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Assessment of arterial stiffness in populations at increased cardiovascular risk
No full textIntroductionArterial stiffness is an established marker of cardiovascular risk. However, its full potential for clinical applications remains unconfirmed due to the lack of accessible assessment methods. Photoplethysmography (PPG), which measures instantaneous blood volume changes in the skin, may be used for evaluation of arterial stiffness. PPG is common in medical pulse-oximeters to measure oxygen saturation levels and pulse rate, and has also recently been incorporated into consumer wearable devices such as smart watches and smart rings. Furthermore, machine learning may be applied on PPG signals and clinical data, to improve assessment of arterial stiffness and to facilitate identification of individuals having an increased cardiovascular risk, diagnose or condition.This thesis aimed to investigate assessment of arterial stiffness in populations at increased cardiovascular risk, using novel and simplified methods to enhance cardiovascular risk stratification. Specifically, we aimed at (1) evaluating an improved overnight PPG-based measure for assessing cardiovascular risk, (2) improving simple PPG- and ECG-based methods for assessing arterial stiffness, (3) evaluating whether arterial stiffness or machine learning-based PPG analysis could improve risk stratification in patients with suspected obstructive coronary artery disease (CAD), (4) predicting the clinically challenging blood pressure phenotype masked uncontrolled hypertension (MUCH) post-myocardial infarction (MI) by applying machine learning methods.Methods and resultsIn Study I, associations between the novel overnight finger PPG-based stiffness index (OSI) and markers of cardiovascular risk and ambulatory blood pressure (ABP) were investigated in a population with confirmed or suspected hypertension (n=79). OSI was positively correlated with cardiovascular risk scores (SCORE2/SCORE2-OP: ρ = 0.40, P = 0.002 and Framingham: ρ = 0.41, P P = 0.002), awake (r = 0.40, P P P P P = 0.001). Generally, OSI showed stronger correlations compared to a previously studied overnight PPG- based marker of arterial stiffness.In Study II, finger PPG and finger blood pressure were collected in generally healthy participants (n=33). Carotid-femoral pulse wave velocity (cfPWV; SphygmoCor) and brachial single cuff-based aortic pulse wave velocity (aoPWV; Arteriograph) were reference methods. PPG waveform features were extracted and engineered, and machine learning was applied for prediction model development. PPG-based models predicted cfPWV (root mean square error [RMSE] 0.70, R2 0.74) and aoPWV (RMSE 0.52, R2 0.92) well, which was comparable to repeatability and agreement of the reference methods. The novel PPG amplitude ratio, "Am b/Am pl", emerged as a key feature in modelling, showing strong correlations with cfPWV and aoPWV (r = - 0.81 and -0.75, respectively; both P In Study III, patients investigated with coronary computed tomography angiography (CCTA) for suspected symptomatic new-onset chronic coronary syndrome (CCS) were assessed with aoPWV by Arteriograph and index finger PPG (n=141). Arterial stiffness measures were compared with clinical risk models in their discriminatory ability for obstructive CAD (CAD-RADS [CAD-reporting and data system] >3, indicating at least one moderate stenosis). aoPWV and PPG-derived cfPWV were not predictive of CAD-RADS ≥3. Machine learning identified three PPG features (waveform area "Ar OS", waveform area ratio "IPA" and time span "Tm N") that provided discriminatory ability for CAD-RADS ≥3 comparable to the risk factor-weighted clinical likelihood model (receiver operating characteristic area under the curve [AUC] 0.73 [95% confidence interval 0.61-0.85] vs 0.72 [0.62-0.82]), when implemented in a random forest model.In Study IV, patients underwent ambulatory blood pressure monitoring (ABPM) following a recent hospitalisation for a MI (n=99). The blood pressure phenotype MUCH (office blood pressure ConclusionsWe developed and evaluated improved arterial stiffness assessment using the easy-to-use finger PPG method. Machine learning was successfully applied to PPG signals and clinical variables to enhance arterial stiffness estimation, and to identify obstructive CAD in patients with suspected new-onset CCS, and MUCH after MI. These findings confirm the potential value of using the widely accessible PPG method and machine learning for improved cardiovascular risk stratification.List of scientific papersThis thesis is based on the following papers, which will be referenced by their corresponding Roman numerals:I. Hellqvist H, Rietz H, Grote L, Hedner J, Sommermeyer D, Kahan T, Spaak J. Overnight stiffness index from finger photoplethysmography in relation to markers of cardiovascular risk and vascular ageing. Heart Vessels. 2025;40(10):895-904. https://doi.org/10.1007/s00380-025-02537-3II. Hellqvist H, Karlsson M, Hoffman J, Kahan T, Spaak J. Estimation of aortic stiffness by finger photoplethysmography using enhanced pulse wave analysis and machine learning. Front Cardiovasc Med. 2024;11:1350726. https://doi.org/10.3389/fcvm.2024.1350726III. Hellqvist H, Karlsson M, Löfmark H, Kahan T, Spaak J. Assessment of arterial stiffness and machine learning analysis of finger photoplethysmography for prediction of obstructive coronary artery disease in patients with suspected chronic coronary syndrome. [Manuscript]IV. Hellqvist H, Erlinge D, Lindahl B, Jernberg T, Oldgren J, James S, Al- Khalili F, Kahan T, Spaak J. Prevalence and prediction of masked uncontrolled hypertension in patients recently hospitalized for myocardial infarction. Eur Heart J Open. 2025;5(6). https://doi.org/10.1093/ehjopen/oeaf138</p
From pregnancy risk to offspring cardiovascular disease : preeclampsia and preterm birth
No full textBackgroundPreterm birth and hypertensive disorders of pregnancy are major contributors to perinatal morbidity and mortality, with lasting effects on both maternal and offspring health. Early pregnancy is a critical period for identifying women at risk of complications such as preeclampsia and preterm birth, however effective predictive and preventive tools are lacking. While advances in perinatal care have improved survival for preterm infants, long- term cardiovascular outcomes remain uncertain.AimsThis thesis investigates:(1) the association between preterm birth (2) the association between preterm birth (3) maternal, interpregnancy, and previous pregnancy factors associated with first-time preeclampsia in second pregnancy; and (4) developing and evaluating a first-trimester prediction model for preterm birth in nulliparous and parous women.MethodsThis thesis is based on four studies using Swedish nationwide register data and a large Swedish multicentre pregnancy cohort. Studies I-III were register-based cohort studies using the Swedish Medical Birth Register with linkages to Swedish national registers including the National Patient Register, Cause of Death Register, Register of Education, Total Population Register, and Multi-Generation Register. Study IV used data from the prospectively collected IMPACT cohort (Study for Improving Maternal, Pregnancy, and Child Outcomes) linked to the Swedish Pregnancy Register.Study I followed over 2.6 million individuals born between 1987 and 2012 from 1 year of age to the end of 2013 for incident heart failure.Study II followed over 3.1 million individuals born between 1987 and 2016 from 1 year of age to the end of 2017 for pulmonary hypertension.Study III included 808,107 women with first and second consecutive singleton deliveries between 1992 and 2019.Study IV included 12,486 women enrolled in the first trimester (10+5 to 14+6 gestational weeks) who subsequently delivered at or after 22 gestational weeks.Exposures In Study I and II, the exposures were gestational age at birth and birth weight for gestational age. For Study III the exposures were complications in first pregnancy, interpregnancy changes (weight/BMI, interval, and new onset chronic disease), and maternal characteristics. Study IV evaluated predictors including maternal and obstetric history, biophysical markers (MAP: blood pressure and mean arterial pressure), biochemical (PAPP-A: pregnancy associated plasma protein A and PlGF: placental growth factor) and ultrasound (UtA-PI: uterine pulsatility index) as predictors of preeclampsia.OutcomesThe outcome in Study I was incident heart failure, and in Study II pulmonary hypertension. In Study III, the outcome was first-time preeclampsia in the second pregnancy. In Study IV, the outcomes were preterm birth (Statistical analysesStatistical analyses in this thesis include Poisson regression (Study I), Cox proportional hazards regression (Study II), modified Poisson regression (Study III), and logistic regression and random forest models (Study IV). Prediction model performance in Study IV was assessed through discrimination (area under the curve, AUC), detection rates at predefined screen-positive rates, and calibration assessment. Additional statistical approaches were applied for sensitivity analyses.ResultsStudy I found a higher risk of heart failure among individuals born preterm, compared to term, with the strongest associations among those born extremely preterm. Associations remained robust after adjustment for maternal characteristics, birth weight, parental cardiovascular history, and after excluding congenital malformations.Study II demonstrated an elevated risk of pulmonary hypertension following preterm birth, particularly among those born before 32 weeks. Associations persisted in sensitivity analyses and after adjusting for maternal and perinatal factors.Study III identified interpregnancy weight gain as a risk factor for first-time preeclampsia in the second pregnancy, while weight loss was associated with lower risk. Previous pregnancy complications, along with interpregnancy diagnosis of chronic disease, were also associated with increased risks.Study IV found acceptable performance of models for predicting preterm birth in parous women, but poor performance in nulliparous women. Biophysical, biochemical, and ultrasound markers added modest incremental gains. Performance was slightly better for early preterm birth, but overall predictive capacity remained limited.ConclusionsThis thesis highlights the long-term cardiovascular consequences of preterm birth for the offspring, as well as the importance of prior pregnancy and interpregnancy factors for maternal risk in future pregnancies. Gestational age at birth adds clinically relevant information to cardiovascular risk assessment in childhood and young adulthood. Interpregnancy weight change is a risk factor for preeclampsia, offering potential opportunities for prevention. Early prediction of preterm birth remains challenging, particularly in nulliparous women. Together, these studies illustrate the strength of Swedish register data for life-course research, and emphasize the need for targeted follow-up and prevention strategies for both mothers and their offspring.List of scientific papersI. Carr H, Cnattingius S, Granath F, Ludvigsson JF, Edstedt Bonamy AK. Preterm Birth and Risk of Heart Failure Up to Early Adulthood. J Am Coll Cardiol. 2017 May 30;69(21):2634-2642. https://doi.org/10.1016/j.jacc.2017.03.572II. Carr H, Gunnerbeck A, Eisenlauer P, Johansson S, Cnattingius S, Ludvigsson JF, Edstedt Bonamy AK. Severity of preterm birth and the risk of pulmonary hypertension in childhood: A population-based cohort study in Sweden. Paediatr Perinat Epidemiol. 2023 Sep;37(7):630-640. https://doi.org/10.1111/ppe.12997III. Carr H, Johansson K, Snowden JM, Newby-Kew A, Cnattingius S, Ludvigsson JF, Stephansson O, Wikström AK, Sandström A. Maternal and Interpregnancy Factors and Risks of First-Time Preeclampsia in Second Pregnancy: A Swedish National Cohort Study. BJOG. 2025 Sep 1. Epub ahead of print. https://doi.org/10.1111/1471-0528.18348IV. Carr H*, Kupka E*, Bergman L, Carlsson Y, Hastie R, Edstedt Bonamy AK, Johansson S, Wang C, Hansson S, Conner P, Lindgren P, Kublickas M, Larsson AO5, Wikström AK, Sandström A. Development of an early pregnancy prediction model for preterm birth - using the Swedish Study for Improving Maternal, Pregnancy, and Child outcomes (IMPACT). Unpublished. [Manuscript]*Shared first authors</p
Deciphering human lung mast cell heterogeneity
No full textMast cells are tissue-resident immune effector cells that play critical roles in allergic responses and pulmonary pathologies. Traditional protease-based classifications vastly underestimate mast cell heterogeneity, and systematic characterization of their functional diversity, particularly across anatomical compartments and in response to epithelial-derived alarmins, has been lacking. This thesis comprehensively characterizes human lung mast cell heterogeneity, functional properties, and alarmin responsiveness through single-cell transcriptomics, optimized functional assays, and multi-omics profiling.Study I employed single-cell RNA sequencing analysis of sorted human lung mast cells to investigate mast cell heterogeneity beyond traditional classifications. The analysis revealed that mast cell heterogeneity manifests primarily as continuous variation in gene expression rather than discrete subpopulations. The traditional MCT/MCTC classification was challenged by striking discordance between mRNA and protein levels, particularly the ubiquitous CPA3 mRNA expression despite variable protein detection. These findings demonstrated that transcriptomic approaches alone are insufficient for defining classical mast cell subsets and highlighted the importance of post- transcriptional regulatory mechanisms in mast cell phenotype determination.Study II performed large-scale single-cell RNA sequencing of 19,232 FACS- sorted mast cells from four anatomical compartments (bronchi, parenchyma, arteries, and veins) across five donors. This comprehensive analysis revealed five transcriptional clusters/states (MC1-MC5) with distinct gene-expression programs, establishing anatomical context as a key organizing principle of mast- cell heterogeneity. MC1 specialized in stress responses, with high expression of SDF2L1, MT2A, and BCL2A1. MC2 displayed broad transcriptional activation, characterized by elevated immediate early response genes such as FOS, JUN, and the growth factor AREG. MC3 showed selective activation with increased expression of signal termination factors DUSP1 and RGS1, together with enrichment for TGF-β-responsive signatures. MC4 represented a pro- inflammatory effector state expressing TNF, IL13, and multiple chemokines, showing preferential localization to bronchi and arteries and enrichment for IL- 33-responsive programs. MC5 exhibited a regulatory phenotype dominated by long non-coding RNAs MEG3 and MEG8. Compartment-resolved analysis demonstrated that bronchial mast cells functioned as inflammatory sentinels optimized for pathogen defense, whereas parenchymal populations displayed homeostatic programs associated with tissue maintenance. Cross-dataset validation confirmed the reproducibility of the MC1-MC4 transcriptional states across independent studies.Study III systematically optimized functional assay conditions to enable robust and reproducible assessment of mast cell activation. The study identified serum-free culture conditions as critical for enhanced IgE-mediated degranulation responses. Pre-incubation in fresh serum-free media for 30 minutes significantly enhanced degranulation, while serum presence abolished this effect, suggesting serum-derived inhibitory factors. CD63 and CD164 were identified as the most stable and reliable degranulation markers. Human lung mast cells did not respond to MRGPRX2 agonist compound 48/80, confirming their distinct phenotype from skin mast cells and highlighting tissue-specific functional adaptations.Study IV investigated the regulation of IL-2 receptor expression by IL-33 in human lung mast cells. Global transcriptomic analysis revealed that IL-33 potently upregulated CD25 (IL-2Rα) and CD132 (γc) without affecting CD122 (IL- 2Rβ), creating a non-functional IL-2 receptor complex. Despite robust CD25 expression and enhanced IL-2 binding capacity, mast cells failed to respond to IL-2, showing no STAT5 phosphorylation or transcriptional changes. Analysis of publicly available single-cell RNA-seq datasets revealed that IL2RA-positive mast cells increased dramatically from 2.0% in healthy control to 23.8% in emphysema patients, with gene expression signatures substantially overlapping IL-33-induced transcriptional profiles. These findings suggest that CD25- positive mast cells may function as IL-2 sinks, potentially modulating local T cell responses and the cytokine microenvironment. Immunofluorescence analysis confirmed heterogeneous CD25 protein expression on mast cells in lung tissues from healthy controls, COPD and IPF patients.Study V performed comprehensive multi-omics profiling to characterize the transcriptional and functional responses of human lung mast cells to the epithelial-derived alarmins IL-33 and TSLP. IL-33 established itself as a potent mast cell activator, inducing over 600 differentially expressed genes at 2 hours, with "signaling by interleukins" emerging as the most enriched pathway. In stark contrast, TSLP failed to elicit transcriptional changes despite inducing STAT5 phosphorylation, revealing a dissociation between signaling and transcriptional outcomes. PTGS2 (COX-2) emerged as the most highly upregulated gene following IL-33 stimulation, yet IL-33-enhanced eicosanoid production remained paradoxically COX-1-dependent, demonstrating the complexity of inflammatory mediator regulation. Comprehensive secretome profiling identified IL-5, IL-13, CSF2/GM-CSF, CCL2, CCL4, and CXCL8/IL-8 as dominant secreted mediators exceeding 1000 pg/mL, with IL-5 and IL-13 particularly enriched in IL-33 responses. Several mediators including GZMA, GZMB, TNFSF12, TGFA, HGF, LIF, and AREG were identified as granule-stored and rapidly released upon IgE- receptor induced degranulation.Collectively, these studies establish that human lung mast cells exhibit substantial heterogeneity organized by anatomical compartmentalization and functional specialization. The IL-33/ST2 axis emerges as the predominant epithelial-mast cell communication pathway, with IL-33 functioning as a master regulator of mast cell phenotypic plasticity and inflammatory responses. The identification of distinct mast cell clusters with specialized functions, combined with comprehensive characterization of IL-33-driven CD25 expression and mediator production, provides mechanistic insights for precision therapeutic approaches targeting specific mast cell subsets and signaling pathways in airway inflammatory diseases.List of scientific papersI. Rönnberg, E., Ravindran, A., Mazzurana, L., Gong, Y., Säfholm, J., Lorent, J., Dethlefsen, O., Orre, A. C., Al-Ameri, M., Adner, M., Dahlén, S. E., Dahlin, J. S., Mjösberg, J., & Nilsson, G. Deciphering human lung mast cell heterogeneity by single cell RNA sequencing. Front Immunol. 2023;14(March):1-9. https://doi.org/10.3389/fimmu.2023.1151754II. Gong, Y., Boey, D., Atanasoai, I., Al-Ameri, M., Sachs, E., Vali, K., Adner, M., Säfholm, J., Dahlin, J., Nilsson, G., & Rönnberg, E. Single-Cell Transcriptomic Profiling Reveals Heterogeneity of Human Lung Mast Cells Across Anatomical Compartments. [Manuscript]III. Gong, Y., Johnsson, A. K., Säfholm, J., Al-Ameri, M., Sachs, E., Vali, K., Nilsson, G., & Rönnberg, E. An optimized method for IgE-mediated degranulation of human lung mast cells. Front Immunol. 2024; May31; 15: 1393802. https://doi.org/10.3389/fimmu.2024.1393802IV. Gong, Y., Atanasoai, I., Siddhuraj, P., Johnsson, A .- K., Peng, Y., Al- Ameri, M., Sachs, E., Vali, K., Adner, M., Säfholm, J., Erjefält, J. S., Nilsson, G., & Rönnberg, E. Expression of CD25 on Human lung Mast Cells and its Regulation by IL-33. [Manuscript]V. Atanasoai, I., Gong, Y., Johnsson, A .- K., Kolmert, J., Al-Ameri, M., Sachs, E., Vali, K., Adner, M., Wheelock, C. E., Säfholm, J., Rönnberg, E., & Nilsson, G. Selective Mast Cell Responsiveness to IL-33, but Not TSLP, Suggests a Dominant Axis of Innate Immune Activation in Airway Inflammation. [Manuscript]</p
The value of international pharmacovigilance databases to help contain antibiotic resistance from a 'one health' perspective
No full textBackgroundAntibiotic resistance (ABR) is a global threat to public health that requires action from a 'One health' perspective. 'One health' highlights the interlinked nature of human, animal and environmental health. ABR can occur within humans, animals and the environment and can transmit between these different areas, thus the need to incorporate 'One health' into efforts to contain ABR. However, the relative importance of different drivers within human, animal and environmental health is not known. A greater understanding of this may allow more targeted interventions across 'One health'. Furthermore, limitations within traditional, laboratory-based surveillance of ABR have led to calls to consider other data sources. One of these hypothesised sources is data from pharmacovigilance databases. Pharmacovigilance databases collect reports of suspected adverse events related to the use of medicines. Pharmacovigilance benefits from a well- established network, with a particularly large reach for human health. This thesis aimed to assess the relative associations of different aspects of 'One health' in the ABR of children from rural India. Furthermore, this thesis aimed to investigate the utility of pharmacovigilance databases as a supplementary tool to that of traditional ABR surveillance across 'One health'.MethodsPaper I was a cohort study that used Escherichia coli isolated from the stools of 125 children (aged between one and three years old) and animals, as well as water sources within the same community. Samples were collected simultaneously across sources at seven time points over a two year period and susceptibility testing for 16 antibiotics performed. Newey-West regression models were used to study temporal associations between resistance levels in humans and that of other sources. SourceR was used for attribution modelling to estimate the proportion of ABR cases in humans which could be attributed to each of the other sources.Paper II analysed potential reports of ABR in VigiBase, a global pharmacovigilance database for humans. The reports were split into 'Probable' and 'Possible' cases of ABR based on the reported adverse events in the report. All 'Probable' reports and a random selection of 599 'Possible' reports were reviewed on a case-by- case basis. The reports were reviewed for their likelihood to be a case of ABR, as well as the reporting of antimicrobial susceptibility testing, previous antibiotic use, if the cases were linked to published scientific literature and the demographics of the reported patients. Chi-square tests and logistic regression models were used to test for differences between the 'Probable' and 'Possible' reports.Paper III studied the reporting of potential ABR cases in international pharmacovigilance databases across 'One health'. VigiBase and EudraVigilance Veterinary, a European-based animal health pharmacovigilance database, were used to identify cases for human, animal and environmental health. No specialist environmental health database was identified. The reports were analysed over time, by continent of the reporting country and by the type of antibiotic reported using the Anatomical Therapeutic Chemical (ATC) classification.In paper IV we compared the reports of potential ABR cases in VigiBase and EudraVigilance Veterinary against the percentage of resistant tests reported to traditional ABR surveillance databases. For humans, the Global Antimicrobial Resistance and Use Surveillance System (GLASS) was used and for animals it was the European Food Safety Authority (EFSA) and European Centre for Disease Prevention and Control (ECDC) joint report on ABR. The most recent data from these ABR databases was from 2022, and the data from the pharmacovigilance databases was limited to all reports up to the end of 2022. Logistic regression models were used to compare how ABR was reported for different ATC subgroups between the different databases.ResultsEighteen of the 69 Newey-West regression models estimating the temporal association between human ABR and that of the other sources were statistically significant. Most of these, eight, were with household drinking water. There were five, three and two statistically significant temporal relationships for wastewater, animals and source of drinking water, respectively. SourceR attribution modelling estimated that the highest proportion of attributable cases of human ABR were from household drinking water, animals and wastewater. The proportion of attributable cases of human ABR was much lower for the source of drinking water.There were more 'Possible' reports of potential ABR in VigiBase (n=20,815) compared to 'Probable' (n=3,497). For both groups, most of the reports were from high-income countries. The 'Probable' reports were more likely to be cases of ABR and report antimicrobial susceptibility testing. The logistic regression models showed that the 'Probable' reports were more likely to be cases of ABR after accounting for potential confounders. However, the 'Possible' reports were more likely to be reported from non-healthcare professionals and contained valuable information regarding patients who experienced an unexpected lack of effect of antibiotic treatment.In terms of total reports, there were more reports for humans (n=29,667) compared to animals (n=5,217) in international pharmacovigilance databases. There were no reports reporting both environment and ABR terms together in either VigiBase or EudraVigilance Veterinary. There were 52 reports of environment-related terms with an antibiotic. There was an increase in reports received annually over time for humans and animals, but this was less clear for environment-related reporting. There was a consistent difference, for at least one antibiotic ATC subgroup, between the antibiotics reported to pharmacovigilance databases for potential cases of ABR and the percentage of resistant tests for these antibiotic groups in specialised databases.Conclusion'One health' should be considered when it comes to ABR surveillance and interventions. In the rural Indian community we studied, the closest over time association was with household drinking water. Pharmacovigilance databases can be used to identify potential cases of ABR from around the globe, but the number of reports of and the scope of the database was greatest for humans followed by animals. There was an absence of a specialised database for environment-related reporting. For humans, the search of VigiBase was able to identify cases of ABR with reasonable accuracy, and this was more so for a more specific search. When compared to traditional ABR databases, there was a consistent difference between the antibiotics in the human and animal-based databases.List of scientific papersI. Mitchell J, Purohit M, Jewell CP, Read JM, Marrone G, Diwan V, Stålsby Lundborg C. Trends, relationships and case attribution of antibiotic resistance between children and environmental sources in rural India. Sci Rep. 2021 Nov 19;11(1):22599. https://doi.org/10.1038/s41598-021-01174-wII. Mitchell J, Westerberg C, Purohit M, Lundquist P, Stålsby Lundborg C. The Enhancing Role of Pharmacovigilance to Conventional Antibiotic Resistance Surveillance: Cross-sectional Identification and Analysis of Reports of Antibiotic Resistance in VigiBase. Int J Infect Dis. 2025 June 4;107947. https://doi.org/10.1016/j.ijid.2025.107947III. Mitchell J, Lundquist P, Westerberg C, Purohit M, Stålsby Lundborg C. A 'One Health' Analysis of Reports of Potential Antibiotic Resistance Cases in International Pharmacovigilance Databases. [Submitted]IV. Mitchell J, Purohit M, Lundquist P, Westerberg C, Stålsby Lundborg C. A Comparison of Antibiotic Resistance Reports in Pharmacovigilance Databases to Conventional Surveillance Across 'One Health'. [Submitted]</p
Understanding corepressor complex function in the epigenetic regulation of macrophage gene expression
No full textMacrophages play a major role in chronic inflammatory diseases such as type 2 diabetes, atherosclerosis, and cancer. Transcription factors, chromatin modifiers, and other coregulators coordinate inflammation and metabolism in macrophages through epigenetic mechanisms of transcriptional repression and activation. Among these, the HDAC3 corepressor complex is a key regulator of macrophage function. This thesis focuses on three of its subunits: G protein pathway suppressor 2 (GPS2), nuclear receptor corepressor (NCOR), and silencing mediator of retinoic acid and thyroid hormone receptor (SMRT). While these subunits together form the so-called core corepressor complex, the common functions of the core complex and the distinct roles of the subcomplexes that they form have remained poorly understood. Therefore, the overall aim of this thesis was to identify both common and distinct roles of these complex subunits in regulating gene expression in macrophages, and to uncover the mechanisms underlying their context-specific functions.Previous studies have shown that GPS2, in a subcomplex with SMRT, acts as an anti-inflammatory chromatin-modifying coregulator in classically activated (M1) macrophages (1,2). In Study I, we investigated the role of GPS2 in alternatively activated (M2) macrophages. To explore this, we primarily used the mouse macrophage cell line RAW264.7 and bone marrow-derived macrophages depleted of GPS2, NCOR, or SMRT, and applied transcriptomic, cistromic, epigenomic, and DNA topology analyses. This study revealed that GPS2 is critical for the epigenetic regulation of M2 macrophage activation, as GPS2 antagonizes enhancer activation mediated by the lysine demethylase KDM1A. Importantly, this regulatory role of GPS2 was found to be dependent on its cooperation with NCOR and SMRT, highlighting a shared function of the corepressor complex in controlling enhancer accessibility and transcriptional regulation in M2 macrophages.NCOR and SMRT are homologous subunits of the corepressor complex, yet previous research has shown that their depletion results in distinct phenotypes. However, their individual roles leading to these distinct outcomes have not been systematically investigated in macrophages. In Study II, we focused on identifying the shared and unique genome-wide roles of NCOR and SMRT in RAW264.7 cells and bone marrow-derived macrophages, using integrative analysis of cistrome, epigenome, and transcriptome data. NCOR depletion primarily affected metabolic gene programs, whereas SMRT depletion had a stronger impact on inflammation gene regulation. Remarkably, these alterations included selective changes in chromatin accessibility and H3K27ac signatures, with SMRT depletion exerting a dominant effect. These differences could not be attributed to differential chromatin recruitment, as NCOR and SMRT exhibit genome-wide co-occupancy in macrophages. Instead, cistrome analyses in NCOR- and SMRT-depleted macrophages revealed a functional hierarchy between the two corepressors. SMRT appears to play a predominant role, as its depletion abolishes chromatin binding of both NCOR and GPS2, and even seems to induce translocation of the entire core corepressor complex to the cytoplasm. In contrast, NCOR depletion has a more limited effect on both SMRT and GPS2, primarily altering SMRT binding preferences to distinct cis-regulatory elements and reducing GPS2 chromatin binding.Overall, this thesis provides insights into the role of the corepressor complex subunits GPS2, NCOR, and SMRT in the epigenetic regulation of inflammation- and metabolism-related gene expression in macrophages. These findings may contribute to future strategies for therapeutic targeting of macrophage epigenetic states in chronic diseases such as diabetes, atherosclerosis, and cancer.List of scientific papersI. Antagonistic action of GPS2 and KDM1A at enhancers governs alternative macrophage activation by interleukin 4. Zhiqiang Huang, Astradeni Efthymiadou, Ning Liang, Rongrong Fan, Eckardt Treuter. Nucleic Acids Research; 2023 Feb 22; Volume 51, Issue 3, Pages 1067-1086, PMID: 36610795. https://doi.org/10.1093/nar/gkac1230 II. SMRT anchors the HDAC3 corepressor complex to chromatin to regulate inflammatory and metabolic pathways in macrophages. Astradeni Efthymiadou, Chaode Gu, Cheng Wang, Hongwei Wang, Ziyi Li, Oihane Garcia-Irigoyen, Rongrong Fan, Eckardt Treuter, Zhiqiang Huang. Nucleic Acids Research; 2025 Sep 23; Volume 53, Issue 17, gkaf880, PMID: 40966497. https://doi.org/10.1093/nar/gkaf880 </p
From blueprint to biodistribution : harnessing DNA nanotechnology for biomedical applications
No full textDNA nanotechnology has enabled the use of DNA as a versatile tool for various biomedical applications, including mapping of biological environments and the formation of precise nanoscale DNA structures. DNA origami nanostructures (DONs) are self-assembled architectures that enable the precise and tunable immobilization of bioactive molecules with nanometer-scale spatial control. DONs have been applied in a range of biomedi- cal contexts, from targeted drug delivery to the modulation of cellular communication. However, translating these advances into functional biomedical tools requires a deeper understanding of how design parameters influence biological interactions and in vivo behavior. To this end, this thesis explores strategies for characterizing, optimizing, and applying DNA nanostructures for targeted and biologically relevant applications, ranging from the characterization of blueprint functionalization to studies of their in vivo biodis- tribution.To address the blueprint of DON functionalization, in Paper I we developed NanoSiTE (Nanostructure Site-occupancy characterization through Tag Extension), a sequencing- based platform for high-throughput characterization and quantification of DON func- tionalization. By encoding structure-, position-, and identity-barcodes, NanoSiTE en- ables high-resolution mapping of the spatial organization and molecular identity of DON- bound components across hundreds of thousands of nanostructures in a single assay. When applied to sheet-like DONs, NanoSiTE detected an unintentional error in the func- tionalization, which was further validated using DNA-PAINT super-resolution microscopy. Moreover, NanoSiTE provided site-specific information about the error that could not be resolved through DNA-PAINT analysis alone. This approach offers an accessible and design-agnostic strategy for the characterization of functionalized DONs, facilitating the broader application of DNA nanotechnology in nanomedicine.The precise immobilization of bioactive ligands on DONs poses a promising platform for the development of multivalent therapies. In Paper II, we investigated the multivalent activation of insulin receptors (IRs) by arranging insulin ligands with varying spatial or- ganization and valency on DONs. Our results demonstrated that IRs form clusters at the cell membrane, and that multivalent activation of these clusters led to increased IR phosphorylation. Moreover, multivalent DONs significantly reduced free glucose levels in an in vivo zebrafish model. The multivalent insulin-DONs also elicited transcriptional responses comparable to those of monovalent insulin, but achieved these effects at sub- stantially lower ligand concentrations caused by a saturation of transcriptional signaling. These findings indicate that both the spatial organization and valency of insulin ligands strongly influence IR-mediated signaling, establishing these parameters as design vari- ables for fine-tuning receptor activation. This work provides insight into the multivalent applications of DONs and highlights the potential of exploiting multivalency as a strategy for targeting insulin resistance.To translate the applications of DONs from in vitro performance to biomedical impact, it is essential to understand their in vivo properties. In Paper III, we employed zebrafish embryos as an in vivo model to investigate the effects of a stabilizing coating on DON biodistribution. We found that the coating not only influenced the biodistribution and cellular interactions of the DONs, but also mitigated their clearance by scavenger en- dothelial cells and macrophages. This work provides valuable insights into the in vivo behavior of DONs and establishes protocols for the use of zebrafish embryos as an in- termediate screening model for in vivo DON studies. Furthermore, employing zebrafish embryos as an intermediate model prior to experiments in higher-order animals aligns with the 3Rs (reduce, refine, replace) principles, offering ethical and practical advantages for in vivo investigation.Finally, in Paper IV, we repurposed a click-chemistry-based approach, previously de- veloped for detecting drug targets in vivo, to decouple nanostructure pre-labelling from in situ detection. This method was applied to visualize the biodistribution of DONs in cleared and fixed tissues across multiple tissue types and spatial scales. Future work will focus on extending these analyses to whole-organ imaging. By eliminating the need for pre-incorporated fluorophores, which are susceptible to quenching during tissue pro- cessing and may induce undesired biological interactions, this approach enables high- resolution detection of DONs with single-cell precision in mouse models, while maintain- ing fluorescence integrity throughout extensive tissue processing.In summary, the work presented in this thesis collectively advance the use of DNA nan- otechnology and DONs as versatile tools for biomedical applications. By addressing the complete trajectory from the blueprint functionalization to in vivo biodistribution, this work establishes new strategies for the characterization, optimization, and application of DONs. Together, these findings provide a foundation for the rational design of DNA- based nanomaterials and their future translation into precise and effective nanomedical platforms.List of scientific papersI. Enya Engström, Georges Kiriako, Tade Idowu, David F. Bonet, Joel Spratt, Yang Wang, Elena Ambrosetti, Ian T. Hoffecker, and Ana I. Teixeira. NanoSiTE: Sequencing-Based Characterization of Site-Occupancy in Functionalized Nanostructures through Combinatorial Barcoding [Manuscript]II. Joel Spratt, José M. Dias, Christina Kolonelou, Georges Kiriako, Enya Engström, Ekaterina Petrova, Christos Karampelias, Igor Cervenka, Natali Papanicolaou, Anto- nio Lentini, Björn Reinius, Olov Andersson, Elena Ambrosetti, Jorge L. Ruas & Ana I. Teixeira. Multivalent Insulin Receptor Activation using Insulin-DNA Origami Nanostructures Nat. Nanotechnol. 19, 237-245 (2024) https://doi.org/10.1038/s41565-023-01507-yIII. Christina Kolonelou, Enya Engström, Lars Bräutigam, Steven Edwards, José M. Dias, Joel Spratt, Christos Karampelias, Iris Rocamonde-Lago, Björn Högberg, Stefan Wennmalm, Hjalmar Brismar, Olov Andersson, Ana I. Teixeira. Effects of oligolysine-Polyethylene Glycol Coating on the Biodistribution of Wireframe DNA origami Nanosheets Zebrafish Embryos ACS Nano 19 (36), 32145-32157 (2025) https://doi.org/10.1021/acsnano.5c05801IV. Enya Engström, Tade Idowu, Verina Leung, Cailynn Wang, Alexandra Selke, Christo- pher Glynn, Iris Rocamonde-Lago, Chayenne V. Tillack, Tess Edman, Jose M. Dias, Zhengyuan Pang, Björn Högberg, Li Ye and Ana I. Teixeira. In Situ Fluorescent Click-labelling of DNA Nanostructures for Subcellular Resolution Imaging In Vivo [Manuscript]</p
Gestational age and cognitive development in childhood.
No full textIMPORTANCE: Preterm and early-term births are known risk factors for cognitive impairment, but studies that comprehensively include genetics, prenatal risk, and child-specific factors in high-risk populations are lacking.OBJECTIVE: To investigate the long-term cognitive outcomes of children born at various gestational ages, including very preterm (28-31 weeks), moderately preterm (32-33 weeks), late preterm (34-36 weeks), and early term (37-38 weeks), compared with full-term (≥39 weeks), accounting for genetics and other risk factors. DESIGN, SETTING, AND PARTICIPANTS: In this prospective, multicenter, longitudinal cross-sectional study, children aged 9 to 10 years were recruited from the Adolescent Brain and Cognitive Development Study between January 1, 2016, and December 31, 2018. Children underwent cognitive assessments using the National Institutes of Health Toolbox, Little Man Task, and Rey Auditory Verbal Learning Test. Polygenic scores for cognitive performance (cogPGS) were generated using results of a genome-wide association study from the genetic variants related to cognitive performance, educational attainment, and mathematical ability. Data analysis was performed from March to June 2024. EXPOSURE: Preterm (very preterm, moderately preterm, late preterm) and early-term birth status, with full-term birth status as the reference group. MAIN OUTCOMES AND MEASURES: The primary outcome of interest was the composite cognitive score, while secondary outcomes included individual cognitive domain scores. Hierarchical regression models were used to examine associations between gestational age and cognitive outcomes, adjusting for socioeconomic status (SES), cogPGS, prenatal risks, and child-specific factors. RESULTS: Among 5946 children included in the study (mean [SD] age, 9.9 [0.6] years; 3083 [51.8%] male), 55 (0.9%) were born very preterm, 110 (1.8%) were born moderately preterm, 454 (7.6%) were born late preterm, 261 (4.4%) were born early term, and 5066 (85.2%) were born full term. The cogPGS was positively associated with the composite cognitive score (β = 0.14; 95% CI, 0.12-0.17; P CONCLUSIONS AND RELEVANCE: In this cross-sectional study of children aged 9 to 10 years, moderately preterm birth was associated with long-term cognitive problems independent of SES, genetics, and other risk factors. These findings underscore the need for continued follow-up of all preterm children, with particular focus on those born before 34 weeks' gestational age, because they may face greater developmental challenges over time.</p
Novel strategies of optimal combinations of targeted therapy in medulloblastoma and neuroblastoma
No full textBackground/Aim: Medulloblastoma (MB) and neuroblastoma (NB) are among the most common malignant solid tumors in children. Despite decades of clinical advances, these cancers often remain difficult to treat due to their heterogeneous and aggressive nature, the emergence of treatment resistance and the toxicity associated with standard therapies such as chemotherapy and radiotherapy. While current multimodal treatments succeed in improving survival in some patient groups, they often result in significant long-term side effects. In addition, relapse and refractory disease continue to be major clinical challenges, emphasizing the urgent need for more effective and less toxic therapeutic strategies. Targeted therapies, which selectively inhibit key oncogenic drivers and molecular pathways involved in tumor progression, offer a promising alternative to traditional treatments. In this PHD thesis, we investigated the preclinical efficacy of mostly FDA-approved inhibitors of PI3K, FGFR, CDK4/6, PARP, WEE1 and AKT, alone or in various combinations, on both MB and NB models using two-dimensional (2D) and 3D cell culture settings.Material and methods: MB cell lines (DAOY, UW228-3, D425, Med8A, and D283) and NB cell lines (SK-N-AS, SK-N-BE(2)-C, SK-N-FI, SK-N-DZ, and SK-N-SH) were cultured and treated with inhibitors against PI3K (BYL719), FGFR (JNJ- 42756493), CDK4/6 (PD-0332991), AKT (AZD5363), PARP (BMN673) and WEE1 (MK-1775). The inhibitors were evaluated both as monotherapies and in various combinations with each other, as well as in combination with conventional chemotherapy and radiotherapy. Their effects were assessed on cell viability, growth, proliferation, cytotoxicity, apoptosis, cell cycle distribution and migration in both 2D and 3D culture models.Key findings: In MB, most drugs presented dose-dependent effects. Moreover, the PI3K inhibitor BYL719 demonstrated synergistic anti-tumor activity when combined with the CDK4/6 inhibitor PD-0332991, the FGFR inhibitor JNJ- 42756493, as well as with the chemotherapeutic agents cisplatin and vincristine. The efficacy of these single inhibitors was further enhanced when combined with radiotherapy. Notably, the WEE1 inhibitor MK-1775, either alone or in combination with the PARP inhibitor BMN673, was effective specifically in Sonic Hedgehog (SHH)-subgroup cell lines (DAOY and UW228-3), but not in Group 3 cell lines (Med8A and D425). In addition, the AKT inhibitor AZD5363 showed synergistic effects when combined with BYL719, cisplatin or vincristine across several MB cell lines.In NB, most drugs presented dose-dependent effects. Moreover, the combination of PI3K and FGFR inhibitors led to enhanced anti-tumor efficacy. However, when paired with chemotherapeutic agents such as cisplatin, vincristine or doxorubicin, the effects varied among NB cell lines, ranging from synergistic to antagonistic responses. Notably, combining the PI3K inhibitor BYL719 and the CDK4/6 inhibitor PD-0332991 resulted in consistent synergistic effects across all NB cell lines. Similarly, combining the PARP inhibitor BMN673 with the WEE1 inhibitor MK-1775 produced additive or synergistic responses in most NB cell lines, although BMN673 alone was largely ineffective.Conclusions: This thesis provides compelling pre-clinical evidence supporting the therapeutic potential of repurposing and combining targeted inhibitor combinations in MB and NB. In MB, PI3K, FGFR and CDK4/6 inhibitors in combination with each other or with radiotherapy demonstrated promising efficacy. In NB, PI3K inhibitors paired with FGFR or CDK4/6 inhibitors also showed strong anti-tumor activity. However, combining these inhibitors with standard chemotherapeutics produced variable responses in both MB and NB, highlighting the need for further investigation. Notably, the combination of WEE1 and PARP inhibitors was effective in SHH MB and NB, whereas PARP inhibition alone showed limited efficacy. Finally, AKT inhibitor showed synergistic interactions when combined with PI3K inhibitors or chemotherapy in MB. By identifying synergistic interactions across both simple 2D and advanced 3D models, this work lays the foundation for the development of more precise and less toxic treatment strategies. Crucially, the findings suggest that rational, mechanism-driven drug combinations may not only enhance survival outcomes but also help preserve the quality of life in pediatric cancer patients. Overall, this thesis contributes to the growing body of evidence supporting the shift towards personalized and mechanism-based treatment therapies in pediatric oncology.List of scientific papersI. Lukoseviciute M, Maier H, Poulou-Sidiropoulou E, Rosendahl E, Holzhauser S, Dalianis T, Kostopoulou ON. Targeting PI3K, FGFR, CDK4/6 Signaling Pathways Together With Cytostatics and Radiotherapy in Two Medulloblastoma Cell Lines. Front Oncol. 2021 Sep 24;11:748657. https://doi.org/10.3389/fonc.2021.748657II. Lukoseviciute M, Need E, Birgersson M, Dalianis T, Kostopoulou ON. Enhancing targeted therapy by combining PI3K and AKT inhibitors with or without cisplatin or vincristine in medulloblastoma cell lines in vitro. Biomed Pharmacother. 2024 Nov;180:117500. https://doi.org/10.1016/j.biopha.2024.117500III. Lukoseviciute M, Theodosopoulou A, Holzhauser S, Dalianis T, Kostopoulou ON. Combination of PARP and WEE1 inhibitors in vitro: Potential for use in the treatment of SHH medulloblastoma. Oncol Rep. 2023 Jun;49(6):125. https://doi.org/10.3892/or.2023.8562IV. Holzhauser S, Lukoseviciute M, Papachristofi C, Vasilopoulou C, Herold N, Wickström M, Kostopoulou ON*, Dalianis T *. Effects of PI3K and FGFR inhibitors alone and in combination, and with/without cytostatics in childhood neuroblastoma cell lines. Int J Oncol. 2021 Feb;58(2):211-225. https://doi.org/10.3892/ijo.2021.5167V. Lukoseviciute M, Holzhauser S, Pappa E, Mandal T, Dalianis T, Kostopoulou ON. Efficacy of combined targeted therapy with PI3K and CDK4/6 or PARP and WEE1 inhibitors in neuroblastoma cell lines. Oncol Rep. 2023 Sep;50(3):166. https://doi.org/10.3892/or.2023.8603VI. Lukoseviciute M, Need E, Holzhauser S, Dalianis T, Kostopoulou ON. Combined targeted therapy with PI3K and CDK4/6, or FGFR inhibitors show synergistic effects in a neuroblastoma spheroid culture model. Biomed Pharmacother. 2024 Aug;177:116993. https://doi.org/10.1016/j.biopha.2024.116993</p
Non-invasive predictors of prognosis in chronic liver disease
No full textIf the liver is exposed to continuous damage over time, accumulation of liver fibrosis occurs in all chronic liver diseases. The amount of fibrosis is traditionally evaluated via liver biopsy and is most often staged as fibrosis stage 0-4, where stage 4 is termed liver cirrhosis, and is the end-stage of chronic liver diseases, regardless of the etiology. This is considered an irreversible condition and is associated with an increased morbidity and mortality, including an increased risk of hepatocellular carcinoma (HCC), and biannual screening with ultrasound scans is recommended to identify smaller tumors eligible for curative treatment.Fibrosis stage by liver biopsy is the marker that best correlates with progression to cirrhosis, decompensated cirrhosis, and hepatocellular carcinoma. However, a liver biopsy is invasive and not an optimal method since it is resource-intensive, comes with a risk of complications, carries a risk of sampling error and interobserver variability, and is not suitable to screen large populations with, and the prevalence of the most common chronic liver disease, metabolic dysfunction- associated steatotic liver disease (MASLD), is 38% globally. Non-invasive tests have the potential to be used instead of a liver biopsy. In this thesis, we aimed to investigate different non-invasive tests and their performance in chronic liver disease, with a special emphasis on MASLD. We investigated non-invasive tests both as screening tools to identify cases with a higher risk of progression, and their performance to predict important outcomes such as progression to cirrhosis, decompensated cirrhosis, HCC, liver transplantation, and liver-related death.In study I, a case-control study, cases were patients with cirrhosis who had died from HCC between 2004 and 2020 in Stockholm County. They were matched to controls, patients with cirrhosis who had not died from HCC, based on age, sex, etiology of cirrhosis, year of cirrhosis diagnosis, hospital of cirrhosis-diagnosis, MELD score, and Child-Pugh Score. Using an adjusted logistic regression model, we investigated the exposure to HCC-surveillance between cases and controls. 72 cases and 72 controls were matched, and we found that HCC surveillance was associated with decreased HCC-related mortality, with an odds ratio (OR) of 0.37 (95%CI=0.16-0.88). The analysis showed that controls who did not die from HCC were more exposed to screening ultrasounds compared to cases, suggesting a protective effect.In study II, we collected liver stiffness measurements (LSM) by vibration- controlled transient elastography (VCTE) from 16 hospitals in Sweden. After linkage to nationwide healthcare registers, we created a cohort of 14,000 patients where disease etiology, comorbidities and outcomes were based on data from the registers. We used a Cox regression model to investigate if LSM by VCTE could be used to predict progression to an outcome associated with portal hypertension or hepatocellular carcinoma. A total of 402 (2.7%) patients developed an outcome associated with portal hypertension, and the risk of an outcome was 48-fold higher in patients with an LSM >25 kPa compared to patients with an LSM 25 kPa had a 34-fold increased rate of hepatocellular carcinoma compared to patients with an LSM In study III, a cross-sectional study with MASLD-patients, we compared the ability of the non-invasive tests FIB-4 (a score based on ALT, AST, platelet count, and age) and ADAPT (a score based on age, diabetes, the collagen formation biomarker PRO-C3, and platelet count) to detect patients with an LSM >8 kPa or >12 kPa. We showed that ADAPT had modestly better discriminative ability than FIB-4 in detecting an LSM >8 kPa in patients with MASLD, and a higher net benefit among across the probability threshold range of 15% - 40%, which means that ADAPT has a higher net benefit as a first-line screening test of fibrosis compared to FIB-4, if we are willing to do 100 LSM by VCTE to find 15-40 patients with an LSM >8 kPa.In study IV, we used longitudinal data from patients with MASLD to investigate how the non-invasive tests LSM by VCTE, FIB-4 and CAP changed over three years. We compared changes in mean values over time, both in the full population and between subgroups where the exposure to disease modifiers such as weight loss and alcohol consumption differed. We also described fluctuations between established categories of LSM and FIB-4, aimed to describe the risk of advanced fibrosis, over time. We could demonstrate that the mean change over time in LSM by VCTE (-0.13 kPa/year, 95%CI =- 0.39 to +0.13) and FIB-4 (0.04/year, 95%CI=0.01-0.06) was negligible, but there were considerable intraindividual fluctuations over time where 55 patients (29%) changed LSM category (12 kPa) between baseline and one year, and 51 patients (27%) changed LSM category between one and three years of follow-up.In conclusion, this thesis found that HCC surveillance in patients with cirrhosis is associated with a decreased HCC-related mortality, which suggests that patients with cirrhosis eligible for curative treatment should continue to be included in HCC-surveillance programs. We also showed that LSM by VCTE is a non-invasive biomarker suitable for risk stratification in patients with chronic liver disease. ADAPT performs modestly better than FIB-4 when used as a first-line test to screen for patients with an LSM >8 kPa, however the added value of ADAPT as a first-line test is unknown and warrants further evaluation. Mean LSM by VCTE and FIB-4 does not change much over three years on a group level, but disease monitoring with non-invasive tests remains challenging with intraindividual fluctuations over time. Further research is needed to find better ways of disease monitoring, where true progressors can be separated from non-progressors with fluctuations due to measurement errors of non-invasive tests.List of scientific papersI. Hegmar H, Bengtsson B, Ullman Nilsson S, Rowe I, Stål P, Hagström H. HCC-surveillance is associated with improved HCC-related mortality in patients with cirrhosis - a case-control study. Scand J Gastroenterol. 2025 Jun 17:1-11. doi: 10.1080/00365521.2025.2517208. Online ahead of print.https://doi.org/10.1080/00365521.2025.2517208II. Hegmar H, Wester A, Aleman S, Backman J, Degerman E, Ekvall H, Lund K, Lundgren Å, Nasr P, Shahnavaz A, Vessby J, Westin J, Önnerhag K, Hagström H. Liver stiffness predicts progression to liver-related events in patients with chronic liver disease - A cohort study of 14 414 patients. Liver Int. 2024 Jul;44(7):1689-1699. https://doi.org/10.1111/liv.15919III. Hegmar H, Wiggers T, Nasr P, Vessby J, Kechagias S, Nyhlin N, Marschall HU, Danielsson Borssen Å, Strandberg R, Karsdal M, Julie Leeming D, Ekstedt M, Hagström H. Performance of novel collagen turnover biomarkers to detect increased liver stiffness in MASLD. J Intern Med. 2024 Aug;296(2):177-186. https://doi.org/10.1111/joim.13813IV. Hegmar H, Strandberg R, Shang Y, Vessby J, Danielsson Borssén Å, Nyhlin N, Kechagias S, Stål P, SWEHEP study group, Ekstedt M, Hagström H. Dynamics of non-invasive tests in metabolic dysfunction-associated steatotic liver disease. [Manuscript]</p
