Introduction. The outermost layer of the epidermis, the stratum corneum (SC), plays a fundamental role in our defense against microorganisms, chemicals, and dehydration. The SC is composed of tightly packed keratinized skin cells, corneocytes. For a functioning skin it is essential that corneocytes are constantly shed (desquamated). Kallikrein-related peptidase (KLK) 5 and KLK7 may be important in the desquamation process through degradation of desmosomal proteins. Severe hereditary diseases, where inhibition of KLK5 and/or KLK7 is missing, points to the importance of regulation of protease activity. KLKs may be regulated in various ways: tissue expression, activation of proforms, specific inhibitors, and physico-chemical properties like pH. Besides their involvement in desquamation, KLKs may also be important in immune defense and inflammation by processing of mediators and via activation of proteinase-activated receptors (PARs). Aims. 1. To identify and characterize previously unknown proteases in the SC. 2. To further characterize KLK5 and KLK7 with special focus on activation mechanisms. 3. To identify new inhibitors of KLKs in human SC. 4. To further characterize KLKs regarding effects of various inhibitors and substrates. 5. To study possible functions of KLKs in inflammation, in particular via activation of PAR-2. Methods. Plantar SC was used as a source for purification of proteins. Recombinant proteins were produced in different expression systems (insect cells, yeast cells, and bacteria). Different activity assays and kinetic studies were performed. Tissue expression was studied by immunohistochemistry, immunoblot and PCR. PAR-2 activation was studied by measurement of intracellular [Ca2+] and immunofluorescense in KNRK-PAR2 cells. Results. Active KLK14 was purified from extracts of plantar SC. KLK14 showed a superior catalytic efficiency as compared to KLK5 when measuring trypsin-like activity. This indicated that KLK14, despite being present in low amounts in skin, may have great relevance for skin physiology. Among enzymes tested only KLK5 showed autocatalytic activity and is so far the only enzyme found in SC that can activate proKLK7. KLK5 could also activate proKLK14. This together with studies of pH dependence on activation placed KLK5 as a possible key activating enzyme in a proposed proteolytic cascade in the SC. In plantar SC extracts we have also identified the novel Kazal-type serine protease inhibitor 9 (SPINK9). Our results indicate that SPINK9 is preferentially expressed in palmo-plantar skin and specific for KLK5. Differences found regarding substrate specificity and inhibition profile can be useful in evaluating the contribution of individual KLKs to the proteolytic activity in crude SC extracts. One interesting finding was that KLK8, present at high protein levels in the epidermis, could not be inhibited by any protease inhibitor found in the extracts. PAR-2 activation studies showed that KLK5 and 14 but neither KLK7 nor 8 can activate PAR-2. Immunohistochemistry preferentially detected KLK14 in intraepidermal parts of the sweat ducts and in dermal sweat glands but we could also show coexpression of KLK14 and PAR-2 in the SC and stratum granulosum of the epidermis in inflammatory skin disorders. To summarize, KLK involvement in desquamation may be dependent on a proteolytic activation cascade regulated by an intrinsic pH gradient and specific inhibitors present in SC. Another possible function of KLKs is as mediators of inflammation through activation of PAR-2.

<p><b>Purpose.</b> The main aim of the present study was to evaluate the effect of a low fat, low lactose diet on acute and late gastrointestinal side effects of pelvic radiotherapy. We also wanted to evaluate if such a treatment would influence the patients health related quality of life (HRQOL) in any way.</p><p><b>Background</b>. Cancer therapies and their side effects may cause nutritional problems and malnutrition. Pelvic radiotherapy, a common treatment modality for patients with carcinoma of the endometrium or cervix, is associated with both acute and late side effects that may affect nutritional status. Acute injury may lead to impaired absorption of nutrients and fluid. The patients experience diarrhoea, weight loss, nausea and vomiting. Bile salt malabsorption may be a factor in the pathogenesis of the diarrhoea. In cases of bile salt malabsorption a low fat diet will cause decreased bile salt excretion and thereby relief of symptoms. This assumption was evaluated in a small, non-randomised study in 1985. The results indicated that a low fat diet may reduce the frequency of diarrhoea and use of anti-diarrhoeal agents during radiotherapy. These findings were regarded as promising and since nutrition management guidelines for radiation enteritis were lacking in the literature, a clinical trial was planned.</p><p><b>Methods</b>. The study was designed as an open randomised clinical trial and conducted at the Norwegian Radium Hospital (NRH). The intervention diet (low fat, low lactose) was to be followed during and six weeks after radiotherapy. Measurements were performed at basement, the 3rd and last week of radiotherapy, six week after and then every 8th week. The entire period was one year. In November 1993 the surviving patients were approached again and asked to complete a questionnaire package similar to the one completed during the clinical trial. The study population was recruited from the department of gynaecology at NRH. The main selection criteria were pelvic radiotherapy (dose above 40 Gy) age = 75 years and a WHO functional status = 2. Patients were consecutive included from May 1988 through May 1990 and 143 women were included. Seventy-one were assigned to the intervention diet and 72 to the control group. In November 1993, 94 women were alive without any known relapse and 79 (84%) accepted participation. The women registered use of Loperamid and the daily number and consistency of bowel movements. The data on bowel movements was categorised and used to evaluate if diarrhoea was present or not. Nutritional status was evaluated by the means of weight development, arm muscle circumference (AMC), serum transferring (STF) and serum albumin (s-Alb). Dietary intake was assessed by 48-hour recall prior to radiotherapy, 4-days unweighed dietary record during radiotherapy and 7-days weighed dietary records during follow-up. 24-hour urinary nitrogen was used to validate the food records. HRQOL was defined as the patients' self-reported subjective physical and psychosocial situation as a consequence of disease and treatment. It was measured with the EORTC Core Quality of Life Questionnaire 36-item version (EORTC QLQ-C36).</p><p><b>Results</b>. During the last week of radiotherapy 14 patients (23%) in the intervention group and 32 (48%) in the control group reported diarrhoea (p< 0.01). The intervention group also used less anti-diarrhoea medication than the control group, 0.6 tablets per day versus 1.1 (p<0.01). Six weeks after end of radiotherapy, no group differences were found with regard to bowel movements or medication. The intervention group had a lower energy intake than the control group during radiotherapy, 5.7 MJ versus 6.5 MJ (p<0.05). The mean daily fat intake was respectively 34.3 g and 60.1 g (p<0.001). The intervention group received a significant lower part of the energy from milk products, meats, fats and sugar than the control group, and consumed more energy from vegetables and fruits, cereals and fish. Weight loss was more pronounced in the intervention group (mean reduction of 2.6 kg versus 1.7 kg) than in the control group (ns) during treatment. Mean values of AMC, s-Alb and STF were within the reference range in both groups during the entire observation period. During the last week of radiotherapy six patients (9%) in the intervention group and 4 (6%) in the control group were mildly depleted (ns). At 12 weeks and after one year none of the patients could be categorised as malnourished. No major differences in HRQOL were found between the two groups during radiotherapy and one-year follow up. Within the control group an association between diarrhoea and deteriorated role functioning, physical functioning and fatigue was found during the last week of radiotherapy that was not found in the intervention group. Regarding late effects of radiotherapy (3-4 years after radiotherapy) both groups had more diarrhoea than in the general population, 23.8 versus 9.5 (p<0.01). There was however a tendency to more pronounced diarrhoea in the control group (29.6 (SD=27.3)) than in the intervention group (19.4 (SD=25.4)) though not statistical significant. Substantial diarrhoea was associated deteriorated SF and fatigue. </p><p><b>Conclusions</b>. The intervention group had less diarrhoea and used less Loperamide during radiotherapy than the control group. This finding did not affect nutritional status since no differences in nutritional status were found between the two groups. Both groups had a reduced energy intake and weight loss during radiotherapy. In the control group diarrhoea increased fatigue and had negative effects on physical functioning and role functioning. The intervention did not lead to differences in late radiation injury and chronic diarrhoea 3-4 years after treatment but diarrhoea was most prominent in the control group. Diarrhoea as a late effect increased fatigue and had a negative influence on social well being.</p>

<p>The onset of cigarette smoking begins primarily in adolescence, and prevalence of smoking among adolescents has been increased during the last ten years. The prevalence of adolescent smoking increases with age and is more common or at least as common in girls as in boys in most western countries.</p><p>Until recently the intensive investigation on health effects of smoking has been mostly conducted among adults. In adolescence the long-term health consequences have been reviewed, but current health problems are probably more important to adolescents and may be more motivating for smoking prevention and cessation. Increased morbidity among adolescent smokers has been reported, but specific current health problems and medication use have received little attention. More</p><p>Control of smoking is a primary health goal. An underlying premise for promotion of physical activity in adolescence is that it may mead to a healthy lifestyle persisting through adulthood. Encouraging participation in sports has been recommended as smoking prevention and as part of smoking cessation programs. Smoking habits within different types of sports has received less attention, and whether physical activity has an impact on lung function is debated.</p><p>Adolescent smokers are often unsuccessful in quitting and difficult to recruit and retain in smoking cessation programs. Occasional smoking may be the strongest risk factor for daily smoking, but occasional smokers could be an important target group for smoking cessation who could be discouraged from moving into daily smoking status. </p><p>The first aim of this thesis was to study associations between smoking and current health status by examining associations between daily smoking and subjective health problems (Paper 1), and gender specific effects on respiratory symptoms and lung function (Paper II). The associations between physical activity and lung function in never smokers and daily smokers were also assessed (Paper III). The second aim was to study factors that might be useful in smoking</p>

<p>Preeclampsia is a complex and variable maternal disturbance that ranges from a dramatic onset at early gestation to slowly developing symptoms towards term. Hypertension and renal involvement with proteinuria are cardinal signs, which are often accompanied by fluid retention, blood-clotting dysfunction, and reduced organ perfusion. HELLP (haemolysis, elevated liver enzymes, and low platelet count) syndrome is regarded as a variant of preeclampsia, and the fulminante disease, eclampsia, includes convulsions. Preeclampsia is the main cause of maternal and fetal morbidity and mortality in western countries (1, 2), and in Nordic countries, 17 percent of maternal deaths have been ascribed to preeclampsia (2). Antenatal care in Norway includes on average 12 doctor/midwife consultations per pregnancy (3), and since blood pressure monitoring and urinary testing are main aims of the consultations, preeclampsia is a pregnancy complication that also generates substantial societal costs.</p> / Paper II, III, IV and V reproduced with permission of Elsevier, sciencedirect.com

<p>Stroke is the third leading cause of death and the major course of long-term disabilities in industrialized countries. Most surviving stroke patients show some degree of spontaneous recovery, but persistent symptoms in sensorimotor and cognitive functions are common. The symptoms can be reproduced in experimental stroke models in rats by occlusion of the middle cerebral artery. Housing rats in an enriched environment (EE), i.e. group housing in a large cage with toys that are changed daily, increases neuronal plasticity in healthy rats and can also improve functional recovery after experimental stroke. </p><p> The present thesis investigates the effect of EE on the recovery of sensorimotor and cognitive functions one month after focal cerebral ischemia in rats, with emphasis on the underlying molecular mechanisms. Furthermore, EE-induced effect on gene expression in healthy rats was investigated after different periods of EE-housing and at different time points of the day. </p><p> We show an improved recovery of both sensorimotor and cognitive functions in rats housed in EE for one month after focal cerebral ischemia. The recovery of sensorimotor function correlated significantly to mRNA expression of the plasticity associated transcription factors NGFI-A and NGFI-B in hippocampus and cortical regions outside the infarct. Social interaction seems to be an important component for the beneficial effects of EE after focal cerebral ischemia. Microarray analysis of hippocampal gene expression after one month of postischemic environmental enrichment revealed no confirmable EE-induced changes that could explain the improved recovery in spatial memory. Interestingly, healthy rats housed in EE showed increased mRNA expression of NGFI-A and Krox-20 exclusively during the dark period of the day compared to rats housed in isolation. In addition, EE housed rats had a substantial diurnal variation in NGFI-A, Krox-20 and NGFI-B mRNA expression; this was absent in single-housed rats. EE-induced changes in gene expression are more evident during the dark period of the day, when rats are more active and can benefit from the stimulating environment. This is important to consider in future investigation of putative mediators of the EE-induced neuronal plasticity. </p><p> In summary, these findings may contribute to an increased understanding of the underlying molecular mechanisms behind improved functional recovery in rats housed in enriched environment after focal cerebral ischemia.</p>

<p>The severity of illness was scored in a cohort of 11751 non-surgical patients presenting at the Emergency Department (ED) during 12 consecutive months and followed for 4.7 years. The scoring system Rapid Acute Physiology score (RAPS) (including blood pressure, respiratory rate, pulse rate and Glasgow coma scale) was calculated for all arrivals at the ED. The RAPS system was also additionally developed by including the peripheral oxygen saturation and patient age, resulting in the new Rapid Emergency Medicine Score, (REMS). REMS was superior to RAPS in predicting in-hospital mortality according to ROC-curve analysis. An increase of one point in the 26 point REMS scale was associated with an Odds ratio of 1.40 for in-hospital death (95% CI 1.36-1.45, p<0.0001). Similar results were obtained in the major patient groups (chest pain, stroke, coma, dyspnea and diabetes). The association between REMS and length of stay in hospital was modest. Charlson Co-morbidity Index could add prognostic information to REMS in a long-term (4.7 years), but not in a short-term perspective (3 and 7 days). REMS was shown to be as powerful a predictor of in-hospital mortality as the more complicated APACHE II. REMS at the ED could also predict long-term mortality (4.7 years) in the total cohort (Hazard ratio 1.26, p<0.0001).</p><p>REMS is a potentially useful prognostic tool for non-surgical patients at the ED, regarding both in-hospital and long-term mortality. It is less complicated to use than APACHE II and has equal predictive accuracy.</p>

The onset of cigarette smoking begins primarily in adolescence, and prevalence of smoking among adolescents has been increased during the last ten years. The prevalence of adolescent smoking increases with age and is more common or at least as common in girls as in boys in most western countries. Until recently the intensive investigation on health effects of smoking has been mostly conducted among adults. In adolescence the long-term health consequences have been reviewed, but current health problems are probably more important to adolescents and may be more motivating for smoking prevention and cessation. Increased morbidity among adolescent smokers has been reported, but specific current health problems and medication use have received little attention. More Control of smoking is a primary health goal. An underlying premise for promotion of physical activity in adolescence is that it may mead to a healthy lifestyle persisting through adulthood. Encouraging participation in sports has been recommended as smoking prevention and as part of smoking cessation programs. Smoking habits within different types of sports has received less attention, and whether physical activity has an impact on lung function is debated. Adolescent smokers are often unsuccessful in quitting and difficult to recruit and retain in smoking cessation programs. Occasional smoking may be the strongest risk factor for daily smoking, but occasional smokers could be an important target group for smoking cessation who could be discouraged from moving into daily smoking status. The first aim of this thesis was to study associations between smoking and current health status by examining associations between daily smoking and subjective health problems (Paper 1), and gender specific effects on respiratory symptoms and lung function (Paper II). The associations between physical activity and lung function in never smokers and daily smokers were also assessed (Paper III). The second aim was to study factors that might be useful in smoking

<b>Purpose.</b> The main aim of the present study was to evaluate the effect of a low fat, low lactose diet on acute and late gastrointestinal side effects of pelvic radiotherapy. We also wanted to evaluate if such a treatment would influence the patients health related quality of life (HRQOL) in any way. <b>Background</b>. Cancer therapies and their side effects may cause nutritional problems and malnutrition. Pelvic radiotherapy, a common treatment modality for patients with carcinoma of the endometrium or cervix, is associated with both acute and late side effects that may affect nutritional status. Acute injury may lead to impaired absorption of nutrients and fluid. The patients experience diarrhoea, weight loss, nausea and vomiting. Bile salt malabsorption may be a factor in the pathogenesis of the diarrhoea. In cases of bile salt malabsorption a low fat diet will cause decreased bile salt excretion and thereby relief of symptoms. This assumption was evaluated in a small, non-randomised study in 1985. The results indicated that a low fat diet may reduce the frequency of diarrhoea and use of anti-diarrhoeal agents during radiotherapy. These findings were regarded as promising and since nutrition management guidelines for radiation enteritis were lacking in the literature, a clinical trial was planned. <b>Methods</b>. The study was designed as an open randomised clinical trial and conducted at the Norwegian Radium Hospital (NRH). The intervention diet (low fat, low lactose) was to be followed during and six weeks after radiotherapy. Measurements were performed at basement, the 3rd and last week of radiotherapy, six week after and then every 8th week. The entire period was one year. In November 1993 the surviving patients were approached again and asked to complete a questionnaire package similar to the one completed during the clinical trial. The study population was recruited from the department of gynaecology at NRH. The main selection criteria were pelvic radiotherapy (dose above 40 Gy) age = 75 years and a WHO functional status = 2. Patients were consecutive included from May 1988 through May 1990 and 143 women were included. Seventy-one were assigned to the intervention diet and 72 to the control group. In November 1993, 94 women were alive without any known relapse and 79 (84%) accepted participation. The women registered use of Loperamid and the daily number and consistency of bowel movements. The data on bowel movements was categorised and used to evaluate if diarrhoea was present or not. Nutritional status was evaluated by the means of weight development, arm muscle circumference (AMC), serum transferring (STF) and serum albumin (s-Alb). Dietary intake was assessed by 48-hour recall prior to radiotherapy, 4-days unweighed dietary record during radiotherapy and 7-days weighed dietary records during follow-up. 24-hour urinary nitrogen was used to validate the food records. HRQOL was defined as the patients' self-reported subjective physical and psychosocial situation as a consequence of disease and treatment. It was measured with the EORTC Core Quality of Life Questionnaire 36-item version (EORTC QLQ-C36). <b>Results</b>. During the last week of radiotherapy 14 patients (23%) in the intervention group and 32 (48%) in the control group reported diarrhoea (p&lt; 0.01). The intervention group also used less anti-diarrhoea medication than the control group, 0.6 tablets per day versus 1.1 (p&lt;0.01). Six weeks after end of radiotherapy, no group differences were found with regard to bowel movements or medication. The intervention group had a lower energy intake than the control group during radiotherapy, 5.7 MJ versus 6.5 MJ (p&lt;0.05). The mean daily fat intake was respectively 34.3 g and 60.1 g (p&lt;0.001). The intervention group received a significant lower part of the energy from milk products, meats, fats and sugar than the control group, and consumed more energy from vegetables and fruits, cereals and fish. Weight loss was more pronounced in the intervention group (mean reduction of 2.6 kg versus 1.7 kg) than in the control group (ns) during treatment. Mean values of AMC, s-Alb and STF were within the reference range in both groups during the entire observation period. During the last week of radiotherapy six patients (9%) in the intervention group and 4 (6%) in the control group were mildly depleted (ns). At 12 weeks and after one year none of the patients could be categorised as malnourished. No major differences in HRQOL were found between the two groups during radiotherapy and one-year follow up. Within the control group an association between diarrhoea and deteriorated role functioning, physical functioning and fatigue was found during the last week of radiotherapy that was not found in the intervention group. Regarding late effects of radiotherapy (3-4 years after radiotherapy) both groups had more diarrhoea than in the general population, 23.8 versus 9.5 (p&lt;0.01). There was however a tendency to more pronounced diarrhoea in the control group (29.6 (SD=27.3)) than in the intervention group (19.4 (SD=25.4)) though not statistical significant. Substantial diarrhoea was associated deteriorated SF and fatigue. <b>Conclusions</b>. The intervention group had less diarrhoea and used less Loperamide during radiotherapy than the control group. This finding did not affect nutritional status since no differences in nutritional status were found between the two groups. Both groups had a reduced energy intake and weight loss during radiotherapy. In the control group diarrhoea increased fatigue and had negative effects on physical functioning and role functioning. The intervention did not lead to differences in late radiation injury and chronic diarrhoea 3-4 years after treatment but diarrhoea was most prominent in the control group. Diarrhoea as a late effect increased fatigue and had a negative influence on social well being.

Preeclampsia is a complex and variable maternal disturbance that ranges from a dramatic onset at early gestation to slowly developing symptoms towards term. Hypertension and renal involvement with proteinuria are cardinal signs, which are often accompanied by fluid retention, blood-clotting dysfunction, and reduced organ perfusion. HELLP (haemolysis, elevated liver enzymes, and low platelet count) syndrome is regarded as a variant of preeclampsia, and the fulminante disease, eclampsia, includes convulsions. Preeclampsia is the main cause of maternal and fetal morbidity and mortality in western countries (1, 2), and in Nordic countries, 17 percent of maternal deaths have been ascribed to preeclampsia (2). Antenatal care in Norway includes on average 12 doctor/midwife consultations per pregnancy (3), and since blood pressure monitoring and urinary testing are main aims of the consultations, preeclampsia is a pregnancy complication that also generates substantial societal costs. / Paper II, III, IV and V reproduced with permission of Elsevier, sciencedirect.com

Stroke is the third leading cause of death and the major course of long-term disabilities in industrialized countries. Most surviving stroke patients show some degree of spontaneous recovery, but persistent symptoms in sensorimotor and cognitive functions are common. The symptoms can be reproduced in experimental stroke models in rats by occlusion of the middle cerebral artery. Housing rats in an enriched environment (EE), i.e. group housing in a large cage with toys that are changed daily, increases neuronal plasticity in healthy rats and can also improve functional recovery after experimental stroke. The present thesis investigates the effect of EE on the recovery of sensorimotor and cognitive functions one month after focal cerebral ischemia in rats, with emphasis on the underlying molecular mechanisms. Furthermore, EE-induced effect on gene expression in healthy rats was investigated after different periods of EE-housing and at different time points of the day. We show an improved recovery of both sensorimotor and cognitive functions in rats housed in EE for one month after focal cerebral ischemia. The recovery of sensorimotor function correlated significantly to mRNA expression of the plasticity associated transcription factors NGFI-A and NGFI-B in hippocampus and cortical regions outside the infarct. Social interaction seems to be an important component for the beneficial effects of EE after focal cerebral ischemia. Microarray analysis of hippocampal gene expression after one month of postischemic environmental enrichment revealed no confirmable EE-induced changes that could explain the improved recovery in spatial memory. Interestingly, healthy rats housed in EE showed increased mRNA expression of NGFI-A and Krox-20 exclusively during the dark period of the day compared to rats housed in isolation. In addition, EE housed rats had a substantial diurnal variation in NGFI-A, Krox-20 and NGFI-B mRNA expression; this was absent in single-housed rats. EE-induced changes in gene expression are more evident during the dark period of the day, when rats are more active and can benefit from the stimulating environment. This is important to consider in future investigation of putative mediators of the EE-induced neuronal plasticity. In summary, these findings may contribute to an increased understanding of the underlying molecular mechanisms behind improved functional recovery in rats housed in enriched environment after focal cerebral ischemia.