This thesis comprised patients with chronic rheumatic diseases. The studies aimed to elucidate food sensitivity by measuring mucosal inflammatory reactivity and thereby a possible link between the gut and joints. In all the studies, the mucosal path technique was used to evaluate the rectal mucosal response to rectal challenge with gluten and/or cow’s milk protein (CM). In some patients with primary Sjögren’s syndrome (pSS) and the genetic susceptibility genes HLA DQ2, mucosal reactivity measured with nitric oxide (NO) was found after rectal gluten challenge without detectable serum antibodies to gluten or transglutaminase. This gluten sensitivity was not linked to coeliac disease. After rectal CM challenge, a rectal mucosal inflammatory response measured with NO and myeloperoxidase (MPO) was detected in 38% of pSS patients, all of whom fulfilled the criteria for irritable bowel syndrome. In a questionnaire study of self-experienced adverse reactions to food, 27% of patients with rheumatoid arthritis (RA) reported intolerance to various foods and CM in particular. After rectal CM challenge performed in RA patients (n=27), strong mucosal reactivity to CM was observed in a few patients and a moderate increase in 23%. After gluten challenge, a moderate increase in mucosal reactivity was found in 35% of patients. No correlation to self-perceived intolerance and mucosal reactivity measured with NO and MPO was seen. Inflammation of the gut is a prominent feature of spondyloarthropathies (SpA). After rectal challenges with CM protein and gluten, an increase in rectal NO production was seen in 26% and 19% respectively (p<0.001). An increase in the mucosal release of MPO as a sign of neutrophil activation was seen in the CM- and gluten-sensitive patients. NO production in SpA patients was more enhanced compared with RA and pSS patients and could contribute to the increased barrier permeability described in SpA patients.

Introduction: Rheumatoid arthritis (RA) is a chronic inflammatory disease. Treatment strategies emphasize early multi-professional interventions to reduce disease activity and to prevent disability, but there is a lack of knowledge on how optimal treatment can be provided to each individual patient. Aim: To elucidate how clinical manifestations of early RA are associated to disease and disability outcomes, to strive for greater potential to establish prognosis in early RA, and to facilitate implementation of decision support through analyses of the decision-making environment in chronic care. Methods: Multivariate statistics and mathematical modelling, as well as field observations and focus group interviews. Results: Decision support: A prognostic tree that predicted patients with a poor prognosis (moderate or high levels of DAS-28) at one year after diagnosis had a performance of 25% sensitivity, 90% specificity and a positive predictive value of 76%. Implementation of a decision support application at a rheumatology unit should include taking into account incentive structures, workflow and awareness, as well as informal communication structures. Prognosis: A considerable part of the variance in disease activity at one year after diagnosis could be explained by disease progression during the first three months after diagnosis. Using different types of knowledge – different expertise – prior to standardized data mining methods was found to be a promising when mining (clinical) data for new patterns that elicit new knowledge. Disease and disability: Women report more fatigue than men in early RA, although the difference is not consistently significant. Fatigue in early RA is closely and rather consistently related to disease activity, pain and activity limitation, as well as to mental health and sleep disturbance. Conclusion: A decision tree was designed to identify patients at risk of poor prognosis at one year after the diagnosis of RA. When constructing prediction rules for good or poor prognosis, including more measures of disease and disability progressions showed promise. Using different types of knowledge – different lenses of expertise – prior to standardized data mining methods was also a promising method when mining (clinical) data for new patterns that elicit new knowledge. / Introduktion: Reumatoid artrit (RA) är en kronisk inflammatorisk sjukdom. Dagens behandlingsstrategi bygger på tidiga multiprofessionella insatser för att reducera sjukdomsaktivitet och minska risken för framtida funktionshinder. Idag finns stora datamängder tillgängliga gällande medicinering och utfall vid RA. Dessa data erbjuder möjligheter att generera ny kunskap som kan användas för att forma beslutsstöd. Syfte: Att undersöka hur olika kliniska manifestationer vid tidig RA samvarierar med funktionshinder och sjukdomsaktivitet, att pröva metoder att ställa prognos vid tidig RA, och att analysera en kontext för beslutsfattande inom vård av kroniskt sjuka. Metod: Multivariat statistik och matematisk modellering, samt observationsstudier och fokusgruppsintervjuer. Resultat: Beslutsstöd: Ett beslutsträd utformades för att bestämma vilka patienter som har dålig prognos (måttlig eller hög DAS-28) ett år efter diagnos. Beslutsträdet hade 25 % sensitivitet, 90 % specificitet och ett positivt prediktivt värde på 76 %. Vid införande av beslutsstöd på en reumatologisk klinik befanns det nödvändigt att hänsyn tas till incitamentsstrukturer, arbetsflöde och samarbetsformer. Informella kommunikationsstrukturer kan också ha stort inflytande på klinisk praxis. Prognos: En betydande del av variansen i sjukdomsaktivitet ett år efter diagnos kan förklaras av sjukdomsprogression första tre månaderna efter diagnos. Att formalisera olika experters erfarenheter före standardiserade ”data mining” metoder är en lovande ansats när man letar efter mönster i (kliniska) databaser. Funktionshinder och sjukdomsaktivitet: Kvinnor rapporterar mer trötthet än män vid tidig RA, men skillnaden är inte konsistent över tid. Trötthet vid tidig RA är nära relaterat till sjukdomsaktivitet, smärta och aktivitets begränsningar, men också till mental hälsa och sömnstörningar. Slutsats: Ett beslutsträd har utformats för att predicera patienter med dålig prognos inom tidig RA. Studier av fler mått på sjukdoms- och funktionshindersprogression behövs vid konstruktion av prediktionsregler för god eller dålig prognos framledes. Att använda sig av kunskap från olika experter – olika experters glasögon – vid sökandet efter mönster i stora datamängder för att generera ny kunskap är en lovande metodik. Implementering av beslutsstöd bör göras under övervägande av incitamentsstrukturer, arbetsflöde och samarbetsformer.

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

Systemisk skleros (SSc) är en autoimmun rheumatisk sjukdom som kännetecknas av fibros i huden och/eller de interna organen, vaskulopati och en autoimmun reaktion från immunförsvaret, med eller utan specifika autoantikroppsprofiler. Diagnostisering och sjukdomsbehandling försvåras av sjukdomens heterogena natur. Det finns därför ett behov av pålitliga autoantikroppsbiomarkörer som kan bistå vid diagnostisering av patienter. Autoantikroppar som förekommer i serum kan avslöja sjukdomstillståndet hos patienter samt indikera en prognos om de korreleras till ett specifikt klinisk symtom. Syftet med denna studie var att identifiera autoantikroppar som kanditater till nya biomarkörer inom systemisk skleros i hopp om att dessa ska kunna förbättra stratifiering av patienter, samt att addera kunskap om autoantikroppsreaktivitet inom sjukdomen. Autoantikroppsprofilerna i 107 serumprover, där 55 tillhörde SSc-patienter och 52 tillhörde inflammatoriska kontroller, analyserades i två faser med en planar antigen array för en initial objektiv identifiering av möjliga autoantikroppskandidater, som sedan verifierades i en suspension bead array. Resultaten konfirmerar reaktivitet mot kända autoantigen, så som centromer protein B (CENPB) och DNA topoisomeras I (TOP1), samt identifierar fosfatidylinositol-5-fosfat 4-kinas typ 2 beta (PIP4K2B) som en ny, potentiellt specifik, autoantikroppskandidat för sjukdomen. Tripartite motif containing 21 (TRIM21) som är ett känt autoantigen hos flera systemiska autoimmuna sjukdomar visar potential för att kunna stratifiera sjukdomen. Resultaten i denna studie adderar ny information till kontexten inom autoantikroppsreaktivitet hos patienter med systemisk skleros som efter en mer omfattande dataanalys förhoppningsvis kommer att vara användbar inom diagnostisering av patienter samt för att skräddarsy behandling av sjukdomen. / Systemic sclerosis (SSc) is a highly heterogeneous rheumatic autoimmune disease that is characterized by fibrosis of the skin and/or visceral organs, vasculopathy, and an irregular immune response with or without specific autoantibody profiles. The heterogenic nature of the disease creates a challenge in diagnosis and clinical management of patients. There is thus a need for reliable autoantibody biomarkers that could aid in patient stratification. Serum autoantibodies are indicative of the disease state and may reveal prognosis if correlated to a specific clinical feature. This study aimed to discover novel autoantibody biomarker candidates with the hopes of improving patient stratification and to provide additional knowledge on the autoantibody reactivity in systemic sclerosis. By using a two-phase study design, an autoantibody profiling of 107 serum samples, consisting of 55 SSc samples and 52 inflammatory controls, was performed using the planar antigen array for initial discovery and a suspension bead array for verification. Resulting data confirms reactivity to known targets such as centromere protein B (CENPB) and DNA topoisomerase I (TOP1), while also identifying phosphatidylinositol-5-phosphate 4-kinase type 2 beta (PIP4K2B) as a potential novel target that is specific to the disease. Tripartite motif containing 21 (TRIM21), a known target among several systemic autoimmune diseases, show potential as a target for patient stratification. The results of this study add new information to the context of autoantibody reactivity in systemic sclerosis, which after more extensive data analysis, could be useful in improving the stratification of patients and in tailoring treatment.

Bakgrund: Ledgångsreumatism (RA) är en kronisk sjukdom som primärt påverkar lederna och har en inverkan på vuxnas dagliga liv. För att uppnå en mer omfattande insikt om sjukdomen och dess konsekvenser, är det av betydelse att utforska vuxnas upplevelser av att leva med RA. Denna insikt är nödvändig för att tillhandahålla adekvat vård och tillgodose de befintliga behoven. Syfte: Syftet med litteraturstudien är att undersöka vuxnas upplevelser av att leva med RA.Metod: En litteraturöversikt baserad på 12 kvalitativa artiklar har genomförts, där urvalet fokuserar på personer över 18 år med diagnosen RA. Genom en kvalitativ metodologi samlades data hämtade från databaserna Cinahl och Pubmed. Artiklarna kvalitet granskades enligt SBU:s bedömningsmall och resultatet analyserades enligt Popenoe m.fl. analysmetodik. Resultat: 3 huvudteman framkom, dessa teman var fysisk påverkan, social påverkan och självbild. Elva subkategorier identifierades, dessa var Upplevelsen av trötthet, Upplevelsen av smärta och kronisk stelhet, Upplevelsen av kvinnors sexuella hälsan, Strategier för att hantera vardagen, Upplevelsen av familje- och vänskapsrelationer, Upplevelsen av arbetsrelationer, Upplevelsen av sexuella relationer, Strategier kring arbetsrelaterad påverkan, Upplevelsen av förändrad kropp, Upplevlesen av att vara beroende av andra och Strategier kring självbilden. Konklusion: Resultatet belyste de utmaningarna som vuxna med RA stöter på dagligen. De dagliga utmaningarna sträcker sig över de fysiska- och psykiska aspekter samt förändringar i självbilden. Vidare framkom det i studien att RA har även en påverkan på kvinnors sexuella hälsa. För grundutbildade sjuksköterskor är det av betydelse att förstå vuxnas upplevelser och deras hantering av sjukdomen. Detta för att kunna tillgodose den vård och stöd som krävs för att förbättra deras övergripande livskvalitet.

In this thesis, we have studied the immunological processes of joint inflammation that may be targets for future treatment of patients with arthritis. We focus on the immune-modulating properties of interferon-α (IFN-α) and uridine in experimental arthritis. The nucleoside uridine, which is regarded a safe treatment has anti-inflammatory properties notably by inhibiting tumor necrosis factor (TNF) release. Because the inflamed synovium in rheumatoid arthritis (RA) is characterised by pathogenic TNF-production, uridine could potentially be away to ameliorate arthritis. Systemic administration of uridine had no effect on antigeninduced arthritis (AIA), which is a T-cell dependent model where animals are immunized twice (sensitization) with bovine serum albumin (mBSA), before local triggering of arthritis by intra-articular antigen (mBSA) re-challenge. In contrast, intra-articular administration of uridine clearly down modulated development of AIA in a dose dependent manner and inhibited the expression of synovial adhesion molecules, influx of inflammatory leukocytes and synovial expression of TNF and interleukin 6, but did not affect systemic levels of proinflammatory cytokines or antigen-specific T-cell responses. Local administration of uridine may thus be a viable therapeutic option for treatment of arthritis in the future. Viral double-stranded deoxyribonucleic acid (dsRNA), a common nucleic acid found in most viruses, can be found in the joints of RA patients and local deposition of such viral dsRNA induces arthritis by activating IFN-α. Here we show that arthritis induced by dsRNA can be mediated by IFN-producing dendritic cells in the joint and this may thus explain why viral infections are sometimes associated with arthritis. Earlier, to study the effect of dsRNA and IFN-α in an arthritis model, that like RA, is dependent on adaptive immunity, dsRNA and IFN-α were administered individually during the development of AIA. Both molecules clearly protected against AIA in a type I IFN receptor-dependent manner but were only effective if administered in the sensitization phase of AIA. Here we show that the anti-inflammatory effect of IFN-α is critically dependent on signalling via transforming growth factor β (TGF-β) and the enzymatic activity of indoleamine 2,3 dioxygenase 1 (IDO). The IDO enzyme is produced by plasmacytoid DC and this cell type was critically required both during antigen sensitization and in the arthritis phase of AIA for the protective effect of IFN-α against AIA. In contrast, TGF-β and the enzymatic activity of IDO were only required during sensitization, which indicate that they are involved in initial steps of tolerogenic antigen sensitization. In this scenario, IFN- α first activates the enzymatic activity of IDO in pDC, which converts Tryptophan to Kynurenine, which thereafter activates TGF-β. Common for IDO-expressing pDC, Kyn and TGF-β is their ability to induce development of regulatory T cells (Tregs). We found that Tregs were crucial for IFN-α-mediated protection against AIA, but only in the arthritis phase. In line with this, adoptive transfer of Tregs isolated from IFN-α treated mice to recipient animals in the arthritis phase clearly protected against AIA. The numbers of Tregs were not significantly altered by IFN-α but IFN-α increased the suppressive capacity of Tregs against antigen-induced proliferation. This enhanced suppressive activity of Tregs in the arthritis phase was dependent on the earlier activated enzyme IDO1 during the sensitization phase of AIA. Thus, presence of IFN-α at the time of antigen sensitization activates the enzymatic activity of IDO, which generates Tregs with enhanced suppressive capacity that upon antigen re-challenge prevents inflammation. We have thus identified one example of how immune tolerance can be developed, that may be a future way to combat autoimmunity.

In systemic sclerosis (SSc), interstitial lung disease (ILD) and engagement of the vascular system lead to increased morbidity and mortality. The aim of this thesis was to elucidate, in a consecutively included cohort of SSc (limited and diffuse) patients (n = 33), the T cell cytokine profile driving the disease in ILD and to explore the role of matrix metalloproteinase 9 (MMP-9) and its inhibitor: tissue inhibitor of metalloproteinase 1 (TIMP-1) in the extracellular matrix (ECM) degrading process leading to fibrous scarring and honey combing. Moreover, to characterize the role of nitric oxide (NO) in vascular engagement. Peripheral arterial changes cause Raynaud’s phenomenon and digital ulcers. Nitric oxide (NO) a main inducer of vasodilation is produced by endothelial nitric oxide synthase (eNOS) in response to changes in blood flow or by inflammatory cytokine inducible (i) NOS. In the vascular smooth muscle cell (VSMC) NO activates guanylate cyclase to produce cGMP, causing relaxation. We showed elevated plasma nitrate, a degradation product of NO, and increased urinary excretion of nitrate and cGMP. Plasma nitrate correlated with elevated levels of endothelial adhesion molecules: endothelial (E) selectin and vascular adhesion molecule 1, indicating that the activated endothelium is the site of NO synthesis by iNOS. Endothelial staining for E-selectin and the finding of iNOS and eNOS in SSc skin biopsies supported this notion. In SSc increased vascular stiffness may limit the NO vasodilatory effects. We found normal endothelium-dependent (i.e. flow mediated (FMD%)) and endothelium-independent (i.e. nitroglycerin-induced (NTG%)) vasodilation in the brachial artery. Radial arterial wall stiffness measured as maximum increase in pulse pressure (dP/dtmax) was increased. FMD% and especially NTG% correlated negatively and dP/dtmax positively to measures of endothelial inflammation: plasma- nitrate and adhesion molecule levels. Thus inflammatory vascular wall changes may interfere with dilation as may the presence of nitrate tolerance. We found elevated alveolar MMP-9 in both its pro- and active form in ILD. The levels correlated to decline in lung capacity, pointing at a causal relation. We suggest that neutrophils secrete MMP-9, which may degrade collagen IV, (the main constituent of basal membranes), collagen V, gelatins, proteoglycans and elastin. MMP-9 activity is partly regulated by the binding of pro- and active form to TIMP-1. Alveolar TIMP-1, which even stimulates fibroblast ECM synthesis, was increased independent of ILD. The inflammatory process in ILD is orchestrated by activated T helper (h) lymphocytes. We found a mixed Th1/Th2 reaction in SSc alveolar T cells expressing messenger for interferon gamma (Th1), IL-6 and IL-10 (both Th2). No particular cytokine mRNA profile distinguished alveolar T cells in ILD. Neutrophils invaded the bronchial epithelium, which seemed otherwise inert as levels of inflammatory cytokine sensitive transcription factors and their nuclear translocation tended to be low. The neutrophil recruitment pathway is uncertain as chemoattractants and endothelial adhesion molecules were normally expressed. In conclusion, MMP-9 probably causes degradation of lung tissue in ILD and may represent a future therapeutic target. Alveolar T cells show a mixed Th1/Th2 cytokine profile independent of ILD. Neutrophils invade the bronchial epithelium. Activated endothelium produces increased amounts of NO and adhesion molecules and the level of activation influences brachial arterial FMD% and NTG% and radial arterial compliance. Nitrate tolerance may be present.

High mobility group box 1 (HMGB1) was first identified as a chromatin-associated protein and later discovered to initiate and regulate inflammation by inducing cytokine production, cell migration and cell differentiation. HMGB1 forms complexes with a variety of proteins (e.g. C1q, LPS, CXCL12, IL-1a, IL1b, Beclin-6, p53) that in turn play a role in different cellular mechanisms. However, most HMGB1-protein complexes identified are found in the extracellular space whereas intracellular HMGB1-protein complexes are far less defined.  Firstly, data of HMGB1 interactome was previously generated by Rebecka Heinbäck, Erlandsson Harris group at KI. The HMGB1 interactome was identified in resting and in LPS-stressed THP-1 cells using a method called BioID.  The objective was to explore possible intracellular HMGB1 protein-protein interactions during resting and inflammatory conditions. HMGB1 in complex with other proteins have been known to exhibit crucial functions, therefore our investigation can lead to important knowledge in developing promising future therapeutics targeting HMGB1 in addition to further knowledge on intracellular functions of HMGB1. In this project, we used a combination of different computational analysis tools to explore the roles of HMGB1 and its interactome. Thereafter, we selected proteins within the BioID dataset that were further investigated for direct protein-protein interactions with HMGB1 using computational modelling as well as laboratory techniques, such as co-immunoprecipitation.  Our data reveals functional and biological differences of HMGB1 in resting and LPS activated THP-1 cells. Within resting cells, the HMGB1 interactome is involved in transduction and transcription processes whereas under LPS-stressed conditions HMGB1 is indicated in apoptosis, HATs, and processes in antiviral mechanisms, mainly when localised in the cytosol. Additionally, we revealed potential direct interaction of HMGB1 to S100A6 and HCLS1, in which both can induce different functionalities. Finally, we have further explored the interaction possibilities of HMGB1:S100A6 complex to RAGE, where we found interesting, preliminary results that should be further explored.  To conclude, this thesis suggests new direct, intracellular interaction partners to HMGB1 and indicates a shift in the HMGB1 interactome following LPS stress.

Background and aims Heart failure (HF) is a major cause of serious morbidity and death in the population and one of the leading medical causes of hospitalization among people older than 60 years. The aim of this thesis was to describe how to create and how to analyze a Heart Failure Registry with emphasis on Anemia and Quality of Life. (Paper I) We described the creation of the Swedish Heart Failure Registry (SwedeHF) as an instrument, which may help to optimize the handling of HF patients and show how the registry can be used to improve the management of patients with HF. (Paper II) In order to show how to analyze a HF registry we investigated the prevalence of anemia, its predictors, and its association with mortality and morbidity in a large cohort of unselected patients with HFrEF included in the SwedeHF, and to explore if there are subgroups of HF patients identifying high--‐risk patients in need of treatment. (Paper III) In order to show another way of analyzing a HF registry we assessed the prevalence of, associations with, and prognostic impact of anemia in patients with HFmrEF and HFpEF. (Paper IV) Finally we examined the usefulness of EQ--‐ 5D as a measure of patient--‐reported outcomes among HF patients using different analytical models and data from the SwedeHF, and comparing results about HRQoL for patients with HFpEF and HFrEF. Methods An observational study based on the SwedeHF database, consisting of about 70 variables, was undertaken to describe how a registry is created and can be used (Paper I). One comorbidity (anemia) was applied to different types of HF patients, HFrEF (EF <40%) (II) and HFmrEF (EF 40--‐49% ) or HFpEF (> 50%) (III) analyzing the data with different statistical methods. The usefulness of EQ--‐5D as measure of patient--‐ reported outcomes was studied and the results about HRQoL were compared for patients with HFpEF and HFrEF (IV). Results In the first paper (Paper I) we showed how to create a HF registry and presented some characteristics of the patients included, however not adjusted since this was not the purpose of the study. In the second paper (Paper II) we studied anemia in patients with HFrEF and found that the prevalence of anemia in HFrEF were 34 % and the most important independent predictors were higher age, male gender and renal dysfunction. One--‐year survival was 75 % with anemia vs. 81 % without (p<0,001). In the matched cohort after propensity score the hazard ratio associated with anemia was for all--‐cause death 1.34. Anemia was associated with greater risk with lower age, male gender, EF 30--‐39%, and NYHA--‐class I--‐II. In the third paper (Paper III) we studied anemia in other types of HF patients and found that the prevalence in the overall cohort in patients with EF > 40% was 42 %, in HFmrEF 38 % and in HFpEF (45%). Independent associations with anemia were HFpEF, male sex, higher age, worse New York Heart Association class and renal function, systolic blood pressure <100 mmHg, heart rate ≥70 bpm, diabetes, and absence of atrial fibrillation. One--‐year survival with vs. without anemia was 74% vs. 89% in HFmrEF and 71% vs. 84% in HFpEF (p<0.001 for all). Thus very similar results in paper II and III but in different types of HF patients. In the fourth paper (Paper IV) we studied the usefulness of EQ--‐5D in two groups of patients with HF (HFpEF and HFrEF)) and found that the mean EQ--‐5D index showed small reductions in both groups at follow--‐up. The patients in the HFpEF group reported worsening in all five dimensions, while those in the HFrEF group reported worsening in only three. The Paretian classification showed that 24% of the patients in the HFpEF group and 34% of those in the HFrEF group reported overall improvement while 43% and 39% reported overall worsening. Multiple logistic regressions showed that treatment in a cardiology clinic affected outcome in the HFrEF group but not in the HFpEF group (Paper IV). Conclusions The SwedeHF is a valuable tool for improving the management of patients with HF, since it enables participating centers to focus on their own potential for improving diagnoses and medical treatment, through the online reports (Paper I). Anemia is associated with higher age, male gender and renal dysfunction and increased risk of mortality and morbidity (II, III). The influence of anemia on mortality was significantly greater in younger patients in men and in those with more stable HF (Paper II, III). The usefulness of EQ--‐5D is dependent on the analytical method used. While the index showed minor differences between groups, analyses of specific dimensions showed different patterns of change in the two groups of patients (HFpEF and HFrEF). The Paretian classification identified subgroups that improved or worsened, and can therefore help to identify needs for improvement in health services (Paper IV).

Background: Stroke is a collective name for a disease caused by circulatory disorders in the brain. The patients who are affected often have complications that are experienced as a major life change. The complications mean that rehabilitative care is necessary, which is based on a good caring relationship. Aim: To describe nurses' experiences of caring for patients in rehabilitation after a stroke. Method: Systematic literature study for analysis of ten qualitative studies. Results: Nurses experienced that the rehabilitative care in the stroke wards meant helping the patients find their ‘self’, by seeing the importance of the caring relationship, relatives and the patients' participation. The nurses also experienced that the rehabilitative care involved working in a team, where the nurses experienced the importance of their extensive role and the teamwork. Conclusion: The rehabilitative care after a stroke meant that the nurses help patients find their 'self'. They perceived it as important for patients to be able to achieve good health after their illness. The nurses also felt that their professional role in the team was extensive because they had a rehabilitative responsibility in addition to the general nurse duties. It was something that the nurses felt required a teamwork in the rehabilitation team. Keyword: Caring, nurse-perspective, rehabilitative care, stroke-care, systematic literature review.