<p>Atherosclerosis is a progressive inflammatory disease that is characterized by the accumulation of lipids, infiltrated cells and fibrous elements in large arteries.</p><p>This thesis focuses on the molecular mechanisms behind foam cell formation and inflammation, two central processes in the development of atherosclerosis. More specific, we studied the effects of proinflammatory cytokines on CXCL16 expression and its role as scavenger receptor on macrophages and smooth muscle cells in atherogenesis. CXCL16 is defined as a chemokine and a scavenger receptor, regulating adhesion and chemoattraction of CXCR6 expressing cells and uptake of oxLDL. We show that the expression of CXCL16 and its receptor CXCR6 are more pronounced in human atherosclerotic lesions compared with non-atherosclerotic vessels. Increased expression of CXCL16 was also seen in atherosclerotic aortas of apoE-/- mice compared with aortas of non-atherosclerotic, age-matched C57BL/6 mice. In vitro, IFN gamma induced CXCL16 expression in primary human monocytes and smooth muscle cells which resulted in an increased uptake of oxLDL. Treatment of mice with IFN gamma also induced CXCL16 expression in atherosclerotic lesions. Thus, we have demonstrated a role for IFN gamma in foam cell formation through upregulation of CXCL16. The expression of CXCR6 was defined to the same regions as for CXCL16 in the lesion, indicating the presence of cells able to respond to CXCL16. Consequently, CXCL16 could serve as a molecular link between lipid metabolism and immune activity in atherosclerotic lesion.</p><p>CD137 belongs to the TNF family and mediates several important processes in inflammation. CD137 is involved in the activation of T cells, NK cells, B cells and monocytes and regulate cytokine production, proliferation and apoptosis in these cells. A limited number of studies have demonstrated CD137 expression on smooth muscle cells and endothelial cells. Our results show that CD137 mRNA is higher expressed in human atherosclerotic lesions compared with unaffected vessels. We found that endothelial cells express CD137 in atherosclerotic lesions and that cultured endothelial cells and smooth muscle cells express CD137 and CD137 ligand in vitro. CD137 was regulated differentially by proinflammatory cytokines (i.e. IFN gamma, TNF alpha, IL-1 beta) and bacterial lipopolysaccharide depending on cell type. Furthermore, we investigated the effects of CD137 signalling, demonstrating that binding of the CD137 ligand to its receptor increases proliferation and migration of smooth muscle cells.</p><p>In summary, this thesis has focused on the expression, regulation and role of CXCL16 and CD137, two genes that have not been described earlier in the concept of atherosclerosis. The findings demonstrate some of the molecular mechanisms involved in vascular inflammation and may increase our knowledge about the development of atherosclerosis.</p>

<p>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. </p><p>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. </p><p>Analysen på meganivån genomfördes utifrån nätverksteorin, teorin om idésystem och socialpsykologi. I analysen på marknadsnivån tillämpades konkurrensstrategier, involveringsteorin, faktorer som påverkar köpbeslut och nätverksteorin. </p><p>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. </p><p>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. </p> / <p>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. </p><p>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. </p><p>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. </p><p>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. </p><p>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. </p>

<p>The main purpose of this thesis was to apply the WHO and NHS palliative care approach to dementia care. </p><p>Thirty-one staff-members in mid-Sweden (studies I and II) and 20 next-of- kin (study IV) were interviewed. In study III, 316 staff-members from dementia care and 121 staff-members from palliative cancer care responded to a questionnaire about family support. The interviews were tape-recorded and analysed with a qualitative phenomenographic (I and II) and a hermeneutic approach (IV). The questionnaires (III) were analysed using qualitative and quantitative content analysis.</p><p>The staff-members stated almost unanimously that daily leadership was lacking, and consequently clear goal formulations and care planning were rare (I). Proper teamwork between the doctor and the staff who worked on a daily basis with the patients was absent (I). With respect to existential issues, education and staff discussions were lacking (II). The staff were at a loss concerning how to deal with these issues. Nevertheless, these issues are central to family-members who have to deal with an existential crisis (IV). Important questions emerged about obligation and guilt, faithfulness, responsibility, and paying back what you once received. Existential isolation could be identified e.g. in the reversal of roles experienced as "being a parent to your parent" and in the burden of "visiting a living dead person". </p><p>There were no routines for bereavement visits. The type of support suggested for dementia family members is partly similar to support in palliative cancer care, but it also differs in other respects such as feelings of guilt because the early signs of the disease are misunderstood, the need for respite because of the long trajectory of dementia diseases, and the occurrence of anticipatory grief because in the late phase family members can no longer make any contact at all with the patient (III).</p><p>A palliative approach can improve the quality of life for the dementia patient and for the family. It can be used as a basis for a clear goal formulation. Some of the suggestions listed in this thesis for improving the quality of care are more a reflection of the need for a change in attitudes rather than the need for substantial budget increases.</p>

<p>Heart failure and left ventricular dysfunction are major causes of morbidity and mortality. In this thesis, metabolic, hormonal, genetic and prognostic aspects of echocardiographically determined left ventricular function were investigated in a fairly large longitudinal population-based study of men. The participants were examined both at age 50 and 70 years and were followed for mortality using the national cause-of-death registry.</p><p>Several factors associated with the insulin resistance syndrome predicted left ventricular systolic dysfunction independent of myocardial infarction, hypertension, diabetes and the use of cardiovascular medication after twenty years follow-up. Plasma levels of N-terminal atrial natriuretic peptide (N-ANP) were significantly increased in men with left ventricular dysfunction in comparison to healthy men. However, the diagnostic accuracy was poor due to the extensive overlapping between the groups. Relations between a haplotype of the novel hUNC-93B1 gene and the E/A-ratio were found and validated in separate samples of the cohort. Myocardial performance index (a Doppler derived index of combined left ventricular systolic and diastolic function) and left ventricular ejection fraction were found to be predictors for cardiovascular mortality independent of traditional cardiovascular risk factors in a longitudinal analysis with a mean follow-up of seven years.</p><p>In conclusion, this thesis showed that left ventricular function is influenced by metabolic, hormonal and genetic factors and that echocardiographic measurements of left ventricular function, such as the myocardial performance index, are strong independent risk factors for cardiovascular mortality in elderly men.</p>

<p>Defects in insulin secretion and insulin action are the major abnormalities in the development of Type 2 diabetes. Hyperinsulinemia is a risk marker for Type 2 diabetes and according to some, but not in all studies also for coronary heart disease (CHD). Conventional insulin assays measure immunoreactive insulin including proinsulin-like molecules. </p><p>Proinsulin and insulin measured by specific methods, insulin sensitivity measured by the euglycemic insulin clamp and early insulin response after a glucose challenge give more detailed information and may be better estimates of true risk for Type 2 diabetes and CHD. </p><p>This study examined relationships between proinsulin, insulin, insulin secretion and insulin sensitivity for the development of Type 2 diabetes and CHD. The investigation of the prognostic significance of proinsulin and insulin for the development of Type 2 diabetes and CHD was performed in prospective studies of 50-year and 70-year-old men in a population-based cohort. The results indicated, that increased proinsulin concentrations, was a marker of increased risk for Type 2 diabetes independent of measurements of insulin secretion and insulin sensitivity whereas insulin was not. Proinsulin was shown to be a predictor for CHD mortality and morbidity, respectively, independent of conventional risk factors, whereas insulin was not. Insulin sensitivity measured by the gold standard euglycemic insulin clamp at age 70 was a predictor of CHD morbidity, independently of established risk factors.</p><p>In summary, these data provide evidence that an increased concentration of proinsulin and not an elevated plasma insulin level per se, that constitutes the association with Type 2 diabetes and CHD and that insulin resistance per se, is associated with CHD risk.</p> / <p>Defekter i insulinsekretionen och insulinkänsligheten i målorganen för insulin är de huvudsakliga orsakerna till utvecklandet av typ-2 diabetes. Förhöjd insulinhalt i blodet indikerar nedsatt känslighet för insulin och är en riskmarkör för typ-2 diabetes men också för hjärt-kärlsjukdom enligt vissa studier.</p><p>Konventionella insulinmätmetoder är ospecifika och mäter immunoreaktivt insulin som förutom insulin också innehåller ett förstadium till insulin, proinsulin.</p><p>Proinsulin och specifikt insulin, insulinkänslighet bestämd med hyperglykemisk insulin clamp teknik och tidigt insulinsvar vid sockerbelastning ger en bättre och mer detaljerad och precis information. Dessa variabler kan därför utgöra en bättre prediktor för typ-2 diabetes och hjärt-kärlsjukdom.</p><p>I denna avhandling har proinsulin, specifikt insulin, tidigt insulinsvar vid sockerbelastning och insulinkänslighet jämförts med varandra som prediktorer för utvecklandet av typ-2 diabetes och hjärt-kärlsjukdom. Två studier har omfattat risken för diabetes och två studier risken för hjärt-kärlsjukdom. Män i medelåldern respektive i högre ålder har studerats. Studierna har utförts i en populations-baserad grupp, en kohort som har sitt ursprung i en stor hälsoundersökning som genomfördes i Uppsala 1970 till 1973.</p><p>Resultaten visar att proinsulin, i motsats till specifikt insulin, är en riskmarkör för utveckling av typ 2 diabetes, oberoende av insulinkänslighet och tidigt insulinsvar vid sockerbelastning. Vidare har visats att proinsulin i motsats till specifikt insulin är en riskmarkör för död respektive sjuklighet i hjärt-kärlsjukdom, oberoende av de kända riskfaktorerna rökning, högt blodtryck och förhöjt kolesterol. Slutligen har visats att insulinkänsligheten i sig är en riskmarkör för hjärt-kärlsjuklighet oberoende av ovanstående riskfaktorer förutom proinsulin.</p><p>Sammanfattningsvis visar resultaten i avhandlingen att det snarare är proinsulinhalten och inte insulinnivån i blodet som står för de observerade sambanden med typ 2 diabetes och hjärt-kärlsjukdom. Nedsatt känslighet för insulin i sig är förenat med ökad risk för hjärt-kärlsjukdom.</p>

<p>Among the great challenges in biology are the precise quantification of specific sets of proteins and analyses of their patterns of interaction on a much larger scale than is possible today. </p><p>This thesis presents a novel protein detection technique - proximity ligation - and reports the development and application of a nucleic acid amplification technique, RCA. Proximity ligation converts information about the presence or co-localization of specific proteins to unique sets of nucleic acid sequences. For detection of target proteins or protein complexes the coincident binding by pairs or triplets of specific protein-binding reagents are required. Oligonucleotide-extensions attached to those binding reagents are joined by a DNA ligase and subsequently analyzed by standard molecular genetic techniques. The technique is shown to sensitively detect an assortment of proteins using different types of binders converted to proximity probes, including SELEX aptamers and mono- and polyclonal antibodies. I discuss factors important for using the technique to analyze many proteins simultaneously.</p><p>Quantification of target molecules requires precise amplification and detection. I show how rolling circle amplification, RCA, can be used for precise quantification of circular templates using modified molecular beacons with real-time detection. The combination of proximity-probe templated circularization and RCA results in a sensitive method with high selectivity, capable of visualizing individual immobilized proteins. This technique is used for localized detection of a set of individual proteins and protein complexes at sub-cellular resolution.</p>

<p>The overall aim of this thesis was to evaluate the outcome when treating children for displaced femoral fractures with external fixation.</p><p>In a consecutive and prospective study during the period 1993-2000, 96 children aged 3-15 years with 98 displaced femoral fractures were treated with external fixation and early mobilisation. The mean age was 8.1 years, the mean hospital stay was 8.7 days and the mean treatment time was 61 days. All fractures healed. Minor complications included pin tract infections (18%), clinical insignificant malunions, heterotopic ossification and two re-reductions. Major complications (6%) included two re-fractures after significant trauma and three plastic deformations after premature fixator removal leading to an osteotomy.</p><p>Radiological evaluation was performed up to one year for the whole group and for a subgroup up to two years. The evaluation showed that malunions were few and prone to remodelling almost completely. Although the fractures were fixated without shortening, as recommended earlier, the overgrowth was far less than expected.</p><p>Isokinetic muscle strength was measured in both hamstrings and quadriceps in 31 of the patients and compared with 31 matched children without previous injury to the legs. Early mobilisation seems to prevent residual muscle weakness previously shown after treatment with traction or cast for femoral fractures in children.</p><p>A cost analysis was performed, comparing three different treatment modalities of femoral shaft fractures: traction in hospital, traction in hospital/at home and external fixation. The analysis included both total medical costs and costs for the care provider. The most important factors were days spent at the hospital and the sick leave for the care provider. Treatment that can minimise these factors will contribute strongly to a lowering of health care costs.</p><p>Conclusion: External fixation of displaced femoral fractures in children can be used as standard treatment in children aged 3-15 years. The treatment provides satisfactory results with a low rate of major complications. Early mobilisation seems to prevent residual muscle weakness. The treatment reduce the number of days in hospital and the number of days of sick leave for the care provider and contributes strongly to lowering health care costs.</p>

<p>Padlock probes are useful in a variety of genetic applications, some of which require that the probes are amplified in order to generate detectable signals. Two general padlock amplification methods, RCA and PCR, are discussed in this thesis.</p><p>The isothermal rolling circle amplification (RCA) mechanism is described in detail as well as how a target strand affects primer extension. A mechanism to resolve the topological constraint imposed by the target strand, to which a padlock probe has been linked, is also discussed. We also present a more powerful amplification technique, termed serial circle amplification, which provides a highly precise tool for nucleic acid studies. Rolling circle products are digested to unit lengths, and each monomer converted to new circular oligonucleotides that can serve as templates in consecutive rounds of RCA. The final products are single-stranded DNA molecules, readily available for hybridization-based detection, for instance using molecular beacons or array hybridization.</p><p>Padlock probes have the potential to be combined in large numbers for parallel gene analysis. A significant improvement of the level of multiplexed genotyping is presented using padlock probes and a molecular inversion strategy. Padlock probes containing common primer sequences along with locus-specific tag sequences were combined in multiplexed ligation reactions. After exonucleolytic selection for circular molecules, the probes were cleaved at uracil residues situated between the primer sequences, which facilitated release from the genomic DNA. A single PCR primer pair amplified all molecularly inverted probes, and the products were finally sorted on microarrays for simultaneous readout. Up to 1,500 genotypes could be detected in parallel, with sufficient signal strength for further scale-up. Finally, an application of the same parallel genotyping strategy is described where a set of padlock probes was used to study tumor induced immune responses. The distribution of TCR Vβ transcripts in tumor infiltrating T-cells and in normal control tissues were investigated in a microarray format.</p>

<p>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.</p><p>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.</p><p>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%.</p><p>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.</p><p>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.</p><p><b>Conclusion:</b> 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.</p>

<p>This dissertation has two parts. Firstly, satisfaction with life as a whole and with 10 life domains (using an instrument termed LiSat-11 with 6-graded scales) is described in a nationally representative sample aged 18-64 years (n: 2,533) and is related to some socio-demographic circumstances. Secondly, vocationally disabled people (n: 109) at an employability institute are prospectively followed in order to determine their life satisfaction and to identify early predictors of vocational rehabilitation outcome.</p><p><u>Main results</u>: Gender independently, 70 % of the national sample were satisfied with life as a whole (were happy). The ten domains formed a 4-factor pattern: ”Closeness, Health, Spare time, Provision”. Seven domains were sizeable predictors of overall life satisfaction. In a complex manner socio-demographics were predictive of (gross levels) all LiSat-11 items. Main predictors were perceived health, immigrant status and educational level. </p><p>Generally, the vocational rehabilitees had low LiSat-11 levels except for the closeness items. They had relatively poor background resources (low “sense of coherence“ level) for successful coping. Whereas a positive rehabilitation outcome was accompanied by increases in several LiSat-11 aspects, only satisfaction with the vocational situation was clearly responsive. Three early predictors of outcome were identified: belief in vocational return, educational level and sense of coherence. </p><p><u>In summary</u>: Besides providing reference values for the LiSat-11 instrument, this dissertation demonstrates that different socio-demographic factors influence different areas of concern (domains) in 18- to 64-year-old Swedes. In turn, satisfaction derived from different areas heavily influences level of overall life satisfaction. Moreover, the vocational rehabilitees generally seemed to be predisposed to being poor copers, possibly a major background of low levels of many LiSat-11 aspects. The identified set of predictors of the outcome of vocational rehabilitation emphasizes a need for focusing on psycho-social aspects within vocational rehabilitation.</p>