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This thesis explores the meaning of medicine and considers ethical challenges that arise when medicine's limits are tested as it enters new grounds. The methodology and argumentation used in the thesis can be described as a two-step process. In the first part, the author investigates three ethical examples representing current controversies on the limits of medicine. This is done in three peer reviewed articles. In the second part the focus of the discussion is on common themes visible in all of the three articles. By paying special attention to these themes important elements of the papers are teased out and the argumentation for them strengthened. Through this reflection it is possible to gain a deeper understanding of what medicine is and ought to be. The three examples that are used to throw light upon medicine’s expansion are surrogacy, obesity, and fetal diagnosis. These examples were chosen mainly because they demonstrate this expansion and have all been in public debate in Iceland in the last decade. They have mainly been approached and discussed as medical issues. In three peer reviewed articles, these categorizations are questioned and the constructional forces in society are investigated to determine how they influence medicine's limits. The second part of the thesis is an ethical reflection upon the discussion of the three key examples in the articles. When this discussion is investigated further, four common themes appear that reveal how medicine has the potential to be oppressive, especially toward already stigmatized and marginalized patients. In the second part, the research question is, “When medicine enters new grounds, as described in the articles, it can deviate from its ends and inherent values. What characterizes this deviation and how can that knowledge be used to interpret the meaning of medicine?” The four themes that are common to the key examples in the articles show how medicine can deviate from its ends and inherent values. The first theme shows how the medical description of the disease and the diagnosis gain a separate existence without a clear connection to the patient's experience. This diverging dichotomy undermines the patient's humanity as he is no longer at the center of the doctor’s attention. The second theme shows how overemphasis on biomedical science can cast a shadow on the patient as a human being. As a consequence, it enforces the tendencies described in the first theme and makes the patient more vulnerable. The third theme regards the voices of people in marginalized positions. It shows how they are especially vulnerable towards trends in medicine that can undermine their humanity. The fourth theme is on social justice. It reveals the importance of viewing the patient relationally. If that is not done, medicine can lead to oppression and therefore social justice in health care is not respected. Investigation of the themes above shows that they are interconnected. They reveal medicine as an endeavor with inherent uncertainty, unavoidable power imbalance, and finally, the dynamic core concept of “disease” that will never be accurately defined. These “ontological characteristics” of medicine make the harm described above prone to happen. It is, therefore, important to recognize these processes, described under the themes, in order to avoid them from causing harm to patients and groups of people. It is necessary to ask how to address these processes that may lead medicine away from its ends and inherent values and ask how can we use that knowledge to interpret the meaning of medicine. Here, an interpretation of medicine as being three dimensional, i.e. based on science, with a clear vocation and inherent values, is proposed. Each dimension is described and the investigation of the themes is used to gain a more concise understanding of the meaning, ends, and inherent values of medicine. This approach, firstly, underlines the importance of a holistic view of medicine where its ends and inherent values are not marginalized. Secondly, the three dimensional model is introduced to argue for the importance of guarding a common core of medicine which can be referred to as a frame of reference in medicine's progress., Þessi ritgerð rannsakar merkingu læknisfræðinnar og beinir sjónum að siðferðilegum álitaefn-um sem vakna þegar læknisfræðin fer inn á ný svið og það reynir á mörk hennar. Aðferðafræðin og rökfærslan í ritgerðinni er sett fram í tveimur hlutum. Í fyrri hluta rannsakar höfundur þrjú siðferðileg dæmi sem varpa ljósi á núverandi umræðu um mörk læknisfræðinnar. Þessi umræða birtist í þremur ritrýndum greinum. Í síðari hluta ritgerðar er umfjöllunin um þessi þrjú dæmi í greinunum, skoðuð saman, hún yfirveguð og endurmetin. Með því að skoða sérstaklega hvað er sameiginlegt í umfjöllun um öll þrjú dæmin má setja fram fjögur þemu. Rannsókn á þeim dýpkar skilning á mikilvægum þáttum sem fjallað er um í greinunum og varpar betra ljósi á það hvað læknisfræði er og hvað hún ætti að vera. Dæmin þrjú sem notuð eru til að varpa ljósi á útþenslu læknisfræðinnar eru: staðgöngumæðrun, offita og fósturgreiningar. Þessi dæmi voru valin þar sem þau hafa öll verið fyrirferðarmikil í opinberri umræðu á Íslandi síðastliðinn áratug. Þar voru þau skilgreind og ávörpuð sem læknisfræðileg álitamál. Í þremur ritrýndum greinum er þessi flokkun dregin í efa og jafnframt rannsakað á hvern hátt samfélagsleg öfl móta læknisfræðina og mörk hennar. Í síðari hluta ritgerðar eru ofannefndar þrjár greinar yfirvegaðar saman til að greina hvað þær eiga sameiginlegt. Þessi athugun sýnir að í öllum þremur lykildæmunum sem greinarnar fjalla um má sjá fjögur sameiginleg þemu, sem afhjúpa hvernig læknisfræðin getur aukið á kúgun hópa sem þegar glíma við jaðarsetningu og stimplun. Rannsóknarspurningin í síðari hluta ritgerðar er: Þegar læknisfræðin fer inn á ný svið, eins og lýst er í greinunum, getur hún vikið frá tilgangi sínum og innri gildum. Hvað einkennir þessar breytingar og hvernig getur sú þekking verið hjálpleg til að túlka merkingu læknisfræðinnar? Þemun fjögur sem sjá má í öllum lykildæmunum sýna hvernig læknisfræðin getur fjarlægst tilgang sinn og innri gildi. Fyrsta þemað fjallar um það hvernig sjúkdómsgreiningin og læknisfræðileg lýsing á sjúkdómnum öðlast sjálfstæða tilvist án skýrra tengsla við upplifun sjúklingsins. Sú tvíhyggja og það bil sem myndast á milli þessara þátta grefur undan mennsku sjúklingsins þar sem athygli læknisins beinist ekki fyrst og fremst að sjúklingnum sjálfum heldur fremur að sjúkdómnum sem einangruðu fyrirbæri. Undir öðru þemanu er rakið hvernig ofuráhersla á vísindi getur varpað skugga á mennsku sjúklingsins. Það eykur þær tilhneigingar sem lýst er í fyrsta þemanu og gerir sjúklinginn enn berskjaldaðri. Í þriðja þemanu er röddum jaðarsetts fólks lýst. Þar er bent á hvernig sjúklingar í jaðarsettri stöðu verða sérstaklega berskjaldaðir fyrir þeim straumum innan læknisfræði sem geta grafið undan mennsku þeirra. Fjórða þemað fjallar um félagslegt réttlæti. Þar er bent á mikilvægi þess að skoða sjúklinginn aðstæðubundið til að hindra kúgun og standa vörð um félagslegt réttlæti í allri læknisþjónustu. Við rannsókn á þessum þemum má sjá að þau tengjast öll innbyrðis. Ennfremur afhjúpa þau að læknisfræðin fæst við hluti sem aldrei eru fyllilega fyrirsjáanlegir, hún inniber óhjákvæmilega valdamismunun og byggir á óljósri kjarnahugmynd, þ.e. sjúkdómi, sem aldrei verður skilgreind nákvæmlega. Þessi eðliseinkenni læknisfræðinnar gera þann mögulega skaða sem lýst er í umræðunni um þemun ávallt yfirvofandi. En einmitt þess vegna er þekking á þeim ferlum sem þar er lýst mikilvæg til að geta fyrirbyggt þann mögulega skaða sem læknisfræðin getur valdið sjúklingum og tilteknum hópum fólks ef ekki er brugðist við. Þegar því hefur verið lýst hvernig læknisfræðin getur fjarlægst tilgang sinn og innri gildi er hægt að spyrja hvernig sú þekking geti gagnast til að túlka merkingu læknisfræðinnar. Hér kynnir höfundur þríhliða sýn á læknisfræðina þar sem henni er lýst þannig að hún grundvallist á vísindum, byggist á köllun og hafi sterk innri gildi. Sérhverju þessara sjónarhorna er lýst og umfjöllun um þemun er notuð til að fá dýpri skilning á merkingu, tilgangi og innri gildum læknisfræðinnar. Þessi þríhliða sýn dregur í fyrsta lagi fram mikilvægi þess að sjá læknisfræðina í víðara ljósi þar sem tilgangi hennar og innri gildum er ekki ýtt til hliðar. Í öðru lagi er þessi þríhliða sýn sett fram til að rökstyðja mikilvægi þess að standa vörð um sameiginlegan kjarna læknisfræðinnar sem vísa má til sem viðmiðs þegar lagt er mat á framþróun hennar.

Publisher's version (útgefin grein), The purpose of this article is to better understand the challenges of avoiding the dark side of technological innovation. Specifically, we analyse 10 public investigations started as a reaction to a major crisis in regenerative medicine at the Karolinska Institute, Sweden, associated with the clinician-scientist Paolo Macchiarini. We interpret the reaction as an attempt to restore the balance between the stimulation and regulation of technological innovation processes by clarifying ambiguities in the regulation at the interface between research and practice. We conceptualise these ambiguities as grey zones–situations when it is unclear if the benefits of experimentation outweigh its risks–and propose that grey zones are continually created and resolved as actors in innovation governance systems counterbalance the generation of novelty and the risk of negative unintended consequences., This research was financed by the Swedish Research Council Distinguished Professor’s Programme, awarded to Professor McKelvey, on “Knowledge-intensive Entrepreneurial Ecosystems: Transforming society through knowledge, innovation and entrepreneurship”, VR DNR 2017-03360.This research was also financed by the Bank of Sweden Tercentenary Foundation (Riksbankensjubileumsfond) through the project “How Engineering Science Can Impact Industry in a Global World”, lead by Professor M. McKelvey (FSK15 1080 1). This project is part of a large research program “The Long Term Provision of Knowledge” financed jointly by the Bank of Sweden Tercentenary Foundation, Formas, Forte and the Swedish Research Council.

Vitað er að mikil aukning hefur verið á grunnfrumu og flöguþekjumeinum í húð síðustu ár í vestrænum löndum en ekki er alveg skýrt hvers vegna svo er. Helstu áhættuþættir þessara meina eru ljós húð og útfjólublá geislun, og einnig hafa sum lyf verið bendluð við aukina áhættu með því að valda ónæmisbælingu eða auknu næmi fyrir útfjólublárri geislun í húð. Ekki er mikið til af rannsóknum sem skoða faraldsfræði og áhættuþætti þessara húðmeina, og það er óljóst hvort sum þessara lyfja sem auka þessa áhættu myndu gera það á Íslandi þar sem er lítil útfjólublá geislun miðað við flest önnur lönd. Helstu markmið þessarar rannsóknarar var að athuga sérstaklega tíðni þessara meina á Íslandi og einnig skoða hvaða áhrif ákveðin lyf gætu verið að hafa á áhættu íslendinga að fá þessi mein. Við skoðuðum sérstaklega hydrochlorothiazide (HCTZ), TNF-alpha hindra og statín, sem hafa í sumum rannsóknum verið bendluð við aukna áhættu á húðmeinum. Einnig þá skoðuðum við hugsanleg tengsl metformin við húðmein, en metformin hefur sýnt að lækki áhættu á krabbameinum í sumum rannsóknum. Gagnagrunnur hjá krabbameinsskrá var notaður til þess að reikna tíðnitölur, og var lyfjagrunnur landlæknisembættis notaður til þess að skoða tengsl við lyf. Niðurstöður okkar sýndu að þrátt fyrir það að útfjólublá geislun á Íslandi sé lág hefur tíðni grunn- og flöguþekjumeina aukist til muna, og Ísland er eina landið þar sem að tíðni grunnfrumumeins og grunns flöguþekjumeins er hærra í konum heldur en körlum. Þetta kann að skýrast af því konur virðast vera líklegri til þess að nota ljósabekki og stunda sólböð þegar þær eru erlendis heldur en karlmenn. Karlmenn vinna oftar úti heldur en konur en erlendis þá eru þeir því í hárri áhættu að fá húðkrabbamein vegna mikillrar geislunar. Á Íslandi er þessi geislun heldur minni. Einnig sáum við að þessi aukning á húðmeinum er mest á búk og fótleggjum kvenna, sem bendir enn frekar til ljósabekkja eða sólarlandafera sem orsök. Varðandi lyf, þá var HCTZ tengt við aukna áhættu á bæði grunn- og flöguþekjuæxlum. HCTZ eykur næmi fyrir útfjólubláum geislum og því var ekki endilega viðbúist að lyfið auki áhættu í landi með svo litla bakgrunns geislun. TNF-alpha hindrar og statín voru bæði tengt við aukna áhættu á flöguþekjumeinum, en ekki grunnfrumukrabbameini. Læknar sem skrifa út þessi lyf þurfa að vera meðvitaðir um þessa tengingu. Metformín var tengt við lægri áhættu á grunnfrumukrabbameini en ekki flöguþekjukrabbameini, en þörf er á frekari rannsóknum til þess að staðfesta þessa tengingu., An epidemic of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) has led to a significant healthcare burden in white populations. The incidence of both cancers is on the rise, the reasons for which are unclear. While the principal risk factors for these cancers are fair skin and ultraviolet radiation (UVR) exposure, certain medications have also been implicated in increased skin cancer risk through immunosuppression, immunomodulation, or UVR sensitization. Whole population studies assessing the epidemiology of and risk factors for BCC and SCC are lacking, and it is unclear whether medications significantly increase the risk of BCC and SCC development in the low UV radiation environment that Iceland provides. The primary objective of this study was to establish incidence rates and tumor burden in an unselected, geographically isolated population that is exposed to low levels of UVR. The secondary objective was to delineate the relationship between SCC/BCC and hydrochlorothiazide (HCTZ), TNF-alpha inhibitors (TNFi), and statins. These medications have, in some studies, been associated with increased risk of BCC and SCC development through UV sensitization, immunosuppression, and immunomodulation, respectively. Lastly, the relationship between metformin, which has been shown in some studies to decrease cancer risk, and BCC and SCC development was investigated. To accomplish our goals, we undertook a whole-population study based on the Icelandic cancer registry. We assessed incidence according to age, residence, and multiplicity and assessed trends using joinpoint analysis. Age-standardized (World) and age-specific incidence rates were calculated along with cumulative and lifetime risks. To assess the relationship between medication and skin cancer, we used a population-based case-control study design. The group of cases consisted of all individuals diagnosed for the first time with SCCis, invasive SCC, and BCC of the skin. For each case, ten unaffected population controls, matched by year of birth and sex, were randomly selected from the National Register of Iceland. We employed conditional logistic regression analysis to calculate multivariate odds ratios (ORs). During the study period, the incidence for all subtypes of KC increased, despite Iceland’s low background UVR. This increase was most prominent in women on sites not generally exposed to UV radiation in Iceland: the trunk and legs. Joinpoint analysis showed the fastest increase in SCCis incidence to be in women. Women with SCCis also had a higher likelihood of developing new lesions than men, with a multiplicity of 1.71. Men are more likely than women to develop invasive SCCs, which occur almost exclusively in the head and neck. Lip SCCs were much more likely to be invasive than in situ. HCTZ was associated with all subtypes of KC. TNFis and statins were associated with SCC but not BCC. Cutaneous KC is becoming a significant public health problem worldwide. Iceland is the only reported population, to our knowledge, in which the incidence of BCC and SCCis is significantly higher in women than in men. While in most countries, men have a higher incidence of BCC and SCC, Iceland's low UV radiation environment might protect men, as women may be more likely to engage in high-risk tanning behaviors. Despite the low background UV radiation in Iceland, high cumulative exposure to the UV sensitizing medication HCTZ was associated with the development of BCC, SCCis, and invasive SCC, suggesting that sun-protective behaviors alone may not eliminate the carcinogenic potential of HCTZ in high UV countries. TNFis and statins increased individual risk for SCC, but not BCC, a phenomenon also seen in organ transplant recipients and patients on immunosuppressive medications such as cyclosporine. These associations require further study. Public health efforts (focusing on the potentially harmful effects of UVR) and physician education will be essential to counteract the increasing skin cancer incidence in Iceland as its population ages. Since metformin use was associated with decreased BCC development, it is possible that metformin might be a reasonable option for patients at high risk for developing BCC, or used to slow the rate of BCC development in patients with multiple skin cancers. This requires further study using prospective design models.

A better understanding of normal organ development can give deeper insight into which genes are harnessed by aberrant cells during cancer formation and progression. In my thesis, I have investigated two seemingly different, however, related, developmental processes in the breast gland: epithelial-to-mesenchymal transition (EMT) and branching morphogenesis. EMT and its reverse process mesenchymal-to-epithelial transition (MET), are important processes during embryogenesis and in diseases, such as cancer, where evidence suggests that they mediate processes such as cell invasion and formation of metastasis. Branching morphogenesis is an essential developmental process that in the breast gland mostly takes place postnatally. Both processes are widely studied due to their importance in multiple fields. However, the involvement of non-coding RNAs in the regulation of gene expression during EMT and branching morphogenesis has recently been appreciated and is a challenging field of study. In my experimental approach, I mainly took advantage of a well-defined series of cell lines referred to as the D492 cell lines, which include D492, D492M and D492HER2. D492 is a breast progenitor epithelial cell line and a model for branching morphogenesis. D492M is a non-tumorigenic cell line derived from D492 through endothelial-induced EMT, while D492HER2 is a tumorigenic cell line derived from D492 through oncogene-induced EMT. Together, D492 and D492M represent a unique in vitro cellular model, enabling research on the phenotypic and functional changes occurring during EMT, while D492M and D492HER2 allow us to study differences in tumorigenicity. The primary aim of this thesis was to study the expression and functional role of non-coding RNAs during branching morphogenesis and EMT in the human breast gland using the D492 and D492M cell lines. The secondary aim was to study the role of extracellular matrix proteins secreted by D492HER2 on cancer growth and angiogenesis. In paper #I, I addressed the role of non-coding RNAs from the DLK1-DIO3 locus in cellular plasticity, EMT and cancer. Here I used primary cells, cancer patient's cohorts and the D492 cell lines. Using the CRISPRi and CRISPRa approaches, we found out that this locus is a marker of mesenchymal cells and affects the cellular plasticity of adult breast epithelial cells. Paper #II was focused on identifying miRNAs highly upregulated in D492 during branching morphogenesis but downregulated in D492M. We identified MIR203a as a novel suppressor of peroxidasin (PXDN), a collagen IV crosslinking agent. Our results indicate that MIR203a may be an essential regulator of branching morphogenesis and basement remodelling in the human breast gland, likely through its target PXDN. Finally, in paper #III and IV, we compared the two D492 derived cell lines D492M and D492HER2. Compared to D492M, the tumorigenic D492HER2 has a partial EMT phenotype, seen by increased expression of epithelial miRNAs. D492HER2 shows higher migratory, invasive, proliferative and angiogenic properties compared to both D492 and D492M. By means of mass spectrometry and RNA sequencing analysis of D492M and D492HER2, we identified extracellular matrix protein YKL-40 and ECM1 as potential candidates contributing to tumorigenicity of D492HER2 and to be partially responsible for the functional differences between the cell lines. Moreover, we showed that ECM1 induces crosstalk with endothelial cells through Notch signalling. Collectively, I have in my thesis partially uncovered the role of non-coding genes from the DLK1-DIO3 locus and MIR203a in EMT and branching morphogenesis. Furthermore, I have also, in collaboration with my co-workers, identified the ECM proteins YKL-40 and ECM1 as potential inducers of cancer growth and angiogenesis., Þekking á þroskun og sérhæfingu vefja gefur innsýn í gen og þroskunarferli sem einnig gegna hlutverki við myndun krabbameina og framþróun æxlisvaxtar. Í þessari ritgerð rannsakaði ég RNA sameindir sem ekki tjá fyrir próteinum (e. non-coding RNAs (microRNA og long noncoding RNA, lncRNA)) og hlutverk þeirra í þroskun og sérhæfingu brjóstkirtilsfruma. Ég skoðaði einkum hlutverk þeirra í bandvefsumbreytingu þekjufruma (e. epithelial to mesenchymal transition, EMT) og í greinóttri formgerð (e. branching morphogenesis). Auk þess rannsakaði ég hlutverk utanfrumupróteina í hegðun og svipgerð brjóstrabbameinsfruma og í nýæðamyndun. EMT og þekjuvefsumbreyting bandvefsfruma (e. mesenchymal to epithelial transition, MET) eru mikilvægir ferlar í fósturþroska og í sjúkdómum á borð við krabbamein þar sem þeir hafa verið tengdir við ífarandi vöxt og meinvarpamyndun. Greinótt formgerð í brjóstkirtlinum hefst að mestu við kynþroska kvenna og er kirtilinn í mikilli ummyndun í hverjum tíðarhring fram að tíðahvörfum. EMT og MET gegna mikilvægu hlutverki í myndun greinóttrar formgerðar í brjóstkirtli. Á síðustu árum hefur komið í ljós að non-coding RNAs hafa mikil áhrif á stjórnun EMT og MET þó enn sé margt á huldu varðandi hlutverk einstakra RNA sameinda í þessu ferli. Rannsóknarmódelið sem ég notaði byggir á brjóstþekjufrumulínunni D492 og dótturlínum hennar. D492 er stofnfrumulína sem getur myndað greinótta formgerð í þrívíðri rækt. D492M er bandvefs-lik dótturlína frá D492 sem hefur undirgengist EMT. D492HER2 er einnig komin frá D492, en í þessari dótturlínu er HER2 æxlisgenið yfirtjáð; frumulína þessi getur myndað æxli í músum. Þessar línur hafa allar sama erfðabakgrunn en ólíka svipgerð og eru því hentugar til rannsókna á greinóttri formgerð, EMT og MET í eðlilegum og illkynja brjóstkirtli. Meginmarkmið verkefnisins var að rannsaka tjáningu og hlutverk RNA sameinda sem ekki tjá fyrir próteinum, bæði microRNA og lncRNA, í greinóttri formgerð, EMT og MET í brjóstkirtli. Jafnframt var markmiðið að rannsaka áhrif utanfrumupróteina sem seytt er frá D492HER2 á æxlisvöxt, svipgerð og nýæðamyndun í frumurækt. Í grein I kannaði ég hlutverk RNA sameinda sem eru staðsett á DLK1-DIO3 genasvæðinu (e. gene locus) á litningi 14 í EMT/MET, stjórnun svipgerðar frumna og í brjóstakrabbameinum. Helstu niðurstöður sýndu að RNA sameindir þessar, þar með talið MEG3 lncRNA og microRNA á þessu genasvæði eru meira tjáð í bandvefsfrumum en þekjufrumum og jafnframt að tjáning þessara RNA sameinda hefur áhrif á sérhæfingu brjóstaþekjufruma yfir í bandvefsfrumur. Í grein II var markmiðið að greina tjáningamynstur microRNA sameinda í greinóttri formgerð í þrívíðri rækt og EMT. Niðurstöður okkar sýna að tjáning microRNA 203a jókst margalt við myndun greinóttrar formgerðar í D492 en var lækkuð í D492M bandvefsfrumulínunni. Við sýndum einnig fram á að sameindin bælir tjáningu peroxidasin (PXDN) millifrumupróteinsins. Niðurstöður okkar benda til þess að microRNA203a sé mikilvægur stýrill við myndun greinóttrar formgerðar og í myndun grunnhimnu í brjóstkirtli og þá mögulega í gegnum PXDN. Í grein III og IV var markmiðið að bera saman svipgerð D492 og D492M við D492HER2 frumulínuna sem ólíkt þeim fyrrnefndu myndar æxli í ónæmisbældum músum. Ólíkt D492M, sem hefur sterka EMT svipgerð, þá sýnir D492HER2 einungis EMT svipgerð að hluta (e. partial EMT) og breytir sinni svipgerð eftir ytri aðstæðum, ásamt því að tjá mun meira af þekjuvefstengdum microRNA sameindum en D492M. Auk þess sýnir D492HER2 mun meira skrið og ífarandi vaxtareiginleika en D492M. Með massagreiningu og RNA raðgreiningu greindum við utanfrumupróteinin YKL-40 og ECM1 sem prótein sem mögulega geta stuðlað að krabbameinseiginleikum D492HER2. Jafnframt hafa YKL-40 and ECM1 áhrif á nýmyndun æða í frumuræktunum. Í ritgerð þessari hef ég rannsakað RNA sameindir sem ekki tjá fyrir próteinum frá DLK1-DIO3 genasvæðinu ásamt microRNA203a og hlutverk þeirra í greinóttri formgerð og í krabbameinum og sýnt fram á að þessar RNA sameindir gegna hlutverki í EMT/MET. Jafnframt hef ég unnið að rannsóknum á hlutverki YKL-40 og ECM1 utanfrumupróteinanna í brjóstakrabbameinum og sýnt fram á hlutverk þeirra í í skriði æxlisfruma og í nýæðamyndun., Landspitali University Hospital - Science Fund, University of Iceland - Research Fund, Rannis - Grant of Excellence, "Vísindasjóður Krabbameinsfélagsins" and "Göngum saman"

Markmið: Að kanna áhættuþætti fyrir fæðingu mikilla þungbura (fæðingarþyngd ≥5000 g) og hugsanlegar afleiðingar þess fyrir móður og barn (grein 1). Að meta efnaskipti mikilla þungbura með því að skoða mynstur þeirra amínósýra og acylkarnitína sem mæld eru í nýburaskimun og bera saman við börn með eðlilega fæðingarþyngd og börn með lága fæðingarþyngd (, Háskólasjóður Eimskipafélags Íslands/Eimskip University Fund. Nýsköpunarsjóður Námsmanna/Student Innovation Fund. Aðstoðakennarasjóður Háskóla Íslands/Assistant Teacher fund in University of Iceland. Vísindasjóður Landspítalans Háskólasjúkrahús/Science fund of Landspitali University Hospital. Rannsóknarsjóður Kvennadeildar Landspítalans Háskólasjúkrahúss/Research Fund at the Women´s Clinic at Landspitali University Hostpital. Rannsóknarsjóður Erfða- og sameindafræðisviðs Landspítalans Háskólasjúkrahúss/Research Fund of the Department of Genetics and Molecular Medicine, Landspitali University Hospital.

Epithelial to mesenchymal transition (EMT) is a developmental trait that is hijacked in some disease conditions such as fibrosis and cancer. In cancer, EMT has been linked to increased invasion and metastasis, and is generally associated with a poor prognosis. In this study, I have compared phenotypic and functional differences between two isogenic cell lines exhibiting an EMT profile, D492M and D492HER2, but to a distinct extent. These cell lines are derived from D492, a breast epithelial cell line with stem cell properties that can generate both luminal and myoepithelial cells, and in 3D culture, it forms branching terminal ductal lobular units (TDLU)-like structures. When co-cultured with breast endothelial cells, D492 undergoes EMT, which is the origin of the D492M subline. Another subline of D492 was generated by overexpressing the HER2 oncogene. D492M has a more fixed EMT phenotype while D492HER2 expresses a more intermediate EMT phenotype. Moreover, D492M and D492HER2 differ in their tumorigenicity, that is, they are non-tumorigenic and tumorigenic, respectively. This study aimed to analyze the expression profile of these cell lines and study how they interact with endothelial cells. This study has prompted the identification of potential oncogenes, YKL-40 and ECM1, and the evaluation of their effects on the cellular phenotype and angiogenic potential in endothelial cells. YKL-40 and ECM1 may provide D492HER2 with increased aggressiveness that supports cancer progression., Bandvefsumbreyting þekjufrumna (e. epithelial to mesenchymal transition (EMT)) er þroskunarfræðilegur ferill sem kemur fyrir í sjúkdómum eins og trefjun (e. fibrosis) og krabbameini. Í krabbameini hefur EMT verið tengt við ífarandi æxlisvöxt og meinvarpamyndun og er ferillinn almennt tengdur slæmum batahorfum. Í þessari rannsókn bar ég saman mun á svipgerð (e. phenotypic) og virkni (e. functional) tveggja frumulína með sama genetíska bakgrunn (e. isogenic) sem sýna mismunandi EMT prófíl, D492M og D492HER2. Þessar frumulínur eru komnar frá D492, brjóstþekjufrumulínu með stofnfrumueiginleika sem getur myndað bæði kirtilþekju- og vöðvaþekjufrumur, og í þrívíðri rækt myndar hún greinótta formgerð. Í samrækt með æðaþeli, undirgekkst D492 frumulínan EMT og við það myndaðist D492M. D492HER2 var hins vegar mynduð með yfirtjáningu á HER2 krabbameinsgeninu. Svipgerð D492M frumulínunnar með tilliti til EMT er lengra komin (e. fixed EMT phenotype) miðað við D492HER2 (e. intermediate EMT phenotype). Ennfremur eru D492M og D492HER2 mismunandi hvað varðar eiginleika til að mynda æxli í músum, það er að segja D492M myndar ekki æxli á meðan D492HER2 myndar æxli. Markmið þessarar rannsóknar var að greina mun í tjáningu gena á milli þessara frumulína og skoða mismun í samskiptum þeirra við æðaþel og stoðvef. Þessi rannsókn hefur leitt af sér greiningu mögulegra krabbameinsgena (e. potential oncogenes) og mat á áhrifum þeirra á frumusvipgerð og æðamyndun í æðaþelsfrumum. YKL-40 og ECM1 geta veitt D492HER2 aukna árásargirni sem styður framrás krabbameins.

Background: Cognitive impairment is a core feature at all stages of the psychotic illness and significantly predicts functional outcomes. Targeting cognition early is theoretically attractive as a means to reverse the functional impairment before it is fully realized and thus improve the long-term outcome and quality of life of patients with psychotic disorders. Cognitive remediation is an effective treatment of cognitive deficits in schizophrenia, but generalization to everyday functioning remains a challenge. Interventions, such as strategy training combined with computerized training, and socialcognitive training have shown promise in bridging the gap between cognitive gains and functional outcomes. However, relatively little is known about the effects of integrated neuro- and social-cognitive remediation in early psychosis and what may aid in implementing these interventions into standard care for early psychosis. Objectives: The overall aim of this thesis was to assess and treat the neuroand social-cognitive impairment among individuals seeking treatment at an early intervention in psychosis (EIP) service in Iceland. In addition, to examine implementation outcomes of the intervention with regards to attendance, fidelity and acceptability. The specific aims of the first study were to investigate the nature of neuro- and social-cognitive impairment and explore the relationship between social cognition and neurocognition, clinical symptoms, and functional outcome. In addition, we sought to investigate the role of neuro- and social-cognitive domains in predicting variance in informant-reported and self-reported functional outcomes. the specific aims of the second study were to evaluate the effects of a novel integrative neuroand social-cognitive remediation on cognition, clinical symptoms and functional outcome. The specific aims of the third study were to evaluate the long-term effects of the intervention on cognition, clinical symptoms, and functional outcomes. Method: All patients between the ages of 18 and 30, who had experienced their first psychotic episode in the past five years and in seeking treatment at the EIP service between 2015-2017, were offered participation in the first study. A total of 70 patients, 82% of the total patient population receiving care agreed to participate. Cognition, clinical symptoms and functional outcome were assessed, and the results were compared to healthy comparison groups. Participants that performed one half a standard deviation below healthy norms in at least one cognitive domain were offered participation in vi the second study. Participants (n=49) were randomly assigned to either a treatment group (n=25) that received integrated neuro- and social-cognitive remediation in addition to their standard treatment, or a wait-list control group (n=24) that continued their standard treatment. Assessments from the first study were used as baseline assessments in the second study, and both groups were reassessed with the measures at post-treatment. In the third study, all participants that received ICR during the trial (n=37) were reassessed on the same variables 12-months after treatment ended. Implementation outcomes were assessed with attendance data, fidelity checks, and feedback from participants and facilitators. Results: Results suggested that, compared to healthy comparison samples, this group of early psychosis patients demonstrated broad cognitive impairments that were maximal in delayed recall and theory of mind (ToM) (

Íslenski hesturinn er eini hestastofninn á Íslandi. Hestar voru fluttir hingað við landnám og hafa verið hreinræktaðir síðan. Vegna landfræðilegrar einangrunar er stofninn berskjaldaður fyrir mörgum sjúkdómsvöldum sem herja á hesta í öðrum löndum. Fimm gerðir herpesveira eru þekktar hjá hestum (equine herpesvirus, EHV), þrjár alfa () EHV 1, 3 og 4 og tvær gamma () EHV 2 og 5. Meirihluti fullorðinna hesta á Íslandi hafa mótefni gegn EHV-4. Sjúkdómseinkenni sem líkjast EHV-3 sýkingu hafa komið fram í hrossum og báðar gammaherpesveirurnar eru algengar í stofninum. Ísland er samkvæmt okkar bestu vitund, eina landið þar sem EHV-1 veiran finnst ekki. Við staðfestum, með einangrun, EHV-3 veiruna í fyrsta skiptið hjá íslenska hestastofninum. Út frá eðli herpesveira má álykta að allar fjórar landlægu herpesveirurnar hafi komið til landsins við landnám. Við rannsóknir á herpesveirum er mikilvægt að notast við frumur úr sama hýsli og veiran. Með því að innleiða æxlisgen í prímer nýrna- og lungnafrumur bjuggum við til hestafrumulínur. Hægt er að rækta frumulínurnar 40 sinnum, ólíkt upprunalegu frumunum sem einungis er hægt að umrækta 10-12 sinnum. EHV-5 veiran hafði mun hærri títer í nýrnafrumulínunni og innleiðslugeta hennar var um fjórum sinnum betri, borið saman við prímer nýrnafrumurnar. Þessar frumulínur nýtast við rannsóknir á hestaveirum. Sýkiferill EHV-2 og EHV-5 og ónæmissvar gegn EHV var skoðað með því að fylgja eftir folöldum frá köstun fram að 22 mánaða aldri. Mæðrum þeirra var fylgt eftir í 6 mánuði. Sértækt EHV mótefnasvar var mælt, veirumagn var greint með qPCR og veirueinangrun var reynd. EHV-2 var einangruð frá 5 daga gömlu folaldi og EHV-5 á degi 12, fyrr en áður hefur fundist. Sértækt EHV mótefnasvar var ekki mælanlegt hjá folöldunum áður en þau komust á spena, en hækkaði nokkrum dögum síðar. Mótefnin frá móður lækkuðu síðan fram að 3-4 mánaða aldri og samhliða jókst EHV-2 magn. EHV-5 náði hins vegar ekki hámarki fyrr en folöldin voru eins árs. Folöldin voru flokkuð í tvo hópa, eftir sértæku EHV heildar IgG mótefnasvari móður í sermi við fæðingu, hátt-svar og lágt-svar. Það var greinileg fylgni milli magns mótefna hjá móður og veirumagns og mótefnaframleiðslu folaldanna. Þetta sást betur hjá EHV-5 þar sem 7 mánuðir voru á milli hópanna tveggja með tilliti til þess hvenær veiran náði hámarki. Fyrir EHV-2 var aðeins mánuður á milli. Með qPCR fékkst mögnun á erfðaefni EHV frá hluta af folaldasýnunum sem tekin voru áður en þau komust á spena. Þetta gæti bent til þess að einhver hluti erfðaefnis veiranna sé innlimaður í litninga hestsins. Þessar heildarniðurstöður gefa innsýn í hvernig flutningur á mótefnum frá móður hefur áhrif á EHV sýkingu og mótefnaframleiðslu afkvæmis. Einnig auka niðurstöðurnar þekkingu okkar á sýkiferli EHV-2 og EHV-5 fyrstu tvö æviárin. Hönnuð var tjáningarkasetta sem tjáir EGFP prótein samhliða tjáningu EHV-2 glýkópróteins B. Framleidd var endurröðuð EHV-2, rEHV2-gB-egfp, sem gat sýkt bæði hestafrumur og kanínufrumur (RK13). Þessi flúrljómandi veira gæti reynst gagnleg í in vitro rannsóknum á EHV-2. Endurraðaðar baculoveirur með tjáningarkassettu sem hefur stýril sem virkar í spendýrum hafa nýst í tilraunabólusetningum, bæði in vitro og in vivo. Útbúnar voru sex ólíkar baculoveiruferjur og prófaðar in vitro. Þrjár voru síðan prófaðar áfram með bólusetningartilraun í folöldum. Bólusett var í eitla, undir húð og í vöðva. Sértækt mótefnasvar gegn markpróteininu var ekki mælanlegt hjá neinu folaldi. Niðurstöður verkefnisins veita gleggri innsýn í herpesveirusýkingar í íslenska hrossastofninum og jafnframt voru hönnuð tól sem auðvelda áframhaldandi rannsóknir á sviðinu., The native Icelandic horse is the only horse breed in Iceland. The horses were brought to the country in the 9th and 10th centuries and have been purebred ever since. Due to this geographic isolation the horses are immunologically naïve to various agents known to infect horses in other countries. Five types of herpesviruses are known in horses, three EHVs; 1, 3 and 4 and two EHVs; 2 and 5. In Iceland, the majority of adult horses are antibody positive against EHV-4, clinical symptoms resembling an infection with EHV-3 have been detected and EHV-2 and EHV-5 are endemic and ubiquitous. To our knowledge, Iceland is the only country free of EHV-1. In this study we isolated and confirmed EHV-3 for the first time in our native population. In light of the nature of herpesviruses it is likely the four EHVs endemic in Iceland arrived with the founders of the breed. Cell lines originating from equines are important when working with EHVs. We established equine cell lines, both kidney and lung, with extended life span by transfecting primary cells with a retroviral vector containing oncogenes. The cell lines can be passaged approximately 40 times, as opposed to the primary cells 10-12 times. EHV-5 grew to a substantially higher titer and the transfection efficiency was four times higher in the kidney cell line than in the primary cells. These cells could have further advantages for equine virus research. The course of EHV-2 and EHV-5 infections and the immune response against EHV was studied by following foals from birth to 22 months of age and their dams during the first 6 months postpartum. The EHV specific antibody responses were evaluated, the viral load was measured with qPCR and virus isolation attempted. Both EHV-2 and EHV-5 were isolated earlier than previously reported on day 5 and 12, respectively. EHV specific antibodies were not detected before colostrum intake but peaked a few days after birth. The maternal antibodies declined when the foals were 3–4 months of age, followed by a peak in the EHV-2 viral load, whereas the EHV-5 viral load peaked when the foals were one year old. Depending on the mare’s EHV specific total IgG levels in serum at birth, the foals were grouped in two groups, high and low. There was a notable correlation between the level of maternal antibodies on the one hand and viral load and induction of endogenous antibody production in the foals on the other hand. These effects were more evident for EHV-5 as there were seven months between the viral load peaks for the high and low groups, compared to one month for EHV-2. Amplification of viral DNA was detected in some foals’ nasal swab and blood leukocyte samples taken before colostrum intake, indicating possible integration of viral DNA sequences into the host chromosome. Overall, these results provide information on how maternal antibody transfer affects EHV shedding and antibody production of the offspring and extends our knowledge on the EHV-2 and EHV-5 infection in foals during the first two years of life. An expression cassette was designed to express EGFP protein as a fusion protein with EHV-2 glycoprotein B. An infectious recombinant EHV-2 virus, rEHV2-gB-egfp, was constructed with homologous recombination. The virus was able to infect both equine and rabbit cells (RK13). The fluorescent virus could be a useful tool in EHV-2 in vitro studies. Recombinant baculoviruses carrying a mammalian cell-active expression cassette have been used for gene delivery in vitro and in vivo. We constructed and tested 6 different rBac-viral vectors in vitro and used three of them in vaccination trials in foals. Regardless of injection site, the foals did not develop measurable antibodies against the target. Overall, the study provides improved tools for EHV research and deeper understanding of the EHV status in the Icelandic horse population., The work was funded by the Icelandic Research Fund, the University of Iceland Research Fund, the Developmental Fund for Icelandic Horse Breeding, the Icelandic Horse Conservation Fund and the Agricultural Productivity Fund of Iceland.

Publisher's version (útgefin grein), Tilgangur: Fáar rannsóknir hafa metið langtímaárangur þverfaglegrar verkjameðferðar þó árangur til skemmri tíma sé vel þekktur. Hér er lýst árangri slíkrar meðferðar á Reykjalundi, endurhæfingarmiðstöð SÍBS, með þriggja ára eftirfylgd. Sérstaklega er fjallað um heilsuhagfræðilegan ávinning af meðferðinni. Efniviður og aðferðir: Um kerfisbundið slembiúrtak var að ræða þar sem fimmta hver beiðni um meðferð á verkjasviði Reykjalundar var valin til þátttöku. Gagnasöfnun stóð yfir í fjögur og hálft ár og eftirfylgd lauk þremur árum síðar. Heilsuhagfræðileg úttekt var gerð að rannsókn lokinni. Niðurstöður: Helstu niðurstöður eru þær að sjúklingar upplifa minni verki, minni ótta og hliðrun tengda vinnufærni, færri þunglyndis- og kvíðaeinkenni og upplifa meiri félagslega færni eftir meðferð. Vinnugeta hópsins í heild jókst og fór vinnufærni úr 36% í 47% eftir meðferðina og við þriggja ára eftirfylgd voru 57% vinnufærir. Heilsuhagfræðileg úttekt sýndi að meðferðin hafði borgað sig upp á þremur árum og ávinningurinn jókst út lífið. Ályktanir: Niðurstöður rannsóknarinnar sýna að þverfagleg endurhæfingarmeðferð gegn þrálátum verkjum skilar árangri varðandi færni, verki og sálfélagslegar afleiðingar þeirra. Heilsuhagfræðilegur ávinningur af meðferðinni er verulegur og miðað við vísitölu neysluverðs í október 2018 skilar kostnaður af meðferðinni sér áttfalt til baka til samfélagsins., Introduction: There is limited research on the long-term benefits of an interdisciplinary pain rehabilitation, even though short-term benefits have been well documented. The present study evaluated the effects of an interdisciplinary pain rehabilitation program with a three-year follow-up. A special emphasis was placed on economic evaluation of the treatment from a societal perspective. Material and methods: The study was conducted at the chronic pain unit of the Reykjalundur rehabilitation center. Every fifth patient referred to the Reykjalundur Rehabiliation Center pain clinic was randomized to participate in this study. Data was collected over the course of 4,5 years with a three years follow-up. Finally, economic evaluation was conducted at the end of the research. Results: After treatment patients experienced less pain, fear and avoidance, anxiety and depression symptoms and improved social functioning. Work ability increased from 36% to 47% at the end of rehabilitation and continued to rise to 57% at three year follow-up. Economic evaluation from a societal perspective showed that cost associated with the rehabilitation had leveled out in three years and continued throughout life. Conclusion: The results indicate that interdisciplinary rehabilitation for chronic pain has a positive impact on function and the experience of pain as well as positive psychosocial effect. An economic evaluation of the treatment shows that the rehabilitation is very cost effective and that each Icelandic krona (IKR) spent is returned eightfold back to society., "Peer Reviewed"

Artículo con numerosos autores, sólo se mencionan el primero, los de la UAM y grupo colectivo, A double burden of malnutrition occurs when individuals, household members or communities experience both undernutrition and overweight. Here, we show geospatial estimates of overweight and wasting prevalence among children under 5 years of age in 105 low- and middle-income countries (LMICs) from 2000 to 2017 and aggregate these to policy-relevant administrative units. Wasting decreased overall across LMICs between 2000 and 2017, from 8.4% (62.3 (55.1–70.8) million) to 6.4% (58.3 (47.6–70.7) million), but is predicted to remain above the World Health Organization’s Global Nutrition Target of, This work was primarily supported by grant OPP1132415 from the Bill & Melinda Gates Foundation awarded to S.I.H.

Thesis for the degree of Philosophiae Doctor, Acute kidney injury (AKI) is a common clinical problem both in the hospital and outpatient setting and is associated with increased morbidity and mortality. Chronic kidney disease (CKD) is a risk factor for developing AKI and AKI is a risk factor for development and progression of CKD. Renal recovery after AKI has been shown to be an independent determinant of patient morbidity and mortality, but studies have been impeded by lack of consensus on how to define renal recovery following AKI. A small absolute change in serum creatinine (SCr) of 26.5 μmol/L within 48 hours is included in the current diagnostic criteria of AKI. However, characteristics and long-term outcomes of the subgroup diagnosed with AKI solely by this part of the criteria, referred to as mild stage 1 AKI in this thesis, has not been studied. The aim of this thesis was to evaluate the incidence, long-term survival and renal recovery of hospital-acquired AKI (H-AKI) and examine time-trends in its incidence and survival. Also to assess the incidence, risk factors and short-term survival of AKI following abdominal surgery. Furthermore, to compare different definitions of renal recovery following postoperative AKI with respect to association with long-term survival, development of incident CKD and progression of preexisting CKD. Finally, to examine the characteristics of mild stage 1 AKI and whether it is associated with long-term survival, development of incident CKD or progression of preexisting CKD. All the studies reported in the papers were retrospective. Paper I included all patients with H-AKI over a 20-year period, from 1993 to 2013. All patients undergoing abdominal surgery in 2007-2014 were included in Paper II, and Paper III and IV included all patients undergoing abdominal, cardiothoracic, vascular or orthopedic surgery in 1998-2015. Data on patient characteristics, comorbidities, perioperative information and SCr measurements were collected from electronic hospital records, national registries and hospital databases. The SCr component of the KDIGO criteria was used to detect AKI in all Papers, except that the absolute increase in SCr of 26.5 μmol/L within 48 hours was excluded in Paper I. Multivariable logistic regression analyses were performed to evaluate risk factors and associations with one-year mortality. Cox proportional hazards regression analysis and propensity score matching were used to evaluate long-term survival, development of incident CKD and progression of preexisting CKD. The mean incidence of H-AKI was 25.8 per 1000 admissions/year and increased significantly over the 20-year study period. H-AKI associated with worse one-year survival that followed an inverse relationship with the severity of H-AKI. However, survival of H-AKI patients improved over the study period. AKI occurred following 6.8% of all abdominal surgeries and was most common following surgery on the esophagus, spleen, stomach and after explorative laparotomy. Independent risk factors for AKI following abdominal surgery were older age, male sex, preoperative CKD, higher ASA class and if the surgery was a reoperation. AKI following abdominal surgery was associated with longer length of stay, more short-term complications and worse 30-day survival. Lack of renal recovery after AKI to a SCr < 1.5 x baseline within 30 days was associated with worse one-year survival and lack of recovery to a SCr < 1.25 x baseline within 30 days was associated with increased risk of developing incident CKD and progression of preexisting CKD. One-third of all postoperative AKI patients had mild stage 1 AKI, which was associated with both development of incident CKD and progression of preexisting CKD, but no association was found with one-year survival. The four papers highlight that AKI is a common problem in both the general hospital population and following surgery. There are independent risk factors for development of AKI following abdominal surgery that can all be assessed preoperatively for patient risk stratification. AKI is associated with both short-term and long-term survival and development of incident CKD and progression of preexisting CKD. Moreover, lack of renal recovery to SCr below 1.5 x baseline value within 30 days associated with worse one-year survival and lack of recovery to SCr below 1.25 x baseline value was associated with development of CKD and progression of preexisting CKD. These results should be considered when a consensus on the definition of renal recovery is reached. Furthermore, mild stage 1 AKI was associated with short-term mortality and both development of CKD and progression of preexisting CKD. This supports the inclusion of small absolute increase in SCr in the AKI definition and the results emphasize the importance of meticulous follow-up of patients with AKI, particularly patients without renal recovery.

The overall aim of this PhD thesis was to cohesively assess the availability and use of electronic genealogy databases and information from cancer registries to construct electronically generated pedigrees for risk assessment in genetic counselling. The thesis is built upon three published papers. Hereditary breast and ovarian cancer (HBOC), due to the Icelandic founder BRCA2 PV was used as an example. A second objective was to determine the optimal size of pedigrees for risk assessment in cancer genetic counselling. Three different approaches were used. Study I was a systematic literature review for articles describing the use of electronic genealogy and cancer databases in clinical service. Key findings: Published data on the use of such databases was limited, and the search identified only four articles fitting the search terms. Two of the papers were discussion papers. One of the four articles described an Icelandic study which applied information from the Genetical Committee of the University of Iceland. Study II was qualitative, on the experience of counsellees where electronically generated pedigrees (EGPs) were used in hereditary breast and ovarian cancer (HBOC) genetic counselling. Data was collected via an online focus group using an online discussion board. In genetic counselling, family health and genealogical history are collected to assess risk and clarify the inheritance mode of a suspected or known disorder. Key findings: Prior to genetic counselling, the majority of participants said that they had known about genetic counselling, and the most common reason for GC was a strong family history of cancer. Most participants were positive towards the use of electronic pedigrees and had trust in both the professionals and the information from the databases used to generate the pedigrees. Some, however, worried that insurance companies would obtain the information from the databases and possibly raise premiums or even deny insurance outright based on the information. Laws against genetic discrimination and the protection of personal data exist, both in health insurance and employment. The majority of participants had either unchanged or better family communication following genetic counselling. As relatives may have a diverse reaction to the offer of genetic testing, good family communication is essential. In Study III, the clinical use of electronically generated pedigrees was assessed, and the optimal pedigree size was calculated. Key findings: Using EGPs for risk assessment in cancer genetic counselling enabled accurate and comprehensive risk assessment in HBOC families. Further, such use is cost-effective and reduces work. We used Receiver Operation Curves (ROC) and C-statistics based on pair-wise comparison to evaluate the effect of pedigree size on the prediction of the presence of the Icelandic founder BRCA2 PV. Optimal results were attained using pedigrees with 3° relatives. Adding 4° relatives did not improve the outcome. Obtaining informed consent for the construction of pedigrees was straightforward, and no breaches of security (i.e. leakage of classified or restricted information) were observed. Conventional methods of collecting and constructing large enough pedigrees are time-consuming and difficult compared to our approach. This thesis reflects the experience of a clinical genetic service using electronically generated pedigrees in clinical practice. This approach is well established in Iceland and has been used for over 13 years in cancer genetic counselling. It is efficient and without complications such as breach of data and mistrust on behalf of the counsellees. A significant result from this work is that the optimal size of cancer pedigree, 3° pedigree which can take up to five generations. Such a pedigree is very difficult and impractical to generate using the conventional handmade technique. This should create a motive to use EGPs in other countries where some or all the resources are readily available.

Introduction and aims: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and its complex pathophysiology is incompletely understood. At the time of beginning of this work, genome-wide association studies (GWAS) on AF had yielded about 30 associations, mostly with common variants in the non-coding genome that affect AF risk through unknown mechanisms. Recently, rare coding variants in the sarcomere genes MYH6 and MYL4 associated with increased risk of AF, representing a novel implication of the sarcomere in arrhythmogenesis in the absence of cardiomyopathy. The aim of this doctoral research was to perform GWASs on AF and search for novel associations. Furthermore, to gain insights into the mechanisms by which novel and published variants affect AF risk by assessing their effects on other cardiovascular diseases and on normal cardiac conduction, using electrocardiogram (ECG) measurements. Through association analysis we observed that one of the strongest AF variants, in MYH6, accounts for 20% of Icelandic cases of coarctation of the aorta (CoA), thus we decided to explore this variant and its effects on structural heart disease in detail resulting in a separate paper. The overall purpose of identifying novel associations of sequence variants with AF is to further the understanding of underlying pathogenesis and facilitate advances in treatment. Methods: We conducted four GWASs. In all cases, genotype information of Icelandic participants was based on whole-genome sequencing of 15,220 and chip-typing of 151,677 individuals performed at deCODE genetics. We tested AF variants for association with measurements in 289,297 sinus rhythm ECGs from 62,974 individuals. Three GWASs on AF and one on CoA were performed: i) A GWAS among 13,471 AF cases and 374,939 controls from Iceland with additional follow up in samples from the US. ii) A meta-analysis of GWAS on AF among 29,502 cases and 767,760 controls from Iceland and the UK Biobank with follow-up in samples from Norway and the US, focusing on low-frequency coding and splice variants. Analysis of 167 RNA samples from the right atrium were used to assess the effects of a novel AF variant at the transcript level. iii) A multi-center meta-analysis of GWASs on AF including >1,000,000 participants from six contributing cohorts, including 60,620 AF cases. iv) A GWAS on CoA among 120 cases and 355,166 controls in Iceland. Detailed phenotyping of carriers of a novel variant was performed. Results: We identified novel AF associations with coding variants in three genes which have a role in maintaining cardiac structure; PLEC, RPL3L and MYZAP. Analysis of RNA samples from the right atrium revealed that a splice-donor variant in RPL3L results in exon skipping. Through a meta-analysis involving >1,000,000 participants from six contributing cohorts, 80 novel AF loci were identified. Pathway and functional enrichment analysis suggested variable mechanisms underlying the associations, including effects on structural remodeling. Assessing variants associations with ECG measurements showed diverse effects of AF variants on normal cardiac conduction. We found that one of the strongest AF variants, a missense variant, p.Arg721Trp, in the sarcomere gene MYH6 was found to explain approximately 20% of CoA cases in Iceland. This variant was previously reported to associate with sick sinus syndrome through GWAS and has strong effects on AF risk and ECG measurements in the current study. Conclusion: The results highlight the important role of myocardial structure in the pathogenesis of AF. Furthermore, they support speculations of a role for subclinical atrial cardiomyopathy in the development of arrhythmia. The diverse associations between AF variants and ECG measurements suggest fundamentally different categories of mechanisms contributing to the development of AF and might help inform on underlying biology of specific AF loci in future studies. We demonstrate a pleiotropic effect of p.Arg721Trp in MYH6 on cardiac function and disease. The variant explains a large proportion of CoA cases in Iceland which may be a relevant fact for genetic counseling. The association with MYH6, that encodes a part of the cardiac contractile unit, complies with the hemodynamic theory of CoA development. Combined the results increase understanding of the pathophysiology of both AF and CoA, thus providing knowledge that will hopefully translate into advances in treatment., nngangur og markmið: Gáttatif er algengast viðvarandi hjartsláttartruflana en núverandi skilningur á flókinni meingerð sjúkdómsins er takmarkaður. Við upphaf þessarar vinnu höfðu víðtækar erfðamengisleitir sýnt fram á tengsl milli um 30 erfðabreytileika og gáttatifs. Flestir eru algengir og staðsettir utan útraða gena og tengjast því sjúkdómnum með óþekktum hætti. Nýlega var sýnt fram á að tveir sjaldgæfir erfðabreytileikar í útröðum vöðvaliðagenanna MYH6 og MYL4 auka áhættu á gáttatifi en slík tenging vöðvaliðunnar við hartsláttartruflanir þegar hjartavöðvakvilli var ekki til staðar var nýmæli. Tilgangur þessa doktorsverkefnis var að framkvæma víðtæka erfðamengisleit með það að markmiði að bera kennsl á áður óþekkt tengsl milli erfðabreytileika og gáttatifs. Jafnframt var markmiðið að öðlast innsýn í með hvaða hætti erfðabreytileikar hafa áhrif með því að kanna tengsl þeirra við aðra hjartasjúkdóma og hjartalínuritsbreytur. Í verkefninu skoðuðum við einnig áhrif MYH6 breytileikans á aðra hjartasjúkdóma og reyndist hann einnig auka líkur á meðfæddum ósæðarþrengslum. Þess vegna var einnig framkvæmd víðtæk erfðamengisleit á þeim meðfædda hjartagalla. Megintilgangur þess að finna áður óþekkt tengsl milli erfðabreytileika og áhættu á gáttatifi er að auka skilning á meingerð sjúkdómsins og stuðla með því að framförum í meðhöndlun hans. Aðferðir: Við framkvæmdum fjórar rannsóknir byggðar á víðtækri erfðamengisleit. Í öllum tilvikum byggðust erfðaupplýsingar Íslendinga á heilraðgreiningu 15.220 einstaklinga og örflögugreiningu 151.677 sem framkvæmdar voru hjá Íslenskri erfðagreiningu. Við könnuðum erfðabreytileika sem fundust og tengdust sjúkdómum nánar með því að meta áhrif þeirra á hjartalínuritsbreytur úr 289.297 hjartalínuritum frá 62.974 einstaklingum sem ekki höfðu greinst með gáttatif eða fengið gangráð. Þrjár rannsóknanna fjölluðu fyrst og fremst um gáttatif og sú fjórða um meðfædd ósæðarþrengsli: i) Víðtæk erfðamengisleit meðal 13.471 tilfella gáttatifs og 374.939 viðmiða frá Íslandi. Niðurstöðum var fylgt eftir í bandarískum gögnum. ii) Safnrannsókn víðtækra erfðamengisleita á gáttatifi meðal 29.502 tilfella og 767.760 viðmiða frá Íslandi og Bretlandi (UK Biobank). Niðurstöðum var fylgt eftir í sýnum frá Noregi og Bandaríkjunum. Áhrif tiltekinnar stökkbreytingar á umritun var metin í 167 RNA sýnum úr hægri gátt. iii) Safnrannsókn víðtækra erfðamengisleita meðal >1.000.000 þátttakenda frá sex rannsóknarverkefnum, þ.m.t. 60.620 tilfelli gáttatifs. iv) Víðtæk erfðamengisleit á meðfæddum ósæðarþrengslum meðal 120 tilfella og 355.166 viðmiða frá Íslandi. Nákvæm svipgerðargreining bera tiltekins erfðabreytileika var framkvæmd. Niðurstöður: Við fundum áður óþekkt tengsl milli gáttatifs og erfðabreytileika í útröðum þriggja gena sem öll gegna hlutverki í viðhaldi eðlilegrar byggingar hjartans; PLEC, RPL3L og MYZAP. Greining RNA sýna úr hjarta leiddi í ljós að erfðabreytileiki í RPL3L olli því að ein útröð gensins var ekki umrituð. Stór safnrannsókn meðal rúmlega milljón þátttakenda leiddi í ljós áður óþekkt tengsl á milli 80 erfðabreytileika og gáttatifs og þau gen sem þóttu líklegust til að útskýra tengslin reyndust hafa áhrif á marga ferla, m.a. byggingu hjartans. Erfðabreytileikar sem auka líkur á gáttatifi höfðu fjölbreytt áhrif á hjartalínuritsbreytur. Víðtæk erfðamengisleit á meðfæddum ósæðarþrengslum fann einungis mislestursstökkbreytinguna p.Arg721Trp í MYH6 en hún ein útskýrir um 20% tilfella hjartagallans á Íslandi. Sami erfðabreytileiki hafði áður verið tengdur aukinni áhættu á sjúkum sínushnút og gáttatifi, auk þess að hafa hér víðtæk og sterk áhrif á hjartalínuritsbreytur. Ályktanir: Niðurstöðurnar benda til mikilvægis byggingareininga hjartans í meingerð gáttatifs og styðja kenningar um að hartavöðvakvilli í gáttum hafi þýðingu í þróun sjúkdómsins. Erfðabreytileikar sem auka líkur gáttatifs höfðu fjölbreytt áhrif á rafleiðni í hjartanu sem bendir til að þeir auki líkur á gáttatifi með ólíkum hætti. Kortlagning á tengslum þeirra við hjartalínuritsbreytur gæti gagnast við frekari rannsóknir á með hvaða hætti einstakir erfðabreytileikar tengjast gáttatifi. Fjölbreytt og víðtæk áhrif p.Arg721Trp í MYH6 á hjartasjúkdóma og starfsemi hjartans benda til að þessi breytileiki tengist gáttatifi ekki eingöngu gegnum sterk tengsl við sjúkan sínushnút. Tengsl meðfæddra ósæðarþrengsla við samdráttareiningu hjartans samræmast kenningum um að skert blóðflæði gegnum ósæðina á fósturstigi stuðli að myndun hjartagallans. Erfðabreytileikinn í MYH6 útskýrir stóran hluta tilfella meðfæddra ósæðarþrengsla á Íslandi og gæti sú vitneskja komið að notum í erfðaráðgjöf. Samanlagt veita niðurstöðurnar aukinn skilning á meingerð bæði gáttatifs og meðfæddra ósæðarþrengsla, en slík innsýn er nauðsynlegt skref í átt að bættum meðferðarúrræðum.

Streptococcus pneumoniae is a Gram-positive diplococcus that is both a commensal bacterium in the upper respiratory tract of humans, and a common pathogen. The infectious manifestations of pneumococci span a range from benign to serious; from acute otitis media (AOM) that often resolves without intervention, to sepsis and meningitis which invariably require hospitalization. Despite its often benign course, AOM is the most common reason for physician visits and antimicrobial prescriptions in children. Likewise, tympanostomy tube placements are the most common surgical procedure requiring general anesthesia in children. Pneumococcal vaccinations have a long history, beginning in 1914 with clinical trials in humans. A 23-valent polysaccharide vaccine was marketed in 1983, but was poorly immunogenic in children. The seven-valent pneumococcal conjugate vaccine became available in 2000. Multiple studies have demonstrated that it offered protection against AOM, tympanostomy tube placements, pneumonia and invasive disease in children. Indirect protection in adults has also been demonstrated. Higher valency vaccines were later developed. In April of 2011, the 10-valent pneumococcal Haemophilus influenzae Protein D conjugate vaccine (PHiD-CV10) was introduced in Iceland. The aim of the study was to evaluate the impact of PHiD-CV10 introduction in Iceland. Special attention was paid to the healthcare burden of children: visits to primary care and to the emergency department of Children‘s Hospital Iceland for AOM, antimicrobial prescriptions, tympanostomy tube placements, and hospitalizations for pneumonia and invasive disease. The population-based impact of PHiD-CV10 was examined, including whether herd effect occurred in adults. Finally, the study focused on estimating the cost-effectiveness of PHiD-CV10 in Iceland. Individual level data were obtained from five population-based registries and Landspitali University Hospital‘s patient registry for the period from 1 January 2005 to 31 December 2017. Data on all administered doses of pneumococcal vaccines and all outpatient antimicrobial prescriptions were extracted from the National Vaccine and National Drug Prescription Registries of the Icelandic Directorate of Health. Visits for respiratory infections were extracted from the Primary Care Registry and Landspitali University Hospital‘s patient registry, and data on tympanostomy procedures were obtained from Icelandic Health Insurance‘s reimbursement database. Immigration and emigration data were provided by Statistics Iceland. Four cohort studies followed 11 Icelandic birth-cohorts 2005-2015. The first such study followed children from birth to 36 months of age with regards to primary care visits for AOM. An Andersen-Gill model that corrected for age, gender and the number of previous AOM visits was applied. The vaccine impact was calculated as (1 - hazard ratio between the last vaccine eligible and last vaccine non-eligible cohort) * 100%, and revealed a 22% reduction in AOM with a 95% confidence interval (CI) 12% to 31%. The incidence of ceftriaxone-treated AOM at Children‘s Hospital Iceland was examined before and after vaccine introduction to estimate the impact on AOM with treatment failure, and revealed a 55% (95% CI 46%-63%) reduction in ceftriaxone-treatment episodes. The second cohort study followed children from birth to 36 months of age with regards to outpatient antimicrobial prescriptions. The same methods were used to calculate vaccine impact. A 5.8% (95% CI 1.6%-9.8%) decrease in the number of prescriptions was established. The third cohort study evaluated tympanostomy procedures. It followed children from birth to 60 months of age and revealed a non-significant increase in procedures, despite the introduction of PHiD-CV10. The fourth cohort study examined the hazard of hospitalization for respiratory and invasive infections. It compared vaccine eligible cohorts to vaccine non-eligible cohorts and found a 20% (95% CI 5%-33%) reduction in pneumonia hospitalizations. A population-based study that included all age-groups, estimated the cost-effectiveness of PHiD-CV10 and examined whether herd effect had occurred. A Bayesian time series methodology was used and included visits and hospitalization for diagnoses unrelated to the vaccine as controls. The study revealed strong evidence of herd effect for otitis media, pneumonia and invasive disease. When taking into account costs avoided because of prevented disease, the introduction of PHiD-CV10 was found to have saved 7,463,176 United States Dollars in the first five years of the program. The studies that comprise this thesis showed a large societal impact of PHiD-CV10 introduction; visits, antimicrobial prescriptions and hospitalizations of children decreased, and indirect protection was observed in adults. The vaccination program was cost-saving from both the health sector and societal perspectives., Streptococcus pneumoniae er Gram-jákvæð baktería sem getur valdið sýkingum í mönnum. Pneumókokkar eru hluti af eðlilegri örveruflóru nefkoks flestra barna, en einnig algengur sjúkdómsvaldur bæði staðbundina og ífarandi sýkinga. Alvarleiki þeirra spannar breitt bil: frá miðeyrnabólgum, sem ganga flestar yfir án inngrips, til blóðsýkinga og heilahimnubólga sem krefjast innlagnar á sjúkrahús. Þrátt fyrir að miðeyrnabólgur séu mildar sýkingar, þá eru þær algengasta orsök læknisheimsókna og sýklalyfjaávísana barna. Rörísetningar í eyru eru algengustu aðgerðir hjá börnum sem krefjast svæfingar. Bólusetningar gegn pneumókokkum eiga sér langa sögu. Fyrstu tilraunir í mönnum áttu sér stað 1914. Fjölsykrubóluefni var fyrst þróað árið 1945 en náði ekki útbreiðslu fyrr en 1983, þegar 23-gilt fjölsykrubóluefni kom á markaðinn. Það vakti hins vegar ófullnægjandi ónæmissvar hjá börnum. Til þess þurfti próteintengingu. Sjö-gilt próteintengt pneumókokka bóluefni kom á markaðinn árið 2000. Fjöldi rannsókna hefur sýnt fram á að notkun þess verndi gegn miðeyrnabólgum, rörísetningum, lungnabólgum og ífarandi sýkingum hjá börnum. Einnig hefur verið sýnt fram á hjarðónæmi hjá fullorðnum. Samtengd bóluefni gegn 10 og 13 hjúpgerðum pneumókokka voru framleidd í kjölfarið. Í apríl 2011 var 10-gilda samtengda pneumókokka bóluefnið innleitt í ungbarnabólusetningar á Íslandi. Markmið þessarar rannsóknar var að meta lýðgrunduð áhrif innleiðingar 10-gilda samtengda pneumókokka bóluefnisins á Íslandi. Sérstök áhersla var lögð á að meta notkun barna á heilbrigðisþjónstu: komur þeirra á heilsugæslu og bráðamóttöku Barnaspítala Hringsins vegna miðeyrnabólgu; sýklalyfjaávísanir og rörísetningar. Einnig voru skoðaðar innlagnir barna á sjúkrahús vegna miðeyrnabólgu, lungnabólgu, blóðsýkingar og heilahimnubólgu. Lýðgrunduð áhrif bólusetningarinnar voru einnig skoðuð og metið hvort hjarðónæmi hafði myndast hjá fullorðnum. Að lokum var markmið rannsóknarinnar að meta kostnaðarvirkni bóluefnisins á Íslandi. Einstaklingsgögnum var safnað úr fimm lýðgrunduðum gagnagrunnum og sjúkraskrám Landspítala Háskólasjúkrahúss fyrir tímabilið 1. Janúar 2005- 31. Desember 2017. Öllum pneumókokkabólusetningum og sýklalyfjaávísunum var safnað úr bólusetningargagnagrunni og lyfjagagnagrunni Embættis Landlæknis. Allar læknisheimsóknir vegna öndunarfærasýkinga voru dregnar úr samskiptaskrá heilsugæslustöðva og sjúkraskrá Landspítala Háskólasjúkrahúss, og upplýsingar um rörísetningar fengust úr endurgreiðslugrunni Sjúkratrygginga Íslands. Upplýsingar um búferlaflutninga barna til og frá Íslandi voru sóttar til Hagstofu Íslands. Fjórar ferilsrannsóknir voru framkvæmdar sem fylgdu eftir fæðingarárgöngum 2005-2015. Sú fyrsta fylgdi öllum börnum frá fæðingu til 36 mánaða aldurs með tilliti til koma á heilsugæslu vegna miðeyrnabólgu. Andersen-Gill líkan var notað sem leiðrétti fyrir aldri, kyni og fjölda fyrri koma vegna miðeyrnabólgu. Áhrif bólusetningarinnar voru metin sem (1 - áhættuhlutfallið milli síðasta bólusetta og síðasta óbólusetta árgangsins) * 100%, sem reyndist vera 22% með 95% öryggisbil 12%-31%. Tíðni ceftriaxone meðferðar við miðeyrnabólgu á Barnaspítala Hringsins var notuð til að áætla áhrif á bóluefnisins á alvarlegar miðeyrnabólgur, og reyndist vera 55% minni í kjölfar bólusetningarinnar með 95% öryggisbili 46%-63%. Önnur ferilrannsóknin fylgdi börnum eftir til 36 mánaða aldurs með tilliti til allra sýklalyfjaávísanna. Sama líkan var notað og áhrifin metin á sama hátt. Sýklalyfjaávísunum fækkaði um 5.8% með 95% öryggisbil 1.6%-9.8%. Þriðja ferilrannsóknin mat tíðni rörísetninga. Hún fylgdi börnum eftir til 60 mánaða aldurs og sýndi fram á ómarktæka aukningu á rörísetningum, þrátt fyrir innleiðingu bóluefnisins. Fjórða rannsóknin skoðaði sjúkrahúsinnlagnir vegna öndunarfærasýkinga. Hún bar saman bólusetta árganga við óbólusetta og sýndi fram á 20% fækkun á innlögnum vegna lungnabólgu, 95% öryggisbil 5%-33%. Lýðgrunduð rannsókn sem tók til allra aldurshópa mat hjarðónæmi og kostnaðarvirkni bóluefnisins. Rannsókninin beitti aðferðum Bayes á tímaraðgreiningu og notaði komur og innlagnir vegna annarra sjúkdóma til samanburðar. Rannsóknin sýndi fram á sterkt hjarðónæmi sem leiddi til fækkunar á miðeyrnabólgum, lungnabólgum og ífarandi sýkingum. Að teknu tilliti til sparnaðar vegna færri sýkinga, sparaði bóluefnið 7,463,176 Bandaríkjadala á fyrstu fimm árum eftir innleiðingu þess. Rannsóknirnar sem þessi ritgerð er byggð á sýndu fram á gríðarlegan samfélagslegan ábáta af innleiðingu pneumókokkabóluefnisins á Íslandi. Innleiðingin olli fækkun á læknisheimsóknum, sjúkrahúsinnlögnum og sýklalyfjaávísunum hjá börnum og hjarðónæmi myndaðist hjá fullorðnum. Að teknu tilliti til sparnaðar vegna færri sýkinga sparaði innleiðing bóluefnisins íslenskt samfélag 7,463,176 Bandaríkjadala á föstu 2015 verðlagi.

Lækningamáttur Bláa Lónsins var uppgötvaður af sórasjúklingum skömmu eftir myndun þess og hafa jákvæð áhrif böðunar í lóninu verið staðfest í klínískum rannsóknum. Enn fremur hefur verið sýnt að böðun í lóninu samhliða UVB meðferð sé árangursríkari en UVB meðferð ein og sér. Þrátt fyrir vinsældir lónsins er lítið vitað um hvernig það hefur áhrif á sóra. Blágrænþörungurinn Cyanobacterium aponinum er ríkjandi lífvera í jarðsjó Bláa Lónsins og framleiðir hann utanfrumufjölsykru (EPS-Ca) sem hann seytir í umhverfi sitt. Tilgáta okkar er að EPS-Ca hafi áhrif á ónæmiskerfið sem geti tekið þátt í að miðla þeim bata sem sórasjúklingar fá við böðun í lóninu. Tilgangur verkefnisins var að kanna verkun og verkunarmáta EPS-Ca í frumum sem taka þátt í meingerð sóra. Utanfrumufjölsykran EPS-Ca var einangruð úr floti C.aponium ræktar frá Bláa Lóninu. Angafrumur, sérhæfðar út frá einkjörnungum, voru ræstar með boðefnunum IL-1β og TNF-α og inneitri (LPS) með eða án EPS-Ca í 24 tíma. CD4+ T frumur úr mönnum voru örvarðar með mótefnum gegn CD3 og CD28 í 72 tíma með eða án EPS-Ca síðasta sólarhringinn. Hyrnisfrumur, fengnar frá ATCC, voru örvaðar með TNF-α og annaðhvort IFN-γ eða IL-17A og meðhöndlaðar með eða án EPS-Ca í 24 tíma. Áhrif EPS-Ca voru metin með því að mæla styrk boðefna í floti frumna með ELISA aðferð, tjáningu innanfrumu- og yfirborðssameinda með frumuflæðisjá og lagsjármyndum, og mRNA tjáningu með rauntíma PCR. Angafrumur þroskaðar í návist EPS-Ca juku seytun þeirra á ónæmisbælandi boðefninu IL-10. Angafrumur þroskaðar í návist EPS-Ca ræstu einnig og sérhæfðu ósamgena CD4+ T frumur í samrækt í T bælifrumur (Treg) á kostnað sérhæfingar þeirra í sjúkdómshvetjandi Th17 frumna. Ennfremur tjáðu angafrumur meðhöndlaðar með EPS-Ca meira af yfirborðssameindinni CD141 en angafrumur þroskaðar án EPS-Ca. CD141 er yfirborðssameind sem hefur verið tengd bæli-angafrumum og niðurstöðurnar sýndu að CD141 jákvæðar angafrumur seyttu meira af IL-10 en angafrumur sem tjáðu ekki CD141. Hins vegar dró EPS-Ca meðhöndlun úr tjáningu angafrumna á Dectin-1 viðtakanum, bæði á mRNA (CLEC7A) og próteinformi. EPS-Ca dró einnig úr umritun á SYK sem er lykilpróteinið í boðleiðinni sem liggur frá Dectin-1 viðtakanum. CD4+ T frumur sem voru örvarðar í návist EPS-Ca seyttu minna af IL-17, IL-13 og IL-10 samanborið við CD4+ T frumur sem voru örvarðar án EPS-Ca. EPS-Ca minnkaði einnig hlutfall T frumna sem tjáðu CD69 á yfirborði sínu. EPS-Ca dró einnig úr fosfæringu á ZAP70 sem er lykilpróteinið í miðlun ræsingar inn í T frumur. Hyrnisfrumur meðhöndlaðar með EPS-Ca seyttu minna af flakkboðunum CXCL10 og CCL20 en hyrnisfrumur örvaðar án EPS-Ca. Enn fremur dró EPS-Ca meðhöndlun úr umritun SYK, CLEC7A og CAMP en CAMP er genið sem tjáir fyrir bakteríudrepandi peptíðinu LL37 sem er tjáð í yfirmagni í húð sórasjúklinga og talið eiga þátt í meingerð sjúkdómsins. Niðurstöður rannsóknarinnar sýna að EPS-Ca breytir svipgerð angafrumna í bæli-angafrumur sem stuðla að sérhæfingu T frumna yfir í T bælifrumur. Einnig dregur EPS-Ca úr boðefnaseytun og ræsingu örvaðra T frumna. EPS-Ca gæti því dregið úr ræsingu og fjölda T frumna sem halda til í húðinni. EPS-Ca minnkaði einnig seytingu hyrnisfrumna á flakkboðum sem kalla T frumur til húðarinnar og minnkaði umritun gena sem tjá fyrir próteinum sem talin eru tengjast meingerð sóra. EPS-Ca virðist því hafa áhrif á allar lykilfrumurnar sem taka þátt í meingerð sóra og virðist áhrifunum miðlað með hindrun á Dectin-1 viðtakanum og Syk boðleiðinni. Niðurstöðurnar benda því til þess að EPS-Ca geti átt þátt í þeim bata sem sórasjúklingar fá við böðun í lóninu og leiða í ljós með hvaða leiðum þeim áhrifum er mögulega miðlað., Regular bathing in the Blue Lagoon in Iceland has been shown to have beneficial effects on the manifestations of psoriasis in clinical studies. Moreover, bathing in the Blue Lagoon in conjunction with UVB treatment gives better results than UVB treatment alone. The beneficial effects may be attributed to the unique chemical and ecological composition of the Lagoon. Our hypothesis is that an exopolysaccharide secreted by Cyanobacterium aponinum (EPS-Ca), one of the two main organisms in the Lagoon, may have specific immunomodulating effects that contribute to the therapeutic benefits obtained by regular bathing in the Lagoon. The objective of the study was to determine the effects of EPS-Ca on immune responses of cells involved in the pathogenesis of psoriasis and to elucidate how EPS-Ca mediates its effects. EPS-Ca was isolated from supernatants of cultures of C. aponinum obtained from the Blue Lagoon. Human monocyte-derived dendritic cells (DCs) were matured with interleukin (IL)-1β, tumor necrosis factor (TNF)-α and lipopolysaccharides (LPS) with or without EPS-Ca for 24 h. CD4+ T cells isolated from human blood were stimulated with antibodies against CD3 and CD28 for 72 h with or without EPS-Ca for the last 24 h of the stimulation. Finally, adult primary keratinocytes, obtained from ATCC, were stimulated with TNF-α and either interferon (IFN)-γ or IL-17, with or without EPS-Ca for 24 h. Cytokine concentration in the supernatant was measured by ELISA, expression of mRNA by RT-qPCR, expression of intra- and extracellular molecules by flow cytometry and confocal imaging. DCs matured in the presence of EPS-Ca secreted more of the immunosuppressive cytokine IL-10 than DCs matured in the absence of EPS-Ca. EPS-Ca treatment also increased the capacity of the DCs to induce differentiation of T cells into T regulatory cells (Tregs) and diminished induction of the disease-inducing T helper (Th)17 cells. EPS-Ca-treated DCs expressed more CD141, a surface molecule that has been linked to regulatory DCs, than DCs stimulated without EPS-Ca. Interestingly, CD141+ DCs secreted more IL-10 than CD141- DCs. EPS-Ca treatment decreased DC expression of Dectin-1 and also decreased transcription of key genes in the Syk signaling pathway (CLEC7A and SYK). T cells stimulated in the presence of EPS-Ca secreted less IL-10, IL-13 and IL-17 and expressed less CD69 than T cells stimulated without EPS-Ca. Furthermore, EPS-Ca decreased the proportion of T cells expressing the active form of the T cell receptor signaling protein, ZAP70. EPS-Ca decreased keratinocyte secretion of CCL20 and CXCL10 and their transcription of CLEC7A, SYK and CAMP, the gene encoding for the antimicrobial peptide, LL37, that has been identified as an autoantigen in psoriasis. These results show that following an in vitro treatment with EPS-Ca, DCs switch their phenotype towards a regulatory one, which has the potential to induce differentiation of T cells into Tregs at the cost of their differentiation into the disease inducing Th17 cells. In addition, EPS-Ca reduced activation of stimulated T cells and keratinocyte production of inflammatory chemokines. Furthermore, EPS-Ca also reduced keratinocyte expression of the gene encoding for LL37, one of the autoantigens in psoriasis. Interestingly, the effects of EPS-Ca seemed to be mediated by its effects on Dectin-1 and the Syk signaling pathway in all the cell types studied. These data indicate that EPS-Ca may contribute to the beneficial effects obtained by psoriasis patients by bathing in the Blue Lagoon and suggests a possible mechanism by which EPS-Ca has its effects., The Icelandic Technology Development Fund, the Landspitali University Hospital Research Fund and the University of Iceland Research Fund.

Sykursýki 2 (SS2) og forstig SS2 eru þekktir áhættuþættir æðakölkunar og alvarlegra fylgikvilla hjarta- og æðasjúkdóma. Skimun sjúklinga með brátt kransæðaheilkenni (BKH) með sykurþolsprófi hefur gefið til kynna hátt algengi ógreindrar SS2 og forstigs SS2. Hins vegar er ekki ljóst hvernig truflun á sykurefnaskiptum verður best greind hjá sjúklingum með BKH. Að auki hefur magn æðakölkunar eða áhætta á fylgikvillum hjarta- og æðasjúkdóma ekki verið metin hjá sjúklingum með BKH sem greindir hafa verið með truflun á sykurefnaskiptum á grundvelli leiðbeininga Alþjóðaheilbrigðisstofnunarinnar (WHO) og Bandarísku sykursýkis–samtakanna (ADA). Markmið þessarar ritgerðar var þríþætt. Í fyrsta lagi að finna áreiðanlega aðferð til að greina SS2 og forstig SS2 hjá sjúklingum með BKH. Í öðru lagi að meta áhrif truflaðara sykurefnaskipta á magn æðakölkunar hjá sjúklingum með BKH. Að lokum að meta aukna áhættu á fylgikvillum hjarta- og kransæðasjúkdóma hjá sjúklingum með BKH og trufluð sykurefnaskipti. Sjúklingum sem lagðir voru inn á hjartadeild Landspítalans með BKH á sautján mánaða tímabili var boðið að taka þátt í rannsókninni. Sykurefnaskipti voru metin hjá sjúklingum án fyrri sögu um sykursýki með mælingum á HbA1c og fastandi glúkósa í plasma (FPG) ásamt tveggja klukkustunda stöðluðu sykurþolsprófi. Þessar mælingar voru framkvæmdar í sjúkrahúslegu og endurteknar að þremur mánuðum liðnum. Til að greina nýja SS2 (nSS2) þurfti að minnsta kosti tvær mælingar sem voru yfir greiningarþröskuldi fyrir sykursýki. Ein mæling með niðurstöðu yfir greiningarþröskuldi fyrir sykursýki eða fyrir forstig SS2 var skilmerki til greiningar á forstigi SS2. Sjúklingar með allar sex mælingar innan eðlilegra marka töldust hafa eðlileg sykurefnaskipti. Sjúklingar með þekkta SS2 (þSS2) voru flokkaðir sem slíkir. Æðakölkun í hálsslagæðum var metin hjá sjúklingum með áður ógreinda sykursýki með staðlaðri hálsæðaómunum þar sem sjúklingar voru flokkaðir eftir því hvort æðakölkun var til staðar eða ekki og heildarflatarmál æðakölkunar reiknað. Þá var sjúklingum fylgt eftir og kannað hvort þeir þróuðu með sér alvarlega fylgikvilla hjarta- og æðasjúkdóma. Af þeim 372 sjúklingum með BKH sem tóku þátt voru 20,7% með eðlileg sykurefnaskipti, 46,5% með forstig SS2, 6,2% með nSS2 og 26,6% með þSS2. Næmi til að greina nSS2 hjá sjúklingum með áður óþekkta sykursýki var 33,3%, 61,1% og 77,8% eftir því hvort notað var HbA1c, FPG og 2hPG í sjúkralegu. Þremur mánuðum seinna voru samsvarandi gildi 27,8%, 61,1% og 72,2%. Jákvætt forspárgildi (PPV) til að greina SS2 var 100%, 91,7% og 51,9% með því að nota HbA1c, FPG eða 2hPG í legu. Samsvarandi gildi þremur mánuðum seinna voru 71,4%, 91,7% og 65,0%. Þegar HbA1c og FPG mælingar í legu og þremur mánuðum seinna eru teknar saman var næmi 88,9% og PPV 80,0%. Með því að nota samsetningar með sykurþolsprófi var næmið til að greina SS2 100% en PPV á bilinu 44,2% til 66,7%. Í sjúklingum með áður ógreinda sykursýki sást æðakölkun í hálsslagæðum hjá 48,5% þeirra sem höfðu eðlileg sykurefnaskipti, 66,9% sem höfðu forstig SS2 og 72,2% sjúklinga með nSS2. Hjá sjúklingum með nýgreint forstig SS2 eða nSS2 var 25,5% og 35,9% aukning á heildarflatarmáli æðakölkunar miðað við sjúklinga með eðlileg sykurefnaskipti (p=0,04). Gerð var fjölþátta aðhvarfsgreiningu þar sem leiðrétt var fyrir hefðbundnum áhættuþáttum æðakölkunarsjúkdóms. Gagnlíkindahlutfall (OR) hjá sjúklingum með nýgreint forstig SS2 eða nSS2 var 2,17 (95% Cl 1,15-4,15) að hafa æðakölkun í hálsslagæðum, samanborið við sjúklinga með eðlileg sykurefnaskipti. Þegar einnig var leiðrétt fyrir blóðglúkósa-gildi tveimur klst eftir inntöku glúkósa var OR 1,77 (95% CI 0,83-3,84). Áhættuhlutfall var 10,9 (95% CI 1,2 – 98,3) fyrir sjúklinga með nSS2 fyrir dauða eða hjartadrep og 2,9 (95% CI 1,0 – 8,0) fyrir alvarlega fylgikvilla hjarta- og æðasjúkdóma eftir 2,9 ár, samanborið við sjúklinga með eðlileg sykurefnaskipti. Hjá sjúklingum með þSS2 var áhættuhlutfallið 14,9 (95% CI 2,0 – 113,7) fyrir dauða eða hjartadrep og 3,3 (95% CI 1,5 – 7,6) fyrir alvarlega fylgikvilla hjarta- og æðasjúkdóma eftir 2,9 ár, samanborið við sjúklinga með eðlileg sykurefnaskipti. Dauðsföll og hjartadrep voru marktækt fleiri hjá sjúklingum með skert sykurþol (IGT), samanborið við sjúklinga með hækkaðan fastandi blóðsykursstjórn (IFG) eða hækkað HbA1c. Við ályktum að unnt sé að greina með öryggi SS2 hjá sjúklingum með BKH með endurteknum mælingum á HbA1c og FPG þar sem greining SS2 eykst ekki að marki með viðbót sykurþolsprófs. Einnig höfum við sýnt fram á að nýgreint forstig SS2 og SS2 hjá sjúklingum með BKH eru sjálfstæðir áhættuþættir fyrir æðakölkun í hálsslagæðum þar sem hækkað blóðglúkósa-gildi tveim klukkustundum eftir inntöku glúkósa hefur sterk tengsl við aukna æðakölkun. Að lokum, sjúklingar með nSS2 og þSS2 eru í aukinni dánar- og hjartadrepsáhættu sem og aukinni hættu á alvarlegum fylgikvillum hjarta- og æðasjúkdóma, samanborið við BKH sjúklinga með eðlileg sykurefnaskipti., Type 2 diabetes mellitus (T2DM) and prediabetes are established risk factors for atherosclerosis and major adverse cardiac events (MACE) in the general population. Screening by oral glucose tolerance test (OGTT) shows high prevalence of undiagnosed dysglycemia among patients with acute coronary syndrome. However, the optimal method to diagnose T2DM and prediabetes in patients with acute coronary syndromes (ACS) has yet to be determined. Furthermore, atherosclerotic burden and risk of future cardiac events among patients with ACS and T2DM or prediabetes as defned by World Health Organization (WHO) and American Diabetes Association (ADA) criteria have not been evaluated. The aim of this thesis is to identify the most reliable method to diagnose T2DM and prediabetes in patients with ACS. In addition, we evaluate atherosclerotic burden and risk of future adverse cardiac events among patients with ACS with different glucose metabolic perturbations according to current WHO and ADA criteria. Patients diagnosed with ACS and admitted to the coronary care unit were consecutively included in the study. Patients without a previous history of diabetes underwent evaluation of their glucose metabolism by HbA1c, fasting plasma glucose (FPG) and 2-hour plasma glucose (2hPG) with standard OGTT, during hospital admission and at 3-month follow-up. Patients were classified into various categories of glucose metabolism: at least two measurements with results above the diabetes cut-off point, according to WHO and ADA critera, were required to diagnose new T2DM (nT2DM). Subjects with one measurement above the cut-off point for diabetes or prediabetes fulfilled the criteria for prediabetes while patients with all measurements within normal range were classified as having normal glucose metabolism (NGM). Patients with previously known T2DM (kT2DM) were classified as such. Patients without a previous history of T2DM underwent standardized ultrasound examination of their carotid arteries to evalute presence of significant plaques and to measure the total plaque area (TPA). Finally, patients were followed for significant clinical outcome parameters, including all-cause death or myocardial infarction (MI) and major adverse cardiac events (MACE). Among the 372 ACS patients included in the study, 20.7%, 46.5%, 6.2% and 26.6% were diagnosed with NGM, prediabetes, nT2DM and kT2DM, respectively. Glucometabolic measurements from patients without a previous diagnosis of T2DM indicated that elevated 2hPG has the highest sensitivity for diagnosing T2DM: 77.8% during hospital admission and 72.2% at followup, compared to HbA1c with 33.3% and 27.8%, respectively, and FPG with 61.1% at admission and follow-up. However, the positive predictive values (PPVs) for diagnosing T2DM were 100%, 91.7% and 51.9% during admission and 71.4%, 91.7% and 65.0% at follow-up for HbA1c, FPG and 2hPG, respectively. By combining HbA1c and FPG measurements during admission and follow-up, the sensitivity to diagnose T2DM was 8.9% and PPV was 80.0%, while combinations of FPG and HbA1c with OGTT had 100% sensitivity and a PPV ranging from 44.2% to 66.7%. Among patients without a previous history of diabetes, a significant atherosclerotic plaque was detected in 48.5%, 66.9% and 72.2% of patients with NGM, prediabetes and nT2DM, respectively. An incremental increase in TPA was found from NGM to prediabetes and nT2DM (p=0.04). Patients with newly diagnosed dysglycemia were found to be at increased risk of having significant atherosclerotic plaque in the carotid arteries, when adjusted for conventional cardiovascular risk factors, with OR of 2.17 (95% CI 1.15-4.15) compared to patients with NGM. When also adjusted for 2hPG, the OR attenuated to 1.77 (95% CI 0.83-3.84). After a mean follow-up period of 2.9 years, compared to patients with NGM, patients with nT2DM and kT2DM had HR 10.9 (95% CI 1.2 – 98.3) and 14.9 (95% CI 2.0 – 113.7), respectively, for death/MI and 2.9 (95% CI 1.0 – 8.0) and 3.3 (95% CI 1.5 – 7.6), respectively, for a composite of MACE. Patients with prediabetes had increased near future risk for death/MI but this did not reach statistical significance. Patients with impaired glucose tolerance suffered significantly more events of death or MI compared to patients with impaired fasting glucose or elevated Hb1Ac. In conclusion, T2DM can be diagnosed with reasonable certainty using repeated measurements of HbA1c and FPG in ACS patients, with limited added value of OGTT. Furthermore, newly detected dysglycemia is an independent predictor of atherosclerotic plaque formation in the carotid arteries with OGTT as the major determinant of risk of carotid plaque burden. Finally, patients with nT2DM and kT2DM were found to have an increased risk of death or MI and MACE compared to ACS patients with NGM.

Acute kidney injury (AKI) is a growing problem worldwide and is associated with high morbidity and mortality. AKI is a known complication following cardiac operations and coronary angiography (CA). Following CA, AKI has been associated with contrast exposure but recently its importance in the development of AKI has been debated. Following open heart surgery, both patient-related and operative risk factors have been identified, where cardiopulmonary bypass (CPB) plays an important role. AKI has been associated with worse short-term survival. The association between AKI following cardiac procedures and patients´ long-term outcome has not been described as well, since many studies have lacked information on long-term follow-up, especially regarding long-term renal function and development of chronic kidney disease (CKD). The aim of the work described in this thesis was to estimate the incidence and risk factors of AKI following CA and three different cardiac operations: coronary artery bypass grafting (CABG), surgical aortic valve replacement (SAVR) and repair of acute type A aortic dissection (ATAAD). Furthermore, the association between AKI and outcome of patients was evaluated, focusing especially on long-term survival and development or progression of CKD. All the studies were retrospective; studies I‒III included all the patients who underwent cardiac catheterisation or open heart procedures in Iceland, but study IV included patients who were operated with ATAAD repair at eight academic hospitals in Denmark, Finland, Sweden and Iceland. Data were gathered from national databases, medical record systems and hospital databases. Detailed information on patient characteristics together with intra- and post-procedural factors were registered. AKI was defined according to the KDIGO criteria in studies I and II and the RIFLE criteria in studies III and IV. Predictors of AKI were identified by using multivariable logistic regression models. Outcome of patients with and without AKI was compared and Cox models and propensity score matching were used to estimate the association between AKI and both long-term survival and kidney function. The incidence of AKI ranged from 2% following CA to 41% after ATAAD repair. Among the patient-related risk factors for AKI were advanced age, obesity, malperfusion and pre-procedural CKD. Contrast dose was mostly associated with AKI in patients who had eGFFR < 45 mL/min/1.73m2 who received more than 150 mL of intra-arterial contrast. CPB was associated with AKI following the open cardiac surgeries, and also with number of transfusions of red blood cells administered perioperatively. Following the procedures, AKI was associated with inferior short-term and long-term survival and was an independent predictor of long-term survival following CA and ATAAD repair. The association between AKI following CABG and mortality appeared to be partially explained by its association with other major complications. Following CA and CABG, AKI was found to be a predictor of development of CKD. The four studies highlight the fact that AKI is a severe complication following different cardiac procedures, and where the incidence is dependent on the complexity of the procedure and the severity of the underlying condition. Some of the identified risk factors of AKI could possibly be modified and may be useful in reducing the likelihood of AKI in high-risk patients. Furthermore, the studies have shown that AKI is not only associated with worse short-term patient outcome but also inferior long-term survival and increased risk of developing CKD., Bráður nýrnaskaði (BNS) er vaxandi vandamál á heimsvísu og tengist hann aukinni sjúkdómsbyrði og dánartíðni. BNS er þekktur fylgikvilli eftir kransæðaþræðingar og opnar hjartaaðgerðir. Hann hefur verið tengdur við notkun skuggaefnis eftir þræðingar en undanfarið hefur verið deilt um mikilvægi þess í meinmyndun BNS. Áhættuþættir BNS eftir opnar hjartaaðgerðir geta verið bæði sjúklinga- og aðgerðartengdir en tími á hjartaog lungnavél gegnir þar stóru hlutverki. BNS tengist verri lifun sjúklinga til skemmri tíma en skortur er á rannsóknum á langtíma afdrifum þessara sjúklinga, sérstaklega með tilliti til langtíma nýrnastarfsemi. Markmið þessarar doktorsritgerðar var að kanna tíðni og áhættuþætti BNS eftir kransæðaþræðingar og þrjár mismunandi opnar hjartaaðgerðir: kransæðahjáveitu, ósæðarlokuskipti og viðgerð á ósæðarflysjun af gerð A. Jafnframt voru áhrif BNS á afdrif sjúklinga metin, sérstaklega með tilliti til langtíma lifunar og þróunar á langvinnum nýrnasjúkdómi (LNS). Rannsóknirnar voru afturskyggnar þar sem rannsóknir I-III náðu til allra sjúklinga sem gengust undir kransæðaþræðingu eða hjartaaðgerðir á Íslandi en rannsókn IV var gerð á sjúklingum sem fóru í viðgerð á ósæðarflysjun af gerð A á átta háskólasjúkrahúsum í Danmörku, Finnlandi, Svíþjóð og á Íslandi. Gögnum var safnað úr miðlægum gagnasöfnum og sjúkraskrám sjúklinga. Skráðar voru ítarlegar upplýsingar um sjúklingatengda og aðgerðartengda þætti og afdrif sjúklinga eftir aðgerð. BNS var skilgreindur samkvæmt KDIGO skilmerkjum í rannsókn I og II en út frá RIFLE skilmerkjum í rannsókn III og IV. Forspárþættir BNS voru fundnir með fjölþátta aðhvarfsgreiningu. Afdrif sjúklinga með og án BNS voru borin saman og voru Cox líkön og propensity score pörun notuð til að meta tengsl BNS við langtíma lifun og þróun á LNS. Tíðni BNS var frá 2% eftir kransæðaþræðingu upp í 41% í kjölfar aðgerðar á ósæðarflysjun. Aldur, þekktur nýrnasjúkdómur fyrir aðgerð, offita og blóðþurrð voru á meðal sjúklingatengdra áhættuþátta BNS. Skuggefnismagn tengdist aðallega aukinni hættu á BNS hjá sjúklingum með gaukulsíunarhraða < 45 mL/mín./1,73 m2 fyrir þræðingu sem fengu > 150 mL af skuggaefni. Tími á hjarta- og lungnavél og gjöf rauðkornaþykknis voru áhættuþættir BNS eftir opnu hjartaaðgerðirnar. Í öllum fjórum rannsóknunum höfðu sjúklingar sem fengu BNS verri langtímalifun en þeir sem ekki fengu BNS og var hann sjálfstæður forspárþáttur lifunar í kjölfar kransæðaþræðinga og aðgerða við ósæðarflysjun af gerð A. Eftir kransæðahjáveitu virtust tengsl BNS við lifun tengjast að verulegu leyti öðrum alvarlegum fylgikvillum. BNS var jafnframt sjálfstæður forspárþáttur fyrir því að sjúklingar þróuðu með sér LNS eftir kransæðaþræðingu og kransæðahjáveituaðgerð. Rannsóknirnar staðfesta að BNS er alvarlegur fylgikvilli eftir bæði kransæðaþræðingar og opnar hjartaaðgerðir. Hugsanlega mætti hafa áhrif á suma þeirra áhættuþátta BNS sem fundnir voru og þannig draga úr líkum á BNS. BNS tengist ekki eingöngu síðri skammtímalifun sjúklinga heldur einnig langtíma lifun og jafnframt auknum líkum á að sjúklingar þrói með sér LNS.

The pneumococcus is a major human pathogen that causes morbidity and mortality worldwide. Pneumococci are normally carried asymptomatically in the nasopharynx of healthy pre-school children. Pneumococcal infections can range from acute otitis media (AOM) and pneumonia to invasive pneumococcal disease (IPD). Vaccination with conjugate pneumococcal vaccines (PCVs) leads to a reduction of serotypes targeted by the vaccines (vaccine-type, VT) but can also lead to replacement by serotypes not targeted by PCVs (nonvaccine-type, NVT). Iceland introduced the 10-valent PCV (PHiD-CV, GSK) into the national immunization program in 2011. The aim of the study was to assess the impact of PHiD-CV on pneumococci isolated from samples from the nasopharynx of healthy children attending day-care centres (DCCs), middle ear (ME) from children with AOM and lower respiratory tract (LRT) from adults with suspected pneumonia. Serotype distribution, genetic lineages and antimicrobial resistance was analysed by comparing the period before vaccine introduction (PreVac; 2009-2011) to the period post vaccine introduction (PostVac; 2012-2017). Nasopharyngeal swabs were collected annually (March, 2009-2017), from children, Pneumókokkar eru mikilvægir sýkingavaldar í mönnum. Heilbrigð börn á leikskólaaldri geta borið pneumókokka í nefkoki án nokkurra einkenna en pneumókokkar geta leitt til miðeyrnasýkingar, lungnabólgu og ífarandi sýkinga. Bólusetning með próteintengdum bóluefnum leiðir til fækkunar stofna af hjúpgerðum sem bóluefnið veitir vörn gegn (bóluefnis hjúpgerð, e. vaccine type: VT) en getur auk þess leitt til fjölgunar stofna af hjúpgerðum sem bóluefnið veitir ekki vörn gegn (ekki bóluefnis hjúpgerð, e. non-vaccine type: NVT). Tíu-gilda próteintengda pneumókokka bóluefnið (PHiD-CV, GSK) var innleitt í ungbarnabólusetningar á Íslandi árið 2011. Markmið rannsóknarinnar var að meta áhrif PHiD-CV á pneumókokka sem ræktaðir voru úr nefkoki heilbrigðra leikskólabarna, miðeyrum (ME) barna með miðeyrnarbólgu og neðri öndunarvegum (LRT) fullorðinna einstaklinga með grun um lungnabólgu. Í rannsókninni var dreifing hjúpgerða, raðgerða (e. sequence types, ST) og sýklalyfjanæmi pneumókokkastofna fundið. Gögn fyrir bólusetningu (2009-2011) voru borin saman við gögn eftir bólusetningu (2012-2017). Nefkoksstrokum var safnað árlega (í mars, 2009-2017) frá börnum

Background and aims: Proton pump inhibitors (PPIs) are commonly prescribed drugs that are used to treat acid-related disorders of the gastrointestinal tract. Over the last decade, PPI use has repeatedly been shown to be increasing worldwide, causing concerns due to reports of unsubstantiated long-term use and potential adverse effects. However, PPIs have also been suggested to promote antineoplastic effects in certain cancer settings via inhibition of specialized proton pumps. These proton pumps are involved in pH regulation in eukaryotic cells and believed to act as facilitators for the acidification of the tumor microenvironment (TME). Our aim was to use the population-based resources available to us in Iceland I) to assess the utilization of PPIs among the adult outpatient population residing in Iceland, II) to explore the potential of PPIs possessing an antineoplastic effect by estimating the risk among PPI users of being diagnosed with a first-time breast cancer, prostate cancer, or malignant melanoma, and III) to assess the potential influence of post-diagnosis PPI use on mortality among prostate cancer patients. Materials and methods: In study I, a drug utilization study, we investigated changes in overall PPI use between 2003 and 2015 among the adult outpatient population in Iceland. We estimated changes in annual incidence and prevalence, duration of PPI treatment, and the concurrent use of ulcerogenic drugs. In study II, a nested case-control study, we identified incident cases of breast cancer, prostate cancer, and malignant melanoma between 2005 and 2014. For each case, up to 10 controls were matched on birth-year, sex, and calendar year using risk-set sampling. Assessing ever use, high use, and cumulative use of PPIs, we calculated odds ratios (ORs) and 95% confidence intervals (CIs) using conditional logistic regression. In study III, a cohort study, we identified patients diagnosed with prostate cancer between 2007 and 2012 among adult residents of Iceland aged between 40 and 85 years. PPI use was modelled in a time-dependent manner. Assessing post-diagnosis use, timing of use, cumulative use and stratifying by clinical stage we estimated the associations with prostate-cancer specific and all-cause mortality using Cox proportional hazard regression models and 95% CIs. Results: In study I, we observed a marked increase in outpatient PPI use over the last decade. Although the annual incidence remained fairly stable between 2003 and 2015, the annual prevalence estimates rose from 8.5 per 100 persons in 2003 to 15.5 per 100 persons in 2015. Furthermore, we found that prevalence increased with age and that 22% of patients were still being treated with PPIs one year after treatment initiation. In study II, we observed the following adjusted odds ratios (ORs) associated with ever use and high use of PPIs, respectively: 1.03 (95% CI: 0.92-1.16) and 0.97 (95% CI: 0.78-1.19) for breast cancer, 1.12 (95% CI: 1.00-1.25) and 1.20 (95% CI: 0.99-1.47) for prostate cancer, 0.84 (95% CI: 0.69-1.12) and 0.59 (95% CI: 0.40-1.13) for malignant melanoma. In secondary analyses, we did not observe a pattern consistent with a dose-response relationship for these three cancer types. In study III, we did not observe a statistically significant association between post-diagnosis PPI use and prostate cancer-specific mortality (HR 0.88; 95% CI: 0.52-1.48) or all-cause mortality (HR 1.02; 95% CI: 0.73-1.43). In secondary analyses, stratification by timing of use yielded adjusted HRs of 0.45 (95% CI: 0.21-0.98) among continuous PPI users and 1.12 (95% CI: 0.61-2.08) among new PPI users for prostate cancer-specific mortality. For all-cause mortality, we observed adjusted HRs of 0.67 (95% CI: 0.43-1.04) and 1.25 (95% CI: 0.82-1.92) among continuous users and new users, respectively. Stratification by cumulative dose and clinical stage did not reveal a statistically significant association with post-diagnosis PPI use for the mortality outcomes of interest. Conclusions: In conclusion, our observations indicate that PPI use in Iceland has increased considerably over the last decade; especially among older adults. Additionally, a high proportion of patients were treated for longer periods than clinical guidelines recommend. Furthermore, our findings do not support a chemopreventive role of PPIs in attenuating the risk of being diagnosed with a first-time breast cancer, prostate cancer, or malignant melanoma. Finally, our results do not indicate that post-diagnosis PPI use influences mortality among prostate cancer patients., Inngangur og markmið: Prótónupumpuhemlar (PPI) eru sýrubindandi lyf sem eru almennt notuð við meðferð á ýmsum magasýrusjúkdómum. Notkun PPI lyfja er útbreidd á heimsvísu og sú umtalsverða aukning sem hefur orðið á notkun þeirra hefur verið gagnrýnd í ljósi mögulegrar ofnotkunar og óvissu sem ríkir um mögulegar skaðlegar aukaverkanir. Sýrubindandi virkni PPI hefur verið talin hafa möguleg krabbameinshindrandi áhrif vegna hæfni þeirra til að hindra virkni sérhæfðra sýruseytandi ensíma. Talið er að slík ensím taki þátt í myndun á súru utanfrumuumhverfi krabbameinsfruma. Markmið okkar var nota lýðgrundaða gagnagrunna á Íslandi til að I) kortleggja notkun PPI lyfja meðal fullorðinna einstaklinga á Íslandi, II) meta áhættu PPI notenda á því að greinast með brjóstakrabbamein, blöðruhálskirtilskrabbamein, eða sortuæxli í húð, og III) meta möguleg verndandi áhrif PPI lyfjanotkunar á lifun sjúklinga með blöðruhálskirtils–krabbamein. Aðferðir: Rannsókn I var lyfjanotkunarrannsókn þar sem við lýstum notkun PPI lyfja á árunum milli 2003 og 2015. Við áætluðum árlegt nýgengi og algengi PPI notkunar, lengd PPI lyfjameðferðar og samhliða notkun lyfja sem geta haft í för með sér blæðingar í meltingarvegi. Rannsókn II var tilfella-viðmiðsrannsókn þar sem tilfellin voru einstaklingar sem greindust með brjóstakrabbamein, blöðruhálskirtilskrabbamein og sortuæxli á milli 2005 og 2014. Hvert og eitt krabbameinstilfelli pöruðum við saman við allt upp að 10 viðmið eftir almanaksári, fæðingarári, og kyni. Við áætluðum PPI notkun þátttakenda, þ.e. hvort leyst hefði verið út að minnsta kosti eina PPI lyfjaávísun, hvort notkun væri ≥1000 skilgreindum dagskömmtum (DDDs) og heildarnotkun og reiknuðum út gagnlíkindahlutföll (ORs) og 95% öryggisbil (CIs) fyrir áhættuna á því greinast. Rannsókn III var hóprannsókn þar sem einstaklingar á aldursbilinu 40 til 85 ára sem greindust með krabbamein í blöðruhálskirtli á milli 2007 og 2012 mynduðu rannsóknarhópinn. Við áætluðum upphaf PPI notkunar (fyrir eða eftir greiningu), heildarnotkun og lagskiptum eftir klínískri stigun. PPI notkun var meðhöndluð sem tímaháð breyta og Cox aðhvarfsgreining var notuð til að reikna út hættuhlutfall (HRs) fyrir dauða af völdum blöðruhálskirtilskrabbameins annars vegar og dauða af öllum orsökum hins vegar með 95% öryggismörkum (CI). Niðurstöður: Niðurstöður úr rannsókn I sýndu að heildarnotkun PPI lyfja á Íslandi fór ört vaxandi á rannsóknartímabilinu. Þótt nýgengi hafi haldist stöðugt jókst algengi PPI notkunar úr 8.5 á hverja 100 einstaklinga árið 2003 yfir í 15.5 á hverja 100 einstaklinga árið 2015. Ennfremur, reyndist algengi hækka með hækkandi aldri og 22% sjúklinga var enn að nota PPI einu ári eftir að meðferð hófst. Niðurstöður úr rannsókn II bentu ekki til þess að PPI notkun hafi í áhrif á krabbameinsáhættu (ORs 1.03; 95% CI: 0.92-1.16 fyrir brjóstakrabbamein, 1.12; 95% CI: 1.00-1.25 fyrir blöðruhálskirtilskrabbamein og 0.84; 95% CI: 0.69-1.12 fyrir sortuæxli). Sömuleiðis virtist PPI notkun ≥1000 DDDs ekki hafa áhrif (OR 0.97; 95% CI: 0.78-1.19 fyrir brjóstakrabbamein, 1.20; 95% CI: 0.99-1.47 fyrir blöðruhálskirtilskrabbamein, og 0.59; 95% CI: 0.40-1.13 fyrir sortuæxli). Niðurstöður okkar bentu ekki til þess að tengsl væru á milli heildarnotkunar á PPI og áhættunnar á því að greinast með brjóstakrabbamein, blöðruhálskirtilskrabbamein, eða sortuæxli. Niðurstöður úr rannsókn III bentu ekki til þess að PPI notkun eftir greiningu hefði áhrif á líkur á dauða af völdum blöðruhálskirtilskrabbameins (HR 0.88; 95% CI: 0.52-1.48) eða dauða af öllum orsökum (HR 1.02; 95% CI: 0.73-1.43). Upphaf PPI notkunar virtist ekki hafa áhrif, en HRs fyrir dauða af völdum blöðruhálskirtilskrabbameins voru 0.45 (95% CI: 0.21-0.98) meðal sjúklinga sem notuðu PPI lyf samfellt bæði fyrir og eftir greiningu og 1.12 (95% CI: 0.61-2.08) á meðal nýrra PPI notenda. HRs fyrir dauða af öllum orsökum voru 0.67 (95% CI: 0.43-1.04) á meðal sjúklinga sem notuðu PPI samfellt og 1.25 (95% CI: 0.82-1.92) á meðal nýrra PPI notanda. Lagskipting eftir heildarnotkun PPI lyfja og klínískri stigun leiddi ekki ljós tölfræðilega marktækt samband á milli PPI notkunar og lifunar. Ályktun: Niðurstöður verkefnisins benda til þess að PPI notkun hafi aukist umtalsvert á Íslandi yfir síðasta áratuginn; sér í lagi hjá eldri einstaklingum. Þar að auki er stór hluti sjúklinga meðhöndlaður lengur en mælt er með í klínískum leiðbeiningum fyrir lyfin. Niðurstöður okkar benda hvorki til þess að PPI notkun hafi áhrif á áhættu á brjóstakrabbameini, blöðruhálskirtils–krabbameini, eða sortuæxlum, né að hún hafi áhrif á lifun meðal sjúklinga með krabbamein í blöðruhálskirtli.

Aims: The aim of this thesis was to evaluate the effects of a new multi-sensory balance training program: the “Reykjavik Model” among unsteady older adults as well as middle aged and elderly people with wrist fractures. Additionally, to explore the characteristics of the people with wrist fractures. Three papers are included in this thesis. The more specific aims were: Paper I: To evaluate the effects of the “Reykjavik Model” on postural control, functional abilities, confidence in activities of daily living and falls among unsteady older adults. Paper II: To investigate vestibular function, mechanoreceptive sensation in lower limbs, postural control, functional abilities, perceived dizziness and confidence in individuals between 50 and 75 years of age with and without fall-related wrist fractures and to evaluate whether these variables are independently associated with having sustained a fall-related wrist fracture. Paper III: To investigate whether “the Reykjavik Model” improves postural control, vestibular function, foot sensation and functional abilities among people with fall-related wrist fractures compared with wrist stabilization training. Methods: Paper I was a quasi-experimental intervention study with pre- and post-test design. Participants were 37 unsteady older adults with a history of falls. Treatment consisted of eighteen multi-sensory balance training sessions (MST) supervised by a physiotherapist. Measurements before and after training were: The Sensory Organization Test (SOT) to assess postural control, the Five-Times-Sit-to-Stand Test (FTSTS) to measure lower limb strength, 30-m normal and fast walk with a turn to measure walking speed, Ascending-Descending 11 steps to assess proficiency in stairs and the Activities-specific Balance Confidence Scale (ABC) to assess confidence during daily activities. Information was gathered about number of falls one year prior to training, during training and six months after completion of training. Paper II was a case-control study with 98 persons aged 50-75 years, having sustained a fall-related wrist fracture. Forty-eight sex, age and physical activity matched individuals, without previous history of wrist fractures, served as controls. Measurements included: Head-Shake test (HST) to measure function of the vestibular system, Tuning fork, Biothesiometer (BT) and Semmes-Weinstein monofilaments (SWM), to measure sensation in feet, SOT to assess postural control, FTSTS to assess lower limb strength, 10-meter-walk test (10MWT) to measure walking speed, the ABC and the Dizziness Handicap Inventory (DHI) scales to assess self perceived confidence and dizziness during daily activities. Paper III was a randomized controlled intervention study. Ninety-eight participants, age 50-75 years, were randomized to multi-sensory (MST) or wrist stabilization training (WT). Treatment consisted of six training sessions supervised by a physiotherapist and daily home exercises for both groups. Results from: HST, video-Head Impulse Test (vHIT), SWM, BT, SOT, 10 MWT, FTSTS, ABC and DHI were compared before and after training. Results: In Paper I significant improvement was observed in all measured parameters (p, Markmið: Markmið þessarar doktorsrannsóknar var að rannsaka áhrif skynörvandi jafnvægisþjálfunar fyrir óstöðugt eldra fólk og miðaldra einstaklinga sem höfðu úlnliðsbrotnað, ásamt að rannsaka hvað einkenndi þátttakendur sem höfðu brotnað á úlnlið. Ritgerðin byggir á þremur vísindagreinum. Nánari markmið voru: Vísindagrein I: Að kanna áhrif skynörvandi jafnvægisþjálfunar á jafnvægi, starfræna færni, öryggi við daglegar athafnir og byltur á meðal eldra fólks með óstöðugleika. Vísindagrein II: Að rannsaka starfsemi jafnvægiskerfis innra eyra, skyn í fótum, jafnvægi, gönguhraða, vöðvastyrk og upplifun á svima og öryggi við daglegar athafnir einstaklinga 50-75 ára sem hlotið höfðu úlnliðsbrot við byltu. Einnig að kanna hvort einhver þessara breyta tengdist því marktækt að hafa úlnliðsbrotnað. Vísindagrein III: Að kanna hvort skynörvandi jafnvægisþjálfun bæti jafnvægisstjórnun, starfsemi jafnvægiskerfis í innra eyra, skyn í fótum og starfræna færni hjá einstaklingum sem hlotið hafa úlnliðsbrot við byltu, samanborið við stöðugleikaþjálfun fyrir úlnlið eingöngu. Aðferðir: Vísindagrein I lýsir hálf-staðlaðri tilraunameðferð með fyrir og eftir-prófi. Þátttakendur (meðalaldur: 80,8 ár±7,1ár; spönn 70-92) voru 37 óstöðugir eldri einstaklingar með sögu um byltur. Þjálfunartímar voru átján undir handleiðslu sjúkraþjálfara. Mælingar voru gerðar fyrir og eftir skynörvandi jafnvægisþjálfun. Jafnvægisstjórnun var metin með skynúrvinnsluprófi, gönguhraði var metinn með 30 metra göngu með snúningi, starfrænn styrkur í neðri útlimum var metinn með fimm sinnum standa-sitja prófi, stigafærni með tímatöku við að ganga upp og niður 11 þrep og öryggi við daglegar athafnir var metið með ABC sjálfsmatskvarða jafnvægis. Fjöldi byltna var skráður tólf mánuðum fyrir þjálfun, á þjálfunartímabilinu og sex mánuðum eftir að því lauk. Vísindagrein II var samanburðarrannsókn með 98 þátttakendum, 50-75 ára, sem leituðu á bráðamóttöku Landspítala í kjölfar byltu og greindust með úlnliðsbrot. Í samanburðarhópi voru 48 heilbrigðir einstaklingar án sögu um úlnliðsbrot. Pörun var gerð m.t.t. aldurs, kyns og hreyfingar síðastliðna tólf mánuði. Starfsemi jafnvægiskerfis innra eyra var metin með höfuð-skak prófi (Head-Shake Test). Þrýstingsskyn undir iljum var metið með Semmes-Weinstein einþráðum (Semmes-Weinstein monofilaments), titringsskyn í fótum var metið með titringsskynmæli (biothesiometer) og tónkvísl. Jafnvægisstjórnun var metin með skynúrvinnsluprófi. Starfrænn styrkur í neðri útlimum var metinn með fimm sinnum standa-sitja prófi og gönguhraði með 10 metra gönguprófi. ABC sjálfsmatskvarði jafnvægis og DHI svimakvarði voru notaðir til að meta eigin upplifun þátttakenda á öryggi og svima í daglegu lífi. Vísindagrein III var slembuð samanburðarrannsókn. Níutíu og átta einstaklingar (meðalaldur: 61,9 ár±7,1ár; spönn 50-75) sem hlotið höfðu úlnliðsbrot við byltu, tóku þátt í rannsókninni, tveimur til fimm mánuðum eftir brotið. Þeim var slembiraðað í annað hvort skynörvandi jafnvægisþjálfun eða stöðugleikaþjálfun fyrir úlnlið, til viðbótar við hefðbundna brotameðferð. Mælingar voru gerðar fyrir og eftir þjálfun. Starfsemi jafnvægiskerfis innra eyra var metin með höfuð-skak prófi og höfuð-rykkja prófi (video-Head Impuls Test). Skyn í fótum var metið með Semmes-Weinstein einþráðum og titringsskynmæli. Jafnvægisstjórnun var metin með skynúrvinnsluprófi, gönguhraði með 10 metra gönguprófi og starfrænn styrkur í neðri útlimum með fimm sinnum standa-sitja prófi. ABC sjálfsmatskvarði jafnvægis og DHI svimakvarði voru notaðir til að meta eigin upplifun þátttakenda á öryggi og svima í daglegu lífi. Þátttakendur í báðum hópum, fengu skriflegar heimaæfingar og mættu í sex þjálfunartíma undir handleiðslu sjúkraþjálfara í þrjá mánuði. Niðurstöður: Vísindagrein I: Marktækar framfarir komu fram í öllum mældum breytum eftir skynörvandi jafnvægisþjálfunina (p, St. Josef’s Hospital Fund, Reykjavik, Iceland. The Icelandic Physiotherapy Association Research Fund. The Landspitali University Hospital Research Fund. The Icelandic Gerontological Society Research Fund. Helga Jónsdóttir and Sigurlidi Kristjánsson Geriatric Research Fund.

The pigment producing melanocytes are derived from the neural crest cells and form precursor cells called melanoblasts. These cells proliferate and migrate to their destination in skin, hair and other organs where they differentiate into melanocytes which produce the pigment melanin. The Microphthalmia-associated transcription factor (MITF) is indispensable for the establishment of fully differentiated melanocytes. MITF controls the expression of genes required for melanocyte survival, proliferation and differentiation. Melanoma cells thus exploit the transcriptional activity of MITF to foster cancer progression. However, the role of MITF in regulating the metastatic potential of melanoma cells is complex and often leads to inconsistent findings. The scope of this thesis was to further elucidate the functional role of MITF in melanoma development. Our findings revealed that MITF knock out (KO) melanoma cells exhibit a reduced proliferation rate compared to the control cell line. Consistent with that, the expression of cell cycle regulators that are known targets of MITF was affected in the KO cells. Surprisingly, both the migration and invasion potential of MITF-KO cells were significantly reduced compared to empty vector cell lines. In contrast, transient depletion of MITF did not affect the invasion potential of melanoma cells. RNA-sequencing followed by differential gene expression analysis revealed a gain of extracellular matrix and neuronal related genes in MITF-KO cells, whereas pigmentation genes that are specific to melanocyte differentiation were lost. Accordingly, the gene expression profile of MITF-KO cells was negatively correlated with the gene signature of melanocytes, whereas a positive correlation was observed with neural crest and Schwann cell signature. Interestingly, the major components of focal adhesions, including paxillin (PAX) and focal adhesion kinase (FAK) are direct targets of MITF and their expression was induced upon MITF depletion. Well in line, the number of FAK and PAX positive focal points were increased in MITF-KO and transient knockdown cell lines. Additionally, expression of N-cadherin was increased in both models whereas E-cadherin was decreased, reflecting marks of mesenchymal transition. Published ChIPseq data show that both E- and N-cadherins have MITF binding sites in their introns and promoter regions, suggesting that they are direct MITF targets. The level of histone modifications reflected major changes in gene expression observed in the MITF-KO cells. The H3K4me3 active mark and the H3K9me3 repressive mark were both altered in the promoter of genes that showed differential expression in MITF-KO cells. Consistent with this, the expression of the histone modifiers PRDM7 and SETDB2 was reduced in the MITF-KO cells. Taken together, we conclude that the loss of MITF drives cells into a de-differentiated state that is governed by a neural crest-like transcriptional program. Furthermore, the maintenance of neural crest gene repertoire is facilitated by epigenetic modifiers that are under MITF regulation. The second part of this thesis investigated the genome wide overlapping targets of the transcription factors MITF, IRF4 and TFEB. All three factors have been shown to collaborate in regulating gene expression in melanoma and melanocytes. Chromatin immunoprecipitation sequencing was performed using eGFP tagged TFEB and IRF4 proteins and genome wide binding sites were identified for each factor. Analysis of the overlapping target genes revealed that MITF and TFEB share binding to lysosomal genes whereas MITF and IRF4 share binding to pigmentation and immue-related genes. Statistically differentially bound sites were identified for each factor, in which MITF displayed unique binding to genes related to neuronal development. TFEB showed exclusive binding to genes related to DNA metabolic processes, whereas IRF4 revealed exlusive binding to genes involved in the hematopoietic system. Thus, the distinct and overlapping binding regions of each factor were identified, which enabled us to dissect the co-operative and independent transcriptional activity of each factor., Litfrumur (e. melanocytes) eiga uppruna sinn í taugakambi (e. neural crest) sem forverafrumur sem fjölga sér síðan og ferðast til áfangastaða sinna í húð, hári og öðrum líffærum þar sem þær sérhæfast og mynda litarefnið melanín. Litfrumur geta ummyndast í æxlisfrumur og myndað sortuæxli en eitt einkenna þeirra er fareiginleikar. Umritunarþátturinn MITF (Microphthalmia-associated transcription factor) er nauðsynlegur fyrir myndun og sérhæfingu litfruma og stjórnar tjáningu gena sem eru nauðsynleg fyrir lifun, fjölgun og sérhæfingu frumanna. Sortuæxlisfrumur nýta MITF til æxlismyndunar. Hlutverk MITF í stjórnun frumufars og íferðar hefur hins vegar ekki verið að fullu ljóst. Í verkefni þessu var skoðað hvað gerist þegar MITF genið er slegið út í sortuæxlisfrumum með hjálp CRISPR tækninnar. Í ljós kom að frumur þessar skipta sér hægar en viðmiðunarfrumur og áhrif sáust á tjáningu gena sem eru mikilvæg fyrir frumuhringinn og eru þekkt markgen MITF. Þetta staðfestir fyrri niðurstöður um að MITF er mikilvægt fyrir stjórnun frumuskiptinga í sortuæxlisfrumum. Hins vegar höfðu sortuæxlisfrumurnar sem skortir MITF mun minni fareiginleika en viðmiðunarfrumurnar. Þegar MITF var tímabundið slegið niður með miRNA aðferð sáust hins vegar engin áhrif á frumufar. Með því að raðgreina RNA fruma sem skortir MITF og bera saman við viðmiðunarfrumur kom í ljós að tap á MITF leiddi til taps á genum sem hafa með myndun litarins að gera en aukningar í tjáningu gena sem tengjast utanfrumuefni (e. extracellular matrix), og taugamyndun. KO frumurnar líkjast helst taugakambs- og Schwann- frumum. Einnig kom í ljós að gen sem tjá fyrir mikilvægum proteinum sem mynda “focal adhesions” í frumum, svo sem paxillin (PAX) og Focal Adhesion Kinase (FAK) eru markgen MITF og tjáning þeirra var örvuð þegar MITF vantaði. Í frumum án MITF (bæði CRISPR og miRNA frumum) jókst fjöldi FAK og PAX-jákvæðra punkta. Tjáning Ncadherin jókst en E-cadherin minnkaði við tap á MITF en þetta eru merki um að frumurnar hafi breytt sér úr þekjuvefsfrumum í bandvefsfrumur en það ferli kallast bandvefsumbreyting þekjufruma (e. epithelial-mesenchymal transition eða EMT) og er mikilvægt í ummyndun fruma í krabbameinsfrumur. Greining á ChIP-seq gögnum sýna að bæði N- og E-cadherin genin eru með MITF bindiset í innröðum og stýrisvæði en það bendir til að MITF stjórni beint tjáningu þeirra. Í frumum sem skortir MITF verða miklar breytingar í tjáningu gena, mun meiri en unnt er að skýra einungis með beinum áhrifum MITF. Til að athuga hvort hluta breytinganna mætti skýra með utangenaerfðum var skoðað hvort breytingar hefðu orðið á histónaumbreytingunum H3K4me3 og H3K9me3 en umbreytingar þessar eru merki um virkt litni annars vegar og óvirkt litni hins vegar. Umbreytingar þessar fundust í stýriröðum gena sem voru mismunandi tjáð í frumum sem skortir MITF og viðmiðunarfrumum sem tjá MITF. Áhugavert er að gen sem tákna fyrir umbreytingarensímunum PRDM7 og SETDB2 voru mun minna tjáð í frumum sem skortir MITF en í viðmiðunarfrumum. Vinna þessi sýnir að tap á MITF leiðir til þess að frumurnar fá einkenni taugakambsfruma og að viðhald slíkar fruma er háð umbreytingarensímum sem setja utangenamerki á histón og að þau ensím eru háð MITF. MITF getur unnið með öðrum umritunarþáttum svo sem IRF4 og TFEB í litfrumum og sortuæxlisfrumum en ekki er ljóst hversu margþætt þetta samstarf er í raun. Í seinni hluta ritgerðarinnar var skörun í bindingu umritunarþáttanna þriggja MITF, IRF4 og TFEB skoðuð í sortuæxlisfrumum með notkun ChIP-seq aðferðarinnar. Notast var við eGFP-merkt TFEB og IRF4 prótein of ChIP-seq aðferðin notuð til að greina bindiset próteinanna í erfðamengi 501mel sortuæxlisfruma. Greining á skörun bindiseta sýndi að MITF og TFEB bindast við gen sem taka þátt í myndun lýsósóma en MITF og IRF4 skarast þegar kemur að genum sem mynda lit og taka þátt í ónæmiskerfinu. MITF var frábrugðið hinum þáttunum í að bindast við gen sem taka þátt í myndun taugakerfisins, TFEB var einstakt í að bindast við gen sem taka þátt í efnaskiptum DNA en IRF4 binst við gen sem tengjast myndun og starfsemi blóðfruma. Við höfum því greint skörun þessara umritunarþátta en einnig einstakt hlutverk þeirra. Þetta leyfir okkur að greina hvernig þessir þættir vinna saman í litfrumum og hvaða hlutverki þeir gegna í þeim.

Aims: The aim of the doctoral project was to develop and assess data extraction and analysis methods specific to the anterior cruciate ligament injury mechanism. The aim of paper I was to evaluate differences in the timing of the peak knee valgus moment in the first 100 ms of a cutting maneuver between boys and girls. The aim of paper II was to explore the feasibility of using a cluster analysis protocol developed for this project to categorize the waveforms of the early stance phase knee valgus moment. The aim of paper III was to test associations between kinematics observed during anterior cruciate ligament injury, and the early peak knee valgus moment waveform extracted with the cluster analysis protocol. Methods: All papers used motion analysis data of subjects recruited from local handball and soccer clubs tested at 9-12 years old (phase I) and/or 14- 18 years old (phase II). Subjects performed 5 cutting maneuvers on each leg, before and after an exercise intervention at each visit (phase I and phase II). Reflective markers and force plates were used to calculate kinematic and kinetic data. For paper I, marker trajectories were low pass filtered at 6 Hz and force plate data at 20 Hz. For papers II & III, raw marker trajectories and force plate data were used to calculate kinematics and kinetics, and the calculated signal low pass filtered at 6 Hz. All hypothesis testing used an alpha of 0.05. Paper III used a Bonferroni adjustment for multiple comparisons. Paper I used a generalized mixed linear model for hypothesis testing. Papers II & III used a two-step cluster analysis process; knee valgus moment data was transformed into signed differences, which were clustered using the Ward.d2 method on Euclidean distances. The clusters were then merged according to visual appearance (six categories for paper II, two categories for paper III) and then then sub-clusters representing the knee valgus moment magnitude created using non-transformed signals and the Ward.d2 method and Euclidean distances. Paper III extracted data for kinematics which have been previously reported from analysis of anterior cruciate ligament injuries. A heel strike landing posture was a binary variable. For continuous kinematic data, a ROC curve was calculated and the Youden’s index used to select a cut-off value which was then used for hypothesis testing. v Paper II tested the frequency distribution of the early peak cluster between sex and phase using McNemar’s test. Paper III tested the association between the early peak cluster and kinematics above / below the cut-off using the Fisher’s exact test. Results: In paper I girls had a later mean knee valgus moment peak (P < 0.001) which resulted in a lower mean time between peak knee valgus moment and peak knee internal rotation moments (0 ms for girls, 5 ms for boys, P < 0.001), as well as a lower mean time between peak knee valgus moment and peak vertical ground reaction force (1 ms for girls vs 7 ms for boys, P < 0.001). In paper II the knee valgus moment waveforms could be categorized into six discrete shapes; early peak, early trough, peak, trough, upslope, and downslope. There was a difference in relative frequencies (P < 0.001) between boys and girls in phase I where boys had more frequent early peaks (575 observed, 464 expected) compared with girls (642 observed, 768 expected). In phase II, however, girls had more frequent early peaks (178 observed, 129 expected) compared with boys (78 observed, 112 expected). In paper III, there was an association between the early peak knee valgus moment, and a heel strike landing posture (Odds ration (OR) 1.5, P = 0.01), medio-lateral distance between trunk and foot center of mass (OR 3.7, P < 0.01), knee flexion excursion (OR 1.9, P < 0.01), knee flexion at initial contact (OR 2.2, P < 0.01), and knee abduction excursion (OR 2.2, P < 0.01). Conclusions: Timing of peak forces during the early stance phase is different between boys and girls in the expected direction (less time between peaks for girls), however not every trial has a peak value and extacting those peaks will therefore not be a complete dataset. Cluster analysis of early stance phase knee valgus moment waveforms produces discrete categories one of which (the early peak) is consistent with the injury mechanism. The early peak is more frequent for adolescent females and is associated with multiple kinematics reported from analysis of ACL injuries. The clusters produced by cluster analysis should be validated against the end-point of ACL injury. The results support strategies to promote forefoot landing postures with more knee flexion to prevent the early peak knee valgus moment waveform., Markmið: Markmið doktorsverkefnis var að þróa og meta aðferðir til að vinna úr gögnum sértækt fyrir slit á fremra krossbandi. Markmið vísindagreinar I var að meta mun á tímasetningum krafta sem verka á fremra krossband, milli drengja og stúlkna. Markmið vísindagreinar II var að kanna hagkvæmni þess að nota aðferð til klasagreiningar sem þróuð var fyrir verkefnið til að flokka bylgjuform kiðvægis í hné. Markmið vísindagreinar III var að kanna tengsl milli bylgjulögunar með snemmbúinn tind, og hreyfinga sem sem eiga sér stað fyrir eða við slit á fremra krossbandi. Aðferðir: Allar vísindagreinarnar nota gögn úr hreyfigreiningu þátttakenda sem fengnir voru úr handbolta- og fótboltafélögum á höfuðborgarsvæði og framkvæmdar ýmist við 9-12 ára (fyrsti fasi) og/eða 14-18 ára (seinni fasi) aldur. Viðföng framkvæmdu við hvort tilefnið 5 endurtekningar á hvorum fæti af gabbhreyfingu, fyrir og eftir æfingarinngrip. Endurskinsmerki voru notuð til að fylgja hreyfingum líkamshluta, kraftplötur mældu gagnkraft jarðar, og hreyfingar og kraftvægi um liðamót voru síðan reiknuð út. Fyrir vísindagrein I voru gögn endurskinsmerkja síuð með lágpassasíu með 6 Hz tíðnimörk, en kraftplötugögn síuð með lágpassasíu með 20 Hz tíðnimörk. Fyrir vísindagrein II og III voru hrágögn notuð til að reikna liðhreyfingar og kraftvægi, sem voru því næst síuð með 6 Hz lágpassasíu. Tilgátuprófanir voru gerðar með marktektarmörk sett á 0,05. Vísindagrein III notaði Bonferroni leiðréttingu fyrir endurtekna samanburði. Vísindagrein I notaði blandaða línulega aðhvarfsgreiningu fyrir endurteknar mælingar. Vísindagreinar II og III notuðu tveggja þrepa klasagreiningu þar sem gögnum var fyrst umbreytt í formerki diffraðs merkis og myndaðir klasar með Ward.d2 aðferð byggðri á fjarlægðum Euclids. Þeir klasar sem mynduðust voru aftur klasagreindir með upprunalega merki innan hvers klasa og myndaðir undirklasar sem aðskildir voru á magni kraftvægis, einnig með Ward.d2 aðferð og fjarlægðum Euclids. Í vísindagrein III voru gögn fyrir hreyfingar sem rannsóknir hafa sýnt að eigi sér stað við áverka á fremra krossbandi dregin út. Hvort fyrsta snerting við jörð var með hæl eða ekki var tvíþátta breyta, en fyrir samfelldar breytur voru reiknuð ROC gröf og hágildi stuðuls Youden notaður til að velja þröskuld sem breytur voru flokkaðar eftir sem tvíþátta í tilgátuprófanir. Vísindagreinar II og III prófuðu tilgátur varðandi tíðnidreifingu á snemmbúnum toppum eftir kyni og aldri (vísindagrein II, próf McNemar) eða liðferlum (vísindagrein III, próf Fisher). Niðurstöður: Í vísindagrein I var munur eftir kyni, en stúlkur höfðu seinni tind í kiðvægi en strákar (P < 0,001) sem skilaði sér í minni meðaltíma milli tinda kiðvægis og innsnúningsvægis (0 ms hjá stúlkum, 5 ms hjá drengjum, P < 0,001), og milli kiðvægis og lóðrétts gagnkrafts jarðar (1 ms hjá stúlkum, 5 ms hjá drengjum, P < 0,001). Í vísindagrein II var mögulegt að flokka bylgjugerð kiðvægis í sex flokka; snemmbúna tinda, snemmbúna dali, tinda, dali, brekku upp, og brekku niður. Það var tíðnimunur eftir kyni (P < 0,001) þar sem drengir í fasa I höfðu tíðari snemmabúna tinda (575 sáust, von á 464) heldur en stúlkur (642 sáust, von á 768). Í fasa II höfðu stúlkur tíðari snemmbúna toppa (178 sáust, von á 129) heldur en drengir (78 sáust, von á 112). Í vísindagrein III fundust tengsl milli snemmbúna tinda kiðvægis og fyrstu snertingu við jörð með hæl (Áhættuhlutfall (ÁH) 1,5; P = 0,01), fjarlægðar milli þungamiðju bols og fótar í breiðskurði (ÁH 3,7; P < 0,01), hné beygju eftir lending (ÁH 1,9; P < 0,01), hné beygju við fyrstu snertingu (ÁH 2,2; P < 0,01), og fráfærslu í hné eftir lending (ÁH 2,2; P < 0,01). Ályktanir: Tímasetning krafttinda í upphafi stöðufasa er mismunandi milli drengja og stúlkna í þá átt sem við er búist (minni tími milli tinda hjá stúlkum), en ekki er mögulegt að staðsetja tind í öllum mælingum og því gefa gögnin ekki rétta mynd af atburðarrás snemma í stöðufasa. Klasagreining bylgjulögunar leiddi af sér flokkun á kiðvægi við upphaf stöðufasa, og amk einum flokki (snemmbúnum tindum) ber saman við það ferli sem veldur áverkum á fremra krossbandi. Snemmbúnir tindar eru tíðari hjá táningsstúlkum, og hafa tengsl við þær hreyfingar sem sést hafa við greiningu á áverkum á fremra krossband. Flokkanir úr klasagreiningu ættu að vera sannreyndar á tíðni krossbandaslita. Niðurstöðurnar styðja notkun inngripa sem hvetja íþróttamenn til að lenda á tábergi í stað hæls með fótinn nálægt bol og meiri beygju í hné til að koma í veg fyrir snemmbúna tinda kiðvægis., Rannís Funding codes: 120410021, 903271305, 1203250031, and 185359051

Pneumococci are commonly carried asymptomatically in the nasopharynx, especially in children. Pneumococci are also one of the major bacterial pathogens causing both severe infections and non-severe infections in both children and adults. The most severe infections are invasive pneumococcal diseases (IPD) being one of the leading causes of mortality and morbidity worldwide. Additionally, pneumococci are among the most common bacterial pathogens causing pneumonia and acute otitis media (AOM) and the most common indication for antimicrobial prescriptions in young children. The aims of the study were to investigate the possible changes in the carriage and serotypes of pneumococci in the nasopharynx of children attending day care centres and evaluate the change in the epidemiology of paediatric pneumococcal infections following the introduction of the pneumococcal nontypable Haemophilus influenzae protein D conjugate vaccine (PHiD-CV) in Iceland in 2011. Around 500 samples were collected yearly from 2009 to 2015, from healthy children two to six years of age, attending 15 day care centres in the Reykjavík, capital area. Samples were inoculated and incubated within four to six hours of sampling using methods maximizing pneumococcal detection. All pneumococcal isolates were serotyped using latex agglutination and PCR. Antimicrobial susceptibility was determined for five common antimicrobials using the 2012 EUCAST methods and criteria. Direct impact was evaluated comparing children born prior to the initiation of the vaccination (vaccine not eligible cohort, VNEC) with children born after the vaccination (vaccine eligible cohort, VEC). The herd impact was evaluated by comparing samples collected from older non-vaccinated children before and after the start of the vaccination. The impact on primary care visits due to AOM was evaluated by following every child born in Iceland from 2005 to 2015 until three years of age or end of the study period. Using unique social security numbers linked to patients’ records allowed the use of individual based cox-regression model for repeated visits analysis to calculate the vaccine impact, (hazard ratio [HR] – 1) x 100%. The vaccine impact on paediatric emergency department visits for respiratory tract infections was determined both by comparing the incidence of infections before and after the vaccination and by comparing VEC to VNEC. Changes in the admission rate because of pneumococcal infections were evaluated by extracting every admission due to specific study diagnoses between 2005 and 2015 for children less than three years of age. Comparing the VNEC and VEC allowed calculating the changes in incidence rate, cumulative incidence rates and hazard of admissions for various pneumococcal infections. The total pneumococcal nasopharyngeal carriage did not change following the PHiD-CV vaccination in Iceland. The carriage of vaccine serotype pneumococci was reduced by 94% in vaccinated children and the herd effect was 56% in older, non-vaccinated children sampled after the initiation of the vaccination. Pneumococcal isolates from vaccinated children had lower penicillin MICs and lower rates of non-susceptibility to other antimicrobials compared to non-vaccinated children. Additionally, multi-resistant pneumococci were reduced by 56% and pneumococci non-susceptible against all tested antimicrobials by 94%. Paediatric emergency department visits due to AOM were reduced by 24% and due to pneumonia by 23% in VEC compared to VNEC. Conversely, visits due to acute bronchiolitis were increased by 53% for the same period. In addition, recurrent AOM was less frequent. The vaccine impact on primary care visits due to AOM was 24%. Fewer children were diagnosed before the age of three, fewer children had recurrent infections and vaccinated children were diagnosed with fewer episodes of AOM. The vaccination was effective in preventing the first two episodes of AOM, with children already diagnosed two times having equal risk of contracting the third episodes, regardless of vaccine status. Admissions due to culture confirmed IPD were reduced by 93%, with no vaccine type pneumococci isolated in the VEC. Admissions for pneumonia were reduced by 20% despite a 32% increase in admissions due to bronchiolitis. The increase in admissions due to bronchiolitis was mainly found in children less than six months of age while the decrease in admissions due to pneumonia was most profound in children 12 – 17 months of age. Conversely, no change was noted in admissions due to AOM, although few in number during the study period. In conclusion, the initiation of PHiD-CV into the vaccination schedule has resulted in almost complete eradication of vaccine type pneumococcal disease among children in Iceland and reduction in most parameters of pneumococcal infections in Iceland measured in this study., Pneumókokkar eru oft bornir einkennalaust í nefkoki, sérstaklega í börnum. Þeir eru einnig með algengustu bakteríum sem valda bæði alvarlegum og mildari algengum sýkingum í börnum og fullorðnum. Alvarlegustu sýkingarnar eru ífarandi pneumókokka sýkingar (IPS) sem eru á meðal þeirra sýkinga sem valda mestri örkumlun og dauða um allan heim. Þar að auki eru pneumókokkar með algengustu bakteríum sem valda lungnabólgum og bráðum miðeyrnabólgum (BMB), algengustu orsök sýklalyfjaútskrifta hjá börnum. Tilgangur þessarar rannsóknar var að finna hugsanlegar breytingar í hlutfalli barna á leikskólum sem bera pneumókokka í nefkoki sínu og meta breytingar í faraldsfræði sýkinga barna vegna pneumókokka eftir upphaf bólusetninga með pneumókokka bóluefni tengdu við prótein D úr Haemophilus Influenzae (PHiD-CV) á Íslandi árið 2011. Um 500 sýni voru tekin árlega frá 2009 til 2015 úr heilbrigðum börnum tveggja til sex ára í 15 leikskólum á höfuðborgarsvæðinu. Sýni voru ræktuð innan 4 – 6 klst frá töku með aðferðum sem auka greiningu pneumókokka sem mest úr sýnunum. Allir pneumókokkar voru hjúpgreindir með latex kekkjun og kjarnsýrumögnun. Næmi fimm mismunandi sýklalyfja var rannsakað og 2012 EUCAST aðferð og viðmiðin voru notuð. Bein áhrif bólusetningarinnar voru metinn með því að bera saman bólusett börn (fædd 2011 og síðar, VEC) við óbólusett börn (fædd 2010 og fyrr, VNEC). Hjarðónæmi var metið með því að bera saman sýni tekin úr eldri óbólusettum börnum fyrir og eftir upphaf bólusetningarinnar. Áhrif bóluefnisins á heilsugæslukomur vegna BMB var metið með því að fylgja öllum börnum á Íslandi frá 2005 til 2015 eftir frá fæðingu til þriggja ára aldurs eða til enda rannsóknartímabilsins. Með því að nota kennitölur barnanna samtengdar við sjúkraskrár þeirra, var hægt að gera einstaklingsmiðaðar aðhvarfsgreiningar fyrir endurteknar komur og reikna út áhrif bóluefnisins (áhættuhlutfall [HR] – 1) x 100%. Áhrif bóluefnisins á komur barna á bráðamóttöku barna vegna öndunarfærasýkinga var fundin með tvennu móti. Annars vegar með því að bera saman nýgengi sýkinganna fyrir og eftir upphaf bólusetningarinnar og hins vegar með þvi að bera saman nýgengi sýkinga barna í VNEC og VEC fæðingarárgöngum. Breytingar í innlögnum barna vegna pneumókokkasýkinga var metið með því að kalla eftir öllum innlögnum sem báru greiningar tengdum öndunarfærasýkingu eða IPS frá 2005 til 2015 í börnum yngri en þriggja ára. Samanburður á milli VNEC og VEC var gerður til að reikna muninn í nýgengi og áhættu innlagna fyrir hvern greiningarflokk. Heildarberahlutfall barna á pneumókokkum í nefkoki breyttist ekki eftir bólusetninguna. Berahlutfall bóluefnishjúpgerða lækkaði um 94% í bólusettum börnum og um 56% í sýnum teknum úr eldri, óbólusettum börnum eftir upphaf bólusetningarinnar. Berahlutfall hjúpgerða sem ekki eru í bóluefninu óx. Pneumókokkar sen óbólusett born báru voru næmari fyrir penisillíni og öðrum sýklalyfjum borið saman við óbólusett börn. Þar að auki fækkaði fjölónæmum pneumókokkum um 56% og pneumókokkum sem voru ónæmir fyrir öllum prófuðum sýklalyfjum fækkaði um 94%. Komum á bráðamóttöku barna vegna bráðrar miðeyrnabólgu (BMB) fækkaði um 24% og vegna lungnabólgu um 23% í VEC samanborið við VNEC. Samhliða því fjölgaði komum vegna bráðrar berkjungabólgu um 53%. Komum vegna BMB á heilsugæslu fækkaði um 24%. Færri börn voru greind með BMB fyrir þriggja ára aldur og færri börn höfðu endurteknar BMB. Bólusetningin var verndandi gegn fyrstu tveim bráðum miðeyrnabólgum, en eftir að börnin höfðu fengið tvær BMB þá voru þau í jafnri áhættu og óbólusett börn að fá enn fleiri BMB. Innlögnum vegna ífarandi pneumókokka sýkinga fækkaði um 93% í bólusettum börnum samanborið við óbólusett og engar bóluefnishjúpgerðir fundust í þeim sýkingum í bólusettum börnum. Innlögnum vegna lungnabólgu í bólusettum börnum fækkaði um 20% þrátt fyrir 32% aukningu í innlögnum vegna bráðrar berkjungabólgu. Fjölgunin í innlögnum vegna bráðrar berkjungabólgu var mest meðal barna yngri en sex mánaða en fækkunin í innlögnum vegna lungnabólgu var mest meðal 12 til 18 mánaða gamalla barna. Enginn munur var á innlögnum vegna BMB, en þær voru fáar á rannsóknartímabilinu. Meginniðurstöður rannsóknarinnar eru því að bólusetning með próteintengdu pneumókokka bóluefni á Íslandi hefur valdið nánast upprætingu bóluefnishjúpgerða meðal barna á Íslandi og fækkun hefur orðið á flestum þeim mælikvörðum á pneumókokkasýkingum sem metnir voru í þessari rannsókn., Háskóli Íslands, Landspítali, GlaxoSmithKline

Publisher's version (útgefin grein). Publisher's note: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations., Discovery of coding variants in genes that confer risk of neurodevelopmental disorders is an important step towards understanding the pathophysiology of these disorders. Wholegenome sequencing of 31,463 Icelanders uncovers a frameshift variant (E712KfsTer10) in microtubule-associated protein 1B (MAP1B) that associates with ID/low IQ in a large pedigree (genome-wide corrected P = 0.022). Additional stop-gain variants in MAP1B (E1032Ter and R1664Ter) validate the association with ID and IQ. Carriers have 24% less white matter (WM) volume (β = −2.1SD, P = 5.1 × 10−8), 47% less corpus callosum (CC) volume (β = −2.4SD, P = 5.5 × 10−10) and lower brain-wide fractional anisotropy (P = 6.7 × 10−4). In summary, we show that loss of MAP1B function affects general cognitive ability through a profound, brain-wide WM deficit with likely disordered or compromised axons., We are grateful to the participants and we thank the psychologists, nurses and staff, in particular Berglind Eiriksdottir, at the Research Recruitment Center and technicians and staff at Röntgen Domus. We also thank the staff at deCODE genetics core facilities and all our colleagues for their important contribution to this work. L.J. received support from the Swedish Society of Medicine, the Swedish Brain Foundation and Swedish Society for Medical Research. The research leading to these results has received support from the Innovative Medicines Initiative Joint Undertaking under grant agreements’ no. 115008 (NEWMEDS) and no. 115300 (EUAIMS) of which resources are composed of EFPIA in-kind contribution and financial contribution from the European Union’s Seventh Framework Programme (EU-FP7/2007-2013), EU-FP7 funded grant no. 602450 (IMAGEMEND) and EU funded FP7-People-2011-IAPP grant agreement no. 286213 (PsychDPC).

Publisher's version (útgefin grein), This article focuses upon issues that public policy makers need to address, when trying to stimulate world-leading research into new areas, which are potentially also valuable to solving societal challenges. Our analysis helps contribute to the theoretical discussions about governance of new knowledge. We focus upon the sequence of events surrounding the main actors of a recent crisis of regenerative medicine in Sweden. We define governance theoretically, and use a conceptual model in order to structure the empirical analysis. Regenerative medicine is an interesting setting to explore these topics, not least because both public and private actors are often involved, and because governments struggle with how to promote ‘translational research’, e.g. diffusing scientific research into clinical practice. Our case study helps understand the process that led up to a crisis in regenerative medicine and identifies and discusses four issues that need to be addressed by policy makers.

Article, With increased development of medical technology (MT), new challenges emerge related to education and training of pharmacists and other healthcare specialists. Currently, only a few universities in the EU promote MT education and research. Objectives: The aim of this study was to evaluate the current status, views on, and need for the education on MT for the pharmacy students and practicing pharmacists in the Baltic and Nordic countries. Methods: The representatives of higher education institutions and community/hospital pharmacists from six Baltic and Nordic countries participated in a qualitative cross-sectional exploratory internet-based study from May to October 2014. Results: Approximately two-third of the respondents considered professional knowledge about MT products important for pharmacists, but half of them had never participated in any MT courses. More practicing pharmacists than representatives of academia underlined the need for increased MT education for pharmacy students in the future. Conclusions: The pharmacists in the Baltic and Nordic countries consider the professional knowledge about MT as pertinent in their education and work. The limited number and status of MT courses available today, however, is a major concern among both pharmacy students and practicing pharmacists in these countries. In the future, increasing education combining theory and practice about MT products would be one possible solution to overcome this challenge., published version, peerReviewed

LIST OF PAPERS This thesis is based on the following papers, which will be referred to in the text by their Roman numerals: I. BERGUR V. STEFÁNSSON, BÖRJE HARALDSSON, ULF NILSSON Ascorbyl free radical reflects catalytically active iron after intravenous iron saccharate injection. Free Radical Biology & Medicine 2008;45:1302–1307. II. BERGUR V. STEFÁNSSON, BÖRJE HARALDSSON, ULF NILSSON Acute oxidative stress following intravenous iron injection in patients on chronic hemodialysis: A comparison of iron-sucrose and iron-dextran. Nephron Clin Pract 2011;118:c249–c256. III. BERGUR V. STEFÁNSSON, MATS ABRAMSON, ULF NILSSON, BÖRJE HARALDSSON Hemodiafiltration improves plasma 25-hepcidin levels. A prospective, randomized, participant-blinded, cross-over study, comparing hemodialysis and hemodiafiltration. Submitted for publication. IV. BERGUR V. STEFÁNSSON, BÖRJE HARALDSSON, ULF NILSSON The consumption of erythropoiesis stimulating agents can be reduced by a new administration regimen. Submitted for publication., In patients with chronic kidney disease, treatment with erythropoiesis-stimulating agents (ESA) effectively corrects anemia. Most of these patients also need supplementation with regular iron injections to secure iron availability for proper erythropoiesis. Following intravenous iron injection, non-transferrin bound iron (NTBI) can appear in the circulation, capable of inducing harmful oxidative reactions. Direct measurement of free iron with the robust technique electron spin resonance (ESR) has not been used to investigate this issue in humans. The main purposes of this thesis were to use ESR to study the levels of NTBI and oxidative stress after intravenous (IV) iron injection and to compare two commercially available IV iron formulations, low-molecular weight iron-dextran (ID) and iron-sucrose (IS), regarding this topic. In addition, the impact of two different hemodialysis modalities on iron homeostasis and the effect of modifying the ESA administration praxis on ESA requirement, were studied. Sixty-four patients on chronic hemodialysis treatment participated in these studies. To investigate the appearance of NTBI and induction of oxidative stress, blood samples were collected before and after IV iron injections. To compare two different hemodialysis modalities, a prospective, randomized, patient-blinded study, with conventional hemodialysis (HD) and on-line hemodiafiltration (HDF), in a 2x2 months design, was conducted. Finally, a retrospective register study was performed on 18 patients, comparing periods with two different erythropoietin administration routines. After injection of IS, a parallel increase in oxidative stress and NTBI was noted, while no induction of oxidative stress was seen following injection of ID. After treatment with HDF, the levels of the iron-regulating peptide, 25-hepcidin, were in all cases within the reference interval. A change in ESA administration regimen, to less frequent dose-adjustments and no withheld doses, could be an explanation for the observed approximately 20 % reduction in ESA requirement. In conclusion, IS injection, but not ID injection, “leaks” catalytically active iron into the blood stream, which then initiates a burst of intravascular oxidative reactions. The increased clearance of 25- hepcidin by HDF could be of benefit for the dialysis patient, bringing the pathological iron homeostasis found in this population toward a more normal state. An erythropoietin regimen with optimal frequency of dose adjustments can reduce ESA demand and thereby decrease health care cost.

The interferon regulatory factor 5 (IRF5) gene encodes a transcription factor that plays an important role in the innate as well as in the cell-mediated immune response. The IRF5 gene has received considerable attention since it was shown to be associated with two autoimmune diseases; systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA). The aim of this thesis was to examine if IRF5 is associated with other autoimmune diseases and to investigate the role of the genetic variation of IRF5. In the first study a set of common polymorphisms in IRF5 were analyzed for their association with two subgroup of inflammatory bowel disease (IBD); Crohn´s diseases (CD) and ulcerative colitis (UC). A strong signal of association of IRF5 with IBD was found. The most strongly associated polymorphism is a 5 base pair (bp) insertion-deletion (indel) in the promoter region of the IRF5 gene. The association was detected within both UC and CD, and appeared to be stronger in UC. In the second study we investigated the association of IRF5 with multiple sclerosis (MS). A similar set of polymorphisms as in the IBD study were genotyped in a cohort of MS patients and controls. The same polymorphisms that were associated with IBD were also found to be associated with MS. In the third study, we performed a comprehensive investigation of the IRF5 gene to detect most of the polymorphisms in the gene, and to determine to what extent they account for the association signals obtained from the gene. IRF5 was sequenced and 34 new polymorphisms were identified. Twenty seven of these, and 20 previously known SNPs in IRF5 were genotyped in an SLE case-control cohort. We found that only two polymorphisms, the 5bp indel and a SNP downstream of IRF5, account for the association signal from all the remaining markers in the IRF5 gene, and that these two polymorphisms are independently associated with SLE. Interestingly, in our studies on IBD and MS, we only observed the signal from the 5bp indel polymorphism as a risk factor for IBDs. In the fourth study the two independent risk alleles in IRF5, were tested for their association with primary Sjögren´s syndrome (pSS). In this study we also included one SNP in the STAT4 gene, since STAT4 had recently been shown to be associated with SLE. Both risk factors in IRF5 and STAT4 were found to be associated with pSS. The regulation of expression of IRF5 was also investigated in the first three studies. We observed allele-specific differences in protein binding as well as increased binding of the transcription factor SP1 to the 5bp risk allele. We also detected increased expression of the IRF5 mRNA from a promoter containing the risk allele. Taken together, the results of our studies suggest a general function for IRF5 as a regulator of the autoimmune response, where the 5bp indel is associated with IBD, MS, SLE and pSS. The additionally polymorphisms, which account for the remaining association signal obtained with SLE and pSS, may contribute to the disease manifestations that are specific for rheumatic diseases. Our studies add to the evidence that there are genes or pathways that are common in multiple autoimmune diseases, and that the type I interferon system is likely to be involved in the development of these diseases.