Abstract available through The FASEB Journal.

Abstract available through The FASEB Journal.

Systemic lupus erythematosus (SLE) is a systemic inflammatory disease. Clinically, the distinction between ongoing inflammation attributed to SLE, and organ damage due to medication or co-morbidities remains challenging. In addition, SLE is a heterogeneous disease where the various disease phenotypes complicate the search for biomarkers that adequately reflect disease activity and/or signs of increasing organ damage. The aim of the thesis was to investigate and evaluate potential new biomarkers of disease activity and/or organ damage in SLE patients. High mobility group box protein-1 (HMGB1) is a nuclear non-histone protein that can shuttle to the cytoplasm, become secreted extracellularly, and participate in systemic inflammation. Administration of monoclonal anti-HMGB1 antibodies has been reported both to attenuate and intensify disease in animal models of arthritis and lupus. In Paper I of the thesis, circulating anti-HMGB1 was found in 23% of the SLE patients and correlated with disease activity variables. The biological role of these autoantibodies remains to be elucidated. As a consequence of massive circulating levels of cellular debris and immune complexes, SLE patients have insufficient capacity to remove such material via the reticuloendothelial system. Pentraxin 3 (PTX3) may possibly protect against lupus flares due to classical complement activation, opsonization of apoptotic cells, and cytokine induction. In Paper II, circulating PTX3 was found to be inhibited or exhausted by interferon (IFN)-α, a key cytokine of SLE pathogenesis, and serum levels of PTX3 in SLE patients were inversely related to IFN-α levels. Suppressed PTX3 levels may contribute to a vicious circle resulting in impaired waste clearance, autoantigen exposure and autoantibody production, and sustained disease activity. Osteopontin (OPN), a protein known to influence cell signaling and apoptosis, has been proposed as a marker of organ damage in pediatric lupus. In a Swedish cross-sectional study, circulating OPN levels were found to be raised in SLE (Paper III). In patients with recent-onset disease, OPN reflected disease activity, while in established disease, OPN appeared to mirror damage accrual and cardiovascular damage. In Paper IV, OPN was instead analyzed in an international longitudinal multi-center study based on patients with recent-onset SLE and follow-up data. OPN turned out to be a poor predictor of organ damage, but significant associations were observed between OPN and disease activity both at disease onset, as well as over 5 years of follow-up. In conclusion, increased anti-HMGB1 antibody and decreased PTX3 levels could potentially sustain the impaired waste-disposal. Of the molecules analyzed in this thesis, OPN seems to be the best marker of disease activity. Further studies of these proteins may help to better understand SLE pathogenesis and to optimize treatment of patients.

Parkinson’s disease (PD) is one of the most common neurodegenerative disorders and it is caused by a loss of dopamine (DA) producing neurons in the basal ganglia in the brain. The PD patient suffers from motor symptoms such as tremor, bradykinesia and rigidity and treatment with levodopa (LD), the precursor of DA, has positive effects on these symptoms. Several factors affect the availability of orally given LD. Gastric emptying (GE) is one factor and it has been shown to be delayed in PD patients resulting in impaired levodopa uptake. Different enzymes metabolize LD on its way from the gut to the brain resulting in less LD available in the brain and more side effects from the metabolites. By adding dopa decarboxylase inhibitors (carbidopa or benserazide) or COMT-inhibitors (e.g. entacapone) the bioavailability of LD increases significantly and more LD can pass the blood-brain-barrier and be converted to DA in the brain. It has been considered of importance to avoid high levodopa peaks in the brain because this seems to induce changes in postsynaptic dopaminergic neurons causing disabling motor complications in PD patients. More continuously given LD, e.g. duodenal or intravenous (IV) infusions, has been shown to improve these motor complications. Deep brain stimulation of the subthalamic nucleus (STN DBS) has also been proven to improve motor complications and to make it possible to reduce the LD dosage in PD patients. In this doctoral thesis the main purpose is to study the pharmacokinetics of LD in patients with PD and motor complications; in blood and subcutaneous tissue and study the effect of GE and PD stage on LD uptake and the effect of continuously given LD (CDS) on LD uptake and GE; in blood and cerebrospinal fluid (CSF) when adding the peripheral enzyme inhibitors entacapone and carbidopa to LD infusion IV; in brain during STN DBSand during oral or IV LD treatment. To conclude, LD uptake is more favorable in PD patients with less severe disease and GE is delayed in PD patients. No obvious relation between LD uptake and GE or between GE and PD stage is seen and CDS decreases the LD levels. Entacapone increases the maximal concentration of LD in blood and CSF. This is more evident with additional carbidopa and important to consider in avoiding high LD peaks in brain during PD treatment. LD in brain increases during both oral and IV LD treatment and the DA levels follows LD well indicating that PD patients still have capacity to metabolize LD to DA despite probable pronounced nigral degeneration. STN DBS seems to increase putaminal DA levels and together with IV LD treatment also increases LD in brain possibly explaining why it is possible to decrease LD medication after STN DBS surgery. / Parkinsons sjukdom (PS) är en av de vanligaste s.k. neurodegenerativasjukdomarna och orsakas av förlust av dopamin(DA)producerande nervceller i hjärnan. Detta orsakar motoriska symptom såsom skakningar, stelhet och förlångsammade rörelser. Levodopa (LD) är ett ämne, som kan omvandlas till DA i hjärnan och ge symptomlindring och det är oftast förstahandsval vid behandling av patienter med PS. Flera faktorer påverkar tillgängligheten av LD, bl.a. den hastighet som magsäcken tömmer sig med och denna verkar förlångsammad hos personer med PS vilket ger sämre tillgänglighet av LD i blodet och därmed i hjärnan. LD bryts även ner i hög grad av olika enzym ute i kroppen vilket leder till mindre mängd LD som hamnar i hjärnan och till fler nedbrytningsprodukter som orsakar biverkningar. Tillägg av enzymhämmare leder till ökad mängd LD som kan nå hjärnan och omvandlas till DA. Det anses viktigt att undvika höga toppar av LD i hjärnan då dessa verkar bidra till utvecklandet av besvärliga motoriska komplikationer hos patienter med PS. Om LD ges mer kontinuerligt, exempelvis som en kontinuerlig infusion in i tarmen eller i blodet, så minskar dessa motoriska komplikationer. Inopererande av stimulatorer i vissa delar av hjärnan (DBS) har också visat sig minska dessa motoriska komplikationer och även resultera i att man kan minska LD-dosen. Huvudsyftet med den här avhandlingen är att studera LD hos patienter med PS; i blod och fettvävnad då LD ges i tablettform och se om det finns något samband med LD-upptag och hastigheten på magsäckstömningen (MT) och om kontinuerligt given LD påverkar LD-upptaget eller MT; i blod och i ryggmärgsvätska då enzymhämmarna entakapon och karbidopa tillsätts LD; i hjärna vid behandling med DBS och då LD ges både som tablett och som infusion i blodet. Sammanfattningsvis kan vi se att LD-upptaget är mer gynnsamt hos patienter med PS i tidigare skede av sjukdomens komplikationsfas. MT är förlångsammad hos patienter med PS och det är inget tydligt samband mellan LD-upptag och MT eller mellan MT och sjukdomsgrad. Kontinuerligt given LD minskar LDnivåerna. Enzymhämmaren entakapon ökar den maximala koncentrationen av LD i blod och ryggmärgsvätska och effekten är mer tydlig vid tillägg av karbidopa vilket är viktigt att ta i beaktande vid behandling av PS för att undvika höga toppar av LD i hjärnan. LD ökar i hjärnan då man behandlar med LD i tablettform och som infusion i blodet och DA-nivåerna i hjärnan följer LD väl vilket visar på att patienter med PS fortfarande kan omvandla LD till DA trots trolig uttalad brist av de DA-producerande nervcellerna i hjärnan. DBS verkar öka DA i vissa områden i hjärnan och tillsammans med LD-infusion i blodet verkar det även öka LD i hjärnan och det kan förklara varför man kan sänka LDdosen efter DBS-operation.

C1q TNF Related Protein 3 (CTRP3) is a member of a family of secreted proteins that exert a multitude of biological effects. Our initial work identified CTRP3’s promise as an effective treatment for Nonalcoholic fatty liver disease (NAFLD). Specifically, we demonstrated that mice fed a high fat diet failed to develop NAFLD when treated with CTRP3. The purpose of this current project is to identify putative receptors which mediate the hepatic actions of CTRP3. Methods We used Ligand-receptor glycocapture technology with TriCEPS™-based ligand-receptor capture (LRC-TriCEPS; Dualsystems Biotech AG). The LRC-TriCEPS experiment with CTRP3-FLAG protein as ligand and insulin as a control ligand was performed on the H4IIE rat hepatoma cell line. Results Initial analysis demonstrated efficient coupling of TriCEPS to CTRP3. Further, flow cytometry analysis (FACS) demonstrated successful oxidation and crosslinking of CTRP3-TriCEPS and Insulin-TriCEPS complexes to cell surface glycans. Demonstrating the utility of TriCEPS under these conditions, the insulin receptor was identified in the control dataset. In the CTRP3 treated cells a total enrichment of 261 peptides was observed. From these experiments 5 putative receptors for CTRP3 were identified with two reaching statistically significance: Lysosomal-associated membrane protein 1 (LAMP-1) and Lysosome membrane protein 2 (LIMP II). Follow-up Co-immunoprecipitation analysis confirmed the association between LAMP1 and CTRP3 and further testing using a polyclonal antibody to block potential binding sites of LAMP1 prevented CTRP3 binding to the cells Conclusion The LRC-TriCEPS methodology was successful in identifying potential novel receptors for CTRP3. Relevance The identification of the receptors for CTRP3 are important prerequisites for the development of small molecule drug candidates, of which none currently exist, for the treatment NAFLD.

Bakgrund: Inflammatorisk tarmsjukdom (IBD) inkluderar Ulcerös kolit och Crohns sjukdom som kännetecknas av återkommande inflammation i tarmen. Etiologin för sjukdomarna är fortfarande okänd och forskning visar en ökning, framför allt i Europa. För att främja hälsa trots en livslång sjukdom behöver individen ta ansvar för att anpassa sin sjukdom genom egenvård, detta för att förebygga exacerbation. Syfte: Syftet med studien var att sammanställa personers upplevelser av att anpassa sitt liv utifrån sin kroniska inflammatoriska tarmsjukdom.  Metod: En beskrivande litteraturstudie baserat på 12 kvalitativa studier. Databaserna som användes vid artikelsökningarna var PubMed och CINAHL. Sökbegränsningarna var engelska, människor och 10 år.  Resultat: En återkommande upplevelse bland personerna med IBD var att livet blev begränsat både gällde skola- och arbetsliv, det sociala livet och kosten. För att anpassa sitt liv med en IBD-sjukdom upplevde personerna att kunskap och stöd från andra var betydande. För att hålla sjukdomen i remission upplevdes behandlingar och kostanpassningar vara en viktig fördel. Upplevelsen av sig själv förändrades där en känsla av att inte vara normal var vanligt, att acceptera och hitta mening i livet var en viktig anpassning och resulterade i ett bättre mentalt välbefinnande. Slutsats: Sjukdomen upplevdes skapa begränsningar i det dagliga livet och ändrade självbilden hos personerna. Att acceptera sitt liv med IBD ansågs vara en viktig anpassning för att skapa möjlighet till att leva sitt liv utan dessa upplevda begränsningar. Enligt författarna kommer resultatet ge sjuksköterskor en ökad förståelse gällande omvårdnaden för personer med en IBD-sjukdom samt möjliggöra en fungerande egenvård för dessa personer. / Background: Inflammatory bowel disease (IBD) include Ulcerative Colitis and Crohn’s disease who are characterized by recurrent inflammation in the bowel. The etiology of the diseases is still unknown, and research shows that it’s increasing, especially in Europe. To promote health despite a lifelong illness, the individual needs to take responsibility for their self-care to keep the disease in check. Aim: The aim of this study was to describe persons experience of adapting their life with their inflammatory bowel disease. Method: A descriptive literature study based on 12 qualitative studies. The databases used were PubMed and CINAHL. The study's limitations were English, humans, and 10 years.  Results: A recurring experience among people with IBD was that life was limited in school, work, social life and diet. Knowledge and support from others were important to adapt to a life with IBD. To keep the disease in remission, treatments and dietary adjustments were perceived as an important advantage. The experience of yourself changed, where a feeling of not being normal was common. Patients who were able to accept their disease, and who also transcended to find a higher purpose, ultimately improved their mental health.   Conclusion: The disease creates limitations in daily life and changes the self-image of people. Accepting a life with IBD was an important adjustment to create the opportunity to live one's life without these perceived limitations. According to the authors, the results will give nurses an increased understanding of caregiving and improved self-care for people with IBD.

Erosiv esofagit (EE) innebär uppkomst av inflammation och slemhinneskador i matstrupen. Den huvudsakliga orsaken till EE är gastroesofageal reflux (GERD), då det sura maginnehållet stöts upp i matstrupen. Bristande funktion av nedre esofagussfinktern (LES) och diafragmabråck kan också orsaka EE. Obehandlad EE kan leda till komplikationer såsom Barretts esofagus (BE), adenocarcinom, förträngning av matstrupen och gastrointestinala blödningar. Diagnostiken sker med hjälp av endoskopi. Behandlingen av EE går bland annat ut på att påskynda läkning av slemhinneskador i matstrupen. Den består huvudsakligen av läkemedelsterapi och livsstil- och kostförändringar, men även kirurgi kan vara en möjlig behandling. Läkemedelsterapi består av syrahämmande läkemedel som hämmar produktionen av magsyra. Protonpumpshämmare (PPI), till exempel lansoprazol (LPZ), är standardbehandlingen vid syrarelaterade sjukdomar, bland annat EE. PPI har dock begränsningar och upp till 20 % med svårare EE uppnår inte läkning. Vonoprazan (VPZ) tillhör kalium kompetitivasyrablockerare (P-CAB) och är ett nytt syrahämmande läkemedel som är godkänt i bland annat Japan och USA för behandling av EE. Syftet med detta litteraturarbete var att undersöka effekten av 20 mg VPZ jämfört med 30 mg LPZ efter åtta veckors behandling av EE, genom att ta del av publicerade kliniska studier. Fyra olika RCT-studier hämtade från databasen PubMed användes i detta litteraturarbete. Alla fyra studier resulterade i att VPZ inte var sämre än LPZ vid behandling av EE i upp till åtta veckor. Fler patienter i VPZ-gruppen uppnådde läkning av EE i samtliga studier. Dessutom visade VPZ ha bättre effekt hos patienter med svårare EE. Number Needed to Treat (NNT) för de olika studierna varierade mycket, därför kunde inte den användas för att beskriva den kliniska effekten av VPZ vid behandling av EE. Både VPZ och LPZ tolererades väl. Slutsatsen var att VPZ 20 mg en gång dagligen var inte sämre än LPZ 30 mg en gång dagligen vid behandling av EE i 8 veckor. VPZ var effektiv och visade bättre resultat än LPZ när det gäller EE-läkning. Detta gäller speciellt patienter med svårare EE. Båda läkemedlen tolererades väl.

The liver is one of the largest organs within the human body and it handles many vital tasks such as nutrient processing, toxin removal, and synthesis of important proteins. The number of people suffering from chronic liver disease is on the rise, likely due to the present ‘western’ lifestyle. As disease develops in the liver there are pathophysiological manifestations within the liver parenchyma that are both common and important to monitor. These manifestations include inflammation, fatty infiltration (steatosis), excessive scar tissue formation (fibrosis and cirrhosis), and iron loading. Importantly, as the disease progresses there is concurrent loss of liver function. Furthermore, postoperative liver function insufficiency is an important concern when planning surgical treatment of the liver, because it is associated with both morbidity and mortality. Liver function can also be hampered due to drug-induced injuries, an important aspect to consider in drug-development. Currently, an invasive liver needle biopsy is required to determine the aetiology and to stage or grade the pathophysiological manifestations. There are important limitations with the biopsy, which include, risk of serious complications, mortality, morbidity, inter- and intra-observer variability, sampling error, and sampling variability. Cleary, it would be beneficial to be able investigate the pathophysiological manifestations accurately, non-invasively, and on regional level. Current available laboratory liver function blood panels are typically insufficient and often only indicate damage at a late stage. Thus, it would be beneficial to have access to biomarkers that are both sensitive and responds to early changes in liver function in both clinical settings and for the pharmaceutical industry and regulatory agencies. The main aim of this thesis was to develop and evaluate methods that can be used for a ‘non-invasive liver biopsy’ using magnetic resonance (MR). We also aimed to develop sensitive methods for measure liver function based on gadoxetate-enhanced MR imaging (MRI). The presented work is primarily based on a prospective study on c. 100 patients suffering from chronic liver disease of varying aetiologies recruited due to elevated liver enzyme levels, without clear signs of decompensated cirrhosis. Our results show that the commonly used liver fat cut-off for diagnosing steatosis should be lowered from 5% to 3% when using MR proton-density fat fraction (PDFF). We also show that MR elastography (MRE) is superior in staging fibrosis. Finally we presented a framework for quantifying liver function based on gadoxetate-enhanced MRI. The method is based on clinical images and a clinical approved contrast agent (gadoxetate). The framework consists of; state-of the-art image reconstruction and correction methods, a mathematical model, and a precise model parametrization method. The model was developed and validated on healthy subjects. Thereafter the model was found applicable on the chronic liver disease cohort as well as validated using gadoxetate levels in biopsy samples and blood samples. The liver function parameters correlated with clinical markers for liver function and liver fibrosis (used as a surrogate marker for liver function). In summary, it should be possible to perform a non-invasive liver biopsy using: MRI-PDFF for liver fat and iron loading, MRE for liver fibrosis and possibly also inflammation, and measure liver function using the presented framework for analysing gadoxetate-enhanced MRI. With the exception of an MREtransducer no additional hardware is required on the MR scanner. The liver function method is likely to be useful both in a clinical setting and in pharmaceutical trials.

CTRP3 is a secreted plasma protein of the C1q family that helps regulate hepatic gluconeogenesis and is downregulated in a diet-induced obese state. However, the role of CTRP3 in regulating lipid metabolism has not been established. Here, we used a transgenic mouse model to address the potential function of CTRP3 in ameliorating high-fat diet-induced metabolic stress. Both transgenic and wild-type mice fed a high-fat diet showed similar body weight gain, food intake, and energy expenditure. Despite similar adiposity to wild-type mice upon diet-induced obesity (DIO), CTRP3 transgenic mice were strikingly resistant to the development of hepatic steatosis, had reduced serum TNF-α levels, and demonstrated a modest improvement in systemic insulin sensitivity. Additionally, reduced hepatic triglyceride levels were due to decreased expression of enzymes (GPAT, AGPAT, and DGAT) involved in triglyceride synthesis. Importantly, short-term daily administration of recombinant CTRP3 to DIO mice for 5 days was sufficient to improve the fatty liver phenotype, evident as reduced hepatic triglyceride content and expression of triglyceride synthesis genes. Consistent with a direct effect on liver cells, recombinant CTRP3 treatment reduced fatty acid synthesis and neutral lipid accumulation in cultured rat H4IIE hepatocytes. Together, these results establish a novel role for CTRP3 hormone in regulating hepatic lipid metabolism and highlight its protective function and therapeutic potential in attenuating hepatic steatosis.

Aim To determine that carbon dioxide (CO2), instead of air, insufflated during colonoscopy reduces pain experienced by patients post colonoscopy. Method A randomised, double blinded, controlled trial with 205 consecutive consented patients referred for elective colonoscopy was undertaken at MidCentral Health Gastroenterology Department between July 2008 and January 2009. Patients were randomised to colonic insufflation with either air or CO2. A comparison of reported pain was undertaken using a 0 -10 point numeric rating scale at several time periods; intra procedure, 10, 30, and 60 minutes post procedure. Results The results were analysed using the SPSS programme. CO2 insufflation was used in 108 patients and air in 97 patients. Pain scores 10 minutes after were 0.43 ± 1.20 for CO2 and 1.61 ± 2.40 for air (P < .0001). 30 minutes after the procedure 90% of patients in the CO2 group reported no pain, compared to 61% of the air group. CO2 significantly reduced the amount of discomfort post colonoscopy at 10, 30 and 60 minutes. Conclusion Those receiving CO2 during colonoscopy experienced less post colonoscopy pain than those who received air insufflation. Carbon dioxide should be considered as the insufflating gas during colonoscopy.