagley et al. 2006). The objectives of the thesis are two-fold. First, to develop a non-invasive method of reproductive monitoring from fecal hormonal metabolites and also to understand the possible role of feces as an inter-sexual signal. The main body of thesis is divided into four chapters. 1) Development and validation of a non-invasive method to estimate progesterone metabolite in feces, to monitor the reproductive cyclicity of female elephants (Chapter 2). 2)Generation and characterization of progesterone and its metabolite, 5α-P-3-OH, profiles of semi-captive females using the developed non-invasive method to measure fecal metabolites (Chapter 3). 3) Validation of developed methodology and assay systems to a wild-population of female elephants (Chapter 4). 4) Feces as a potential source for inter-sexual chemical signaling in Asian elephants (Chapter 5). The above studies were carried out on semi-captive male and female elephants maintained in the forest camps of Mudumalai Wildlife Sanctuary (MWLS), Tamil Nadu and Bandipur National Park (BNP), Karnataka, India (Chapters 2, 3 and 5). For Chapter-4, free-ranging females of the MWLS were examined. 1. Development and validation of a non-invasive method to estimate progesterone metabolite in feces, to monitor the reproductive cyclicity of female elephants Niemuller et al. (1993) generated a profile of the progesterone metabolite, 5βpregnanetriol, to assess the estrous phase of Asian elephants based on non-invasive urine sampling. However, the collection of urine is difficult and to some extent impossible in the case of semi-captive and as well as that of wild elephants. Thus, the method of choice in this study was the development and validation of a non-invasive approach to measure fecal progesterone metabolites to assess reproductive status of females. Sampling was carried out at monthly intervals on three female elephants at the MWLS forest camp, while three other females maintained at the BNP forest camp were sampled fortnightly. An enzyme linked immuno-sorbent assay was developed to measure the concentration of the progesterone metabolite, 5α-P-3OH in the fecal samples of the semi-captive females. Using varying concentrations of the hapten (5α-P3OH), from low (0.1 mM) to high (1 mM), a standard curve was first generated, which had a linear range between 0.25 mM to 62.5 mM, with an EC50 of 1.37 mM. The linear range was then used to detect the concentrations of 5α-P-3OH in the fecal samples of females examined. The non-invasive method was further validated as there existed a positive correlation (p<0.1) between the levels of fecal 5α-P-3OH and that of concentration of circulating P4, measured in blood samples. This is the first valid documentation of a non-invasive method based on fecal progesterone metabolite pattern in order to assess the reproductive status of the female Asian elephants. 2. Generation and characterization of reproductive hormone profiles of semi-captive females using the developed non-invasive method to measure fecal metabolites With the establishment of a non-invasive method to understand occurrence of estrus in female elephants (described in Chapter 2), attempts were made to generate hormonal profiles over a longer time interval through more frequent sampling. Based on sampling at weekly intervals, the concentrations of both fecal 5α-P-3OH and that of native P4 hormone in the blood were determined, and the females were then identified as belonging to different reproductive states of hormonal cycling (follicular and luteal phases), non-cycling and pregnant categories. Of the 7 females sampled at both MWLS and BNP, three distinct categories of hormone-metabolite profiles emerged. The first category included four females that showed regular cyclicity throughout the sampling period, as monitored through the measurement of fecal 5α-P-3OH and serum P4 levels. The estrous cycle of all the four females was divided into two phases (follicular and luteal), based on the patterns of fecal 5α-P-3OH and serum P4 concentrations. The follicular phase of the estrous cycle was assigned when the values of both fecal 5α-P-3OH and serum P4 remained below 0.3 µg/gm and 0.3 ng/ml, respectively, for a considerable time period (viz. >2 wk). However, the luteal phase was characterized, when the levels of fecal 5α-P-3OH and serum P4 remained at or above 0.3 µg/gm and 0.3 ng/ml respectively, over a period of more than 2 - 3 wk. The second category had two females showing a ‘flat-lining pattern’ for the levels of fecal 5α-P-3OH and serum P4 concentrations, without any peak or dip in their concentrations. Since the reproductive pattern for both these females was flat-lined throughout their sampling period (51 wk), maintaining the levels of fecal 5α-P-3OH and serum P4 below 0.3 µg/gm and 0.3 ng/ml respectively, the females were considered to be non-cycling or anestrus. The third category had one female in which the levels of both fecal 5α-P-3OH and serum P4 measured were consistently high throughout the entire sampling period (26 wk). The levels of both fecal -P-3OH and serum P4 were above 0.3 µg/gm and 0.3 ng/ml, respectively. At the end of the sampling period, this female delivered a male calf; thus, the measured concentrations of fecal 5α-P-3OH and serum P4 signified the levels maintained during the gestational phase of this female. Sampling and hormonal analyses were also carried out for a male in the MWLS forest camps to investigate the baseline concentrations of fecal 5α-P-3OH and serum P4. The male showed consistently low concentrations of both fecal 5α-P-3OH and serum P4 throughout the sampling period (16 wk), below the margin of 0.3 µg/gm and 0.3 ng/ml, respectively. In this part of the study, it was confirmed that the reproductive status of a female elephant can be correctly assessed on the basis of measurements of fecal 5α-P-3OH alone, with repeated sampling of the female over a longer time scale. It was also shown that the strength of the positive correlation between the concentrations of the fecal 5α-P3OH and the serum P4 increased (p<0.01) for a larger sample size than that obtained for a comparatively smaller sample (described in Chapter 2). 3. Validation of developed methodology and assay systems to wild-population of female elephants So far, the non-invasive method to estimate fecal progesterone metabolite in order to predict occurrence of estrus of elephants was largely applied to semi-captive females (described in Chapters 2, 3). However, the necessity of such a method is being recognized for assessing the reproductive status of free-ranging females. Several findings have described differences in the rate and type of steroid metabolite excretion among individuals maintained under different diet regimes (Wasser et al. 1993; Smith et al. 2006). For instance, female elephants in the forest camps are provided with supplementary diet consisting of sugarcane, rice and millets. This diet is strikingly different from the feeding materials consumed by wild/free-ranging elephants (Sukumar 2003). Therefore, differences in dietary components can potentially influence the fecal steroid metabolites’ excretory patterns shown by semi-captive vis-a-vis wild females, which can affect the validity of measuring fecal 5α-P-3OH to predict females’ reproductive status. In order to examine this problem, the non-invasive method was applied to the population of wild elephants in the forests of MWLS, through random one time sampling of 30 individual female elephants. The steroid extraction efficiency (73 ± 11.0%, mean ± S.D., n =30) determined for the fecal samples collected from the wild females was not significantly different from the coefficient calculated in the case of the semi-captive females (80 ± 4.3%, mean ± S.D., n = 38). This indicated that dietary differences between wild and captive elephants did not influence levels of fecal hormonal metabolites in feces, unlike earlier observations on baboons (Wasser et al. 1993), old world primates (Wasser et al. 1988) and sheep (Smith et al. 2006). The values of the fecal allopregnanolone determined in the case of the wild females, ranged from as low as 0.06 µg/gm to as high as 23µg/gm of the sample, thus showing the heterogeneity of the samples, indicating that the females may be belonging to different reproductive phases. However, since sampling was carried out randomly, with an adult female being sampled just once, at this stage, it is not possible to identify or elaborate on the reproductive phase of the females. This is the first study reporting the values of the fecal progesterone metabolite in female Asian elephants in the wild. Further studies may be required to carry out long term monitoring of the wild females, through repeated collection of fecal samples over time from particular female. 4. Feces as a potential source for inter-sexual chemical signaling in Asian elephants In this Chapter-5, behavioral trials were conducted on male elephants to understand the role of fecal matter in conveying inter-sexual chemical signals. This was demonstrated by analyses of specific chemosensory behavioral responses shown by males towards the fecal samples of females that were strangers and belonging to different reproductive stages. Males showed four prominent behavioral responses namely ‘distant sniff’, ‘close sniff’, ‘check’ and ‘place’ towards the fecal samples of females. The sum of frequencies of these four responses (distant sniff, close sniff, check and place) was much higher for samples of the follicular (pre-ovulatory) phase females as compared to those of the luteal (post-ovulatory) phase females (p<0.005). Thus, for the first time, it was shown that male elephants are able to discriminate the different reproductive phases of females based on their specific behavioral response towards the fecal samples of the opposite sex. In conclusion, the thesis has focused on understanding and providing new insights regarding the reproductive biology of the female Asian elephants. This has been achieved through the development of the non-invasive method based on measuring the concentrations of the fecal progesterone metabolite and through the analyses of the chemosensory responses performed by the males towards the fecal samples of strange females. These methods can potentially be applied to the populations of both wild and captive/semi-captive female elephants in order to evaluate their reproductive status, through non-invasive measures. The information derived from the application of such methods will help in understanding the reproductive potential of the wild elephants under various environmental and ecological conditions. Further, the non-invasive measurement of reproductive hormones will help in monitoring the reproductive state of the individuals and thus aid in planning strategies for the welfare and management of the elephants maintained in captive or semi-captive conditions.

Adolescent athletes with type 1 diabetes (T1DM) face unique challenges when compared to peers with and without diabetes. Continuous subcutaneous insulin infusion (CSII) provides a method of insulin delivery that can enhance flexibility in insulin regimens and lifestyle that may be especially appealing to the adolescent athlete. No studies have explored the impact of athletics in this population. This descriptive qualitative study explored and described the experiences of adolescent athletes using CSII as their primary insulin delivery method, with a focus on athletic participation and performance. The purposeful sample consisted of four adolescent athletes, ages 13 to 15 years with T1DM, using CSII, in excellent diabetes control, and recently participated in organized sports activities. After written informed consent, data were collected through a semi-structured interview with the adolescent and parent. Results were transcribed verbatim and analyzed for emerging themes. Four themes emerged from the transcripts along with multiple subcategories. The main themes included: protecting the pump and infusion site; dealing with highs and lows; maximizing participation and performance; and keeping watch. Information gathered from this study will prepare healthcare professionals to anticipate the needs of adolescent athletes using CSII when prescribing a diabetes management regimen.

This thesis project will investigate the effects of fasting on the serum levels of two key regulatory hormones, insulin and thyroid hormone (T3) and the effects of these hormones on the trafficking of Glut4 on soleus muscle.

Introduction: The late menopausal transition is a time of increased risk of depression in the general population. Nonetheless, mood course during the late menopausal transition in women with bipolar disorder in relatively unknown. Methods: Mood state data in 519 reproductive age women (5989 clinic visits), 116 late menopausal transition (perimenopausal) women (2046 visits), and 133 postmenopausal women (1,437 visits) with bipolar disorder who were receiving optimized naturalistic treatment in the multisite STEP-BD study over an average of 19.8±15.5 months were analyzed for proportion of clinic visits with syndromal depression, mood elevation and euthymia between the three groups. History of postpartum and perimenstrual mood exacerbation as well as hormone therapy use were evaluated as potential predictors of mood. Results: No significant difference in the proportion of clinic visits with syndromal depression was found between reproductive age (18.1%), perimenopausal (18.1%) and postmenopausal (19.3%) women. Reproductive age women had significantly greater proportion of visits with syndromal mood elevation (5.3%) compared to perimenopausal (4.1%, Z=2.1, p2(3, N = 9960) = 19.8, p Conclusions: While proportion of clinic visits with syndromal depression did not differ among the three reproductive groups, thirteen women who had recorded transition from perimenopause to postmenopause showed significantly greater depression than reproductive age, perimenopausal or postmenopausal women. Proportion of visits with euthymia or with syndromal mood elevation decreased from reproductive age to perimenopausal to postmenopausal women. Reported history of mood exacerbation during times of hormonal fluctuation, or current use of hormone therapy, was not significantly associated with depression during the perimenopause. Limitations include women excluded due to absence of menstrual data. Future studies should include hormonal assessments.

Background: Puerto Ricans experience high prevalence of type 2 diabetes (diabetes). Stress is a risk factor for diabetes. The allostatic load (AL) model explains how stress influences disease through a chain of physiological changes. Puerto Ricans experience psychological and physiological (obesity and high glycemic load (GL)) stressors linked with diabetes, yet how these stressors impact the AL chain and how their interplay affects glucose metabolism remains unknown. Methods: Using data from the Boston Puerto Rican Health Study, this thesis sought to examine: 1) the relationship between GL and primary AL markers, 2) the interaction between perceived stress and GL on HbA1c, and if primary AL markers mediate this interaction, and 3) the interaction between change in weight and in perceived stress on HbA1c. Results: 1) GL change over 2 years was associated with increases in primary AL markers in women. 2) Women with high perceived stress and high GL had higher HbA1c and primary AL markers did not mediate this interaction. 3) In women, there was an interaction between change in weight and perceived stress on HbA1c over 2 years, with the effect of weight change on HbA1c being greater with increases in perceived stress. None of these associations were observed in men. Conclusion: This study partially confirms the AL model in Puerto Rican women but not in men. It provides data to inform intervention targets to prevent and manage diabetes in Puerto Rican women and identifies women at high risk of diabetes in this minority group.

Bakgrund: I Sverige är det cirka 50 000 personer som lever med diabetes mellitus typ 1. Det är en kronisk komplex sjukdom som kräver livslång behandling.  Sampel med vården krävs under hela sjukdomsförloppet där en god vårdrelation blir betydande. Självkännedom och god självkänsla underlättar för egenvården eftersom det handlar om att kunna se de egna styrkorna för en god hanteringsförmåga av sjukdomen. Syfte: Syftet var att beskriva erfarenheter av egenvård hos unga vuxna med diabetes mellitus typ 1.  Metod: En kvalitativ litteraturöversikt med induktiv ansats har gjorts. Resultatet baseras på 12 vetenskapliga artiklar. Resultat:  Två huvudteman framkom i resultatet och ett av de var utmaningar med fyra underteman: rädsla och oro, begränsningar, övergång till vuxen livet och hur vardagen kan påverka egenvården. Andra huvudtemat var socialt stöd med tre underteman: stöd från familj och vänner, vårdpersonalens betydelse och okunskap från omgivningen påverkar egenvården. Slutsatser: Stöd från familj och vänner var av stor betydelse när det gällde hur de unga vuxna med diabetes mellitus typ 1 skötte egenvården. Vårdpersonal hade ett stort ansvar i att stötta och vägleda personer till egenvård. Utomståendes okunskap kunde leda till försämrad egenvård för personerna. / Background: In Sweden there are about 50 000 people living with diabetes mellitus type 1. It is a chronic complex disease and demands a lifelong treatment. Teamwork with the healthcare is required throughout the course of the disease and a good relationship with the health care providers becomes significant. Self-awareness and good self-esteem facilitate self-care when it comes to being able to see one’s own strengths for a good management ability of the disease. Aim: The aim was to describe experiences of self-care among young adults with diabetes mellitus type 1. Method: A qualitative literature research that has an inductive design has been done. The results are based on twelve different scientific articles. Results:  Two main themes have emerged in results and one of them was challenge with four sub themes: fear and anxiety, limitations, transitions to adult life and how daily life can affect self-care. The other main theme was social support with three sub themes: support from family and friends, the importance of healthcare professionals and lack of knowledge by others that affects self-care. Conclusion:  Social support from family and friends was important when it comes to how young adults with diabetes mellitus type 1 managed self-care. Healthcare professionals have a big responsibility in supporting and guiding people to self-care. Lack of knowledge from others could lead to mismanagement of self-care.

Developing a tissue-engineered Blood Vessel Mimic (BVM) to represent diabetic macrovascular disease could expedite design of new vascular devices specifically tailored to diabetic patients. In contribution toward this model, this thesis assessed Human Umbilical Vein Endothelial Cell (HUVEC) responses to high glucose conditions. Interleukin 6 (IL-6) and Cluster of Differentiation 36 (CD36) were selected to signify oxidative stress activity, a hallmark of diabetic macrovascular disease. Next, activity of potential reference genes B2M, HPRT1, and ACTB was assessed. All genes were found to exceed acceptable variability, so the E-ΔC T method of data analysis was selected. Next, cellular responses to high glucose treatment at 10.5 mM glucose and 25.5 mM glucose for 7 and 14 days were measured by qPCR. IL-6 mRNA expression increased significantly (p<0.001) following treatment with 25.5 mM glucose at both timepoints. Finally, fluorescent staining for Reactive Oxygen Species (ROS) production and cell viability was performed on HUVECs treated with 10.5- and 25.5-mM glucose for 24 and 48 hours. No differences in ROS production or cell viability were detected due to uncontrolled cell damage during the two-hour staining and imaging procedure. This thesis was limited by low reaction efficiency in qPCR reactions due to mistaken purchasing of primers with included probe-quencher reporters. Measurement of reaction efficiency facilitated valid analysis of data collected using these primers. Imaging experiments were unsuccessful due to a lack of incubation equipment designated for cells undergoing live staining and imaging. Alternative imaging assessments of oxidative stress activity were proposed to circumvent this problem.

A web installation that uses blood glucose levels uploaded by diabetics to create music. Available at https://radiodiabetes.eu / En webbinstallation som låter diabetiker ladda upp sina blodsockervärden och skapar musik av dessa. Tillgänglig på https://radiodiabetes.eu