Background Chronic myeloid leukemia (CML) is a relatively rare hematological malignancy with a constant incidence of approximately 90 new cases each year in Sweden (0.9 cases/100 000 inhabitants). The etiology is largely unknown but high doses of ionizing radiation are a known but rare risk factor. The treatment options were for a long time limited to chemotherapies i.e. hydroxyurea and busulfan, interferon’s and allogeneic hematopoietic stem cell transplantation and the median survival were only about four years. Since the beginning of the 21st century a new way of treating CML has been introduced, the tyrosine kinase inhibitors (TKI), leading to a rapid decrease in leukemic cells and symptoms. Due to the TKIs, the overall 5-year survival is nowadays approximately 85 % and CML patients have time to develop other diseases, including other malignancies. The aims of this thesis was to investigate the present and future prevalence of CML and the prevalence of other malignancies prior and subsequent to the diagnosis of CML, malignancies among first-degree relatives of persons with CML. In addition, the incidence of autoimmune and chronic inflammatory diseases among patients with CML was also investigated.   Methods From the Swedish CML register, data over nearly all Swedish CML patients from 2002 and forward were obtained for paper II-IV. For paper I, the Swedish cancer register was used to identify all Swedish CML patients since 1970 and the Swedish cause of death register was used to identify an eventual date of death for these patients. With a constant incidence and the relative survival rates for CML patients between 2006 and 2012 as a model, the present and future prevalence was calculated. For paper II-IV, data from the Swedish cancer register was used to identify other malignancies than CML. For paper II, information about autoimmune and chronic inflammatory diseases was retrieved from the Swedish national patient register. For paper II and IV, five controls matched for year of birth, gender and county of residence were randomly selected from the Swedish register of the total population. To calculate odds ratio (OR), conditional logistic regression was used. To calculate the risk of a second malignancy for paper III, Standardized incidence ratio (SIR) was used. In paper IV, first-degree relatives (parents, siblings and offsprings) for both cases and controls were retrieved from the Swedish multi-Generation Register, where persons born later than 1932 and registered in Sweden at some time since 1961 are registered.   Results Prevalence and survival As shown in paper I, the 5-year overall survival for CML patients increased remarkably from 0.18 to 0.82 between 1970 and 2012. The prevalence increased from 3.9 to 11.9 per 100 000 inhabitants in Sweden between 1985 and 2012. By assuming no further improvements in relative survival as compared to the survival rates between 2006 and 2012, the prevalence by 2060 is expected to increase to 22.0 per 100 000 inhabitants. This corresponds to 2 587 CML patients as compared to 1 137 CML patients in 2012.   Malignancies, autoimmune and chronic inflammatory diseases prior to CML In study II, more than 45 000 person-years of follow-up were evaluated in 984 CML patients diagnosed between 2002 and 2012. With an OR of 1.47 (95 % CI 1.20–1.82) and 1.55 (95 % CI 1.21–1.98), respectively, the prevalence of prior malignancies and autoimmune diseases were significantly increased as compared to matched controls. On the other hand, no association between CML and chronic inflammatory diseases was shown.   Second malignancies In 868 CML patients, diagnosed between 2002 and 2011, 52 malignancies were observed in the Swedish cancer register, as shown in paper III. When compared to expected rates in the background population, a significantly increased risk of second malignancies with a SIR of 1.52 (95 % CI 1.13–1.99) was shown. When looking at specific cancer types, gastrointestinal as well as nose and throat cancer were significantly increased.   Familial aggregation of malignancies 984 CML patients were identified in paper IV. However, 184 had a birth date prior to 1932, subsequently only 800 patients were analyzed. Among them, 4 287 first-degree relatives were identified, compared to 20 930 first-degree relatives of the matched controls. 611 malignancies were retrieved; no significant increase of malignancies in first-degree relatives of CML patients was shown (OR 1.06; 95 % CI: 0.96–1.16).   Conclusion Since CML patients nowadays have a high survival rate, the calculations in this thesis shows that the prevalence of CML will almost double by 2060. CML patients have an increased risk of developing malignancies prior and subsequent to the diagnosis of CML, suggesting a hereditary or acquired predisposition to develop cancer. Since there is no familial aggregation of malignancies in CML patients, a hereditary predisposition to develop cancer is unlikely to be part of the pathogenesis of CML, leaving an acquired predisposition more likely.

Chronic myeloid leukaemia (CML) is characterised by the constitutively active tyrosine kinase BCR-ABL. Standard treatment with tyrosine kinase inhibitors (TKI) in the chronic phase (CP) of CML conveys excellent long-term prognosis but is associated with side effects and costs. Treatment free remission (TFR) is possible in a proportion of patients discontinuing treatment after obtaining deep treatment responses but it is not fully known how to select the right patients for stopping attempts. Treatment of accelerated phase (AP) and blast crisis (BC) is more complicated and the prognosis more dismal. In this thesis, we have studied factors of importance for outcome in CML patients with focus on immunological factors and clinical management. In a cohort of 32 newly diagnosed CP-CML patients, evidence of active immune escape mechanisms were found. These declined with the course of TKI treatment and at the same time, effector lymphocyte responses were elicited. These anti-leukaemia immune responses might help in the long-term control of CML. Multiple plasma protein markers were also measured with three multiplex platforms in a smaller cohort of patients (n=14). Inflammatory cytokines and other plasma proteins were affected by TKI treatment and multiplexing seems useful for finding potential biomarkers with biologic or prognostic significance in CML. Patients progressing to AP/BC were studied in a population-based material from the Swedish CML register. Approximately 4% of TKI-treated CP-CML patients transformed to AP/BC within 2 years of diagnosis. Monitoring of treatment responses was suboptimal in 1/3 of these patients and the median survival was 1.4 years after diagnosis of AP/BC. Thus, minimising the risk of disease progression through strict adherence to guidelines for monitoring and treatment is essential. In a cohort of patients (n=50) discontinuing TKI treatment within a large European trial, musculoskeletal pain was reported by 30% of patients, starting within 1- 6 weeks of TKI discontinuation and spontaneously resolving over time in most cases. Patients (n=56) were also evaluated with a multiplex platform with a total of 162 inflammation- and cancer-related plasma proteins. No predictive protein biomarkers for successful TKI discontinuation could be found. However, profound effects of TKI-treatment were seen and plasma proteomics could be useful for understanding effects of long-term TKI-treatment.

Hematopoietic stem cells (HSCs) have historically been difficult to maintain ex vivo with many attempts to culture them in vitro by mimicking their natural biological environment. Providing a hypoxic environment is one way to achieve this goal and can be performed by using hypoxia stimulating compounds that inhibits the degradation of HIF1a which plays an important role in regulating hypoxia. For each sample 50 murine HSCs were isolated with fluorescence-activated cell sorting (FACS) and cultured with different concentrations of the hypoxia inducible compound Adaptaquin for 13 days followed by analysing with flow cytometry. The results showed an increase in proliferation of treated cells with the highest average total viable cell count for cells treated with 100 nM Adaptaquin of 4,70 ± 1,12 x 105 cells compared to the control which had 2,39 ± 0,76 x 105 cells. The HSC frequency was highest in the control samples with an average of 1,91 ± 0,42 % compared to the 5 mM treated samples with the highest average HSC frequency which was 1,52 ± 0,82 %. The biggest noticeable difference between the control and treated samples was seen when observing the total cell count. The difference in proliferation was on the other hand too small to see significant difference between the samples. The conclusion is that Adaptaquin did not have any significant impact on keeping the cells undifferentiated but could have a potential to be used as a compliment to other factors to maintain HSCs in vitro and to mimic its hypoxic biological environment. / Hematopoetiska stamceller (HSCs) har historiskt sett varit svåra att odla ex vivo och många försök har genomförts in vitro genom att efterlikna deras naturliga biologiska miljö. Att tillhandahålla en hypoxisk miljö är en metod för att uppnå detta och kan göras med användning hypoxi-stimulerande substanser som hämmar nedbrytningen av HIF1a som spelar en viktig roll i regleringen av hypoxi. För varje prov isolerades 50 murina HSCs med fluorescence-activated cell sorting (FACS) och odlades med olika koncentrationer av det hypoxi-inducerande ämnet Adaptaquin under 13 dagar följt av analys med flödescytometri. Resultaten visade en ökning i avseende på proliferationen hos behandlade celler där det högsta genomsnittliga totala antalet levande celler behandlade med 100 nM Adaptaquin som var 4,70 ± 1,12 x 105 celler jämfört med kontrollen som hade 2,39 ± 0,76 x 105 celler. HSC-frekvensen var högst i kontrollproverna med ett genomsnitt på 1,91 ± 0,42 % jämfört med proverna behandlade med 5 mM Adaptaquin som hade den högsta genomsnittliga HSC-frekvensen som låg på 1,52 ± 0,82 %. Den största synliga skillnaden mellan kontroll- och behandlingsprover var synlig när det observerade totala antalet celler jämfördes mellan behandlade prover som i genomsnitt hade fler totala celler. Skillnaden i proliferation var å andra sidan för liten för att se en signifikant skillnad mellan proverna. Slutsatsen är att Adaptaquin inte hade någon signifikant påverkan på att hålla HSCs odifferentierade men kan ha potential att användas som ett komplement till andra faktorer för att odla HSCs in vitro och efterlikna dess hypoxiska biologiska miljö.

Allt mer forskning kring digitala bildanalysplattformar sker då de har visat lika bra eller bättre prestation än existerande manuella och automatiserade metoder samt effektiviserat handläggningstiden för patientprov. Nyligen har företaget CellaVision utvecklat ett prototypprogram som via bildanalys kan räkna och klassificera retikulocyter. Syftet med studien var att jämföra noggrannheten och precisionen av CellaVisions prototypprogram för retikulocytnumrering med manuell mikroskopering och en automatiserad cellräknare. Totalt 40 blodutstryk tillverkades av 20 blodprov med abnormala värden retikulocyter (>2,5%) och 20 med normala värden retikulocyter (0,5-2,5%). Blodutstryken analyserades med prototypprogrammet, manuell mikroskopering och den automatiserade cellräknaren varpå retikulocytkoncentrationen för respektive resultat jämfördes med Pearsons korrelationstest och Bland-Altmananalys. Blodutstryk tillverkades av tre nivåer retikulocytkontroller och analyserades flertal gånger med prototypprogrammet vars retikulocytkoncentration jämfördes med andra metoders retikulocytkoncentrationer. Samma blodutstryk analyserades med olika antal inskannade celler för att utvärdera hur variationen påverkades. Resultaten från komparabilitetsstudien visade att prototypprogrammet erhöll en utmärkt korrelation och en god överensstämmelse med de andra metoderna. Precisionsstudien visade att prototypprogrammet erhöll konsekventa retikulocytkoncentrationer vid repeterade analyser och en låg variationskoefficient (0,25-10%) vid högre antal inskannade celler vid tre olika nivåer av retikulocytkontroller. Resultaten visar CellaVisions prototypprogram designat för retikulocyträkning erhåller en god noggrannhet och en hög precision vid jämförelse med manuell mikroskopering och en automatiserad cellräknare, dock behöver större studier utföras då antalet patientprov var begränsade. / More and more research on digital image analysis platforms is taking place as they have shown to have as good or better performance than existing manual and automated methods and have also streamlined the processing time for patient samples. Recently, the company CellaVision has developed a prototype program that can enumerate and classify reticulocytes via image analysis. The purpose of the study was to compare the accuracy and precision of CellaVision's prototype program for reticulocyte numbering with manual microscopy and an automated cell counter. A total of 40 blood smears were made from 20 blood samples with abnormal reticulocyte values (>2,5%) and 20 with normal reticulocyte values (0,5-2,5%). The blood smears were analysed with the prototype program, manual microscopy, and the automated cell counter, after which the reticulocyte concentration for each result was compared with Pearson's correlation test and Bland-Altman analysis. Blood smears were made by three levels of reticulocyte controls and analysed several times with the prototype program whose reticulocyte concentration was compared with the other methods' reticulocyte concentrations. The same blood smears were analysed with different numbers of scanned cells to evaluate how the variation was affected. The results of the comparability study showed that the prototype program obtained an excellent correlation and a good agreement with the other methods. The precision study showed that the prototype program obtained consistent reticulocyte concentrations in repeated assays and a low coefficient of variation (0,25-10%) in higher numbers of scanned cells at three different levels of reticulocyte controls. The results showed the CellaVision's prototype program designed for reticulocyte counting obtained good accuracy and high precision when compared with manual microscopy and an automated cell counter, however, larger studies need to be performed as the number of patient samples was limited.

The presence of TP53 mutations has been associated with inferior outcome in diffuse large B-cell lymphoma (DLBCL) and chronic lymphocytic leukemia (CLL). In DLBCL, the impact of the TP53 codon 72 polymorphism and MDM2 SNP309 has not been clearly elucidated, whereas MDM2 SNP309 was suggested as a poor-prognostic marker in CLL. In addition, p16INK4a promoter hypermethylation has been implicated as a negative prognostic factor in DLBCL. The aim of this thesis was to further evaluate these molecular markers in well-characterised materials of DLBCL and CLL. In paper I, we investigated the prognostic role of TP53 mutation, codon 72 polymorphism and MDM2 SNP309 in DLBCL (n=102). The presence of TP53 mutations (12.7%) correlated with a poor lymphoma-specific and progression-free survival, and a particularly pronounced effect was observed in the germinal center subtype. Neither the MDM2 SNP309 nor the TP53 codon 72 polymorphism had an impact on age of onset or survival. In paper II, we applied pyrosequencing to measure the level of p16INK4a methylation in DLBCL (n=113). Thirty-seven percent of cases displayed p16INK4a methylation; however, no clear association could be observed between degree of methylation and clinical characteristics or lymphoma-specific survival. In papers III–IV, we investigated the prognostic role of MDM2 SNP309 (n=418) and TP53 mutation (n=268) in CLL. No correlation was observed between any particular MDM2 SNP309 genotype and time to treatment and overall survival. Furthermore, no association was found between the different MDM2 SNP309 genotypes and established CLL prognostic markers. TP53 mutations were detected in 3.7% of CLL patients; where the majority showed a concomitant 17p-deletion and only three carried TP53 mutations without 17p-deletion. We confirmed a significantly shorter overall survival and time to treatment in patients with both TP53 mutation and 17p-deletion. Altogether, our studies could confirm the negative prognostic impact of TP53 mutations in DLBCL, whereas MDM2 SNP309 and TP53 codon 72 polymorphisms appear to lack clinical relevance. We also question the role of p16INKa methylation as a poor-prognostic factor in DLBCL. Finally, the presence of TP53 mutation in CLL appears to be rare at disease onset and instead arise during disease progression.

Chronic lymphocytic leukemia (CLL) is a heterogeneous malignancy displaying varying clinical outcome, where molecular markers today can divide patients into prognostic subgroups. Despite the introduction of new agents for treatment, remissions are usually not sustained in CLL and resistance towards treatment can partly be explained by aberrant apoptosis. The aim of this thesis was to find new drugs for CLL patients resistant to conventional therapy and to analyze genes involved in apoptosis within different prognostic subgroups. In paper I-II, the in vitro activity of substances was investigated using the fluorometric microculture cytotoxicity assay (FMCA). When evaluating rapamycin (paper I), an inhibitor of mTOR, in 97 tumor samples from different entities, CLL was found to be one of the most sensitive tumor types. Combination experiments on patient CLL cells indicated that rapamycin acted synergistically with the CLL drugs vincristine and chlorambucil. An investigation of 20 anti-cancer agents in cells from 40 CLL patients (paper II) revealed that prednisolone and rolipram displayed high activity in poor-prognostic patients, in particular IGHV unmutated CLL. Furthermore, when used in combination these agents were found to produce a synergistic effect. In paper III, the anti-apoptotic BCL2 family member BFL1 was evaluated in 37 CLL cases. Levels of BFL1 were higher in fludarabine-resistant patients compared to fludarabine-sensitive patients. In addition, the high expression of BFL1 inversely correlated to fludarabine-induced apoptosis in CLL cells. A single nucleotide polymorphism in the anti-apoptotic BCL2 gene (-938C>A) has been suggested as a novel poor-prognostic marker in CLL. In paper IV, we investigated this BCL2 polymorphism in 268 CLL patients and correlated genotypes to clinical data. However, no association could be confirmed between this polymorphism and clinical outcome or established prognostic markers. In conclusion, this thesis has shown that rapamycin is a potential drug for treatment in CLL. Furthermore, prednisolone and rolipram were identified as interesting candidates for treatment of poor-prognostic patients. Finally, the anti-apoptotic protein BFL1 may contribute to chemoresistance and hence represents a potential therapeutic target in CLL, whereas from our data, the BCL2 -938C>A polymorphism does not appear to have any prognostic significance.

The clinical course of chronic lymphocytic leukemia (CLL) is highly heterogeneous, which has prompted the search for biomarkers that can predict prognosis in this disease. The IGHV gene mutation status and certain genomic aberrations have been identified as reliable prognostic markers of clinical outcome for this disorder. However, the search for more feasible prognostic markers in CLL is still being pursued. Recently, certain single nucleotide polymorphisms (SNPs) in the GNAS1, BCL2 and MDM2 genes and the RNA expression levels of the LPL, ZAP70, TCL1, CLLU1 and MCL1 genes were suggested as novel prognostic markers in CLL. In papers I-III, we performed genotyping analyses of the GNAS1 T393C, BCL2 -938C>A and MDM2 SNP309 polymorphisms in 268-418 CLL patients and related the genotypes with clinical data. Association studies between the polymorphisms and established prognostic markers (i.e. IGHV mutation status, genomic aberrations, CD38 expression) were also performed. Our studies did not find any significant relationship between these SNPs with either clinical outcome or other known prognostic markers in CLL. In paper IV, we measured the RNA expression levels of LPL, ZAP70, TCL1, CLLU1 and MCL1 in 252 CLL cases and correlated these levels with clinical outcome. Here, we verified that high expression of all these RNA-based markers, except MCL1, were associated with an unfavourable prognosis. We also confirmed a close relationship between IGHV mutation status and the RNA-based markers, especially for LPL and CLLU1 expression. Among the RNA-based markers, multivariate analysis revealed LPL expression as the strongest independent prognostic marker for overall survival and time to treatment. Furthermore, the RNA-based markers could add further prognostic information to established markers in subgroups of patients, with LPL expression status giving the most significant results. In summary, data from papers I-III could not verify the GNAS1 T393C, BCL2 -938C>A and MDM2 SNP309 polymorphisms as prognostic markers in CLL. Future SNP markers must hence be confirmed in large, independent cohorts before being proposed as prognostic marker in CLL. In paper IV, we conclude that LPL expression appears to be the strongest among the RNA-based markers for CLL prognostication. Further efforts to standardize LPL quantification are required before it can be applied in the clinical laboratory to predict clinical outcome in this disease.

Bakgrund - Hemofili A och B är X-kromosombundna blödarsjukdomar, som beror på genetiska avvikelser i de gener som kodar för koagulationsfaktor VIII respektive IX. I dagsläget förlitar sig hemofilipatienter på kontinuerliga intravenösa injektioner med faktorkoncentrat, för att förhindra att potentiellt livshotande blödningar uppstår. Genterapi med rekombinanta adeno-associerade virus (AAV) skulle kunna erbjuda ett kurativt behandlingsalternativ, genom införandet av friska arvsanlag i hepatocyter. Syfte - Syftet med den här litteraturstudien var att undersöka huruvida genterapi medierad av AAV-vektorer är en effektiv och säker behandling mot hemofili A och B ur ett långsiktigt perspektiv. Metod - Studien är genomförd som en systematisk litteraturstudie och är baserad på sex originalartiklar framsökta via databasen PubMed, med sökorden "hemophilia AND gene therapy". Specificerade sökkriterier användes för att underlätta relevansbedömning och valet av artiklar. Resultat - En ökad endogen koagulationsfaktorproduktion kunde påvisas hos majoriteten av studiedeltagarna efter genterapibehandlingarna. Sammantaget observerades också en väsentlig blödningsreducering och en minskad faktorkoncentratanvändning. Störst förbättring noterades i de kohorter som erhållit högre genterapidoser eller den muterade faktor IX Padua-genen. Ingen immunrespons mot transgenprodukten detekterades i någon studie. Däremot sågs ett humoralt immunsvar mot AAV-kapsiden hos samtliga studiedeltagare. En mycket stor variation i T-cellssvar mot AAV-kapsiden kunde noteras. Förhöjda nivåer av alaninaminotransferas (ALAT) var den vanligast förekommande incidenten, men samtliga fall kunde framgångsrikt behandlas med glukokortikoidpreparat. Slutsats - Genterapibehandling med rekombinanta AAV-vektorer mot hemofili A och B förefaller effektiv och säker. Förhöjda ALAT-nivåer återstår dock som en behandlingsproblematik. Längre uppföljningar av fler genterapibehandlade hemofilipatienter krävs, för att kunna dra några definitiva slutsatser, väga risker mot nytta, samt optimera och individanpassa doser. / Background - Hemophilia A and B are X-linked bleeding disorders, resulting from defects in the genes encoding coagulation factors VIII and IX respectively. The current treatment for hemophiliacs entails frequent intravenous injections of coagulation factor concentrates, to prevent potentially life-threatening hemorrhages. Gene therapy utilizing recombinant adeno-associated viruses (AAV) could offer a potentially curative treatment option through the introduction of healthy genes into hepatocytes. Aim - The aim of this literature study was to investigate the long-term efficacy and safety of AAV vector-mediated gene therapy for the treatment of hemophilia A and B. Methods - The study is conducted as a systematic literature study and is based on six original articles retrieved from the search engine PubMed, using the key words "hemophilia AND gene therapy". Specific search criteria were used to facilitate the relevance assessment and selection of articles. Results - An increased endogenous coagulation factor synthesis was noted in the majority of the study participants after the gene therapy. Overall, a significant reduction in bleeding episodes and the use of factor concentrates were observed. The greatest improvements were noted in the cohorts that received the higher gene therapy doses or the mutated factor IX Padua gene. None of the study participants had an immunologic response to the transgene product. A humoral immune response against the AAV capsid was seen in all participants though. Large differences in AAV capsid-specific T-cell activation were observed. The most common adverse event was an elevation in the alanine aminotransferase (ALT) level. However, these events could be controlled with glucocorticoids. Conclusions - AAV vector-mediated gene therapy for the treatment of hemophilia A and B had a positive efficacy and safety profile. Although increased ALT levels remain a concern. Monitoring of larger numbers of study participants for longer follow-up periods is necessary for any definite conclusions to be drawn, to weigh risks against benefits and to optimize individual dosing.

I dagsläget är introduktionsutbildningen för sjuksköterskorna på kliniken för hematologi på Karolinska Universitetssjukhuset otillräcklig vilket kan bidra till en äventyrad patientsäkerhet. Kliniken hoppas på att, med hjälp av ett interaktivt nätbaserat lärverktyg, kunna effektivisera sjuksköterskornas interna utbildning, göra deras utbildningsmaterial lättare att lära och motivera dem till fortsatt lärande.   Detta examensarbete undersökte huruvida klinikens förhoppningar kunde uppnås. Detta undersöktes genom att skapa och utvärdera en prototyp till ett lärverktyg. Genom att kombinera teorier och forskning kring nätbaserad utbildning, användarcentrerad design, interaktionsdesign och lärandeperspektiv utvecklades ett prototypverktyg för nätbaserat lärande.   För att identifiera sjuksköterskornas behov och situation gjordes en förstudie i form av en enkät- och intervjuundersökning på klinikens personal samt en intervjustudie med ansvarig personal på kliniken och sjukhuset. En prototyp av verktyget utvecklades och dess användbarhet utvärderades tillsammans med sjuksköterskorna. Verktyget utvärderades även gällande hur det kunde effektivisera lärandet av det utbildningsmaterial inom cytostatika som tillhandahålls av landstinget; detta genom utformandet och testandet av en kurs.   Examensarbetets resultat identifierar de faktorer som bidrar till att göra ett nätbaserat lärverktyg användbart för klinikens personal. Dessa faktorer, tillsammans med identifierandet av de faktorer som påverkar deras lärandeprocess, bidrar till att effektivisera sjuksköterskornas introduktionsutbildning. Som slutsats kan ett lärverktyg som utvecklas tillsammans med berörd personal enligt en kombination av design- och lärandeperspektiv göras användbart och utbildande för att säkerställa sjuksköterskornas kompetenser och bidra till en ökad patientsäkerhet. / Today, the introductory training for the nurses of the clinic for hematology at the Karolinska University hospital is insufficient which could jeopardize the patient safety. The clinic is hoping, by using an interactive net based learning tool, to be able to streamline the nurses’ internal education, make their learning material more easily learnt and motivate them to continue learning.   This thesis examined whether the clinic’s desired results could be achieved. This was examined by creating and evaluate a prototype of a learning tool. By combining theories and research about net based education, user centered design, interaction design and learning perspectives a prototype was developed for net based learning.   In order to identify the nurses’ needs and situation, a pre-study was conducted in the form of surveys and interviews with the clinic’s personnel followed by an interview study with responsible staff at the clinic and the hospital. A prototype was developed and its usability was evaluated together with the nurses. The tool was also evaluated by its ability to streamline the learning of the educational material regarding Cytostatic which was given by the county council; this by designing and testing of a course.   The results of the thesis identifies the factors which contributes to making a net based learning tool usable for the clinics staff. These factors, together with identifying the factors that affect their learning process, contributes to streamline the nurses’ introductory training. In conclusion, a learning tool which has been developed with affected personnel through a combination of design and learning perspectives can be made usable and education in order to ensure the nurses’ competence and contribute to an increased patient safety.

Vid blodgivning donerar blodgivare blod frivilligt. Blodet kan sedan användas inom sjukvården för exempelvis blodtransfusion, vilket kräver blodprodukter kompatibla med patienten. Förekomst av leukocyter i blodprodukter medför en ökad risk för febrila transfusionsreaktioner hos transfunderade patienter. Därför krävs det att vid framställning leukocytreducera blodprodukter och utföra kvalitetskontroll. Med analysen B-leukocytpartikelkoncentration (LPK) kan totalantalet leukocyter i helblod beräknas. Flödescytometri är en metod som kan analysera optiska och fluorescerande egenskaper hos exempelvis celler i en suspension, vilket kan användas för att kvantifiera cellantal. BD Leucocount™-Kit (BD Biosciences) är avsett för flödescytometrisk analys av antalet kvarvarande leukocyter i leukocytreducerade blodprodukter. Vid framställning av blodprodukter ska helblodspåsen vila vid rumstemperatur i minst 3 timmar efter blodgivning. I Falun används antingen ett dagsprogram där produktion sker samma dag som blodgivningen, eller ett övernattningsprogram där produktion sker dagen därpå. Prover från 505 kontrollerade erytrocytenheter, samlade i Falun, har påvisat en skillnad i leukocytkoncentration beroende på vilket program som använts. Anledningen till att erytrocytenheternas leukocytinnehåll skiljer sig är inte känt. Syftet med denna studie är därav att undersöka om vilotiden har någon effekt på leukocytkoncentrationen i helblodspåsar. LPK varierade mellan helblodspåsarna. Ett ökande leukocytantal observerades över tid i majoriteten av helblodspåsar, inklusive medelvärde. Däremot kunde inte hypotesprövning påvisa statistisk signifikans. Hypotesen om att leukocytantalet ökar över tid går emot grundläggande hematologi. Utifrån resultaten i denna studie kan inte hypotesen bevisas. Vidare studier bör genomföras. / During blood donation, blood donors donate blood voluntarily. The blood can then be used in healthcare for, for example, blood transfusions, which requires blood products compatible with the patient. The presence of leukocytes in blood products increases the risk of febrile transfusion reactions in transfused patients. Therefore, leukocyte-reduction in blood products is necessary during production. Each blood center must perform quality control on produced blood products. With the analysis B-leukocyte particle concentration (LPK), the total number of leukocytes in whole blood can be calculated. Flow cytometry is a method that can analyze the optical and fluorescent properties of, for example, cells in a suspension, which can be used to quantify cell numbers. The BD Leucocount™-Kit (BD Biosciences) is intended for flow cytometric analysis of the number of leukocytes remaining in leukocyte-reduced blood products. When producing blood products, the whole blood bag should rest at room temperature for at least three hours after the donation. In Falun, either a day program is used where production takes place on the same day as the blood was donated, or an overnight program where production takes place the next day. Samples from 505 controlled erythrocyte units, collected in Falun, have shown a difference in leukocyte concentration depending on the program used. The reason why the leukocyte content of erythrocyte units differs is not known. The purpose of this study is therefore to investigate whether the resting period has any effect on the leukocyte concentration in whole blood bags. The LPK varied between the whole blood bags. An increasing leukocyte count was observed over time in most of the whole blood bags. However, hypothesis testing did not show statistical significance. The hypothesis that leukocyte counts increase goes against basic hematology. Based on the results of this study, the hypothesis cannot be proven. Further studies should be conducted. / <p>Vårdförbundet tilldelade Leo Svahn stipendium 2021 för <em>bästa kandidatuppsats inom biomedicinsk laboratorievetenskap</em>.</p>