Bakgrund: Sveriges befolkning blir i dag äldre och antalet äldre som behöver palliativ vård ökar. Då en äldre familjemedlem vårdas palliativt förändras livet runtomkring denne. Eftersom närstående ofta är involverade i denna vård krävs det mycket av dessa när det kommer till anpassningen till den nya situationen. Syfte: Att beskriva närståendes erfarenheter av att vårda äldre familjemedlemmar palliativt Metod: Metoden som använts är en litteraturbaserad studie, där nio vetenskapliga artiklar analyserats och sammanställts. Resultat: Närståendes förutsättningar för att orka ge god vård och vara delaktiga var att det fanns ett samspel, en god kommunikation och stöd av vårdpersonalen. Vid brist på detta upplevdes känslor av maktlöshet och ensamhet. Vårdinsatser av närstående resulterade i att de kände sig isolerade och de kände ett ansvar för familjemedlemmarnas vård vilket påverkade dem fysiskt och psykiskt. Vårdandet väckte existentiella frågor och en rädsla för att bli ensam. Döden kunde kännas som en befrielse när den önskades av familjemedlemmarna. Slutsats: För att kunna stödja närstående på bästa sätt behöver sjuksköterskor vara lyhörda för vilket behov av stöd som varje enskild närstående behöver.

Bakgrund: Närstående till patienter i palliativ vård upplever ofta en väldigt svår livssituation. Livet sätts på prov och närstående upplever både fysiska och psykiska påfrestningar av olika slag. I Socialstyrelsens kunskapsstöd för palliativ vård anges att närstående till patienter i palliativ vård bör erbjudas stöd i form av samtal som rör emotionella och existentiella frågor. Trots det tyder forskning på att närstående fortfarande upplever att de inte får det stöd de behöver för att hantera svåra känslor och existentiella funderingar. Syfte: Att belysa existentiella upplevelser hos närstående till patienter i palliativ vård. Metod: En allmän litteraturstudie baserad på 10 artiklar med kvalitativa data. Resultat: Sju mönster identifierades: maktlöshet – kontroll; oro, stress – trygghet; hopplöshet – hopp; ensamhet – samhörighet; minskat själv – personlig växt; meningslöshet – meningsfullhet och begränsat liv – helt liv. Dessa beskriver sju kontinuum av existentiella upplevelser som närstående kan röra sig utmed, fram och tillbaka, över tid. Slutsats: Närståendes existentiella upplevelser påverkas av både patientens mående, de närståendes egna resurser och vårdpersonalens stöd och insatser. Det upplevs som viktigt att komma till acceptans med hjälp av egna resurser och med stöd av vårdpersonal, att känna delaktighet i vårdandet av den sjuke, få information och kunskap, kunna bibehålla sitt vardagsliv, att få möjlighet att berätta och att bli bemött som en unik individ med egna intressen och behov. Klinisk betydelse: Lindring av existentiellt lidande är en av sjuksköterskans viktigaste och svåraste uppgifter. Denna litteraturstudie bidrar med kunskap om närståendes existentiella upplevelser och diskuterar hur sjuksköterskan kan bemöta och stödja dessa upplevelser. / Background: Next-of-kin to patients in palliative care often experience a difficult life situation. Life is put on trial and next-of-kin experience both physical and mental stresses of various kinds. The National Board of Health and Welfare (Socialstyrelsen) has issued a knowledge support for palliative care, which states that next-of-kin to palliative patients should be offered support in the form of conversations about emotional and existential issues. Despite this, research suggests that next-of-kin still feel that they do not get the support they need to manage difficult emotions and existential musings. Aim: To illuminate the existential experiences of next-of-kin to patients in palliative care. Method: A general literature review based on ten articles comprising qualitative data. Result: Seven patterns were identified: powerlessness – control; anxiety, stress – assurance; hopelessness – hope; loneliness – togetherness; reduced self – personal growth; meaninglessness – meaningfulness and restricted life – complete life. These patterns describe seven continua of existential experiences that next-of-kin can move along, back and forth, over time. Conclusion: Next-of-kin’s existential experiences are affected by both the patient ́s wellbeing, the next-of-kin's own resources and nursing staff support. It is experienced as important to come to acceptance by using ones own resources and with the support of health professionals, to be included in the care of the patient, to get information and knowledge, to be able to maintain everyday life, to get the opportunity to share thoughts and to be met as a unique individual with own interests and needs. Clinical significance: Relief of existential suffering is one of the nurse's most important and difficult tasks. This study contributes to the knowledge of next-of-kin’s existential experiences and discusses how nurses can respond to and support these experiences.

Studiens syfte har varit att se vad sjuksköterskan i sin omvårdnad kan göra för att stödja barn i åldrarna tre till tolv år som är anhöriga till svårt sjuka föräldrar samt i samband med förälderns bortgång. Studien har genomförts som en litteraturstudie. Det har inte direkt forskats så mycket om sjuksköterskans roll vid bemötande av barn som är anhöriga till en svårt sjuk förälder. Den forskning som finns om barn fokuseras till stor del på situationer då det är barnet som är sjukt och föräldrarna är anhöriga. Vissa forskare har dock intresserat sig för stöd av anhöriga i stort. Resultatet av vår studie visar att behovet av stöd finns hos barn och att sjukvårdspersonalen förefaller lämna över ansvaret till föräldrarna. Särskilt påtalas i litteraturen vikten av att uppmuntra föräldrarna till att informera barnet framförallt av förberedande karaktär. Även barns deltagande i förälderns omvårdnad ses som ett viktig stöd för barnet. Det stöd som riktas till barn under den svårt sjukes vårdtid kan även antas ha bety delse för barnet att förbereda sig inför döden och att gå vidare efter dödsfallet utan några fantasier och känsla av skuld, skyldighet. The purpose of this study has been to explore what the nurse can do in her nursing care to support children of the ages 3?12 years who are next of kin to critically ill parents and in the event of the parents death. The study was carried out as a litterature review. There have not been done a lot of direct research on the nurse?s role in treating children who are next of kin to a critically ill parent. The research that has been carried out on children are mainly focused on situations where the child is ill and the parents are next of kin. However some researchers have shown interest in the support of next of kin in general. The result of our study shows that there is a need of support among children and it appears that nursing staff hands the responsibility over to the parents. In the litterature the emphasis is on encouraging parents to inform the child, especially in an preparatory manner. Also a childs participation in the parents nursing care is seen to be an important support of the child. The support d irected toward a child during the critically ills hospitalization could be seen as having a great influence on the child in its preparation for death and on the child moving along after the death without any fantasies and feelings of guilt.

Understanding the factors influencing species ranges and dispersal are becoming increasingly important as climate change alters species distributions worldwide. If species are to persist, life-history strategies must rapidly evolve to accommodate shifting environments. This dissertation assesses the factors modulating dispersal in corals. First, I examined if there were any systematic differences in settlement between Indo-Pacific and Caribbean coral larvae that might explain Caribbean recruitment failures. No differences were observed, however I detected significant divergences in settlement cue preferences among coral species across both the Caribbean (Diploria strigosa, and Montastraea franksi) and the Indo-Pacific (Acropora tenuis, A. millepora, and Favia lizardensis), even for coral larvae from the same reef. Secondly, I established the extent of coral dispersal between remote reefs. I evaluated the genetic diversity and divergence across Micronesia for two coral species and investigated if these islands served as a connectivity corridor between the Indo-West-Pacific (Coral Triangle) and the Central Pacific. I found isolation-by-distance patterns whose strength depended on species, suggesting these corals are not panmictic across their ranges and that island stepping-stones facilitate gene flow to remote Pacific reefs. Next, I investigated genetic structure of symbionts in these same corals, to see if horizontally transmitted symbionts are less dispersive than their coral hosts. Symbiont genetic divergence between islands was an order of magnitude larger than host divergence and both host species and environment modulated symbiont composition. These results suggest that symbiont populations are host-specific and associating with local symbionts might be a mechanism for broadly dispersing corals to adapt locally. Lastly, I estimated heritable variation in dispersal-related traits in coral larvae. I observed strong heritable variation in gene expression, as well as parental effects on two phenotypic traits, settlement and fluorescence. I observed that patterns of differential expression in three-day-old larvae predicted variation in settlement and fluorescence two days later. Correlations between proteoglycan expression and settlement suggest that the larval extracellular matrix plays a role in settlement. Down-regulation of ribosomal proteins and differential expression of oxidative stress genes correlated with increasing fluorescence, possibly indicating reduced growth and increased stress. Overall, this dissertation contributes to our knowledge of factors affecting coral dispersal and the potential for evolution of dispersal-related traits. / text

Transcriptional regulation is a complicated process controlled by numerous factors such as transcription factors (TFs), chromatin remodeling enzymes, nucleosomes, post-transcriptional machineries, and cis-acting DNA sequence. I explored the complex transcriptional regulation in eukaryotes through three distinct studies to comprehensively understand the functional genomics at various steps. Although a variety of high throughput approaches have been developed to understand this complex system on a genome wide scale with high resolution, a lack of accurate and comprehensive annotation transcription start sites (TSS) and polyadenylation sites (PAS) has hindered precise analyses even in Saccharomyces cerevisiae, one of the simplest eukaryotes. We developed Simultaneous Mapping Of RNA Ends by sequencing (SMORE-seq) and identified the strongest TSS and PAS of over 90% of yeast genes with single nucleotide resolution. Owing to the high accuracy of TSS identified by SMORE-seq, we detected possibly mis-annotated 150 genes that have a TSS downstream of the annotated start codon. Furthermore, SMORE-seq showed that 5’-capped non-coding RNAs were highly transcribed divergently from TATA-less promoters in wild-type cells under normal conditions. Mapping of DNA-protein interactions is essential to understanding the role of TFs in transcriptional regulation. ChIP-seq is the most widely used method for this purpose. However, careful attention has not been given to technical bias reflected in final target calling due to many experimental steps of ChIP-seq including fixation and shearing of chromatin, immunoprecipitation, sequencing library construction, and computational analysis. While analyzing large-scale ChIP-seq data, we observed that unrelated proteins appeared to bind to the gene bodies of highly transcribed genes across datasets. Control experiments including input, IgG ChIP in untagged cells, and the Golgi factor Mnn10 ChIP also showed the strong binding at the same loci, indicating that the signals were obviously derived from bias that is devoid of biological meaning. In addition, the appearance of nucleosomal periodicity in ChIP-seq data for proteins localizing to gene bodies is another bias that can be mistaken for false interactions with nucleosomes. We alleviated these biases by correcting data with proper negative controls, but the biases could not be completely removed. Therefore, caution is warranted in interpreting the results from ChIP-seq. Nucleosome positioning is another critical mechanism of transcriptional regulation. Global mapping of nucleosome occupancy in S. cerevisiae strains deleted for chromatin remodeling complexes has elucidated the role of these complexes on a genome wide scale. In this study, loss of chromodomain helicase DNA binding protein 1 (Chd1) resulted in severe disorganization of nucleosome positioning. Despite the difficulties of performing ChIP-seq for chromatin remodeling complexes due to their transient and dynamic localization on chromatin, we successfully mapped the genome-wide occupancy of Chd1 and quantitatively showed that Chd1 co-localizes with early transcription elongation factors, but not late transcription elongation factors. Interestingly, Chd1 occupancy was independent of the methylation levels at H3K36, indicating the necessity of a new working model describing Chd1 localization.

Antibodies are essential molecules that help to provide immunity against a vast population of environmental pathogens. This antibody conferred protection is dependent upon genetic diversification mechanisms that produce an impressive repertoire of lymphocytes expressing unique B-cell receptors. The advent of high throughput sequencing has enabled researchers to sequence populations of B-cell receptors at an unprecedented depth. Such investigations can be used to expand our understanding of mechanistic processes governing adaptive immunity, characterization of immunity related disorders, and the discovery of antibodies specific to antigens of interest. However, next generation sequencing of immunological repertoires is not without its challenges. For example, it is especially difficult to identify biologically relevant features within large datasets. Additionally, within the immunology community, there is a severe lack of standardized and easily accessible bioinformatics analysis pipelines. In this work, we present methods which address many of these concerns. First, we present robust statistical methods for the comparison of immunoglobulin repertoires. Specifically, we quantified the overlap between the antibody heavy chain variable domain (V H ) repertoire of antibody secreting plasma cells isolated from the bone marrow, lymph nodes, and spleen lymphoid tissues of immunized mice. Statistical analysis showed significantly more overlap between the bone marrow and spleen VH repertoires as compared to the lymph node repertoires. Moreover, we identified and synthesized antigen-specific antibodies from the repertoire of a mouse that showed a convergence of highly frequent VH sequences in all three tissues. Second, we introduce a novel algorithm for the rapid and accurate alignment of VH sequences to their respective germline genes. Our tests show that gene assignments reported from this algorithm were more than 99% identical to assignments determined using the well-validated IMGT software, and yet the algorithm is five times faster than an IgBlast based analysis. Finally, in an effort to introduce methods for the standardization, transparency, and replication of future repertoire studies, we have built a cloud-based pipeline of bioinformatics tools specific to immunoglobulin repertoire studies. These tools provide solutions for data curation and long-term storage of immunological sequencing data in a database, annotation of sequences with biologically relevant features, and analysis of repertoire experiments. / text

Bakgrund: Palliativ vård i hemmet är en ökande företeelse. Närstående vill ofta delta i vården som informella vårdgivare trots att det innebär stor påverkan på deras livssituation. Den palliativa vårdens uppgift är att i livets slutskede lindra och möjliggöra ett så bra liv som möjligt inte bara för patienten utan också för dennes närstående. Syfte: Syftet med studien var att belysa hur närstående upplever sin situation i den palliativa hemsjukvården. Metod: En litteraturstudie har genomförts med sökning i databaserna Cinahl, Pubmed och Medline. Tolv artiklar valdes ut för resultatet. I sju av de utvalda artiklarna användes kvalitativ metod, i två artiklar kvantitativ metod och i tre både kvalitativ och kvantitativ metod. Sju studier var svenska och övriga från Canada, Italien, Japan och Australien. Resultat: Resultatet visade att närståendevårdare hade både positiva och negativa upplevelser av att delta i vården av patienten och att de ofta kände otillräcklighet, osäkerhet och trötthet, vilket sedan gav upphov till många andra symtom såväl fysiska som psykiska och existentiella. Resultatet visade också att  närståendevårdarna hade ett stort behov av att få stöd, information och utbildning av sjuksköterskan i det professionella vårdteamet såväl under pågående vård som efter att patienten avlidit. Diskussion: Det blir ofta en svår balansgång för närståendevårdare mellan att ta hand om patienten och de egna behoven av vila och egen tid. De närstående behöver därför mycket stöd från det professionella vårdteamet för att kunna hantera sin roll som informell vårdare. Sjuksköterskan måste kunna uppmärksamma den enskilde individens unika behov genom att vara behjälplig i att finna omvårdnadsåtgärder som kan hjälpa de närstående att få så bra balans som möjligt i sitt dagliga liv trots vårdbördan. Jag anser att Carnevalis omvårdnadsmodell kan vara ett stöd i detta arbete. / Background: Palliative homecare is a growing phenomenon. Next of kins often participate in the care as informal caregivers, although it means a major impact on their lives. The goal of palliative care is to relieve and allow as good a life as possible, not only for the patients but also for their next of kins. Aim: The aim of the study was to shed light on how next of kins perceive their situation in palliative homecare. Methods: A literature study has been accomplished through searches in the databases Cinahl, Pubmed and Medline. Twelve articles were selected for the result. In seven of the articles qualitative method was used, in two articles quantitative method and and three articles both qualitative and quantitative method were used. Seven studies were Swedish and the others were from Canada, Italy, Japan and Australia. Results: The result showed that informal caregivers had both positive and negative experiences of taking part in the care of the patient and they often felt insufficiency, uncertainty and fatigue, which caused other symptoms, both physical and psychological and spiritual. The result also showed that the informal caregivers had a great need to get support, information and training from the nurse in the professional care team both during treatment and after the patient had died. Discussion: There is often a difficult balance for the next of kins between taking care of the patient and their own personal needs of rest and personal time. Next of kins therefore need support from the professional care team to manage their role as informal caregivers. The nurse must be able to pay attention to the individuals unique needs and to assist in finding nursing interventions that can help next of kins to get the best possible balance in their daily lives despite the care burden. I consider that Carnevalis nursing model can be supportive in this work.

Mitochondrial diseases involving dysfunction of the respiratory chain are the most common inborn errors of metabolism. Mitochondria are found in all cell types besides red blood cells; consequently, patients can present with any symptom in any organ at any age. These diseases are genetically heterogeneous, and exhibit maternal, autosomal dominant, autosomal recessive and X-linked modes of inheritance. Historically, clinical genetic evaluation of mitochondrial disease has been limited to sequencing of the mitochondrial DNA (mtDNA) or several candidate genes. As human genome sequencing transformed from a research grade effort costing $250,000 to a clinical test orderable by doctors for under $10,000, it has become practical for researchers to sequence individual patients. This thesis describes our experiences in applying "MitoExome" sequencing of the mtDNA and exons of >1000 nuclear genes encoding mitochondrial proteins in ~200 patients with suspected mitochondrial disease. In 42 infants, we found that 55% harbored pathogenic mtDNA variants or compound heterozygous mutations in candidate genes. The pathogenicity of two nuclear genes not previously linked to disease, NDUFB3 and AGK, was supported by complementation studies and evidence from multiple patients, respectively. In an additional two unrelated children presenting with Leigh syndrome and combined OXPHOS deficiency, we identified compound heterozygous mutations in MTFMT. Patient fibroblasts exhibit severe defects in mitochondrial translation that can be rescued by exogenous expression of MTFMT. Furthermore, patient fibroblasts have dramatically reduced fMet-\(tRNA^{Met}\) levels and an abnormal formylation profile of mitochondrially translated \(COX_1\). These results demonstrate that MTFMT is critical for human mitochondrial translation. Lastly, to facilitate evaluation of copy number variants (CNVs), we developed a web-interface that integrates CNV calling with genetic and phenotypic information. Additional diagnoses are suggested and in a male with ataxia, neuropathy, azoospermia, and hearing loss we found a deletion compounded with a missense variant in D-bifunctional protein, \(HSD_{17}B_4\), a peroxisomal enzyme that catalyzes beta-oxidation of very long chain fatty acids. Retrospective review of metabolic testing from this patient revealed alterations of long- and very-long chain fatty acid metabolism consistent with a peroxisomal disorder. This work expands the molecular basis of mitochondrial disease and has implications for clinical genomics.

Characterization of the RNA transcriptome by next-generation sequencing can produce an unprecedented yield of information that provides novel biologic insights. I describe four approaches for sequencing different aspects of the transcriptome and provide computational tools to analyze the resulting data. Methods that query the dynamic range of gene expression, low expressing transcripts, micro RNA levels, and start-site usage of transcripts are described.

The pathophysiology of asthma is characterized by airway inflammation, remodeling and hyper-responsiveness. Phenotypic changes in airway smooth muscle cells (ASM) play a pivotal role in the pathogenesis of asthma. ASM cells promote inflammation and are key drivers of airway remodeling. While airway hyper responsiveness and inflammation can be managed by bronchodilators and anti-inflammatory drugs, ASM remodeling is poorly managed by existing therapies. Therefore, targeting ASM remodeling remains a challenge, and a deeper understanding of the molecular mechanism that regulates ASM phenotypes in asthma pathogenesis will facilitate the search for next-generation asthma therapy. MicroRNAs are small yet versatile gene tuners that regulate a variety of cellular processes, including cell proliferation and inflammation - two phenotypes that are often altered in asthmatic ASM. We thus hypothesized that microRNAs regulate ASM phenotypes in asthma and represent new targets for future therapy. In this thesis, we used a genomic approach that combined next-generation sequencing with functional cellular assays to characterize the role of microRNAs in regulating airway smooth muscle function and drug response to conventional therapies. In Chapter 2, we identified miR-10a as the most abundant microRNA expressed in the primary human airway smooth muscle (HASM) cells. Using an unbiased target identification approach, we identified several novel potential targets of miR-10a, including the catalytic subunit alpha of PI3 kinase (PIK3CA)--the central component of the PI3K pathway. We demonstrated that miR-10a directly suppresses PIK3CA expression by targeting its 3' Untranslated region (3'-UTR). Inhibition of PIK3CA by miR-10a reduced AKT phosphorylation and blunted the expression of cyclins and cyclin-dependent kinases that are required for HASM proliferation. In Chapter 3, we examined the effect of conventional asthma therapies on miRNA expression. While we did not find significant changes in miRNA levels, it remains to be determined whether microRNAs play a role in ASM tissue response to asthma therapy. Our study is the first to examine the role of microRNAs in ASM proliferation. Results from our study identified a novel microRNA-mediated regulatory mechanism of PI3K signaling and ASM proliferation. They suggest further that miR-10a is a potential therapeutic target to treat airway remodeling in asthma.