Objective: The objective of this thesis was to facilitate clinical trials of the optimal lipid based approach (e.g.: omega-3 containing lipid emulsions or minimization of conventional lipid) for the prevention of Intestinal Failure Associated Liver Disease (IFALD). This was achieved through 3 related projects. Project 1: The first project examined the risk of advanced IFALD associated with exposure to conventional intravenous lipid in a logistic regression model. The study demonstrated that each day of conventional lipid (> 2.5 g/kg/day) was associated with a significant increase in the risk of advanced IFALD [Odds Ratio: 1.04 95% CI: 1.003 – 1.06]. Project 2: The second project surveyed experts in Intestinal Failure regarding their beliefs of the efficacy of lipid minimization and lipid emulsions containing omega-3 fatty acids relative to conventional emulsions. The goal of the project was to develop prior distributions of the treatment response for these therapies that can be used in Bayesian analyses of clinical trials. Our results demonstrated consistent expert opinion that the novel lipid based approaches are superior to conventional therapy. Estimates of the treatment effect were similar for the two approaches (median elicited treatment response, relative to conventional lipid, was a relative risk of 0.53 for omega-3 lipid and 0.45 for lipid minimization). Project 3: The final project was a pilot randomized controlled trial of an omega-3 emulsion. The study demonstrated that the randomized design is a feasible strategy for evaluating lipid based approaches for the prevention of IFALD. A Bayesian preliminary assessment of the results of the trial, suggests a high likelihood that the trial will demonstrate a difference between the conventional and omega-3 emulsion evaluated in the trial. However, since the analysis was blinded, the direction of the difference is not known. Conclusion: This thesis will contribute to the design and analysis of high quality and feasible randomized trials that will allow investigators to address the optimal lipid based approach to the management of IFALD.

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2005. / Härtill 4 uppsatser.

The issue of abortions raises a number of conflicting opinions. Although women in the western society can use methods of a birth control, there are still unwanted pregnancies ending in the abortion. This intervention is legal in our society, but many people condemn it. Based on my diploma thesis I therefore wanted to ascertain opinions and attitudes of contemporary young women to the issue of an unwanted parenthood and abortions. I was primarily interested whether their opinions were influenced by a level of their education attainment. In relation to the aim of my thesis one of two determined hypotheses was confirmed. The research showed that an opinion of unmarried young women to this issue was not influenced by their education. Most women think that the right to undergo the abortion has every woman no matter what her reason is. Though, at the same time women perceive the intervention as a desperate solution of a hopeless situation, which they would undergo only from compelling reasons such as for example health problems or a pregnancy after the rape. Economic and social reasons are no longer a sufficient argument for them.

Biorelevant in vitro release/dissolution tests are designed to predict the in vivo behavior of a drug and are crucial in understanding its in vivo performance. Currently, there is no standardized compendial in vitro release testing methods or regulatory guidance’s for release/dissolution testing of implants due to their complex physiological locations.Furthermore, existing compendial methods do not capture the local release profile of ‘novel’ parenterals in physiological low fluid volume surrounding areas. Long acting and in situ forming implants with orthobiologic proteins and peptides have increased over the past few decades due to a better understanding of genetic engineering. One of these products, INFUSE® Bone Graft (Medtronics, MN, USA), is an implant which helps in bone regeneration at the trauma site and is comprised of a) an absorbable collagen sponge (ACS) and b) recombinant human bone morphogenetic protein-2 (rhBMP-2). INFUSE® Bone Graft is an FDA approved product for acute, open shaft tibial fractures, lumbar spinal fusions and sinus or ridge augmentations in the jaws. The evaluation of implant products such as INFUSE® Bone Graft requires a good understanding of local and systemic release in vivo in order to ensure safe, effective, and predictable product performance. The primary goal of this study is to develop a predictive ‘biorelevant’ release model, which factors in clinically relevant physiological parameters suitable for studying and effectively predicting extended release of implants, using INFUSE Bone Graft® as our model implant. A novel biorelevant in vitro model was designed and tested. The model was observed to be discriminatory between two different carrier formulations of rhBMP-2 using a model independent approach - similarity factor (f2). Additionally, a high throughput assay to quantify rhBMP-2 release using high performance liquid chromatography with UV/VIS detection was also developed and validated. Successful completion of this study facilitated an in vitro release study design that incorporated the complex biorelevant parameters of implant dosage forms, the model will offer crucial insights into biological performance, and aid in developing methods to characterize release of other similar dosage forms.

This diploma thesis deals with home parenteral nutrition in the day and night regime and its effect on patients. Parenteral nutrition is usually administered at night so that patients can do normal daily activities and so that nutrition administered in this way has the least impact on their lives. Parenteral nutrition is not a physiological route of nutrient administration and it is not natural for the human body to process nutrients at night. The first part of the theoretical work presents parenteral nutrition and its composition, indications, contraindications and complications. The next part of the thesis describes home parenteral nutrition and its organisation which is necessary for this form of nutritional support to be implemented. It is necessary to monitor many laboratory values on parenteral nutrition, the theoretical part specifically mentions cholesterol, triacylglycerols, glycemia or liver function tests. One of the important parts is the chapter about circadian rhythms, hormones and metabolic changes in energy intake at night. Qualitative research was chosen for this work, which involved 17 patients on home parenteral nutrition. These patients were getting their nutrition during the night. Their laboratory values such as liver function tests, glycaemia and blood fats was evaluated and...

The purpose of this study was to ascertain the number of registered dietitians in Tennessee who perceive they are practicing at advanced levels versus those making recommendations only. Job satisfaction according to order writing privileges was also assessed. A five question survey was sent to hospitals meeting selection criteria. Thirty-three surveys (89%) were returned. Eighty-nine percent of dietitians with order writing privileges considered themselves to be advanced level practitioners compared to 60% in the group of dietitians who did not have order writing privileges. Dietitians with order writing privileges indicated greater job satisfaction compared to dietitians that did not have that privilege. Greater job satisfaction was reported with advanced level skills which included order writing privileges. This study may show the need for dietitians to pursue advanced level skills in order to be challenged by their work, which may improve job satisfaction, and advancement in the field of nutritional care.

Pre-filled syringes: Examination of the needs for ready-to-administer parenteral drugs at Uppsala University hospital  Background: Many parenteral drugs delivered to hospital wards are not ready-to-administer drugs. These drugs are delivered as concentrates or lyophilizates (dry powders) and need preparation by responsible healthcare professionals/nurses before they can be administered. Today, however, there is a shortage of nurses that forces the hospital management to find new ways to free nursing time and open more hospital beds. Aim: The purpose of this study was to examine the consumption of parenteral drugs at the Uppsala University Hospital that could potentially be provided by the extemporaneous manufacturing unit, CBE, as prefilled syringes. Methods: Quantitative data from the Concise Database hosted by the Swedish eHealth Agency was used to derive data on parenteral medications used in Region Uppsala year 2021. Information regarding common drug’s dilutions and shelf life was obtained from the information systems/databases MedMark, MetaVison, and Micromedex. In addition to the collected data, a small sub-study with two nurses was conducted regarding their thoughts on parenteral drug preparation and pre-filled syringes. Results: Quantitative data showed the top 40 most used non-ready to administer drugs for Region Uppsala, year 2021.The most common drugs that need precreation is antibiotics. According to drug stability and shelf-life data, longer shelf life could be obtained using extemporaneous compounding. This cross-sectional study also indicate freed nursing time between 6-11 full-time nursing estimates. Based on the unstructured interviews, positive attitudes are seen towards the provision of parenteral drugs in pre-filled syringes.  Conclusion: It can be concluded that ready-to-administer drugs for parenteral use could possibly be provided by CBE, using extemporaneous compounding. This can thereby increase the safety and quality of parenteral drugs used in the clinical environment, and potentially free nursing time.

In the recent years, it has been well established that primary respiratory viral infection-induced lung resident memory CD8 T cells (TRM) characterized by the expression of integrins CD49a and CD103, as well as the early-activation marker CD69, constitute the first line of defense against reinfection. On the other hand, viral vector-based respiratory mucosal (RM) vaccination, as well as parenteral vaccination followed by airway luminal manipulation induce lasting and protective lung T cell immunity towards pulmonary tuberculosis (TB). However, it remains poorly understood whether and how these TB vaccination strategies induce TRM in the lung. As such, within this thesis we will investigate generation of lung CD8 TRM upon different TB vaccination strategies and the underlying mechanisms regulating establishment of such cells. Here using distinct models of replication-deficient adenoviral vector-based TB vaccination, we find that RM vaccination leads to generation of lung CD8 TRM identified by the expression of CD69, CD103, and very late activation Ag 1 (VLA-1). These TRM-associated molecules are acquired by CD8 T cells in distinct tissues. In this regard, VLA-1 is acquired during T cell priming in draining mediastinal lymph nodes (dMLNs) and the others acquired after T cells entered the lung. Once in the lung, Ag-specific CD8 TRM continue to express VLA-1 at high levels through the effector/expansion, contraction, and memory phases of T cell responses. We also reveal that VLA-1 is not required for homing of these cells to the lung, but it negatively regulates them in the contraction phase. Furthermore, VLA-1 has a negligible role in the maintenance of such cells in the lung. Separately, we have observed that while parenteral intramuscular vaccination alone does not induce lung CD8 TRM, subsequent RM inoculation of an Ag-dependent, but not a non-specific inflammatory agonist induces lung CD8 TRM. Such generation of lung CD8 TRM needs CD4 T cell help. These findings not only fill the current knowledge gap, but also hold important implications in developing effective vaccination strategies towards mucosal intracellular infectious diseases such as acquired immunodeficiency syndrome (AIDS), TB and herpes virus infection. / Thesis / Doctor of Philosophy (PhD)

Introduction : Les enfants prématurés ont la particularité de naître alors que leur développement est souvent incomplet et nécessite la mise en œuvre de soins intensifs visant à poursuivre leur croissance en dehors de l’environnement utérin. Souvent cependant, le stade développemental de l’enfant ne lui permet pas d’assimiler une alimentation entérale du fait de l’immaturité de son système digestif. Le recours à une voie centrale délivrant les nutriments assurant le développement devient alors une nécessité. Ce type de nutrition, appelée nutrition parentérale (NP, ou total parenteral nutrition TPN), permet l’administration de molécules simples, directement dans le sang du prématuré. Il n’est toutefois pas exempt de risques puisqu’exposée à la lumière, la NP peut s’oxyder et générer des molécules oxydantes telles que des hydroperoxydes lipidiques susceptibles de se fragmenter par la suite en hydroxy-alkénals. Ceci devient problématique au vu de l’immaturité des systèmes de défenses antioxydants du nouveau-né prématuré. L’utilisation prolongée de la NP est d’ailleurs à l’origine de maladie hépatiques dans lesquelles le stress oxydant et la nécro-inflammation sont des composantes majeures. Nous avons émis l’hypothèse que l’infusion chez les enfants prématurés, d’aldéhydes d’origine lipidique est en relation avec le développement du stress oxydant et de l’inflammation hépatique. Objectif : Notre étude a consisté à évaluer la relation entre les quantités d’hydroxy-alkénals dans la NP et les effets hépatiques engendrés sur les marqueurs de stress oxydant et les voies de signalisation responsables d’une induction de processus inflammatoire. Dans ce but, nous avons cherché à mesurer la peroxydation lipidique dans l’émulsion lipidique de la NP et la conséquence de l’infusion en continue d’hydroxy-alkénals sur les marqueurs de stress oxydant, sur la voie de signalisation médiée par le Nuclear Factor κB et sur le déclenchement du processus inflammatoire hépatique. A la suite de ce travail, nous avons également travaillé sur des alternatives à la photoprotection, qui est la seule méthode réellement optimale pour réduire la peroxydation des lipides de la NP, mais cliniquement difficilement praticable. Résultats : Nos résultats ont mis en évidence la génération de 4-hydroxynonenal in vitro dans la NP, ce phénomène est augmenté par une exposition lumineuse. Dans ce cadre, nous avons montré l’inefficacité de l’ajout de multivitamines dans l’émulsion lipidique comme alternative à la photoprotection. Dans la validation biologique qui a suivi sur un modèle animal, nos résultats ont permis de démontrer que l’augmentation des adduits glutathion-hydroxynonenal était imputable à l’augmentation de 4-hydroxynonenal (4-HNE) dans la NP, et non à une peroxydation endogène. Nos données indiquent que la probable augmentation hépatique des niveaux de 4-HNE a conduit à une activation du NFκB responsable de l’activation de la transcription des gènes pro-inflammatoires du Tumour Necrosis Factor-α (TNF-α) et de l’interleukine-1 (IL-1). Nous avons alors évalué la capacité d’une émulsion lipidique enrichie en acides gras polyinsaturés (AGPI) n-3 à baisser les concentrations de 4-HNE dans la NP, mais également à moduler le stress oxydant et les marqueurs pro-inflammatoires. Enfin, nous avons démontré, en collaboration avec l’équipe du Dr Friel, que certains peptides isolés du lait humain (par un processus mimant la digestion) permettent également une modulation du stress oxydant et du processus inflammatoire. Conclusion : Le stress oxydant exogène issu de la NP a conduit par activation de facteurs de transcription intra-hépatiques au déclenchement d’un processus inflammatoire potentiellement responsable du développement de maladies hépatiques reliées à la NP telle que la cholestase. Dans ce sens, les AGPI n-3 et les peptides antioxydants peuvent se poser en tant qu’alternatives crédibles à la photoprotection. / Introduction: Premature infants usually born before full term require intensive care to continue to grow up outside the uterine environment. Premature newborns are born with gastrointestinal systems that are too immature to absorb nutrients safely. Therefore they receive their initial nutrients through intravenous feeding, called total parenteral nutrition which delivers simple nutrients directly into bloodstream. However, light exposed-TPN can generate oxidant molecules such as lipid hydroperoxides, which can potently break up into hydroxy-alkenals. Prolonged use of TPN is also a cause of liver disease in which oxidative stress and necro-inflammation are major components. Thus, we hypothesize that lipid aldehydes contained in TPN are associated with oxidative stress and hepatic inflammation developments. Objectives: The aim of our study is to assess the relationship between quantities of hydroxyl-alkenals generated in TPN and effects on oxidative stress biomarkers and cell-signalling pathways molecules implicated in hepatic inflammation induction. To this end, we measure lipid peroxidation in the TPN lipid emulsion in and the consequence of continuous infusion of hydroxy-alkenals on markers of oxidative stress, on cell-signaling pathway mediated by the NFkB, and on liver inflammation induction. Following these data, we also worked on alternatives of photoprotection, which is the only optimal method for preventing lipid peroxidation, but unfortunately clinically impractical. Results: In vitro studies have highlighted the generation of 4-HNE in the TPN, increased under light exposure. In this context, we have demonstrated that the addition of multivitamins in the lipid emulsion cannot be a valuable alternative to photoprotection. Concerning the biological validation in our guinea pig animal model, our results demonstrated that the increase of GS-HNE adducts was due to increased 4-HNE in the TPN, and does not provide from endogenous peroxidation. Our data also indicate that the increase of hepatic 4-HNE led to an activation of NFkB, responsible for the activation of the transcription of proinflammatory genes TNF-α, IL-1. In the next study, we have evaluated the ability of a lipid emulsion enriched with n-3 polyunsaturated fatty acids (PUFA) to reduce 4-HNE concentrations generated in TPN, and to modulate oxidative stress markers and pro-inflammatory process on the same animal model. We also have demonstrated, in collaboration with Dr Friel’s team, that two antioxidant peptides (derived from a process mimicking digestion process of human milk) allow also a modulation of oxidative stress and inflammatory process in the liver. Conclusion: This form of exogenous oxidative stress from the TPN led to an inflammatory process resulting from the activation of intrahepatic transcription, which is potentially responsible of liver disease development such as cholestasis. In this sense, the n-3 PUFA and antioxidant peptides may arise as a valuable alternative of photoprotection.

Introduction: Le supplément d’oxygène et la nutrition parentérale (NP) sont les deux sources majeures de stress oxydant chez le nouveau-né. Lors de la détoxification des oxydants, le potentiel redox du glutathion s’oxyde. Notre hypothèse est que le supplément d’oxygène et la durée de la NP sont associés à un potentiel redox plus oxydé et à une augmentation de la sévérité de la dysplasie bronchopulmonaire (DBP). Patients et Méthodes: Une étude observationnelle prospective incluant des enfants de moins de 29 semaines d’âge gestationnel. Les concentrations sanguines de GSH et GSSG à jour 6-7 et à 36 semaines d’âge corrigé étaient mesurées par électrophorèse capillaire et le potentiel redox était calculé selon l’équation de Nernst. La sévérité de la DBP correspondait à la définition du NICHD. Résultats: Une FiO2≥ 25% au 7ième jour de vie ainsi que plus de 14 jours de NP sont significativement associés à un potentiel redox plus oxydé et à une DBP plus sévère. Ces relations sont indépendantes de l’âge de gestation et de la gravité de la maladie initiale. La corrélation entre le potentiel redox et la sévérité de la DBP n’est pas significative. La durée de la NP était responsable de 15% de la variation du potentiel redox ainsi que de 42% de la variation de la sévérité de la DPB. Conclusion: Ces résultats suggèrent que l’oxygène et la NP induisent un stress oxydant et que les stratégies visant une utilisation plus judicieuse de l’oxygène et de la NP devraient diminuer la sévérité de la DBP. / Introduction: oxygen supplementation and total parenteral solution (TPN) are two main clinical practices that sustain oxidative stress. Glutathione is a key molecule that detoxifies peroxides resulting in a more oxidized redox potential. We hypothesize that O2 supplementation and longer TPN duration are associated with both more oxidized redox potential and more severe bronchopulmonary dysplasia (BPD). Patients and methods: A prospective observational study including infants of less than 29 weeks gestational age. GSH and GSSG from whole blood sampled on day 6-7 and at 36 weeks of corrected age (CA) were measured by capillary electrophoresis and redox potential was calculated using Nernst equation. BPD was classified according to NICHD guidelines. Results: There was a significant association between FiO2 ≥ 25% on day 7 of life and TPN duration longer than 14 days and both more oxidized redox potential and more severe BPD. TPN duration explained both 15 % of total variation observed in redox potential and 42 % of total variation in BPD severity. These associations remained significant after adjustment for gestational age and illness severity. The relation between the severity of BPD and the redox potential in blood was not significant. The statistic power (1-β) to show an effect of redox potential on severity of BPD was 52%. Conclusion: Both redox potential of glutathione and BPD severity are both associated with early O2 supplement and TPN. Strategies targeting judicious use of O2 supplement and either decreasing the duration or using safer formulation of TPN are expected to help reducing BPD.