Introduction: Emergence of resistance to artemisinin-based combination therapy (ACT) is a major threat to combat Plasmodium falciparum malaria. Regular therapeutic studies to monitor treatment efficacy is essential, and genotyping of molecular makers is useful for mapping development and spread of resistance. Aims: The study aims are to assess efficacy of artesunate-amodiquine (ASAQ) and prevalence of molecular markers of drug resistance in Zanzibar in 2017. Methods: Treatment efficacy of the clinical trial conducted in 2017 was compared with efficacies in 2002 and 2005. A total of 142 samples were genotyped for single nucleotide polymorphisms (SNPs) in the P. falciparum chloroquine resistance transporter gene (pfcrt) gene, the P. falciparum multi drug resistance 1 (pfmdr1) gene, and in the P. falciparum Kelch 13 (PfK13) propeller region. Prevalence of SNPs were assessed during the period 2002-2017. Results: Cure rate was 100% in 2017, compared to 94% and 96%, in 2002-2003 and 2005, respectively. Day 3 fever clearance rate were also high 93% (2002-3), 99% (2005) and 98% (2017) in all studies. Prevalence of pfcrt 76T, pfmdr1 86Y, 184Y and 1246Y and pfmdr1 (86Y, 184Y and 1246Y) YYY haplotypes were significantly decreased between 2002-3 and 2017 (p &lt; 0.001). No SNP in the PfK13 gene related to artemisinin resistance was identified. Conclusion: Efficacy of ASAQ remains high after fourteen years as first-line treatment, despite the wide-scale use of ASAQ, and there is no evidence of selection of resistance markers in Zanzibar. Continuous monitoring of drug efficacy and resistance markers is recommended. / <p>This master thesis is a collaboration project between Institutionen för kvinnors och barns hälsa, Department of Women's and Children's Health, Uppsala Universtiy and Anders Björkman group, Department of Microbiology, Tumor and Cell Biology (MTC), C1, Karolinska Institutet. Laboratory examinations were mainly conducted at MTC house, Karolinska Institutet.</p>

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&gt;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&gt;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: Provmaterial för joniserat kalcium är känsligt för pH-förändringar och med tanke på svårstuckna patienter är det betydelsefullt att undersöka lägre fyllnadsnivåers påverkan på analysresultatet. På grund av olika pre-analytiska faktorer kan tidsgränsen (4 timmar) för analys av standardbikarbonat överskridas. Förvaring av post-analytiska serumprover medför att kompletteringsanalyser kan beställas. Begränsad dokumentation finns om avkorkade serumprovers stabilitet i rumstemperatur. Syfte: Syftet var att undersöka hur lägre fyllnadsnivåer av serum påverkar analysresultatet för joniserat kalcium, om standardbikarbonatsprover på helblod kan analyseras senare än 4 timmar och hur länge serumprover kan stå i rumstemperatur utan kork för eventuella kompletteringsanalyser. Metod: Koncentrationen av analyten joniserat kalcium i serumprover med fyllnadsnivåerna 1 mL och 2 mL jämfördes med maximalt fyllda provrör. Kylskåpsförvarade helblodsprover analyserades för standardbikarbonat efter 4-7 timmar. Avkorkade serumprover analyserades för 10 biokemiska analyter efter att ha stått i rumstemperatur 2-8 timmar. Genomsnittlig procentuell avvikelse jämfördes med en analytisk och biologisk imprecisionsgräns för att bedöma analyters stabilitet. Resultat och slutsatser: Analysresultat av joniserat kalcium i lägre fyllnadsnivåer var tillförlitliga. Stabiliteten av standardbikarbonatsproverna kunde inte bedömas och därmed kunde inte en eventuell tidsgränsändring rekommenderas. De biokemiska analyterna var stabila upp till 8 timmar i rumstemperatur. / Background: Ionized calcium concentrations decrease when samples are exposed to air. Due to pre-analytical factors, the 4 hour time limit for analysis of standard bicarbonate, can sometimes be exceeded. There is limited documentation about additional analyses on post-analytic decapped serum samples stored at room temperature. Aim: The aim was to examine how lower sample volumes affect the concentration of ionized calcium, if the time limit for analysis of standard bicarbonate on whole blood can be prolonged and how long decapped serum samples can be stored at room temperature for eventual additional analyses. Methods: The concentration of ionized calcium was analyzed on serum samples filled with 1 mL and 2 mL and were compared to maximally filled samples. Refrigerated whole blood samples were analyzed for standard bicarbonate after 4-7 hours. Ten biochemical analytes were measured in decapped serum samples after 2-8 hours of storage at room temperature. The mean percentage deviation was compared to an analytical and biological imprecision limit to determine analyte stability. Results and conclusions: Ionized calcium concentrations in lower sample volumes were reliable. The stability of standard bicarbonate could not be determined, therefore a longer possible time limit could not be recommended. The biochemical analytes were stable for 8 hours.

Venous thromboembolism that cause blood clotting in blood vessels, prevent blood circulation, depending on changes in one or more of the coagulation factors II, VII, IX and X. Patients who have had a blood clot or cardiovascular diseases are treated with oral anti-vitamin K (Warfarin®) to reducing and prevent relapse. Warfarin is also used as a preventive treatment before the disease. An overdose of Warfarin® may cause bleeding-complications and low dose cause blood clotting. The dosage of the drug is controlled by measuring prothrombin in plasma. The aim of this study was to investigate if prothrombin-complex value changes due to re-spinning and re-analysis after six hours. Fitty whole blood samples from warfarin-treated patients were divided into three subgroups, those with protrombinkomplex-values of 2-4 (n=20), &gt;4 (n=15) and &lt;2 (n=15). The samples were centrifugated and measured (Method A), re-centrifugated and measured (Method B) or re-analysed after six hours (Method C). All results were compared in a Bland-Altman plot as follows: Method B vs. Method A and Method C vs. Method A. The scatter graph yielded a strong correlation between Method A and Method B (R2=0.9984) and Method A and Methods C (R2=0.9977). The results from t-test showed a significance level (p&lt;0.001) for both analyses (statistical significance=p&lt;0.05). In this study we showed that prothrombin complex value ware stable after re-centrifugation and re-measurement after six hours. Statistical calculations yielded a strong correlation between the methods (A, B, C), and there was no significance difference between the methods.

Thoracic surgical procedures require partial or complete airway separation and the opportunity to exclude one lung from ventilation (one-lung ventilation, OLV). OLV is commonly associated with profound pathophysiological changes that may affect the postoperative outcome. It is injurious in terms of increased mechanical stress including alveolar cell stretch and overdistension, shear forces secondary to repeated tidal collapse and reopening of alveolar units and compression of alveolar vessels. Ventilation and perfusion distribution may thus be affected during and after OLV. The present studies investigated the influence of OLV on ventilation and perfusion distribution, on the gas/tissue distribution and on the lung histomorphology in a pig model of thoracic surgery. Anaesthetised and mechanically ventilated piglets were examined. The ventilation and perfusion distribution within the lungs was assessed by single photon emission computed tomography. Computed tomography was used to establish the effects of OLV on dependent lung gas/tissue distribution. The pulmonary histopathology of pigs undergoing OLV and thoracic surgery was compared with that of two-lung ventilation (TLV) and spontaneous breathing. OLV induced hyperperfusion and significant V/Q mismatch in the ventilated lung persistent in the postoperative course. It increased cyclic tidal recruitment that was associated with a persistent increase of gas content in the ventilated lung. OLV and thoracic surgery as well resulted in alveolar damage.  In the present model of OLV and thoracic surgery, alveolar recruitment manoeuvre (ARM) and protective ventilation approach using low tidal volume preserved the ventilated lung density distribution and did not aggravate cyclic recruitment of alveoli in the ventilated lung. In conclusion, the present model established significant alveolar damage in response to OLV and thoracic surgery. Lung injury could be related to the profound pathophysiological consequences of OLV including hyperperfusion, ventilation/perfusion mismatch and increased tidal recruitment of lung tissue in the dependent, ventilated lung.  These mechanisms may contribute to the increased susceptibility for respiratory complications in patients undergoing thoracic surgery. A protective approach including sufficient ARM, application of PEEP, and the use of lower tidal volumes may prevent the ventilated lung from deleterious consequences of OLV.

Cancerassocierade antigen (CA) används vid diagnostisering, prognosbestämning och för att följa behandling vid cancer. Exempel på CA är CA 15–3, CA 19–9 och CA 125. Syftet med arbetet var att undersöka hållbarheten för blodprover förvarade i primärrör som skulle analyseras för CA 15–3, CA 19–9 och CA 125 och jämföra med nuvarande metod på klinisk kemi, Oskarshamn, Region Kalmar län. Enligt nuvarande metod överförs plasman till nya provrör innan analys. Metoden som användes var att dubbelprov togs och det ena förvarades i primärrör och analyserades på Roche Cobas 411® tre, fem och tio dagar efter provtagning. Det andra provet överfördes till nytt provrör inför analys. Den procentuella skillnaden mellan analys av CA i primärrör och överfört prov beräknades. För alla tre analyserna var den procentuella skillnaden störst hos de lägsta koncentrationerna av CA. Medelvärde för analyserna av CA, standardavvikelse (SD) och variationskoefficient beräknades. SD för CA jämfördes mot kontrollerna MAS Omni Immune Pro 1 och MAS Omni Immune Pro 3s SD. Provernas SD var mindre för kontrollerna förutom för CA 19–9 &gt;1100 kIE/L. I den gruppen analyserades dock för få analyser för att utföra statistisk analys och gav därmed ingen slutsats hur CA 19–9 påverkades av de olika förvaringarna. För övriga analyser och för CA 19–9 i lägre koncentrationer kunde slutsatsen dras att prover kunde förvaras i primärrör i tio dagar utan att analysresultatet påverkades. / Cancer-associated antigens (CA) are used for diagnosis, establish prognosis and to monitor treatment of cancer. Three CA are CA 15-3, CA 19-9 and CA 125. The aim of this study was to evaluate the stability of CA 15-3, CA 19-9 and CA 125 blood samples in primary tubes coated with Litium-heparin gel and compare the results with the method used at Klinisk Kemi Oskarshamn, Region Kalmar where the samples today are transferred to new tubes before analysis. In this study two samples were collected from each patient, one was stored and analyzed according to the current method. The other sample was stored in the primary tube and analyzed three, five and ten days after collection. Roche Cobas 411 instrument was used for analysis. The mean value for the samples in primary tubes was compared to the current method and were calculated in percent. The difference was more distinct when the concentration of the analyte was low. The mean value, standard deviation (SD) and variation coefficient were calculated for each analyte. The SD of the samples were compared to the SD of the controls IM 1 and IM3. All the obtained SD from the samples were lower than the control SD, except for CA 19-9 &gt; 1100 kIE/L. Unfortunately, there were only three test results in the concentration interval and therefore no statistic conclusion could be made. The conclusion for the other analytes CA 15-3, CA 125 and CA 19-9 in lower concentrations was that the storage in primary tubed up to ten days did not affect the test results.

Fästingburet encefalitvirus (TBEV) är ett RNA-virus som tillhör genuset flavivirus. Vid en TBEV-infektion är feber, trötthet, allmänpåverkan samt huvudvärk och muskelvärk vanligt förekommande symtom. Viruset överförs via saliven från fästingar under de första minuterna efter fästingbett. TBEV-IgM och ibland även TBEV-IgG återfinns i serum då symtom i centrala nervsystemet (CNS) yttrar sig i den andra fasen av sjukdomsförloppet. De senaste åren har prevalensen av fästingburen encefalit (TBE) ökat. Sedan 2017 har över 300 fall av TBE rapporterats årligen i Sverige. Laterala flödesanalyser (lateral flow assays, LFA) är billiga, enkla, snabba och baseras på portabla instrument som används bland annat inom biomedicinsk vetenskap. ReaScan® TBE IgM från det finska företaget Reagena är ett snabbtest, baserat på LFA-tekniken, för detektion av TBE-specifika IgM-antikroppar i humant serum och likvor. Syftet med studien var att undersöka om ReaScan® TBE IgM kan användas för att diagnostisera TBE på laboratoriet för Klinisk Mikrobiologi på länssjukhuset i Kalmar. Metodens prestanda undersöktes genom att analysera totalt 23 serumprover, 13 prover från TBE-patienter och 10 prover från icke-TBE-patienter. Sensitiviteten uppskattades genom att analysera 13 serumprover där förekomst av TBE-antikroppar sedan tidigare konfirmerats. Specificiteten uppskattades genom att analysera 10 serumprover från patienter utan känd TBEV-infektion. Den diagnostiska sensitiviteten respektive specificiteten beräknades till 100 %. På grund av den begränsade storleken på undersökningsmaterialet är dock den beräknade sensitiviteten och specificiteten ej helt tillförlitlig. Metodens prestanda ansågs vara tillräckligt god för att den skall kunna användas som en screening-metod för TBEV-IgM-antikroppar på laboratoriet för Klinisk Mikrobiologi på länssjukhuset i Kalmar. / Tick-borne encephalitis virus (TBEV) is an RNA virus that belongs to the genus flavivirus. Symptoms that commonly present during a TBEV infection include headaches, muscle pains, fever and malaise. The virus is transmitted with the saliva from ticks during the first minutes of their blood meal. TBEV-IgM and sometimes TBEV-IgG antibodies can be detected in the patient’s serum when central nervous system (CNS) symptoms present in the second phase of the disease. Over the last couple of years, the prevalence of tick-borne encephalitis (TBE) has increased. Since 2017 over 300 cases of TBE are reported every year in Sweden. Lateral flow assays (LFA) is the technology behind inexpensive, simple, quick and portable instruments that are used within the biomedical science field among others. ReaScan® TBE IgM developed by the Finnish company Reagena is a rapid test, based on the LFA technique, used for the detection of TBEV specific IgM antibodies in human serum and cerebrospinal fluid. The trial aimed to evaluate whether ReaScan® TBE IgM could be used to diagnose TBE at the laboratory of Clinical microbiology at the County hospital in Kalmar. The performance of the test was determined by analysing a total of 23 serum samples, 13 of which consisted of samples from patients with a previously confirmed TBE diagnosis and 10 samples from patients with no known TBEV infection. The diagnostic sensitivity and specificity were both determined to be 100 %. Due to the limited sample size, the calculated sensitivity and specificity are not particularly reliable.  The performance of the test was satisfactory and it could be used as a screening method for the detection of TBEV IgM antibodies at the department of Clinical microbiology at Kalmar County Hospital.

Introduktion Antibiotikaresistens är ett globalt växande problem. Till gruppen β-laktamantibiotika hör piperacillin-tazobaktam och cefotaxim som båda verkar genom att försvaga cellväggen med kovalenta bindningar till peptidoglykanlagret som lyserar cellen. E. coli och K. pneumoniae tillhör gruppen Enterobacteriaceae, som är en del av den humana tarmfloran och ofta förekommande vid urinvägsinfektion och sepsis. Utvidgat Spektrum β-Laktamas (ESBL) är ett enzym som finns hos Enterobacteriaceae och som hydrolyserar β-laktamantibiotika. Matrix assisted laser desorption ionization time of flight mass spectrometry (MALDI-TOF MS) är en kvalitativ analysteknik för detektion av kemiska föreningar i avseende på massa och laddning. Kännedom om antibiotikametaboliters molekylvikt vid hydrolys möjliggör detektion. Liquid Chromatography Tandem Mass Spectrometry (LC-MS/MS) är en högsensitiv kvantifieringsmetod som separerar molekyler i avseende på polaritet för vidare detektion i avseende på massa och laddning. Syfte Syftet med denna studie var att vidareutveckla en snabb och effektiv metod för att påvisa nedbrytning av piperacillin-tazobaktam och cefotaxim i blodplasma med LC-MS/MS. Material och Metod Tiofaldigt sjunkande koncentrationer av piperacillin-tazobaktam från 2000 till 2 µg/ml, och cefotaxim med koncentrationerna 500 till 0,5 µg/ml analyserades med MALDI-TOF MS, dels intakt men även med bakterierna E. coli och K. pneumoniae med uttryck av olika resistensmekanismer. Vid optimerade koncentrationer spikades plasmaprover med nedbrutet antibiotika som sedan kvantifierades med LC-MS/MS. Resultat Lägsta detektionsgräns med MALDI-TOF MS för intakt och hydrolyserat piperacillin-tazobaktam var 20/2,5 µg/ml. För cefotaxim var lägsta gränsen 5 µg/ml. Med kliniskt relevanta blodkoncentrationer gick hydrolys inte att detektera för. Med tre bakteriekolonier/50 µl kunde dock hydrolys detekteras och kvantifieras med LC-MS/MS. Slutsats Detektion av β-laktamantibiotika är möjligt med både MALDI-TOF MS och LC-MS/MS. För att påvisa hydrolys krävdes större mängder bakterier än förväntat med LC-MS/MS. / Introduction Antibiotic resistance is a global growing problem. Piperacillin-tazobactam and cefotaxime are parts of the group β-lactam antibiotics. The common feature is to inhibit the cell wall synthesis by covalent bindings to the peptidoglycan layer and thereby causing lysis of the bacterial cell. E. coli and K. pneumoniae are members of the Enterobacteriaceae which is a part of the human normal flora but also are commonly associated with urinary tract infections which sometimes develops into to sepsis. Extended Spectrum β-Lactamases (ESBLs) are enzymes with hydrolytic abilities acting on β-lactam antibiotics, expressed by Enterobacteriaceae. The qualitative, Matrix assisted laser desorption ionization time of flight mass spectrometry (MALDI-TOF MS) can be used to detect chemical compounds in the ratio of mass to charge in accordance to their molecular weight. Liquid Chromatography Tandem Mass Spectrometry (LC-MS/MS) is a highly sensitive two-step method of quantification which first separate molecules by their polarity attraction force and then by the ratio of mass to charge. Aim The aim of this study was to develop a fast and efficient method to determine degradation of piperacillin-tazobactam and cefotaxime in blood plasma by LC-MS/MS. Method Tenfold dilution of piperacillin-tazobactam in concentrations of 2000 to 2 µg/ml, and cefotaxime in concentrations of 500 to 0,5 µg/ml where analyzed by MALDI-TOF MS, intact and also with the bacteria E. coli and K. pneumoniae with different expression of antibiotic resistance. Optimized concentrations where fixed in blood plasma and then quantified by LC-MS/MS. Result The detection limit by using MALDI TOF MS of hydrolyzed as well as non-hydrolyzed piperacillin-tazobactam was 20/2,5 µg/ml. The detection limit in cefotaxime was 5 µg/ml. Hydrolysis could not be detected in clinically fixed blood concentrations. Detection and quantification of hydrolysis by LC-MS/MS was possible in a concentration of three bacteria colonies/50 µl. Conclusion It is possible to detect hydrolysis in both MALDI TOF MS and LC-MS/MS. A larger amount of bacteria than expected was needed to demonstrate hydrolysis In LC-MS/MS.

Neurografi är en grundläggande metod för att diagnosticera perifera nervsjukdomar, metoden reflekterar det funktionella tillståndet av myeliniserade axon. Neurografi är uppdelat i två delar, motorisk och sensorisk neurografi. Vid undersökningen erhålls va-riabler så som amplitud, latenstid och nervledningshastighet, samtliga variabler är på-verkade av vävnadstemperatur. Vid kalla temperaturer sjunker nervledningshastigheten, amplituden förändras och latenstiden förlängs. Syftet med studien är att kartlägga till vilken grad temperaturen påverkar sensorisk neurografi och om motorisk neurografi på-verkas av temperatur. I studien undersöktes den sensoriska och motoriska grenen på n. tibialis vid hudtempe-raturerna &gt; 30° C, mellan 25 – 28° C samt &lt; 24° C. Huden kyldes med vatten och hud-temperaturen mättes med en örontermometer. Sensorisk nervledningshastighet och amplitud visade en signifikant skillnad mellan de tre temperaturintervallerna medan motorisk nervledningshastighet och amplitud inte vi-sade någon signifikant skillnad. / Electroneurography is a fundamental method for diagnosing peripheral nerve disorder, the method reflects the functional condition of the myelin coated axons. Electroneurog-raphy is divided into two parts, sensory and motor neurography. During the examination are variables as amplitude, latency and conduction velocity acquired, all those variables are affected by temperature. At cold temperature conduction velocity declines, ampli-tude changes and latency extend. The purpose of the study is to map out to what degree the temperature is affecting sensory neurography and if motor neurography is affected by temperature. The study examined the sensory and motor branch of n. tibialis at the skin temperature &gt; 30° C, between 25 – 28° C and &lt; 24° C. The skin was cooled by water and the skin temperature was measured by an ear-thermometer. Sensory conduction velocity and amplitude had a significantly difference at the three temperature intervals meanwhile motor conduction velocity and amplitude did not.

Syfte: Apné/hypopné index (AHI), antalet apnéer/hypopnéer per sömntimma, är den vanligaste parametern som används för att beskriva graden av sömnapné. Syftet med studien är att undersöka effekten av olika hypopnékriterier för AHI, med desaturationsnivå 3% eller 4% d.v.s. om det finns en signifikant skillnad i AHI vid användning av hypopnékriterier 3% jämfört med 4 %. Metod och material: Polygrafiska registreringar från 40 patienter analyserades retrospektivt. Hypopnéer definierades först som 30–90% minskning av luftflödet under &gt;10 sekunder förknippat med 3% desaturation. Därefter definierades hypopnéer med 4% desaturation. Patentregistreringarna tolkades manuellt på Fysiologkliniken vid Västmanlands sjukhus Västerås. Resultat och slutsats: En signifikant skillnad föreligger i AHI vid användning av de olika hypopnékriterierna, (p &lt;0,001). AHI varierade från medianvärdet 8,5 (2,9–17,6) för vid användning av tolkningskriterium 4% desaturation till 15,7 (6,5–24) vid användning av tolkningskriterium 3%. Det är viktig att följa de nya uppdaterade kriterierna från American Academy of Sleep Medicine och Svenska sömnapnéregistret för att kunna ställa rätt diagnos och behandling för patienten. / Purpose: The apnea/hypopnea index (AHI) is the most common parameter used to describe the severity of sleep apnea. The purpose of this study was to examine the effect of different oxygen desaturation levels (3% and 4%) on AHI i.e. if there is a significant difference in the AHI when using different hypopnea-criteria. Method and material: Polygraphic recordings of 40 patients were analyzed retrospectively. Hypopneas were first defined as 30-90% drop in airflow for &gt;10 s associated with 3% oxygen desaturation. Then hypopneas were defined as with 4% oxygen desaturation. Results and conclusion: There is a significant difference in AHI when using different hypopnea criteria, i.e. 4% or 3% desaturation. AHI varied from 8,5 (2,9–17,6) when using hypopnea criteria 4% to 15,7 (6,5–24) when using 3%. It is important to follow the new updated criteria from the American Academy of Sleep Medicine and the Swedish Sleep Apnea Register in order to provide the right diagnosis and treatment for the patient.