Haemophilia B - Diagnostic Insights, Genetic Aspects and Clinical Outcomes

Haemophilia B (HB) is a rare inherited bleeding disorder caused by the deficiency of coagulation factor IX (FIX). The major clinical issues are bleedings, often targeting the joints, and the development of neutralising antibodies, i.e. inhibitors, to the FIX replacement therapy. Historically HB has been seen as identical to the more common haemophilia A (HA), i.e. deficiency of coagulation factor VIII (FVIII), but important differences between the two diseases exist. As a result of the rarity of HB, much of our knowledge of HB has been extrapolated from what is known about HA. To improve the care for persons with HB (PwHB), studies focusing on HB are of importance. The aim of this thesis was to characterise HB regarding its diagnostic challenges, treatment, clinical outcomes, and the quality of life of PwHB, and to compare some of these aspects to those of HA.Paper I describes the comparison of the one-stage and the chromogenic assays in measuring the FIX activity level. In HA, a discrepancy between the two methods in measuring FVIII has been reported in approximately one-third of persons with non-severe HA; however, this has not previously been evaluated in HB. We found that 25% of persons with non-severe HB had discrepant results between the two methods, with higher values recorded when the chromogenic method was used. All but one of these persons had the same FIX gene (F9) mutated amino acid. This was the first study to show that assay discrepancy occurs in HB and we concluded that both the one-stage and the chromogenic assays are needed for the correct diagnosis and classification of HB.Papers II-IV describe a cohort of 79 persons with severe HB from the Nordic countries, and 79 matched controls with HA. In Paper II, joint assessment using ultrasound and haemophilia joint health score (HJHS) was conducted and showed that despite the fact that 95% of PwHB were treated with prophylaxis, 37% reported joint bleedings during the prior year. Ultrasound scores were overall low and HJHS scores were significantly lower among PwHB compared with persons with HA (PwHA), indicative of a milder arthropathy in patients with severe HB than in PwHA. Treatment adherence was evaluated using Validated Haemophilia Regimen Treatment Adherence Scale (VERITAS) questionnaires and showed overall good adherence.Paper III presents information on F9 variants, inhibitors, and immune tolerance induction (ITI) therapy in PwHB. We found a high proportion of severe F9 gene defects and a relatively high prevalence of inhibitors of 15%. Of inhibitor patients, 92% had experienced allergic manifestations and 25% nephrotic syndrome. ITI success was independent of the F9 variant and was attained despite allergic reactions and previous ITI failures. Immunosuppression included in the ITI regimen showed a high beneficial rate and may enhance the chances of success. Analyses of noninhibitory anti-FIX antibodies (NNAs) with a multi analyte profiling-based fluorescence immunoassay (xFLI) and an enzyme-linked immunosorbent assay (ELISA) were conducted, but no NNAs were identified. In Paper IV, health-related quality of life (HRQoL) was assessed using the EQ 5D 3L questionnaire and showed a high frequency of pain, mobility problems and anxiety/depression in PwHB, indicating that areas of insufficient care exist. No significant differences in HRQoL between PwHB and PwHA were found, and impaired joint health assessed by the HJHS was found to have a significant negative impact on HRQoL

Causes and consequences of the round goby invasion in the Baltic Sea and beyond

Species invasions have increased rapidly over time and pose negative effects on ecosystems and societies worldwide. The round goby, one of the most widespread invasive fishes in the northern hemisphere, established in the Baltic Sea in 1990. My results show that the round goby, in contrast to most native species in the coastal fish community, exhibits territorial behaviour and parental care, which may have given it a competitive advantage and facilitated its establishment in the Baltic Sea. I found the major diet components of the round goby to be macroinvertebrates, but DNA metabarcoding revealed feeding also on several fish species, likely in their early life stages. Further, the round goby constituted prey for cod, perch and pike. When round goby was abundant in the environment, the reliance on fish prey increased for both round goby and its predators. As a potential consequence of round goby expansion to freshwater, I further studied round goby interactions with spawning salmon. Presence of round goby delayed salmon spawning, and male and female salmon resided closer together in the presence of higher densities of round goby compared to lower densities, which could be interpreted as a protective behaviour. In order to minimise the negative effects of the round goby in and around the Baltic Sea, I recommend management measures to reduce its abundances and prevent further spread, for example by strengthening native coastal predatory fish populations, developing a round goby fishery and developing a system for early detection and eradication of the round goby in rivers and streams

Svenska kommuners inköp - Vad styr priset på kontorsmateriel vid offentliga upphandlingar?

Syfte: Syftet med uppsatsen är att undersöka vad som styr priset på olika typiska kontorsmateriel och att med stöd av resultaten peka på områden som kan förbättras. Metod: Metoden är deduktiv, kvantitativ och använder regressionsanalyser såväl som deskriptiv statistik för att beskriva data. Teoretiska perspektiv: De hypoteser som testas vilar på teori om auktioner. Empiri: Empirin består av ett stickprov av Sveriges kommuner. Information som samlades in rörde de priser som avtalades vid den senaste upphandlingen, antal anbud som lämnades in, vilket anbudsförfarande som användes och vilken upphandlingsvolymen var. Resultat: Regressionsanalysen visade att befolkningstäthet har betydelse för priset som avtalas vid upphandlingar av en av de undersökta produkterna. Detta resultat stöddes av tendenser i ett par andra regressioner men i de flesta fall kunde inget samband mellan de oberoende variablerna och priset visas. Den deskriptiva analysen visade att ett fåtal aktörer dominerar vid upphandlingar

Mångfald och kreativitet i filmprojekt – en kvalitativ studie om filmarbetare och olika kulturella bakgrunder som resurser

15 år i filmbranschen har gett mig möjligheten att få ta del av en mängd kreativa arbetsmiljöer där de olika kulturella bakgrunderna har medverkat till att arbetsmiljön och arbetsuppgifterna har blivit alltmer intressanta och där produktiviteten ökat avsevärt. Jag har arbetat med många långfilmsproduktioner, samproduktioner med Danmark, England och Tyskland. Syftet med mitt uppsatsarbete är att ta reda på hur kreativa projektorganisationer, såsom filmprojekt, drar nytta av att anställa filmarbetare med olika kulturella bakgrunder och se det som en resurs och inte ett hinder för att skapa en kreativ arbetsmiljö. Jag har intervjuat ett antal filmarbetare med olika yrkesfunktioner som har lång erfarenhet av svenska filmproduktioner men även samproduktioner med andra länder i Europa. Min frågeställning undersöktes utifrån en kvalitativ ansats med hjälp av semistrukturerade intervjuer där jag har arbetat med tillhörande frågeteman. Resultatet av studien visar att det finns ett samband med kreativitet och olika kulturella bakgrunder. Oavsett var man jobbar så är världen så mycket större än där man befinner sig. Det handlar inte bara om ett sätt att arbeta utan ett sätt att se på kreativitet, fantasin är olika eftersom den är relaterad till din personliga erfarenhet, det landet som man kommer ifrån, kulturen som man är uppvuxen i. Kreativiteten inom filmyrket är inte bara något visuellt, alltså det som händer framför kameran, det ligger mycket i själva genomförandet, där man hittar gemensamma kreativa vägar

T cells that are naturally tolerant to cartilage-derived type II collagen are involved in the development of collagen-induced arthritis

INTRODUCTION: A discussion is ongoing regarding the possible role of cartilage-directed autoimmunity as a part of the pathogenesis of rheumatoid arthritis (RA). One possibility is that the association of RA with shared epitope-expressing DR molecules reflects a role for major histocompatibility complex (MHC) class II molecules as peptide receptors, and that the predilection of the inflammatory attack for the joint indicates a role for cartilage as a source of the antigenic peptides. A direct role for CII in the development of arthritis is apparent in the CIA model, in which a definite role for MHC class II molecules and a role for CII-derived peptides have been demonstrated [1,2,3]. Remarkably, it was found that the identified MHC class II molecule in the CIA model A(q) has a structurally similar peptide binding pocket to that of the shared epitope, expressing DR4 molecules [4]. In fact, DR4 (DRB1(*)0401) and DR1 (DRB1(*)0101) transgenic mice are susceptible to CIA because of an immune response to a peptide that is almost identical to that which is involved in A(q)-expressing mice [5,6]. They are both derived from position 260-273 of the CII molecule; the peptide binds to the A(q)molecule with isoleucine 260 in the P1 pocket, but with phenylalanine 263 in the P1 pocket of the DR4 and DR1 molecules. Although these findings do not prove a role for CII in RA, they show that such recognition is possible and that there are structural similarities when comparing mouse with human. However, there are also strong arguments against such a possibility. First, arthritis can evolve without evidence for a cartilage-specific autoimmunity, as seen with various adjuvant-induced arthritis models [7,8] and in several observations using transgenic animals with aberrant immunity to ubiquitously expressed proteins [9,10,11]. Moreover, the MHC association in the adjuvant arthritis models correlates with severity of the disease rather than susceptibility [7,8], as has also been observed in RA [12]. Second, it has not been possible to identify the CII-reactive T cells from RA joints, or to achieve a strong and significant CII proliferative response from T cells derived from RA joints. Most recently these negative observations were corroborated using DR4+CII peptide tetramer reagents [13]. On the other hand, it has also been difficult to isolate autoreactive CII-specific T cells from CIA, and it can be anticipated that, even in the CIA model, T cells that are specific for CII will be hard to find in the joints [4]. We believe that the explanations for these observations in both experimental animals and humans are related to tolerance. The CIA model in the mouse is usually induced with heterologous CII, and is critically dependent on an immune response to the glycosylated CII peptide 256-270, which is bound to the MHC class II A(q) molecule. In CII transgenic mice, expressing the heterologous (rat) form of the immunodominant CII 256-270 epitope in cartilage, we observed partial T-cell tolerance. This tolerance is characterized by a low proliferative activity, but with maintained effector functions such as production of IFN-γ and the ability to give help to B cells to produce anti-CII IgG antibodies [14]. Interestingly, these mice were susceptible to arthritis. However, a possibility was that T cells that had newly emerged from the thymus and that were not yet tolerized when the mice were immunized with CII led to the induction of arthritis. We have now addressed this possibility and found that induction of tolerance occurs within a few days, and that mice lacking recent thymic emigrants (ie thymectomized mice) display partially tolerant T cells and susceptibility to arthritis to the same extent as nonthymectomized mice. In addition we found that T cells that are reactive with the nonmodified peptides are relatively more affected by tolerance than T cells that are reactive with the more immunodominant glycosylated variants. OBJECTIVES: To investigate the possibility that T cells that are naturally tolerant to the cartilage protein CII are involved in the development of arthritis, and to exclude a role for nontolerized recent thymic T-cell emigrants in the development of arthritis. MATERIALS AND METHODS: A mutated mouse CII, expressing glutamic acid instead of aspartic acid at position 266, was expressed in a transgenic mouse called MMC (mutated mouse collagen) that has been described earlier [14]. The mice were thymectomized, or sham-operated, at 7 weeks of age and allowed to recover for 4 weeks before being immunized with rat CII in complete Freund's adjuvant. Arthritis development was recorded and sera analyzed for anti-CII IgG, IgG(1) and IgG(2a) levels. To assay T-cell effector functions, other MMC and control mice were immunized in the hind footpads with rat CII in complete Freund's adjuvant, and the draining popliteal lymph nodes were taken 10 days later. The lymph node cells (LNCs) were used for proliferation assay, IFN-γ enzyme-linked immunosorbent assay (ELISA) and B-cell enzyme-linked immunospot (ELISPOT). For the proliferation assay, 10(6) cells were put in triplicate cultures in microtitre wells together with antigen and incubated for 72h before thymidine-labelling and harvesting 15-18h later. For IFN-γ ELISA analysis, supernatant from the proliferation plates was removed before harvesting and used in an ELISA to quantify the amount of IFN-γ produced [15]. B-cell ELISPOT was performed to enumerate the number of cells producing anti-CII IgG [16]. T-cell lines that were reactive towards rat CII were established by immunization with rat CII. An established T-cell line that was reactive with CII and specific for the CII 256-270 peptide was restimulated with freshly collected, irradiated, syngenic spleen cells and rat CII for 3 days followed by 2 weeks of IL-2 containing medium. Immediately before transfer, the cells were labelled with the cytoplasmic dye 5 (and 6)-carboxyfluorescein diacetate succinimidyl ester (CFSE) [17]. Labelled cells (10(7)) were injected intravenously into transgenic MMC mice and nontransgenic littermates. The mice were killed 4 days after cell transfer, and the concentration of CFSE-labelled cells was determined by flow cytometry. RESULTS AND DISCUSSION: To investigate whether and how quickly CII-reactive T cells will encounter CII in vivo, an established T-cell line that is reactive towards rat CII was labelled with the cytoplasmic dye CFSE and transferred into MMC-QD and control mice. Four days later the mice were killed, and it was found that MMC-transgenic mice had dramatically fewer CFSE-labelled cells in the spleen than did nontransgenic littermates (0.11% compared with 0.57%). Similarly, reduced numbers of CFSE-positive cells were observed in blood. This indicates that the T cells encountered the mutated CII that was present in the cartilage of MMC mice, but not in the nontransgenic littermates. Presumably, CII from cartilage is spread by antigen-presenting cells (APCs) to peripheral lymphoid organs. This observation also suggests that newly exported T cells from the thymus will be tolerized to CII in the periphery within less than 4 days. To further investigate whether the MMC mice harbours naïve or tolerized T cells, the mice were immunized with CII at different time points after thymectomy that were well in excess of the times required for their encounter with CII. After 10 days, the response was analyzed in vitro towards both the nonglycosylated and the glycosylated CII 256-270 peptides as well as towards purified protein derivative. The galactosylated form of the peptide (Fig. 1) was used because this is the most immunodominant modification [18]. In contrast to control mice, LNCs from transgenic mice did not proliferate significantly towards the nonglycosylated peptide, indicating that these cells have been specifically tolerized, which is in accordance with earlier observations [14]. A reduced, but still significant proliferation was also observed toward the immunodominant glycosylated CII peptide. Most important, however, was that the proliferative response in the MMC mice did not decrease after thymectomy. Similarly, a significant IFN-γ production towards the glycosylated CII peptide was observed in the MMC mice. The response was somewhat reduced compared with that observed in nontransgenic littermates, and this was especially true for the response toward the nonglycosylated peptide. Again, no decrease in the MMC response by thymectomy was observed. Taken together, the T-cell response in transgenic mice was reduced in comparison with that in the nontransgenic littermates. Furthermore, the response in transgenic animals did not decrease by thymectomy (4 or 8 weeks before immunization), showing that autoreactive T cells are still maintained (and partially tolerized) with significant effector functions at least up to 8 weeks after thymectomy, excluding a exclusive role for recent thymic emigrants in the autoimmune response towards CII. To investigate whether thymectomized mice, lacking recent CII-specific thymic emigrants, were susceptible to CIA, mice were immunized with CII 4 weeks after thymectomy and were observed for arthritis development during the following 10 weeks. Clearly, the thymectomized MMC mice were susceptible to arthritis (five out of 18 developed arthritis; Fig. 2), and no significant differences in susceptibility between thymectomized and sham-operated mice, or between males and females, were seen. In accordance with earlier results [14], MMC transgenic mice had a significantly reduced susceptibility to arthritis as compared with the nontransgenic littermates (P < 0.0001 for arthritic scores, disease onset and incidence). All mice were bled at 35 days after immunization, and the total levels of anti-CII IgG were determined. Transgenic mice developed levels of anti-CII IgG significantly above background, but the antibody titres were lower than in nontransgenic littermates (P < 0.0001). No effect on the antibody levels by thymectomy was observed, nor did thethymectomy affect the distribution of IgG(1) versus IgG(2a) titres,indicating that the observed tolerance is not associated with a shift from a T-helper-1- to a T-helper-2-like immune response. These findings show that T cells that are specific for a tissue-specific matrix protein, CII, are partially tolerized within a few days after thymus export and that these tolerized cells are maintained after thymectomy. Most important, mice that lack newly exported CII reactive T cells are still susceptible to CIA, suggesting that the partially tolerant T cells are involved in development of arthritis. In the light of these data it is possible to explain some of the findings in RA. T-cell reactivity to CII has been shown in RA patients, but with a very weak proliferative activity [19,20]. This is fully compatible with observations in mouse and rat CIA when autologous CII, and not heterologous CII, are used for immunization. This is particularly true if the responses are recorded during the chronic phase of disease, in which the antigen-specific T-cell responses seem to be suppressed in both humans and experimental animals. These observations were confirmed in a recent report [21] in which it was shown that CII-reactive T-cell activity could be detected in RA patients if IFN-γ production but not proliferation was measured. In the present studies in mice the strongest response is seen towards post-translational modifications of the peptide. Because the T-cell contact points are the same whether the peptide is bound to DR4 or to A(q), it is fully possible that post-translational modifications of the peptide also plays a significant role in humans [22]. The fact that IgG antibodies specific for CII are found in many RA patients could be explained by maintained B-cell helper functions of CII-reactive T cells. In fact, it has been reported [23,24] that the occurrence of IgG antibodies to CII is associated with shared epitope DR4 molecules. These observations are thus compatible with a role for CII reactivity in RA. To avoid any confusion, it needs to be stressed that RA is a heterogeneous syndrome in which not only CII, but also other cartilage proteins and other mechanisms are of importance. Such a pathogenic heterogeneity is reflected by the multitude of experimental animal models that have demonstrated how many different pathways may lead to arthritis [25]

A case study evaluating the ergonomic and productivity impacts of partial automation strategies in the electronics industry

A case study is presented that evaluates the impact of partial automation strategies on productivity and ergonomics. A company partly automated its assembly and transportation functions while moving from a parallel-batch to a serial line-based production system. Data obtained from company records and key informants were combined with detailed video analysis, biomechanical modelling data and field observations of the system. The new line system was observed to have 51% higher production volumes with 21% less per product labour input and lower work-in-process levels than the old batch-cart system. Partial automation of assembly operations was seen to reduce the total repetitive assembly work at the system level by 34%. Automation of transportation reduced transport labour by 63%. The strategic decision to implement line-transportation was found to increase movement repetitiveness for operators at manual assembly stations, even though workstations were constructed with consideration to ergonomics. Average shoulder elevation at these stations increased 30% and average shoulder moment increased 14%. It is concluded that strategic decisions made by designers and managers early in the production system design phase have considerable impact on ergonomic conditions in the resulting system. Automation of transport and assembly both lead to increased productivity, but only elements related to the automatic line system also increased mechanical loads on operators and hence increased the risk for work-related disorders. Suggestions for integrating the consideration of ergonomics into production system design are made