From cytologic features to serum markers: advancing prognostication of uveal melanoma

Uveal melanoma (UM) is the most common primary intraocular malignancy in adults. As surveys show, almost all patients diagnosed with UM want prognostic information. However, the tools available today for early prognostication in UM are limited; beyond what information can be obtained by tumor size and location, current methods typically rely on tumor tissue obtained from enucleated eyes or invasive biopsies, or on repeated sampling of peripheral plasma or serum. Therefore, improving the toolbox for prognostication of aggressive vs. less aggressive disease is the focus of this dissertation. In paper I, we explored the scope of digital image analysis of cytologic features in uveal melanoma. We know that cytologic features such as shape and size of tumor cells can predict metastatic death in uveal melanoma. Currently, however, cytologic analysis is conducted manually by visual inspection of pathologists, which is time-consuming and impacts its reproducibility. In this study, we analyzed twelve morphometric variables in a large number of uveal melanoma cells. We then correlated the results with BRCA associated protein-1 (BAP-1) expression and BAP-1 gene mutation status, monosomy 3, gene expression classification as well as patient survival. We demonstrated that digital image analysis of variables describing the shape and size of tumor nuclei correlated to BAP-1 status, to monosomy 3, and to gene expression class. Mean time consumption per tumor was less than 2.5 min. Thus, digital image analysis is a fast and highly reproducible technique, that for the first time allows to objectively quantify cytologic tumor features in large tumors and gives prognostic information on survival in UM. In paper II, we explored if biopsies from posterior UM hold the same prognostic information as tissue from enucleated specimens. We classified BAP-1 expression in transvitreal biopsies of posterior UM and correlated our results with BAP-1 expression in subsequent biopsies. We found that BAP-1 expression in transvitreal biopsies was concordant with BAP-1 in enucleated specimens. Moreover, BAP-1 expression in transvitreal biopsies identified patients with poor metastasis-free survival. Thus, transvitreal biopsies can be a good prognostic tool for patients that do not undergo enucleation. The results also indicate the need to further study BAP-1 expression in even smaller UMs, to infer the tumor size at which loss of BAP-1 starts to occur, and to correlate it with the early seeding of micrometastases. In paper III, we explored prognostic testing on serum samples obtained from patients at diagnosis of uveal melanoma. We first screened for cancer-related proteins by protein profiling in order to find potential biomarkers. Second, we performed ELISA to evaluate the serum levels of the best candidates. Third, receiver operating characteristics were used to define thresholds for metastatic risk. This led to a prognostic test (serUM-Px) that stratifies patients into low, intermediate, and high-risk categories which we tested in a training cohort and validation cohort. We found that serUM-Px is a prognostic test, based on a single peripheral venous blood sample at the time of UM diagnosis, which can be used to stratify patients into low, intermediate and high metastatic risk categories. Thus, this test predicts metastases many years in advance without the need for biopsy or repeated sampling. In paper IV, we wanted to assess the prognostic utility of Tenascin C (TNC) in uveal melanoma. Therefore, we collected peripheral blood samples from 82 patients with small posterior uveal melanomas between 1996 and 1999 as described above for paper III. TNC concentrations were examined 2021. RNA sequencing data of TNC from an additional 80 larger tumors were collected. These levels were subsequently linked with the cumulative incidence of metastasis-related death through competing risk data analysis. In our analysis we observed no significant disparities in tumor size, age at diagnosis, visual acuity, serum protein levels, or treatment modality between patients with above or below median serum or tumor TNC levels. However, above median TNC RNA was associated with BAP1 mutation, monosomy 3, and epitheloid cytomorphology. The competing risk analysis indicated increased metastatic mortality in patients with above median TNC and primary tumor TNC RNA compared to their below median counterparts. We conclude that TNC is a prognostic biomarker in uveal melanoma that exhibits elevated levels in peripheral blood and tumors at diagnosis in patients destined for metastatic death

Monitoring of the oral anticoagulants apixaban and rivaroxaban to optimize individual safety and efficacy

The oral anticoagulants apixaban and rivaroxaban are administered at fixed doses without requiring routine monitoring. However, there is a dose and exposure dependency in efficacy and safety, and monitoring the anticoagulants may improve treatment outcomes. The aim of this thesis was to evaluate different laboratory methods for monitoring apixaban and rivaroxaban and to show the typical exposure levels in patients. Additionally, the study aimed to study the exposure in certain specific populations (i.e. those with obesity and renal impairment), to elucidate whether monitoring would be especially valuable for these patients. In studies I and II, we evaluated various coagulation assays for the monitoring of apixaban and rivaroxaban. While PT-INR (venous) and aPTT were not sensitive enough to be used for this purpose, the anti-Factor Xa assay showed a strong correlation with LC/MS-MS. However, for precise estimations of apixaban/rivaroxaban concentrations in the lower range, LC-MS/MS is the preferred method to use. A large interindividual variability in trough concentrations was observed, 12-fold for apixaban (6-fold within the same dosage group) and 17-fold for rivaroxaban (17-fold for the standard dose and 3- fold for the reduced dose). In study III, we explored the influence of obesity on apixaban trough and peak concentrations. A specific dose recommendation for obese patients may not be necessary given that the concentrations were largely similar to those in matched normal weight patients. However, obese patients exhibited an extensive 18-fold interindividual variability in trough concentrations. Consequently, monitoring apixaban concentrations could be valuable for specific obese patients to ensure optimal treatment outcomes In study IV, we examined the impact of renal function on apixaban exposure in AF patients. Patients with moderate renal impairment had twice as high apixaban trough concentrations compared to patients with normal renal function. This indicates that the recommended 5 mg twice daily dose might be excessive for some patients with moderate renal impairment, and that monitoring ought to be recommended

Catheter ablation of atrial fibrillation : methods for improving outcome

Introduction: The most common arrhythmia world-wide is atrial fibrillation (AF). The arrhythmia is diagnosed through an electrocardiogram (ECG). Patients with AF often experience symptoms including palpitations, dyspnoea, fatigue, and an overall reduced quality of life. Patients with AF also face a higher risk of stroke, which is due to thrombus formation in the left atrial appendage, and heart failure, attributable to a fast heart rate. Numerous risk factors for the development of AF have been identified, including advanced age, male sex, underlying heart disease, obstructive sleep apnoea syndrome (OSAS), and intensive prolonged physical activity, among others. Additionally, epidemiological studies have shown a relationship between gastroesophageal reflux disease (GERD) and AF. The two main treatments for AF are catheter ablation and antiarrhythmic drugs, with catheter ablation being the more effective option. Catheter ablation of AF is known to be associated with certain complications, and as a result, the traditional approach in most centres has been to keep patients hospitalised overnight to monitor for any complications that may occur following the ablation procedure. The cornerstone of catheter ablation of AF is pulmonary vein isolation (PVI). However, this treatment does not benefit all patients, especially those with persistent AF. Approximately 60% of patients with persistent AF achieve arrhythmia freedom through PVI. Fibrosis in the left atrium (LA), when detected through voltage mapping, showing low voltage zones (LVZ), is known to be associated with an even poorer prognosis. Therefore, it is essential to further investigate the mechanisms of AF and to develop additional ablation methods, to help a larger proportion of patients. The aims of this thesis are: 1) to determine the safety of same-day discharge after the ablation procedure, aiming to increase the overall effectiveness of this treatment; 2) to evaluate, in a randomised controlled trial (RCT), whether ablation of LVZs in addition to PVI increases arrhythmia-free survival, compared to PVIonly; 3) to validate the accuracy of an ECG device, the Coala Heart Monitor (CHM), in detecting atrial arrhythmias; 4) to identify independent predictors of the presence of LVZs; and 5) to assess whether symptoms of GERD is a predictor of LVZs in the posteroinferior part of the LA. Methods and results: Study I was a registry-based study that included all AF ablations performed at Karolinska University Hospital over the 2001-2020 period, encompassing a total of 5414 procedures. All complications were registered, and the medical records of patients who suffered from a complication were thoroughly reviewed. The complications were categorised based on the time of occurrence: from intraprocedural up to six hours post-ablation, and from six hours post-ablation until discharge the following day. We found that most complications occurred either intraprocedurally or within the first six hours following ablation. Furthermore, 73 complications were observed between six hours after the ablation until discharge, of which 12 were severe. Of these 12, it appears unlikely that a longer hospital admission would have altered the outcomes. Study II outlines the protocol for an RCT where we aim to randomise 206 patients with LVZs in the LA to PVI-only or to PVI + LVZ ablation. The primary outcome is freedom from atrial arrhythmias at 12 months following one or two ablation procedures conducted within a six-month period with a blanking period of 3 months after the first procedure. As of now, we have randomised 166 patients, however, as the study is still ongoing, the results are not yet available. Study III is a validation study in which a handheld ECG device, the CHM, was validated for detecting AF and atrial tachyarrhythmia (ATA), encompassing both AF and atrial flutter, with a 12-lead ECG serving as the reference standard. A total of 200 12-lead ECGs and simultaneous CHM registrations were collected. All registrations were interpreted in a blinded fashion by two electrophysiologists. The sensitivity and specificity for detecting ATA were found to be 98.9% (95% confidence interval (CI): 94.0–100) and 100% (95% CI: 96.6–100), respectively. The sensitivity and specificity for detecting AF were 100% (95% CI: 95.3–100) and 97.5% (95% CI: 93.0–99.5), respectively. In Studies IV and V, we utilised a subset of the cohort from Study II, which comprised both randomised and non-randomised patients. In Study IV, we conducted a comparison between patients with LVZs in the LA and those without LVZs, with the aim of identifying independent predictors for the presence of LVZs. We discovered that female sex (odds Ratio (OR): 4.83, 95% CI: 2.66–8.76, P <0.001), age (OR: 1.08, 95% CI: 1.03–1.13, P =0.002), coronary artery disease (CAD) (OR: 3.20, 95% CI: 1.32–7.77, P =0.010), and an enlarged LA (OR: 1.10, 95% CI: 1.04–1.17, P=0.001) were independent predictors of the presence of LVZs. In Study V, we conducted a comparison between patients with and without symptoms of GERD. We found that patients with symptoms of GERD exhibited significantly higher odds of possessing LVZs in the posteroinferior wall of the LA, with an OR of 2.26 (95% CI: 1.24-4.13, P =0.008) in the adjusted analysis. Conclusions: Same-day discharge after AF ablation appears to be safe six hours after ablation. The CHM demonstrates high accuracy, in detecting ATA and AF when compared to a 12-lead ECG, suggesting its suitability for follow-up in AF patients, and for screening purposes. Female sex, advanced age, CAD, and an enlarged LA were identified as independent predictors of LVZs. This information can be valuable in the planning process for AF ablation. Patients with symptoms of GERD exhibit increased odds of presenting with LVZs in the posteroinferior wall of the LA, which may partially explain the observed higher risk of AF in patients with GERD

Improvement of microbiological diagnostics in sepsis

Sepsis, a life-threatening condition characterized by a dysregulated host response to infection, poses significant diagnostic and therapeutic challenges, contributing to high morbidity and mortality rates worldwide. The overall objective of this thesis is to provide an insight in how to improve the microbiological diagnosis of sepsis both by optimizing current blood culture (BC) practices and by evaluating novel diagnostic methods. The thesis also explores the impact on microbiological diagnosis imposed by two major recent events; the change of clinical sepsis criteria and the COVID-19 pandemic. The thesis consists of the four following projects: Study I was a prospective non-inferiority study, assessing the utility of implementing a single-sampling strategy (SSS) versus multi-sampling strategy (MSS) for BCs in sepsis. The study group consisted of 549 suspected BSI episodes. The outcomes were detection of pathogens and occurrence of sample contamination. We found no significant difference in pathogen detection rates, and a tendency toward less contamination using SSS, thereby suggesting a potential simplification of the BC sampling protocol without compromising diagnostic yield. In Study II, we described microbiological findings when using different sepsis criteria (Sepsis-2 versus Sepsis-3) in 514 patients with suspected sepsis. There were 357/514 (79.5%) Sepsis-3 and 411/514 (80.0%) Sepsis-2 episodes, with twothirds of patients fulfilling both definitions. The BC positivity rate was 130/357 (36.1%) and 145/411 (35.3%) in Sepsis-2 and Sepsis-3, respectively. The study shows that even with the improved definition, the frequency of BC positivity remains largely consistent. Study III explored the changes in bacteremia rates during the COVID-19 pandemic, comparing BCs from patients with COVID-19 (n = 3,027) with two control groups without COVID-19, consisting of a contemporary group (n = 6,663) during the same period, as well as historical group (n = 8,175) from a year prior. Clinically relevant growth was found in 6.5% of the BC episodes in the COVID-19 group compared to 10.8% and 10.4% in the control groups respectively. Contamination was present in 8.4% in the COVID-19 group compared to 5.0% and 4.3% in the control groups. The study concluded that in COVID-19 patients, frequency of relevant growth was lower and contamination rates were higher. Study IV retrospectively evaluated the diagnostic performance of T2Bacteria, a rapid molecular-based tool, against traditional BCs. We compared 640 T2Bacteria results to all BCs sampled within ± 72 hours of the T2Bacteria sampling. In total, 46/101 (45.5%) episodes were T2Bacteria positive/BC negative and 26/101 (25.7%) were T2Bacteria negative/BC positive. Only 29 (28.7%) episodes were positive using both methods. Total turn-around time was 27 hours and 33 minutes for T2Bacteria and 36 hours and 48 minutes for BCs (p < 0.001). We concluded that identification using molecular methods directly from blood provide a valuable complement to BCs. Collectively, the findings from these studies adds to the understanding of microbiological diagnosis in sepsis, and highlights the need of both improving established methods, as well as the judicious implementation of novel techniques

Neurocomputational modelling of human decision making and volition : from neural mechanisms to behavioral outcomes

In today's world, amidst the bombardment of information, the mental health and well-being of a society with higher level of responsibility hinge on a central issue related to decision making and human agency. The essence of studying these issues lies in unraveling the role of individual and social life experiences in evolving human choices and intentional actions. Researchers aim to unravel the foundational principles shaping individual behavior by comprehending how the brain, as a complex system, can be conceptualized, understood psychologically, and addressed socially. In this thesis, neurocomputational models are developed to bridge the gaps between micro (neuronal), meso (brain areas), and macro (cognition/behavior) levels. These models primarily focus on the mesoscale neurodynamics of cortical structures, with the goal of linking neural structures, functions, and the influences of internal and environmental factors on decision-making processes and volitional action control. These are neurally-inspired models, providing insight into the dynamics of neural oscillations through attractor networks, recognized as distinctive markers of various cognitive functions. My research is divided into two parts based on studying decision making without and with considering human agency, respectively. In the first part, the focus is on studying the neural mechanisms underlying decision making without explicitly considering human agency. Two slightly different neurocomputational models are developed based on the sources of input information, i.e. either internal or external. In both these models, an integration of rational and emotional processes is the essence of decision-making process. This interplay results in different model behaviors due to the sources of information: 1) the subjective values and attitudes and 2) the observational-based perceived behavior of others. The former model type addresses how an individual's behavior dynamically changes in response to the interplay between rational and emotional factors regarding internal signals while the latter one deals with the social adaptive characteristic of an individual, where dynamic changes in her behaviors are connected with the impact of trust on rational-emotional interactions. This part was part of the EU-funded project COMPLEX - Knowledge Based Climate Mitigation Systems for a Low Carbon Economy. In the second part, the central premise is understanding volitional decision-making process while individual’s actions are goal-directed guided by either internal or predicted external triggers. In this context, fundamental questions concerning the causal efficacious of intentions in decision making, as well as distinctions between 1) self-initiated and 2) externally-triggered actions, were explored. In this regard, a neurocomputational model has been developed to study the neurodynamics of structures involved in the intentional preparatory process of these two volitional processes, while shedding light on the dynamics of attractor networks and neurodynamical changes. Furthermore, the obtained results in both volitional contexts have been compared qualitatively with real EEG data to validate the models as well as explain the observed real neural behavior regarding this descriptive comparison. This research was conducted as a part of the Neurophilosophy of Free Will project funded by a joint Templeton/Fetzer grant. Regarding the fact that the simulation results mimic EEG and MEG readouts, further qualitative comparisons with experimental and clinical data should be conducted in the future. However, due to limitations in the available data, the next step can involve providing data with higher resolution using source-localized electrodes. Additionally, I intend to disentangle a meta-model to investigate how two models of self-initiated and externally-triggered actions can be transformed to each other. This exploration can provide insights into the behavioral adaptations of human beings in everyday life

Diet, genetic susceptibility, latent autoimmune diabetes in adults, type 1 and type 2 diabetes

Diabetes is one of the most common chronic diseases, yet our understanding of modifiable risk factors remains incomplete. This project aimed to elucidate the role of diet in the risk of latent autoimmune diabetes in adults (LADA), type 1 and type 2 diabetes and explore whether genetics modify this relationship. Paper I was a systematic review and meta-analysis examining the evidence on the association between diet and the risk of type 1 diabetes. The most compelling evidence suggested that longer breastfeeding and later introduction of gluten may reduce the risk of type 1 diabetes, while higher cow’s milk intake in childhood may increase the risk. Other factors in infancy and childhood were also associated with type 1 diabetes, but the evidence was of low certainty. Paper II, based on the European EPIC-InterAct case-cohort, found no associations between dairy products and the risk of islet autoimmunity or diabetes in adults. However, circulating fatty acids 15:0 and 17:0, proposed biomarkers of dairy fat, were associated with a reduced risk of diabetes in individuals with and without islet autoimmunity. Furthermore, low 17:0 concentrations were associated with a higher risk of progressing from marked autoimmunity to adult-onset diabetes. In Paper III, data from the Swedish ESTRID case-control study was used to investigate the association between the intake of antioxidant nutrients and the risk of LADA and type 2 diabetes. These results were complemented with Mendelian randomization (MR) analyses. The findings indicated inverse associations between dietary vitamin C and E with LADA with more evidence of autoimmunity but not LADA with low autoantibody levels or type 2 diabetes. The results for vitamin E were further supported in MR analyses. Paper IV utilized data from ESTRID and the Norwegian HUNT cohort. The results indicated inverse associations between moderate alcohol consumption and the risk of LADA and type 2 diabetes. Moreover, it was revealed that inverse associations with LADA were limited to those with high genetic susceptibility to type 2 diabetes. In contrast, inverse associations with type 2 diabetes were evident only in individuals with low genetic susceptibility to the disease. This research emphasizes the potential of diet in preventing diabetes and proposes that the effects of different dietary factors may vary across the life course and are likely influenced by genetic susceptibility to diabetes

Single-cell analysis on specification of mammalian germline and its role in health and diseases

Germ cell specification is the first step for developing reproductive cells. The specification requires formative pluripotent stem cells as precursors. Previous attempts to capture formative pluripotency used opposite manipulation of Wnt signaling, activating or inhibiting, and achieved two distinctive states that indicated two ends of the formative pluripotency spectrum. Study I explored the role of Wnt signaling in the formative pluripotency spectrum. We produced a new form of formative pluripotency in epiblast-like stem cells (EpiLSCs) with activation of Wnt. We developed a computational single-cell method for transcriptionally aligning various cell lines within the formative pluripotency spectrum. Our analysis highlighted that EpiLSCs filled the gap in the pluripotency spectrum between previously published cell lines. Additionally, we revealed context-dependent roles of Wnt signaling in sustaining pluripotency and facilitating differentiation at the two ends of the formative pluripotency spectrum. Female germ cell specification in humans generally exhibits lower efficiencies than males in vitro. Human X chromosome inactivation has a large extent of incompleteness, resulting in escapees. Whether the female lower efficiencies are related to X-linked escapees is unknown. Study II investigated the influence of Xlinked escapees on germ cell specification in females and individuals with Klinefelter syndrome (KS), a condition typically characterized by an extra copy of the X chromosome and infertility. Through RNA sequencing and functional assays, we identified critical X-linked escapees, CHRDL1, IGSF1, and USP9X, inhibiting germ cell specification in females and KS. We found that USP9X elevated SOX2 to repress oxidative phosphorylation, promote mitochondria fusion and clustering, and perturb SOX17's regulation, exerting a profound reduction in germ cell specification. Germ cells carry both genetic and epigenetic information. Sperm's small RNA composition is shaped by the soma-to-germline communication pathway and, therefore, is responsive to environmental exposure. Polycystic ovary syndrome (PCOS) is an epigenetically heritable disorder affecting female offspring. The possibility of PCOS equivalent in males has prompted questions about the potential impact on male offspring and whether sperm small RNA plays a role in it. In study III, using a Swedish registered cohort, a Chile longitudinal cohort, and a mouse model, we found that women with PCOS transgenerationally transmitted reproductive and metabolic dysfunction into their male offspring. Using small RNA sequencing, we identified transgenerationally altered sperm small RNA in the mice, which overlapped with changes in the sons of women with PCOS, suggesting potential mechanistic parallels of inheritance between mice and humans. In this thesis, we uncover critical insights into the Wnt's context-dependent roles in the formative pluripotency spectrum, the repression of XCI escapees on germ cell development, and sperm small RNAs' transgenerational transmission. Additionally, this research paves the way for further exploration into germ cell development for individuals with KS and the inheritance of PCOS in male offspring, offering potential avenues for therapeutic interventions

Randomised clinical trials with hyperbaric oxygen in COVID-19 and Long COVID : transcriptomic insights into benefits and harms

The flow from transcription of genes through translation and processing of proteins is a common basis for all life. Redox homeostasis is crucial for the defence against oxidative stress. We adapt through hormesis; non-lethal stress regulates redox-sensitive systems to maintain homeostasis. If the stress is chronic or acutely overwhelming, the cells can either go into apoptosis or into senescence to maintain homeostasis. Similar effects have been seen with HBOT as with intermittent oxygen deprivation. Hyperbaric oxygen therapy (HBOT) is delivered in a pressure chamber by breathing 100% oxygen intermittently, several times a week, in an ambient pressure equivalent to 10-20 meters of seawater. The aim of this thesis was to evaluate potential harms of HBOT for novel indications and to explore biomarkers in experimental and clinical trials in order to enable future precision medicine. We used methods evaluated on healthy volunteers in randomised clinical trials (RCTs) conducted in compliance with good clinical practice (ICH-GCP). In Paper I, we evaluated Electron paramagnetic resonance (EPR) spectroscopy for measuring reactive oxygen species (ROS) in blood and RNA sequencing (RNAseq) of monocytes in peripheral blood (PBMC), and compared HBOT and HIIT in ten healthy volunteers. We could measure ROS in blood in the same physiological range in both interventions. We also discovered pathways involved in adaption to hypoxia and inflammation that were similar in both interventions. In Papers II and III, we evaluated harms and explored RNAseq in PBMC in an open label RCT where 31 patients with severe COVID- 19 were randomised to HBOT or best practice. We observed similar frequencies of adverse events (AEs) in the two groups and could not see any negative effect on vital signs or oxygenation. We discovered a unique transcriptomic signature in the subjects that had received HBOT. The differentially expressed genes were associated with the unfolded protein response, apoptosis, and immune response. In Paper IV, we evaluated harms and described health related quality of life (HRQoL)in an interim analysis of the first 20 subjects froma placebo controlled RCT where 80 patients with Long COIVD were randomised to HBOT or sham treatment. We reported more AEs than expected and severe physical and mental disabilities with a very poor HRQoL. Most AEs were mild, and all were transient. We have shown that HBOT shares similarities in immune response with HIIT in healthy volunteers. HBOT has a favourable profile of harms and has a potent immunomodulatory effect that is associated with fast recovery for critical COVID-19 patients. HBOT has a favourable profile of harms for patients with post COVID-19 condition. The results provide a base for future clinical trials with HBOT

Prenatal risk factors for severe cardiovascular diseases up to middle-age : a Nordic collaborative study

Background and objectives: Cardiovascular diseases (CVDs) are major causes of death and disability. However, the established traditional risk factors cannot explain a substantial proportion of CVD cases, prompting investigations into novel risk factors. A growing body of evidence underscores the potential role of suboptimal intrauterine conditions on the development of CVD. Nonetheless, our knowledge about the associations between factors contributing to an adverse intrauterine environment and the risk of developing CVD remains limited. The overall objective of this thesis is to enhance our comprehension of the potential role of prenatal risk factors in developing CVD later in life. More specifically, the thesis aims to study the following research questions: (1) Are negative birth outcomes such as preterm birth, being small (SGA) or large (LGA) for gestational age related to the atrial fibrillation risk later in life (Study I)? (2) Is maternal preeclampsia and its subtypes linked to increased risks of stroke and ischemic heart disease in the offspring (Study II)? (3) Is maternal polycystic ovary syndrome (PCOS) associated with the risks of overall CVD and its major subtypes in her offspring (Study III)? and (4) Is prenatal exposure to maternal severe stress related to the risk of heart failure later in life (Study IV)? Methods: We performed four register-based prospective cohort studies, including all live singletons from Denmark (Study I: 1978-2016, Studies II-IV: 1973-2016) and Sweden (Studies I-IV: 1973-2014), and live births from a randomly selected 90% of all births in Finland Studies I and II; 1987-2014). The size of the study population was 8,012,433 in Study I, 8,475,819 in Study II, 6,839,703 in Study III, and 6,758,560 in Study IV. Information on birth outcomes, maternal and offspring's health and covariates were obtained through linkage to population-based socioeconomic and health registers. Each study participant was followed up until the earliest diagnosis of the CVD of interest, emigration, death, or end of follow-up (Denmark: December 31, 2016; Finland: December 31, 2014; Sweden: December 31, 2020), whichever occurred first. We examined the association between prenatal exposures (including preterm birth, SGA, LGA, maternal preeclampsia, PCOS, and severe stress) and CVD outcomes in offspring using multivariable Cox regression models. Furthermore, we used family- based study designs, i.e. sibling and cousin comparison analyses, to account for unmeasured familial genetic and environmental confounders. Additionally, we investigated the mediating roles of abnormal birth outcomes and congenital heart disease in case of some of the observed associations. Results: In Study I, we found that being born preterm or LGA was linked to an increased risk of atrial fibrillation in both childhood and adulthood. The associations persisted in the sibling comparison analyses. In contrast, SGA was related to an increased atrial fibrillation risk in childhood but not in adulthood. In Study II, we found that individuals prenatally exposed to maternal preeclampsia had higher risks of stroke and ischemic heart disease than those unexposed, and that the associations were more pronounced in cases of severe than milder forms of preeclampsia. The associations of the severe forms of maternal preeclampsia with the offspring's risk of stroke remained in the sibling comparison analyses. In Study III, maternal PCOS was associated with elevated risks of overall CVD, hypertensive disease, stroke, and ischemic heart disease in the population analysis; most of these associations, except that observed in case of stroke, remained in the cousin comparison analysis. When investigating the interaction between maternal PCOS and its prevalent comorbidities, we found that individuals born to mothers with both PCOS and its common comorbid conditions, i.e. diabetes, hypertensive disease, or psychiatric disorders, had higher CVD risks than those born to mothers with only PCOS. In Study IV, we found that offspring exposed to maternal loss of a close family member the year prior to or during pregnancy did not have a higher risk of heart failure than those unexposed. However, the severe forms of maternal bereavement, specifically loss due to unnatural causes and loss of a child or partner, were linked to an increased risk of heart failure in the offspring. When splitting follow-up for Studies I-IV at the age of 18, we found that the association between preterm birth and the risk of atrial fibrillation, maternal preeclampsia and the risk of stroke, and severe maternal stress and the risk of heart failure were stronger during childhood than during adulthood. In the mediation analyses, there was some evidence that the association between maternal PCOS and the risk of CVD in offspring was to a modest extent mediated by preterm birth, LGA, and congenital heart disease. In the case of the link between severe maternal stress and the risk of heart failure, we observed considerable contributions from congenital heart disease and preterm birth. Conclusions: This thesis revealed associations of prenatal risk factors with increased risks of CVD up to early middle-age. Specifically, our findings suggest that preterm birth, SGA, and LGA were related to elevated risks of atrial fibrillation. Additionally, maternal preeclampsia, especially its severe types, was associated with elevated risks of stroke and ischemic heart disease in offspring, while maternal PCOS was associated with increased risks of overall CVD and its major types. Moreover, severe maternal stress was associated with an elevated risk of heart failure in offspring. If subsequent studies confirm our findings, early-life prevention and targeted intervention programs may be developed to inform health policies, eventually resulting in a reduced burden of CVD

Enhancing hospital care coordination : a resilience-centric approach to challenges and potential strategies

Background: The realms of patient flow management and care coordination, both aiming to optimize care delivery, are governed by distinct operational logics. Patient flow management is primarily a strategic tool concerned with optimising resource utilization via efficient movement of patients through the healthcare system. Care coordination emphasizes a holistic patient-centred approach. It focuses on integrating and coordinating services across the continuum of care to meet the individual patient needs. Technological improvements, demands for cost control and a shift toward redirecting lower acuity patients to primary and secondary care levels, accentuates the need for specialized staff and equipment in increasingly specialised hospitals. Resource constraints enhances conflicting quality, safety, and production goals as they keep challenging frontline hospital managers to constantly adapt to new situational demands. The theoretical description of hospitals as complex adaptive systems suggest that resilience is essential for maintaining the systems functions and avoiding loss of control of care delivery. The ability to adapt in response to both critical events and long-term pressures are a hallmark of resilient systems. Adaptations require adaptive capacity, such as extra resources, opportunities, degrees of freedom and/or a flexible goal setting. As well as strategies for control at individual, team, and strategic levels. For this thesis, the system’s ability to adapt is explored through care coordination at the first line management level. Care coordination has been studied primarily in specific single unit settings or for specific type of management roles such as navigators, nurse coordinators and lead medical doctors. There is a need for studies of how adaptive capacity is realised in-situ from a systems perspective, in highly specialised hospital settings, and to harness first line managers experiences of improvisations and informal practices (Invisible work). Aim: This thesis aims to contribute to bridging the gap between theory and practice of how first-line hospital managers realise adaptive capacity to avoid loss of control. Methods: An ethnographic approach that build three cases of care coordination in various in-hospital settings. The studies utilise a broad, inductive-deductive approach to explore how care coordination is realised in-situ using primarily participant shadowing observations and interviews for data collection. Study I. Describes care coordination in a Neonatal Intensive Care Unit. That is an integrated system of intensive care, emergency intake, step down unit and home care nested within one department. This study includes 100 hours of shadowing observations of coordinators, their conversations, tasks, meetings, and artefacts. Data were analysed using an inductive-deductive approach to content analysis from the perspective of resilience engineering. Study II. Explores the intersection of hospital wide patient flow management and care coordination (between wards and units). It incorporates five semistructured individual interviews with high level managers, 56 hours of shadowing observations with hospital bed-coordinators and 14 observations of hospital coordination team huddles. Inductive-deductive content analysis was applied, guided by a framework of Joint Cognitive Systems. Study III. Explores lead-nurses’ strategies and challenges for coordinating care at the emergency department (ED). Data were collected through four focus group interviews guided by a table-top sandbox simulation of the ED. Analysis were conducted using reflexive thematic analysis. Findings: Study I. Describes a functional relationship between operational stress and a progression of adjustments in the actual situation, expressed through recurring patterns of adaptation. Everyday work of the management team was characterised by seamlessly and actively organising and reorganising. Sacrificing low level goals based on up-to-date information and making continuous assessments of what would be minimally intrusive for the overall performance of the ward. Study II. Adds to the exploration of care coordination by describing how situations in the hospital’s patient flow is defined as problematic (or disastrous) by being on a course towards unacceptable quality- and safety trade-offs. And additionally, how the hospital management team huddle is an arena for sensemaking and negotiation between wards, but also act as a threshold and delay for information and decisions. Study III. Describes that the “normal state” of the ward is a moving target depending on the current demands. Activities for monitoring the status of the ward are in competition with coordinating activities as they both require managers attention. Coordinating care within the ED extends beyond the boundaries of the physical department within a variety of temporal demands for “on-the-day” adaptations and anticipatory strategies. Conclusions: The apparent stability of the organisation was found to be a dynamic balance between patient flow and care coordination activities. Care coordination is a team effort that transcend physical or organisational boundaries, teams of managers assert dynamic control as their strategies allow the system to increase the complexity of its control function when needed. The distributed nature of care coordination offers no ‘one point of control’ for tactical or strategic decision makers, which is problematic as a point of control is a common target for patient flow management interventions. Furthermore, frontline managers lacked the aid of tailored decision support systems for matching and visualising current operational stress of their units. It was not obvious outside the head of individual managers what strategies were available for any given situation