The thiopurines, 6-mercaptopurine and its prodrug azathioprine, are used in the treatment of inflammatory bowel disease, ulcerative colitis and Crohn´s disease. The main active metabolites are the phosphorylated thioguanine nucleotides (6-TGNs) and methylated thioinosine monophosphate (meTIMP). Both groups contribute to the immunomodulatory effects. About 30-40% of patients fail to benefit from thiopurine treatment. A well-known cause of adverse reactions is decreased or absent thiopurine S-methyltransferase (TPMT) activity. Low TPMT activity is inherited as an autosomal codominant recessive trait and is present in approximately 10% of the population. Although several clinical issues can be solved from determination of TPMT activity, there are cases where it is not possible. In Sweden approximately 25% of IBD-patients display suboptimal 6-TGN concentrations and unexpectedly high concentrations of meTIMP despite a normal TPMT activity. A high meTIMP/6-TGN concentration ratio has been associated with both unresponsiveness to therapy and emergence of adverse reactions. Inosine 5’-monophosphate dehydrogenase (IMPDH) may constitute a candidate gene to explain this metabolite profile, as it is strategically positioned in the metabolic pathway of thiopurines where it competes with TPMT for their common substrate 6-TIMP. In paper I a pyrosequencing method was developed for genotyping of at that time all known genetic variants of TPMT. The concordance between genotype and phenotype in 30 individuals was 93%. The allele frequencies of TPMT*3A, *3B, *3C and *2 in a Swedish background population (n=800) were in agreement with those in other Caucasian or European populations. In Paper II-IV we explored the molecular basis of different metabolite profiles, i.e. low, normal and high meTIMP/6-TGN concentration ratios. The activity of IMPDH was measured in mononuclear cells (MNC). Patients with high metabolite ratios had lower IMPDH activity than patients with normal or low ratios, explained by an inverse correlation to red blood cells concentration of meTIMP. No correlation to 6-TGN was observed. Downregulation of IMPDH activity in HEK293 cells with genetically engineered TPMT activity was associated with an increase in meTIMP, but unexpectedly also of 6-TGN, irrespective of the TPMT status. These results suggest effects of pharmacogenes other than TPMT and IMPDH. A whole genome expression analysis was performed, (1) to identify new candidate genes that could explain differences in metabolite profiles, and (2) to study genes with known associations to the metabolic pathway of (thio)purines. The whole genome expression analysis did not identify any significant group differences. In analysis of the thiopurine related genes, three clusters of co-regulated genes were defined. A co-operation between expression levels of SLC29A1 and NT5E in explaining the meTIMP/6-TGN concentration ratio was observed, and individually SLC29A1 and NT5E correlated to 6-TGN and meTIMP, respectively. Pysosequencing is a convenient and flexible method which is now run in parallel to phenotyping in our laboratory. Our results also illustrate the complexity of the thiopurine metabolism and suggest that differences between metabolite profiles are explained either by interactions between several genes, each with a small contribution, or at the post-transcriptional level. Search for more precise tools to explain differences in metabolite profiles is needed. Furthermore, in order to investigate small effects it is necessary to analyse metabolite concentrations and gene expression levels, as well as enzyme activities in the target cells of therapy (MNC).

Budd-Chiari syndrome (BCS) i.e. thrombosis in the hepatic veins and/or inferior vena cava, and portal vein thrombosis (PVT) are rare disorders. Epidemiological data are scarce and previous reports have been from highly specialised referral centres. The aims of the thesis were: (i) to investigate the epidemiology, clinical features and survival of Swedish patients with BCS or PVT, and to (ii) determine common underlying risk factors i.e. thrombophilic factors and genetic markers of myeloproliferative disorders (MPD). In the first two papers we retrospectively reviewed the medical records of all BCS (1986-2003) and PVT (1995-2004) patients identified by searching the computerized patient registers of 11 hospitals including all university hospitals and liver transplantation units. In the following two papers we excluded patients with malignancy and included new cases diagnosed during the years 2004-2009; blood samples were collected and compared with controls and other patient groups. A total of 43 patients with BCS were identified (median age 40 years, 24 women). The mean agestandardised incidence and prevalence rates were 0.8 per million per year and 1.4 per million inhabitants respectively. Two or more risk factors were present in 44%. The overall transplantationfree survival at 1, 5 and 10 years was 47%, 28% and 17% respectively. 173 patients (median age 57 years, 93 men) with portal vein thrombosis were identified. The incidence and prevalence rates were 0.7 per 100 000 per year and 3.7 per 100 000 inhabitants, respectively. In the absence of cirrhosis and malignancy, being the most common risk factors, the survival at 1 year and 5 years was 92% and 76%, respectively. We observed an increased plasma level of the procoagulant factor VIII in BCS (mean 1.63 kIE/L), PVT without cirrhosis (1.87 kIE/L), PVT with cirrhosis (1.97 kIE/L), deep vein thrombosis (1.41 kIE/L) and cirrhosis patients alone (2.22 kIE/L), all p <0.001 compared to healthy controls (1.04 kIE/L). Elevated factor VIII levels were found in 50% of BCS and in 85% of PVT patients without previously identified prothrombotic risk factors. The somatic JAK2 V617F-mutation, a marker of MPD, was present in 63% of BCS and 14% of PVT patients. The frequency of the germline JAK2 46/1 haplotype was significantly higher in BCS (53%) and PVT (36%) patients compared to controls (27%) (p=0.02). However, the enrichment was only observed in JAK2 V617F positive patients. Conclusions: The incidence and prevalence rates of BCS in Sweden were calculated to be 0.8/million inhabitants per year and 1.4/million inhabitants, respectively. The rates of PVT were higher; 0.7/100 000 inhabitants per year and 3.7/100 000 inhabitants, respectively. In BCS the transplantation-free survival was poor, whereas in PVT the survival was variable and highly dependent on the presence of underlying disease. Concurrent prothrombotic risk factors are common in both disorders. High plasma levels of procoagulant factor VIII was observed in a majority of idiopathic BCS and PVT. The prevalence of the somatic JAK2 V617F mutation was high in our cohort and associated with the presence of a germline JAK2 46/1 haplotype.

Ruptured tendons heal faster if they are exposed to mechanical loading. Loading creates deformation of the extracellular matrix and cells, which give rise to intracellular signalling, increased gene expression and protein synthesis. The effects of loading have been extensively studied in vitro, and in intact tendons in vivo. However, the response to loading in healing tendons is less known. The general aim of this thesis was to understand more about the response to mechanical loading during tendon healing. The specific aims were to find out how short daily loading episodes could influence tendon healing, and to understand more about genes involved in tendon healing. The studies were performed using rat models. Unloading of healing tendons resulted in a weaker callus tissue. This could be reversed to some extent by short daily loading episodes. Loading induced more matrix production, making the tendons thicker and stronger, but there was no improvement in the material properties of the matrix. Lengthening is one potential adversity with early loading, during tendon healing in patients. This was also seen with continuous loading in the rat models. However, short loading episodes did not result in any lengthening, not even when loading was applied during the inflammatory phase of healing. It also appeared as loading once daily was enough to make healing tendons stronger, while loading twice daily with 8 hours interval did not give any additional effect. The strongest gene expression response to one loading episode was seen after 3 hours. The gene expression changes persisted 12 hours after the loading episode but had disappeared by 24 hours. Loading appeared to regulate genes involved in inflammation, wound healing and coagulation, angiogenesis, and production of reactive oxygen species. Inflammation-associated genes were regulated both by continuous loading and by one short loading episode. Inflammation is an important part of the healing response, but too much can be harmful. Loading might therefore have a role in fine-tuning the inflammatory response during healing. In conclusion, these studies show that short daily loading episodes during early tendon healing could potentially be beneficial for rehabilitation. Loading might have a role in regulating the inflammatory response during healing.

Damage control surgery (DCS) offers an alternative to the traditional surgical management of complex or multiple injuries in critically injured patients. If a patient survives the initial phase of DCS, complications may occur, one of these being intraabdominal hypertension (IAH) and it´s potential development into the abdominal compartment syndrome. The indications for DCS have been widened and DCS principles can be applied in situations where time and resources are essential factors. The DCS principles of rapidly controlling intestinal spillage have not been evaluated. The aim of the studies in Papers I and II was to evaluate the principles of spillage control of intestinal contents according to the DCS concept and more specifically the effects of early rapid control of multiple bowel perforations on cardiovascular and pulmonary function compared with conventional small bowel resections in an animal model with abdominal trauma. In Paper I the animal model using anaesthetised pigs included a gunshot wound to the abdomen which caused multiple small bowel injuries. Haemorrhagic shock was combined with the gunshot wound in Paper II. The results presented in Paper I showed a significant reduction in rise in systemic vascular resistance and pulmonary vascular resistance, and a trend towards higher cardiac output and lower oxygen consumption in the bowel ligation group. In Paper II the results show a longer persistence of lactic acidaemia in the bowel ligation group. The aim of the study in Paper III was to assess visceral (intestinal, gastric and renal) microcirculation parallel with central haemodynamics and respiratory function during stepwise increases in intraabdominal pressure. In Paper IV we studied mucosal barrier function and morphology in the small bowel and colon of the pigs which were subjected to IAH. The IAP in anaesthetised pigs was increased stepwise using CO2 inflation, by 10 mm Hg at 10-minute intervals up to 50 mm Hg, and followed by exsufflation (Paper III). The microcirculation was selectively studied using a 4-channel laser Doppler flowmeter (Periflex 5000, Perimed, Sweden). The mucosal tissues were mounted in modified Ussing chambers for assessment of barrier function (E.coli K12 uptake and 51Cr-EDTA permeability) (Paper IV). The results showed that the microcirculation of the small bowel mucosa and colon mucosa was significantly less affected compared to the seromuscular layers. The microcirculation of gastric mucosa, renal cortex and the seromuscular layer of small bowel and colon were significantly reduced with each increase. Cardiac output (CO) decreased significantly at IAP levels above 10 mm Hg and the respiratory function data showed an increasing airway pressure and a concomitant reduction in thoracic compliance. Transmucosal passage of E. coli was increased three-fold in the small bowel after ACS with a significant correlation to the degree of mucosal microcirculatory reperfusion after exsufflation. 51Cr-EDTA permeability was unaffected. Bacterial passage in the colon was unchanged, whereas 51Cr-EDTA permeability after ACS increased by up to 181% of baseline and was correlated to significant histopathological changes in the mucosa. In Paper I we have demonstrated that early rapid control of multiple bowel perforations in a model with moderate shock resulted in less impairment of SVR and PVR than conventional resection and anastomosis. The use of DCS principles, however, had no beneficial effect on cardiovascular function when haemorrhagic shock was combined with abdominal missile trauma (Paper II), on the contrary bowel ligation was followed by more prolonged lactic acidosis than conventional repair. The studies in Paper III and IV indicate that the microcirculation of intestinal mucosa and especially small bowel mucosa seem better preserved in response to intraabdominal hypertension caused by CO2 insufflation than other intraabdominal microvascular beds. The short term ACS in this model caused morphological changes in the intestinal mucosa, and mucosal barrier dysfunction. The response pattern concerning barrier function changes after CO2 insufflation differs between small bowel and colonic mucosa. The small bowel mucosa showed increased bacterial passage, and the colonic mucosa an increase in paracellular permeability and secretory response.

Hepatitis B virus causes liver disease and up to 2 billion people have been in contact with the virus world wide. It can cause both acute and chronic disease. The routes for transmission are through blood, mother to infant at time of delivery and sexually. Chronic hepatitis B infection is a risk factor for development of liver cirrhosis and hepatocellular carcinoma. Prevention of hepatitis B virus infection is highly desirable. Since the early1980s hepatitis B vaccine has been available. It can effectively prevent the disease and has been found to be safe. The World Health Organisation, WHO, has recommended all countries to implement the vaccine in their children’s vaccination programmes and many countries have followed this recommendation. In Sweden so far the recommendation is vaccination of identified risk groups for hepatitis B. Health care workers who are at risk of having blood contact in their work is one such risk group. In a large study on health care workers who were intradermally vaccinated with the hepatitis B vaccine, 960/1406 (68.3%) developed protective levels of antibodies to HBsAg (anti-HBs; defined as >10 mIU/mL) after three doses. After administering of an additional fourth dose to non-responders the response rate was 1187/1335 (88.9%). Risk factors for non-response were smoking and age above 40 years. Also, the vaccine response rates improved during the study and a risk of giving a too small dose with intradermal administration was also identified. This suggests that intradermal administration is dependent on well trained personnel. A genetic factor which has been proposed to be associated with a non-responder status to HBV vaccination is the HLA haplotype of the host. In a study in on 69 responders and 53 non-responders the haplotypes were therefore determined. It was found that [DQB1*0602; DQA1*0102; DR15] and [DQB1*0603; DQA1*0103; DRB1*1301] were more likely to be found in responders (p<0.025 and p<0.05 respectively). In non-responders the haplotype [DQB1*0604; DQA1*0102; DRB1*1302] was found more frequently (p<0.005). This study supports that the HLA class II of the host is involved in the ability to respond to the HBV vaccination. To further test the genetic link between the HLA of the host and a non-responder status, relatives to known intradermal non-responders with known haplotypes for DQA1, DQB1 and DRB1 were vaccinated in the same way, intradermally. The response rate in the relatives was 15/26 (58%) which is lower than expected suggesting a genetic influence on the vaccine response. In this study 5/6 with the haplotype [DQB1*0604; DQA1*0102; DRB1*1302] were non-responders which is in line with the previous data that this haplotype is correlated to hepatitis B vaccine non-response. Finally, to test a strategy by which we could induce an effective anti-HBs seroconversion in non-responders we revaccinated these with the combined hepatitis A and B vaccine intramuscularly at a double dose. Already after the first revaccination dose 26/44 (60%) responded with protective antibodies compared to 2/20 (10%) in a vaccine naïve reference group, suggesting an anamnestic response. After three doses 42/44 (95%) responded in the non-responder group and 20/20 (100%) in the reference group. All participants in the study responded to the hepatitis A antigen. In conclusion these studies show that intradermal vaccine administration can be used and is effective, and that the ability to respond is influenced by several, including genetic, factors. Importantly a non-responder status to hepatitis B vaccination is not absolute, a double dose of the combined HAV and HBV vaccine effectively overcomes this non-response in most individuals.

Background & alms: The main cause of chronic gastritis is Helicobacter pylori (H. pylori). Clinical manifestations of chronic gastritis are ulcer disease, gastric cancer and mucosa-associated lymphoma tissue (MALT) lymphoma in the stomach. It is uncertain whether gastritis can be diagnosed macroscopically at endoscopy. H. pylori infection may be diagnosed by several different methods, the accuracy of which needs to be explored. Some individuals with H. pylori related chronic gastritis will develop atrophy of the gastric mucosa. This condition is the main risk factor for cancer development and may also be associated with vitamin B12 deficiency leading to hyperhomocysteinaemia. The natural history of chronic gastritis in terms of development of atrophy and ulcer disease in the adult general population is largely unknown. Material & methods: A sample of 50 I volunteers from the general population in the municipality of Linköping was examined with esophago-gastro-duodenoscopy (EGD) with biopsy. Blood samples were collected in the fasting state and the subjects answered a questionnaire about lifestyle factors, medications and disease history. In-hospital diagnoses and causes of death during follow-up of the population were extracted from local and national patient files. Re-examination was done in 314 subjects after a median follow-up interval of 8.4 years. Five diagnostic tests (serology UBT, RUT, culture and microscopic examination) for H. pylori infection were used at re-examination. Results: The best values of sensitivity and specificity were for visible vessels in relation to microscopic presence of severe atrophy in the gastric corpus mucosa (80% and 87%, respectively). There was a positive relation of S-homocysteine to male gender, age, S-cystatin C (renal function), methylenetetrahydrofolate reductase 677TT genotype and atrophic gastritis. Logistic regression analysis showed an association of S-homocysteine higher than 14.5 Ilmol/L to cardiovascular diseases (OR 2.05), but not to dementia overall. The incidence ofulcer was 0.45 per 100 person years and was associated with weekly NSAID use, weekly alcohol consumption (OR 19.4) and smoking (OR 31.0), but not with H. pylori status. Among subjects with chronic gastritis, the incidence of atrophy of the corpus mucosa was 1.4 per 100 person years. Considering diagnostic test for H. pylori infection the accuracy was 0.86 for serology, 0.94 for UBT, 0.94 for RUT, 0.93 for culture, and 0.93 for histological examination. There was a strong correlation between the results of UBT and the histological scores of H. pylori colonisation as well as between the results of UBT and scores of RUT. Conclusions: The occurrence of chronic gastritis or H. pylori infection is not evaluable macroscopically at gastroscopy, except for the absence of rugae or visible vessels in the gastric corpus mucosa. Serum Hcy concentrations are dependent on gender, age, the levels of vitamin B12 and folate, renal function, the occurrence of atrophic gastritis and the MTHFR 677 TT genotype. Elevated S-Hcy is a risk factor for cardiovascular disease. The incidence of atrophy of the corpus mucosa is 1.4 per 100 person years for chronic gastritis overall. Chronic gastritis with or without H. pylori infection is a variable process in which milder degrees of atrophy of the corpus mucosa may appear or disappear. In contrast, moderate-to-severe atrophy of the corpus mucosa rarely regresses. Age and the degree of chronic inflammation in the gastric corpus mucosa are major risk factors for the development of atrophy. The incidence of ulcer was 0.45 per 100 person years. There are only minor differences in accuracy between the three invasive tests for H. pylori infection. The UBT is recommended for situations where endoscopy is not required. RUT may be recommended as the first non-invasive method of choice in the diagnosis of H. pylori infection.

Patients who require critical care, including those with burns, are affected by a systemic inflammatory reaction, which at times has consequences such as multiple organ dysfunction and failure. It has become increasingly evident that other factors important in the development of organ dysfunction are disturbances at the tissue level, in the microcirculation. Such disturbances activate cascade systems including stress hormones, all of which have local effects on organ function. Despite this knowledge, monitoring and treatment in critical illness today relies mainly on central haemodynamics and blood sampling. Microdialysis is a minimally invasive technique that enables us to study the chemical composition and changes in biochemistry in the extracellular, extravascular space in living tissues. Most of our current experience is from animal models, but the technique has also been used in humans and has become routine in many neurosurgical intensive care units to monitor brain biochemistry after severe injury. In skin, this experience is limited. During the first half of this thesis we studied the injured and uninjured skin of severely burned patients. The results show that there are severe local metabolic disturbances in both injured and uninjured skin. Most interesting is a sustained tissue acidosis, which is not detectable in systemic (blood) sampling. We also recorded considerable alterations in the glucose homeostasis locally in the skin, suggesting a cellular or mitochondrial dysfunction. In parallel, we noted increased tissue glycerol concentrations, which indicated appreciable traumainduced lipolysis. We also examined serotonin kinetics in the same group of patients, as serotonin has been claimed to be a key mediator of the vasoplegia and permeability disturbances found in patients with burns. We have shown, for the first time in humans to our knowledge, that concentrations of serotonin in skin are increased tenfold, whereas blood and urine concentrations are just above normal. The findings support the need for local monitoring of substances with rapid local reabsorption, or degradation, or both. The results also indicate that serotonin may be important for the systemic response that characterises burn injuries. In the second half of the thesis we evaluated the effects of microdosing in skin on metabolism and blood flow of vasoactive, mainly stress-response-related, drugs by the microdialysis system. The objectives were to isolate the local effects of the drugs to enable a better understanding of the complex relation between metabolic effects and effects induced by changes in local blood flow. In the first of these two studies we showed that by giving noradrenaline and nitroglycerine into the skin of healthy subjects we induced anticipated changes in skin metabolism and blood flow. The results suggest that the model may be used to examine vascular and metabolic effects induced locally by vasoactive compounds. Data from the last study indicate that conventional pharmacodynamic models (Emax) for time and dose response modelling may be successfully used to measure the vascular and metabolic response in this microdosing model. We conclude that the microdialysis technique can be successfully used to monitor skin metabolism and iso late a mediator (serotonin) of the local skin response in burned patients. It was also feasible to develop a vascular model in skin based on microdialysis to deliver vasoactive substances locally to the skin of healthy volunteers. This model provided a framework in which the metabolic effects of hypoperfusion and reperfusion in skin tissues could be examined further.

Echocardiography is an ultrasound-based bedside, non-invasive and easily available cardiac diagnostic technique visualising the heart’s morphology and function. Quantification of cardiac wall motion can be measured with the tissue Doppler Imaging (TDI) modality which provides in humans a high diagnostic capacity to differentiate healthy from diseased myocardium with reduced function. Heart failure, as a consequence of, for example, myocardial or ischaemic heart disease, demands both bedside and intraoperative diagnostic procedures for myocardial functional and perfusion assessment. In the late stages of heart failure cardiac left ventricular assist devices (LVAD) may be the treatment of choice. Such new technologies are commonly evaluated in large animals before application in humans is accepted. With the aim of evaluating TDI´s applicability and feasibility in a large animal model 21 calves (aged 3 months and weight around 70 kg), were studied with colour TDI (Paper I). Analysis was performed either during coronary artery occlusion when the laser Doppler perfusion imaging technique (LDMP) was refined (Paper II), or after implantation of the LVAD, Heart Mate II® (Papers III, IV). All animals were haemodynamically monitored (pressures, flows, heart rate) and ECG was continuously recorded. Transthoracic and epicardial echocardiography (TTE) were performed before and after sternotomy and intraoperatively during experimental progressive heart failure. Heart chamber dimensions, native stroke volume, systolic and diastolic regional basal myocardial peak velocities (cm/s; systolic S´, early diastolic E´, and atrial A´, strain (%), strain rate (s-1) and displacement (mm) were determined. Second harmonic imaging (SHI) was applied in order to better visualise air bubbles (Paper IV). In Paper I compiled baseline values were established before and after sternotomy for central haemodynamic and echocardiographic parameters, including the TDI myocardial motion variables velocity, strain rate, strain and displacement. Blood pressure and heart rate changed significantly after sternotomy, but the TDI derived data did not change significantly. In Paper II we report that movement artifacts of the laser Doppler myocardial perfusion measurements can be reduced, both when myocardium is normally perfused and during coronary occlusion, by using the TDI velocity registrations showing wall motion to be minimal. The optimum interval depends on the application but late systole as well as late diastole is preferred. After LVAD implantation in Paper III the flow characteristics and myocardial motion during variations in afterload TDI show that myocardial velocities decrease concomitantly with myocardial depression and are significantly correlated to native stroke volume, heart rate, systemic arterial resistance and cardiac output, but not with left ventricular size, fractional shortening or pump speed. Echocardiography together with TDI thereby offers additional means for monitoring and quantifying residual myocardial function during LVAD treatment. SHI is superior in the early detection of single air-bubbles in the ascending aorta prior to significant air embolism during manipulation of the LVAD pump speed, as shown in Paper IV. A prompt decrease in size of the left atrium during speed adjustment may be a warning that massive air embolism is imminent whereas the commonly used left atrial pressure not provide the same warning. / The title of article II is in the list of publications "Correlation between laser Doppler perfusion monitoring and myocardial tissue Doppler echocardiography in the beating heart" and in the published article the title is "Myocardial tissue motion influence on laser Doppler perfusion monitoring using tissue Doppler imaging".

Head and neck cancer is the sixth most common cancer world wide. In Sweden approximately 850 new cases are diagnosed each year, and two thirds are men. The past decades of improved treatment strategies have unfortunately not significantly improved the five-year survival rates for this group of patients. Therefore, it is important to rapidly find combinations of new and strong predictive markers for treatment response. Different predictive markers have been investigated for decades, without succeeding in finding means to securely predict response to treatment. Models to combine markers are called for. The aim of this thesis was to test multiple predictive markers on both gene and protein level to evaluate their predictive value for radiotherapy and cisplatin response. Furthermore, to combine, and correlate them to treatment response in order to extract the panel of markers that strongest correlated to the investigated treatment. Cell lines derived from 42 patients with head and neck squamous cell carcinoma (HNSCC) were used for protein quantification with Western blot and ELISA of the proteins survivin, Epidermal Growth Factor Receptor, Bcl-2, Bcl-XL, Bax, Bad, Bak, PUMA, Heat shock protein 70, MDM2, p53, SMAD4, Cyclooxygenase-2, and Cyclin D1. The expression of the selected proteins was related to the mean expression of normal oral keratinocytes (NOK) from healthy individuals. Furthermore, mutations in the p53 gene, along with single nucleotide polymorphisms in the genes of p53, MDM2, FGFR4, XRCC1, XRCC3, XPD, and XPC were analysed. To allow a large number of predictive markers on both protein and gene level to be combined and correlated to treatment response, the number of negative points (NNP) model was introduced. Both correlations of sensitivity to radiotherapy and to cisplatin treatment was analysed among the cell lines. In the first paper, including nine cell lines, the panel of EGFR, survivin, and splice site/missense p53 mutations correlated strongest to radioresponse. In paper II, 42 cell lines were used and the combination of survivin, Bcl-2, Bcl-XL, Bax, COX-2, and the p53 Arg72Pro polymorphism was found to most strongly correlate with radioresponse. In paper IV, the panel correlating strongest with cisplatin sensitivity consisted of EGFR, Hsp70, Bax, and Bcl-2 in combination with SNPs in the DNA-repair genes XRCC3 and XPD. The predisposition of the FGFR4 Gly388Arg polymorphism for the development of HNSCC was investigated in paper III. DNA was isolated from 110 tumour biopsies, and restriction fragment length polymorphism analysis showed that 58% of the individuals in the control group carried the FGFR4 Arg388 allele, whereas the frequency in the tumour group was 45%. The Gly388 allele gave a significantly higher risk of developing HNSCC, suggesting Gly388 to be the risk allele for cancer development. Furthermore, a novel mutation was found in the FGFR4 gene. The influence of this new mutation is however unknown. In conclusion, predictive markers for treatment sensitivity need to be combined to receive an accurate prediction of treatment response.

Background: Patients on the ICU often spend a great deal of their time either unconscious or heavily sedated. When they return from the zone between life and death they are often in a state of confusion where dreams and delusions are intertwined with reality and it is not always easy to distinguish them apart. These experiences could lead to psychological problems and post-traumatic stress disorder (PTSD). Recovery may be improved by filling in the significant memory gaps and explaining what really happened during the “chaotic” time on the ICU. The provision of a diary describing the patients’ stay in ICU on a day to day basis and a follow-up meeting (together named the ICU-diary concept), may help the whole family to understand. Aim: The principal aim of this thesis was to see if the ICU-diary concept was of help to patients and relatives in the recovery after critical illness. A further aim was to look for precipitants in the ICU of PTSD. Material and Methods: ICU patients in a handful of European countries and their relatives have been studied. The studies have been single and multi-centred and we have used descriptive observational, randomised controlled and cohort study designs, including matched case-control designs. Quantitative methods have been used with questionnaires and structured interviews using established instruments (i.e Post-traumatic stress syndrome screening-14, Post-traumatic diagnostic scale, ICU memory tool, Short Form-36, Pearlin-Schooler Mastery Scale, Hopelessness scale) as the principal means of data collection. Results: The ICU-diary concept was seen to be a positive and useful aid in helping patients and their relatives understand the events that took place during the time on the ICU. It also decreased the risk for PTSD among patients and relatives. Patients that were supported with the ICU-diary concept perceived a better health-related quality of life even 3 years after the ICU stay. We did not find any definite improvement by the ICU-diary concept in mastery and hope. Variations in how the patients were cared for in the ICU had a significant effect on the development of PTSD. The implementation of an ICU diary, for instance, was associated with a lower frequency of PTSD. Conclusions: The ICU-diary concept was found helpful by patients and their relatives. It was associated with a reduction in new onset PTSD and improved health-related quality of life. The results are encouraging and suggest that an ICU diary may represent an important first step to help patients and relatives come to terms with their experiences during critical illness.ISBN 978-