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Am I mad, bad or dangerous? A novel intervention approach for unwanted intrusive thoughts
No full textBackground: Unwanted intrusive thoughts (UITs) containing unacceptable and taboo themes is regarded as a common and, for most, transient cognitive phenomenon. However, these thoughts can become so frequent and distressing that the individual’s daily functioning and well-being are impaired, even to the extent that the individual fulfils the criteria for obsessive-compulsive disorder (OCD). Among parents of infants and toddlers, distressing and impairing UITs, mainly of infant-related harm, are a very common symptom. Patients who suffer from OCD with taboo obsessions as well as parents with UITs of infant-related harm are reluctant to reveal their thoughts to healthcare personnel, due to the shame or stigma related to the thought content. Some OCD patients with taboo obsessions avoid seeking treatment and may respond less well to standard psychological treatment for OCD. There are no recommended treatment options for the larger population of parents who suffer from UITs. Therefore, there is a need to develop alternative treatments targeting both taboo obsessions among OCD patients and UITs among parents of infants and toddlers.Aims: The overall aim of this thesis was to develop and evaluate the effect and the mechanism of change of a novel, online intervention approach for OCD patients with taboo obsessions and for parents of infants and toddlers with distressing UITs of infant-related harm.Method: The online intervention developed and investigated in this thesis was based on the cognitive model of obsessions, and was evaluated among patients with OCD and taboo obsessions and parents of infants and toddlers with distressing UITs of infant-related harm. Study I was a pilot study including 19 patients with OCD, primarily taboo obsessions. The participants received therapist-supported online cognitive therapy (I-CT) for 10 weeks. Study II was a randomized controlled trial with a mediation analysis including 68 OCD patients with taboo obsessions. Participants were randomized to either the therapist-supported I-CT for eight weeks or control condition containing online general psychological support. Study III was a cross-sectional survey study including 594 parents of infants and toddlers. Study IV was a randomized controlled pilot trial with a mediation analysis including 43 parents of infants and toddlers who reported daily distressing UITs about intentionally harming their child. Participants were randomized to either eight-week self-guided I-CT or waiting-list control. Study V was a qualitative interview study using thematic analysis to investigate parents’ experiences of taking part in the self-guided I-CT for parents with excessive levels of UITs.Results: Results from Study I showed that intervention completion was high and that most participants were satisfied with the I-CT intervention. I-CT was associated with a large reduction in OCD-symptom severity (bootstrapped within-group d = 1.67 [95% CI; 0.67 to 2.66]). The effect was driven mainly by the participants who understood and were able to apply the cognitive model to their own situation. A time-series analysis indicated that the reduction of OCD-symptom severity was preceded by a reduction in negative appraisals of the taboo obsessions. In Study II, participants in both the I-CT group and the control condition had a significant reduction of OCD-symptoms from pre- to post-intervention. The reduction of OCD-symptoms was significantly larger in the I-CT group, with a moderate effect size (bootstrapped between group d = 0.69 [95% CI; 0.20 to 1.19]). The mediation analysis revealed that 55% of the treatment effect was mediated by a reduction in negative appraisals. In Study III, 56% of the parents’ reported experiencing or previously having experienced UITs about intentionally harming their child. For around one fifth of the parents the UITs were difficult to control and/or had a negative impact on their relationship or attachment to the child. Positive attitudes toward internet-delivered interventions for UITs were endorsed by 51% of the parents. Study IV showed that participants randomized to the self-guided I-CT had a significantly larger reduction of UITs compared to participants in the waiting-list control condition (bootstrapped between-group d = 0.99 [95% CI; 0.56 to 1.43]). The effect of the intervention was mediated by a reduction in negative appraisals. The thematic analysis conducted in Study V divided the parents’ experiences of the self-guided I-CT into two main themes: (1) Changed perception of the unwanted intrusive thoughts, and (2) Different paths to recovery. Overall, results showed that the parents believed that the intervention was helpful by changing the way they interpreted their thoughts, and they reported experiencing several benefits in their daily life due to the intervention.Conclusions: I-CT targeting UITs is an acceptable and feasible intervention, both delivered in a therapist-guided format for OCD patients with taboo obsessions and in a self-guided format for parents with UITs of infant-related harm. Results from Studies I, II and VI suggest that the intervention is effective in reducing distressing and impairing taboo obsessions and UITs. The effect appears to be mediated by a change in negative appraisals. The online cognitive intervention is therefore a promising complementary intervention alternative to standard psychological treatments for OCD patients with taboo obsessions, and an easily accessible, scalable intervention for the large population of parents suffering from UITs.List of scientific papersI. Olofsdotter Lauri, K., Aspvall, K., Bagøien Hustad, I., Malmqvist, K., Serlachius, E., Mataix-Cols, D., Rück, C., Ivanov, V., & Andersson, E. (2022). Initial evaluation of a therapist-supported online cognitive therapy self-help for patients with taboo obsessions. British Journal of Clinical Psychology. 61(4), 964-982. https://doi.org/10.1111/bjc.12369 II. Olofsdotter Lauri, K., Aspvall, K., Lybert, N., Samuelsson, C., Liliequist, B., Håkansson, E., Serlachius, E., Rück, C., Mataix-Cols, D., & Andersson, E. Efficacy and mediators of online cognitive therapy for taboo obsessions in adults with obsessive-compulsive disorder: Randomized Controlled Trial. [Manuscript]III. Olofsdotter Lauri, K., Aspvall, K., Serlachius, E., Mataix-Cols, D., Rück, C., & Andersson, E. (2022). Perceived need of psychological support for taboo obsessions in new parents: A cross-sectional survey. Journal of Obsessive-Compulsive and Related Disorders. 34, 100733. https://doi.org/10.1016/j.jocrd.2022.100733 IV. Olofsdotter Lauri, K., Aspvall, K., Mataix-Cols, D., Serlachius, E., Rück, C., & Andersson, E. (2023). An online self-guided cognitive intervention for unwanted intrusive thoughts about harming infants in new parents: initial randomised controlled trial with mediation analysis. Cognitive Behaviour Therapy. 1-18. https://doi.org/10.1080/16506073.2023.2229015 V. Olofsdotter Lauri, K., Bragesjö, M., Aspvall, K., Lybert, N., Samuelsson, C., Serlachius, E., Rück, C., Mataix-Cols, D., & Andersson, E. "I’m not afraid to be alone with the baby now": Parents’ experiences of an online self-guided cognitive intervention for unwanted intrusive thoughts about harming their child. [Manuscript]</p
Innovations in pancreatology
No full textIn paper I, we explored the presence and potential significance of intracystic pancreatic microbiomes in patients with suspected pancreatic cystic neoplasms (PCNs), who underwent pancreatic surgery. Paired samples of plasma and cyst fluid were gathered from 105 patients, and bacterial DNA was analyzed using quantitative polymerase chain reaction (qPCR) and PacBio sequencing. Levels of Interleukin (IL)-1β were also quantified. Results indicate significantly higher levels of intracystic bacterial DNA, IL-1β and lipopolysaccharide (LPS) in intraductal papillary mucinous neoplasms (IPMNs) with high-grade dysplasia (HGD) and IPMNs with invasive cancer compared to non-IPMN PCNs. While intracystic microbiota composition varied greatly among individuals, analyses revealed the co-existence and enrichment of bacterial taxa of the oral cavity, containing Granulicatella adiacens and Fusobacterium nucleatum, in IPMN with HGD. Increased levels of bacterial DNA within the cysts were correlated with prior exposure to endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) with biopsy, but independent of proton-pump inhibitor (PPI) and antibiotic usage. These findings emphasize the possible significance of oral microbiome in the development of precursors of pancreatic cancer and provide insights into their etiopathology and management. Further investigation is warranted.In paper II, our investigation focused on cultivating pancreatic microbiome from PCNs with suspicion of invasive cancer, aiming to shed light on its potential importance in the initiation and progression of pancreatic cancer. Pancreatic cyst fluid samples acquired during surgery revealed culture positivity predominantly in the IPMN group of lesions. Within the bacteria isolates, Gammaproteobacteria and Bacilli were identified as dominant, using MALDI-TOF MS profiling analysis. Ex vivo co-culture models with pancreatic cell lines showed consistent pathogenic properties in cultivated bacteria, mainly Enterococcus faecalis, Klebsiella pneumoniae, and Granulicatella adiacens, including intracellular survival capability, induction of cell death, and genotoxic effects resembling double-stranded DNA breaks. These findings provide novel perspectives into the pancreatic microbiota’s potential involvement in the association between PCNs and cancer.Paper III is a retrospective observational cohort study assessing the outcomes of total pancreatectomy with islet autotransplantation (TP-IAT). This study included patients operated between 2004 and 2020 at Karolinska University Hospital. We focused on the safety, morbidity, mortality, and function of the islet graft. A total of 24 patients were operated with TP-IAT, with the islet autotransplantation (IAT) site being either the liver or skeletal muscle of the forearm. The 90-day mortality was zero, and the major postoperative morbidities were primarily related to the total pancreatectomy procedure. Postoperative fasting C-peptide levels were detectable, with higher levels observed in patients in the liver-IAT subgroup. While insulin independence was not attained, patients in the liver-IAT subgroup required significantly lower insulin doses at the last follow-up compared muscle-IAT subgroup. TP-IAT appears safe with tolerable risks, but achieving insulin independence should not be anticipated, as the reported five-year insulin independence is 20%. The liver may be a superior site for islet autotransplantation compared to skeletal muscle.Paper IV is a multicenter retrospective cohort study comparing the outcomes of surgery with or without neoadjuvant therapy (NAT) in patients with pancreatic cancer (PC) suspected of portal venous involvement. Data from 361 patients who underwent NAT and 690 patients who underwent upfront surgery (US) from nine centers between 2007 and 2017 were analyzed. Patients who received NAT had fewer venous resections and less venous infiltration, perineural invasion, angioinvasion, lymph node involvement, and R1 resections compared to those who underwent US. In patients undergoing venous resection, there were no significant differences in major postoperative complications and reoperations between the US and NAT groups. However, patients who received NAT without venous resection experienced fewer major complications, reoperations, and lower 90-day mortality compared to those who underwent US. Furthermore, NAT was associated with better overall survival. These findings suggest that NAT may improve patient selection for surgery and lead to fewer complications and better survival outcomes in PC patients with venous involvement.List of scientific papersI. Rogier Aäron Gaiser, Asif Halimi, Hassan Alkharaan, Liyan Lu, Haleh Davanian, Katie Healy, Luisa W Hugerth, Zeeshan Ateeb, Roberto Valente, Carlos Fernández Moro, Marco Del Chiaro, Margaret Sällberg Chen. Enrichment of oral microbiota in early cystic precursors to invasive pancreatic cancer. Gut. 2019 Dec;68(12):2186- 2194. doi: 10.1136/gutjnl-2018-317458. Epub 2019 Mar 14. https://doi.org/10.1136/gutjnl-2018-317458 II. Asif Halimi, Giorgio Gabarrini, Michał Jacek Sobkowiak, Zeeshan Ateeb, Haleh Davanian, Rogier Aäron Gaiser, Urban Arnelo, Roberto Valente, Alicia Y W Wong, Carlos Fernández Moro, Marco Del Chiaro, Volkan Özenci, Margaret Sällberg Chen. Isolation of pancreatic microbiota from cystic precursors of pancreatic cancer with intracellular growth and DNA damaging properties. Gut Microbes. 2021 Jan- Dec;13(1):1983101. doi: 10.1080/19490976.2021.1983101. https://doi.org/10.1080/19490976.2021.1983101 III. Klara Fröberg, Asif Halimi, Miroslav Vujasinovic, José Caballero-Corbalan, Urban Arnelo, Ernesto Sparrelid, Olle Korsgren, Johannes-Matthias Löhr, Torbjörn Lundgren, Poya Ghorbani. Outcome after total pancreatectomy with islet autotransplantation: A European single-center study. Scand J Surg. 2023 Dec 25:14574969231220176. doi: 10.1177/14574969231220176. https://doi.org/10.1177/14574969231220176 IV. Asif Halimi, Eline S. Zwart, Bengi S. Yilmaz, Benediktas Kurlinkus, Reea Ahola, Marco Del Chiaro, Ernesto Sparrelid, Elena Rangelova, Laura Maggino, Giuseppe Malleo, Gabriella Lionetto, Roberto Salvia, Keith J. Roberts, Francesco Giovinazzo, Massimo Falconi, Stefano Crippa, Giulio Belfiori, Geert Kazemier, Patrick Maisonneuve, Johanna Laukkarinen, Güralp O. Ceyhan. Neoadjuvant therapy is superior to upfront surgery for pancreatic cancer with venous involvement. [Manuscript]</p
Immune responses after SARS-CoV-2 infection and/or vaccination
No full textFrom the start of the COVID-19 pandemic, it was clear that studying immune responses after SARS-CoV-2 infection and later on, after vaccination, was of outmost importance in battling the pandemic. To understand immunological responses and their potential durability and robustness was key when planning and predicting the course of the pandemic, although the virus was continuously evolving. The overarching aim of the studies in this thesis was to investigate immune responses after SARS-CoV-2 infection and/or vaccination through the longitudinal blood and mucosal sampling from healthcare workers and COVID-19 patients in the ongoing and observational COVID-19 Immunity (COMMUNITY) study taking place at Danderyd Hospital, Stockholm, Sweden.In study I, we included 2149 healthcare workers and determined the seroprevalence of SARS-CoV-2 antibodies in an early phase of the pandemic. We found a high seroprevalence (19%) compared to society in general at the time. We also reported symptoms and occupational exposure in relation to seroprevalence. We found that symptoms most associated with seroprevalence were anosmia and ageusia and a strong association between seroprevalence and patient contact exposure, implying an occupational risk for SARS-CoV-2 infection among healthcare workers.In study II we investigated immune responses 8 months post infection in 370 healthcare workers and 51 hospitalized COVID-19 patients. We demonstrated a robust and long-lasting humoral and cellular response. We also studied the risk of reinfection by a three month PCR screening study of 252 seropositive and 48 seronegative participants. The results indicated that the risk of reinfection was substantially lower among healthcare workers who had experienced a previous SARS-CoV-2 infection.In study III we investigated immune responses after a single dose of ChAdOx1 nCoV-19 vaccine in 82 healthcare workers with previous SARS-CoV-2 infection and compared them with 65 SARS-CoV-2 naïve participants that received two doses of the BNT162b2 mRNA vaccine. Our findings showed similar or higher responses in the group with hybrid immunity (infection followed by vaccination) despite having received a single dose, opening up for the possibility for a single dose vaccine regimen for previously infected individuals.In study IV we proceeded to investigate long term humoral and cellular immune responses after hybrid immunization. Using longitudinally collected samples from 514 healthcare workers, both SARS-CoV-2 naïve and recovered, across different vaccine platforms and regimens, we found unanimously enhanced vaccine responses among those who had SARS-CoV-2 infection prior vaccination.Finally, in study V we investigated the protective role of mucosal anti-spike IgA against Omicron infection in 338 triple-vaccinated healthcare workers. Participants with highest levels of mucosal anti-spike IgA were primarily individuals with prior SARS-CoV-2 infection. Additionally, we determined that those with highest levels of mucosal anti-spike IgA had a significantly lower risk of breakthrough infection compared to those with lower levels.Taken together, these studies emphasize important aspects of SARS-CoV-2 infection and immune responses, which have been pivotal in addressing the challenges and developing strategies in the battle against the COVID-19 pandemic.List of scientific papersI. Rudberg AS*, Havervall S*, Månberg A, Jernbom Falk A, Aguilera K, Ng H, Gabrielsson L, Salomonsson AC, Hanke L, Murrell B, McInerney G, Olofsson J, Andersson E, Hellström C, Bayati S, Bergström S, Pin E, Sjöberg R, Tegel H, Hedhammar M, Phillipson M, Nilsson P, Hober S, Thålin C. SARS-CoV-2 exposure, symptoms and seroprevalence in healthcare workers in Sweden. Nature communications. 2020 11;1 5064-. *Contributed equally https://doi.org/10.1038/s41467-020-18848-0 II. Havervall S*, Ng H*, Falk AJ*, Greilert-Norin N, Manberg A, Marking U, Lauren I, Gabrielsson L, Salomonsson AC, Aguilera K, Kihlgren M, Mansson M, Rosell A, Hellström C, Andersson E, Olofsson J, Skoglund L, Yousef J, Pin E, Lord M, Åberg M, Hedhammar M, Tegel H, Dönnes P, Phillipson M, Nilsson P, Klingström J, Mangsbo S, Hober S, Thålin C. Robust humoral and cellular immune responses and low risk for reinfection at least 8 months following asymptomatic to mild COVID19. Journal of Internal Medicine. 2022 291;1 72-80. *Contributed equally https://doi.org/10.1111/joim.13387 III. Havervall S*, Marking U*, Greilert-Norin N, Ng H, Gordon M, Salomonsson AC, Hellström C, Pin E, Blom K, Mangsbo S, Phillipson M, Klingström J, Hober S, Nilsson P, Åberg M, Thålin C. Antibody responses after a single dose of ChAdOx1 nCoV-19 vaccine in healthcare workers previously infected with SARS-CoV-2. EBioMedicine. 2021 70; 103523-. *Contributed equally https://doi.org/10.1016/j.ebiom.2021.103523 IV. Havervall S, Marking U, Greilert-Norin N, Gordon M, Ng H, Christ W, Phillipson M, Nilsson P, Hober S, Blom K, Klingström J, Mangsbo S, Åberg M, Thålin C. Impact of SARS-CoV-2 infection on vaccine-induced immune responses over time. Clinical & translational immunology. 2022 11;4 e1388-. https://doi.org/10.1002/cti2.1388 V. Havervall S*, Marking U*, Svensson J, Greilert-Norin N, Bacchus P, Nilsson P, Hober S, Gordon M, Blom K, Klingström J, Åberg M, SmedSörensen A, Thålin C. Anti-Spike Mucosal IgA Protection against SARS-CoV-2 Omicron Infection. The New England journal of medicine. 2022 387;14 1333-1336. *Contributed equally https://doi.org/10.1056/NEJMc2209651 </p
Developing an embryonic stem cell-based cell product for age-related macular degeneration
No full textAge-related macular degeneration (AMD) remains a major cause of blindness with no current cure. With the increasing ageing population in the developed world, a high number of AMD patients is expected. AMD can be distinguished between dry or wet AMD. 10-15% of patients present wet AMD which can be treated with anti-VEGF injections. In contrast, dry AMD management has just recently advanced towards a new drug to treat and to halt the progression of the disease by targeting the complement system. However, we are still far from cure of AMD and more efforts are needed towards development of stable and long-term treatment. With the lack of conventional drug options, the field has moved into the investigation of stem cell-derived therapies. In the case of AMD, the cells that degenerate are retinal pigment epithelium (RPE) cells. For a decade, the lab has worked towards the development of a xeno-free, chemically defined, and scalable protocol to generate stem cell-derived RPE. This is achieved whereas translation into the clinic remains. Within my PhD studies, I have performed the following studies:Firstly, by using single-cell RNA sequencing (scRNAseq) we explored the different cell types that emerged during in vitro differentiation towards hESC-RPE at various time points. The transcriptomic profiling showed a diversity of cells recapitulating the early embryonic development in the first weeks of gestation, showing genetic expression of neural crest, placodal and mesenchyme. The differentiation protocol has a replating step in the middle of the protocol, that induced a rapid move of the cell’s profile towards a pure RPE population which by the end of the protocol matured further. At the replating step, cells could be driven to other lineages with the selection of NCAM1 positive population showing the potential of this retinal progenitor’s marker. Thus generated mature, pure, and functional hPSC-RPE were transplanted into rabbit’s eyes, a largeeyed animal model. After 28 days, transplanted cells were retrieved and scRNAseq was performed revealing that those cells were able to mature even further in vivo.Secondly, cryopreservation offers a highly important step in the manufacturing process of a cell product. Cryostorage offers flexibility between the manufacturing location, the testing of the product, and the patient availability. It also confers the ability to produce larger batches, reducing the costs of manufacturing. After the discovery of the incapability of our hPSC-RPE to cryopreserve, we introduced and optimized an extra replating step, regarding time and densities, to be able to successfully cryopreserve our drug product. This replating step didn’t impact the identity of the hPSC-RPE, since after preservation it had characteristic RPE traits and preserved functionality. Transcriptionally, the replated hPSC-RPE presented a cycling profile and a shrinker maturation profile compared to the terminally mature hPSC-RPE obtained in the original protocol. A noninvasive tool is presented to track the optimal replating time window before cryopreservation based on brightfield images based on the cobblestone morphology of the cells.Lastly, we addressed translation towards the clinic. We proceeded to good manufacturing practice (GMP) adaptation of our protocol that introduced slight differences to improve cost-effectiveness, scale up the manufacture, and introduce large-batch instruments into our process. We successfully completed one engineering and one GMP batch in the Cell Therapy Center of Karolinska University Hospital and cryopreserved them. Most have been used in the extensive release testing, stability program, and preclinical testing presented here. Conventional release testing was complemented with newly developed and validated assays including a more sensitive in vitro assay for lingering pluripotent stem cells or transformed cells. Dose precision and in-use stability studies were performed to mimic the surgical setting for suspension injections. Route of administration feasibility was tested in nude rats, evaluating subretinal injection through transscleral or transvitreal route, revealing that the latter minimized the risk of procedure-related complications. The 28-days toxicology studies in nude rats showed no human cells outside the eyes. No unexpected pathological outgrowth or clinical symptoms were observed in the nude rats dosed with the drug product. Efficacy studies in Royal College of Surgeons (RCS) rats for 90 days after injections show reduced degeneration of the neuroretina of the rats. Optokinetic response and electroretinography showed higher light sensitivity in dosed animals than in vehicles, showing functionality of the implant. Further application to the Swedish Medical Agency is planned for late this year.Taken together, the studies presented in this thesis represent a step forward toward the first stem cell-based therapy to treat AMD in Sweden. I) An unbiased characterization of our hPSC-RPE differentiation protocol is presented showing all cellular composition through the different stages by scRNAseq. II) An optimization step to produce large batches and cryostore the hPSC-RPE cells for flexible manufacturing and delivery of cells. III) Our drug product, CellThRPE1, has been extensively tested and is ready for regulatory review prior to entering the clinical phase.List of scientific papersI. Sandra Petrus-Reurer#, Alex R. Lederer#, Laura Baqué-Vidal, Iyadh Douagi, Belinda Pannagel, Irina Khven, Monica Aronsson, Hammurabi Bartuma, Magdalena Wagner, Andreas Wrona, Paschalis Efstathopoulos, Elham Jaberi, Hanni Willenbrock, Yutaka Shimizu, J. Carlos Villaescusa, Helder André, Erik Sundstrӧm, Aparna Bhaduri, Arnold Kriegstein, Anders Kvanta, Gioele La Manno, and Fredrik Lanner. Molecular profiling of stem cell-derived retinal pigment epithelial cell differentiation established for clinical translation. Stem Cell Reports. 2022, 17, 1458-1475. #Co-first authors. https://doi.org/10.1016/j.stemcr.2022.05.005 II. Laura Baqué-Vidal#, Heather Main#, Sandra Petrus-Reurer, Alex R. Lederer, Nefeli-Eirini Beri, Frederik Bär, Hugo Metzger, Cheng Zhao, Paschalis Efstathopoulos, Sarah Saietz, Andreas Wrona, Elham Jaberi, Hanni Willenbrock, Hazel Reilly, Mona Hedenskog, Elisabeth MoussaudLamodière, Anders Kvanta, J. Carlos Villaescusa, Gioele La Manno, and Fredrik Lanner. Clinically compliant cryopreservation of differentiated retinal pigment epithelial cells. Cytotherapy. 2024, 000, 1-11. #Co-first authors. https://doi.org/10.1016/j.jcyt.2024.01.014 III. Laura Baqué-Vidal, Heather Main, Hazel Reilly, Mona Hedenskog, Nefeli-Eirini Beri, Hugo Metzger, Paschalis Efstathopoulos, Filippo Locri, Sarah Saietz, Frederick Bär, Andreas Wrona, Christoffer von Halling Laier, Daniel R. Muth, Flavia Plastino, Yesenia Ortega Melin, Ásbjörg Geirsdóttir, Elham Jaberi, Simona Graziano, Sonja Pikkupeura, Hanni Willenbrock, Yutaka Shimizu, Eugene Padi, Gunther Galler, Stéphanie Berggren, Angelika Holm, Ulrica Eistrand, Fabio Elefante, Linda Boye Jensen, Karsten Nielsen, Marie Kragh, Johannes Roubroeks, Helder André, Dorthe Bach Toft, Michael Wagner Christiansen, Pontus Blomberg, Katrin Markland, J. Carlos Villaescusa, Anders Kvanta, and Fredrik Lanner. Manufacture, Preclinical Quality, Safety and Efficacy of CellThRPE1, a Human Embryonic Stem Cell-Derived Retinal Pigmented Epithelial Cell Product for the Treatment of Dry-related Retina Degeneration. [Manuscript]</p
Severe poisonings in Sweden : demography, intensive care, and death
No full textBackground: Poisonings are common and diverse in their origins, clinical presentations, and outcomes. Poisoning accounts for a substantial number of hospital admissions with need for a higher level of care. The hospital mortality is low but never the less around 1,000 people die from poisoning each year in Sweden. Patients suffering from the most severe poisonings are treated in the intensive care unit and may suffer a cardiac arrests prior to admission or during hospitalisation. A significant proportion of patients dies outside of hospital. Robust information regarding these patients is scares.Aim: The overall aim of the thesis was to increase knowledge about patients suffering from severe poisoning in Sweden. The specific aims were to describe national data for characteristics, short and long-term mortality for patients treated in the intensive care unit (ICU) due to poisoning, to compare key characteristics and outcomes between out-of-hospital cardiac arrest caused by poisoning vs. other causes, and to describe the national patient population deceased due to poisoning including toxicology results.Methods and results: Four epidemiological studies are included in the thesis. Study I and II were cohort studies based on three national registers, the Swedish intensive care register, the national patient register, and the cause of death register. Variables were collected for all adult patients treated in a Swedish ICU during 2010-2011, with 8,155 registered ICU admissions. Patients had a median age of 38 years and men and women were equally represented. Almost half of the patients had a previous hospitalisation due to poisoning. Approximately 30% were unconscious on admission to the ICU and 14.6% were mechanically ventilated during their stay. The in-hospital mortality was 1.9% and the subgroup with the highest mortality was older men without a previously known poisoning. The population’s one-year mortality was 4.5% and also here it was higher for older men. The whole population had a nine-fold increased risk of death during the year following ICU admission compared to population based controls. The highest mortality was found in women between 19-39 years, with a 50 times higher mortality compared to controls and the clear majority of deaths after hospital discharge (94%) was caused by suicide and/or accidents. Study III was a cohort study based on the Swedish register for cardiopulmonary resuscitation, the national patient register, and the cause of death register. All adult patients with an out-of-hospital cardiac arrest (OHCA) during 2007-2021 were included. In total, 66,261 OHCA patients were included, of whom 5.2% were found to receive a diagnosis of poisoning. Poisoned OHCA patients had a median age of 43 years (compared to 73 of the whole group) and included more men. The cardiac arrests due to poisoning were less likely to be witnessed and less likely to have a shockable first rhythm. Despite this, they had a somewhat lower mortality than the other cardiac arrests groups (84% vs 88%). Study IV was a cohort study which included all adult patients who died from poisoning between 2000-2021, according to the cause of death register. Variables were also added from the national forensic database. The results showed that 1.3% of annual deaths in Sweden were caused by poisoning (n poisoning deaths=27,057/n deaths=2,018,495). Patients who died due to poisoning had a median age of 53 years and 70% were men. In total, 87% of these deaths underwent some sort of forensic examination. Drugs (synthetic narcotics and opioids) caused 46% of deaths and alcohols caused 33%. Positive toxicologic tests were found in 83% of patients. Temporal trends show an increase in opioids, antidepressants/neuroleptics, and sedative/antiepileptic substances in femoral blood of patients who died around 2014-2017.Conclusion: Poisoning is a common cause of ICU admission, non-medical OHCA, and death in Sweden. Many patients have a previous history of poisoning before ICU admission, and a mix of substances is the most common poisoning. The ICUmortality is low but the long-term mortality is high for these often young patients, and death is in many cases caused by a new poisoning. Patients with OHCA due to poisoning are younger than patients with OHCA of other causes and have better survival. Deaths out of hospital are often due to illicit drug use.List of scientific papersI. Lindqvist E, Edman G, Hollenberg J, Nordberg P, Ösby U, Forsberg S. Intensive care admissions due to poisoning. Acta Anaesthesiol Scand. 2017 Nov;61(10):1296-1304. https://doi.org/10.1111/aas.13005 II. Lindqvist E, Edman G, Hollenberg J, Nordberg P, Forsberg S. Longterm mortality and cause of death for patients treated in Intensive Care Units due to poisoning. Acta Anaesthesiol Scand. 2019 Apr;63(4):500-505. https://doi.org/10.1111/aas.13289 III. Lindqvist E, Hollenberg J, Ringh M, Nordberg P, Forsberg S. Out-ofhospital cardiac arrest caused by poisoning – a Swedish nationwide study over 15 years. Resuscitation. 2023 Dec 1;193:110012. https://doi.org/10.1016/j.resuscitation.2023.110012 IV. Lindqvist E, Hollenberg J, Ringh M, Nordberg P, Svensson L, Druid H, Forsberg S. Death and forensic toxicology in Swedish poisonings. [Submitted]</p
Delineating cell types and toxicity in human ovaries from birth to sexual maturity
No full textThe ovary contains the female germ cells known as oocytes, which are essential for female fertility. The immature oocytes reside within primordial follicles in the ovarian cortex and are referred to as the ovarian reserve. Disruption of ovaries by various external factors, such as environmental pollutants, medical conditions, and gonadotoxic treatments can impair fertility. While the pathways behind disruption have been studied in adult ovarian tissue, much remains to be elucidated, especially regarding paediatric ovarian tissue. The molecular and transcriptomic landscape of ovarian tissue from children remains poorly characterised, making it even more challenging to estimate its sensitivity to ovarian disruption. Ovarian tissue cryopreservation is an established method for preserving fertility in adults requiring gonadotoxic treatments, resulting in nearly 300 live births. Paediatric ovarian tissue is cryopreserved using the protocols as in adults, despite previous studies showing differences in the competency of residing follicles. Additionally, patients requiring fertility preservation often have received gonadotoxic treatments or have medical conditions associated with infertility prior to fertility preservation, urging further study of their effect on the ovarian reserve. This thesis aims to provide a better understanding of i) the basic biology of the ovary from birth to reproductive age, and ii) the effect of chemical exposures and medical intervention on the ovary through histologic and transcriptomic assessment of the ovarian cortex in patients from child- to adulthood.Paper I and paper II histologically quantified cortical follicles in biopsied ovarian tissue to elucidate the associations between different exposures and the ovarian reserve. In paper I the association between serum levels of 31 environmental pollutants and both the ovarian reserve and odds of infertility were investigated in a cohort of pregnant women. Some pollutants correlated negatively with odds of infertility and healthy follicle population, but not with atretic follicles. In paper II, a reference standard for ovarian reserve size was established for women up to 25 years old, allowing assessment of the normality of a patient’s ovarian reserve size using Z-scores. This standard was tested in patient cohorts with different medical conditions and exposures to gonadotoxic treatments, identifying patients at risk of reduced ovarian reserve. Particularly, the youngest patients were found to be at risk of a decreased ovarian reserve due to their treatments. These papers illustrated the reduction of the ovarian reserve either through gonadotoxic chemicals or underlying genetic conditions. Paper II prompts further studies of ovarian reserve quality and size especially in the youngest patients in need of fertility preservation.In Paper III and Paper IV transcriptomic analysis of cortical follicles and cells from child and adult ovaries were carried to identify differences possible agedependent changes. In paper III, sequencing of whole isolated follicles from both child and adult ovarian cortex revealed two transcriptomically distinct, yet morphologically similar follicle types. Type 1 follicles exhibited expected gene expression profiles for oocytes and granulosa cell, while Type 2 showed lower oocyte gene expression and higher predicted signalling activity. Although, gene expression patterns underlying follicle development were similar in children and adults, differences were discovered in extracellular matrix and theca cell biology. Additionally, previous chemotherapy exposure associated with increased interferon signalling in child follicles. In Paper IV, single cell sequencing of cells from child and adult ovarian cortex identified 10 distinct cell types of which four had not been previously described in human ovarian cortex: theca cells, Schwann Cells, lymphatic endothelial cells and epithelial cells. Furthermore, this study revealed changes in stromal populations over age, possibly suggesting differences in its function during different stages towards sexual maturity. These findings confirm the dissimilarities between child and adult ovarian cortex and underscore the need for further research into the effect of age and different exposures on ovarian tissue and the reserve.List of scientific papersI. Richelle D. Björvang*, Jasmin Hassan*, Maria Stefopoulou, Kristina Gemzell-Danielsson, Matteo Pedrelli, Hannu Kiviranta, Panu Rantakokko, Päivi Ruokojärvi, Christian H. Lindh, Ganesh Acharya, Pauliina Damdimopoulou. Persistent Organic Pollutants and the Size of Ovarian Reserve in Reproductive-aged Women. Environmental International. 2021 Oct; 155:106589. *Equal contribution authors. https://doi.org/10.1016/j.envint.2021.106589 II. Jasmin Hassan, Katri Knuus, Atte Lahtinen, Ilmatar Rooda, Marjut Otala, Timo Tuuri, Sebastian Gidlöf, Erik Edlund, Judith Menezes, Johan Malmros, Petra Byström, Mikael Sundin, Cecilia Langenskiöld, Hartmut Vogt, Per Frisk, Cecilia Petersen, Pauliina Damdimopoulou and Kirsi Jahnukainen. Reference Standards for Follicular Density in Ovarian Cortex from Birth to Sexual Maturity. Reproductive Bio-Medicine Online. 2023 Oct;47(4):103287. https://doi.org/10.1016/j.rbmo.2023.103287 III. Ilmatar Rooda, Jasmin Hassan, Jie Hao, Magdalena Wagner, Elisabeth Moussaud-Lamodière, Kersti Jääger, Marjut Otala, Katri Knuus, Cecilia Lindskog, Kiriaki Papaikonomou, Sebastian Gidlöf, Cecilia Langenskiöld, Hartmut Vogt, Per Frisk, Johan Malmros, Timo Tuuri, Andres Salumets, Kirsi Jahnukainen, Agne Velthut-Meikas, Pauliina Damdimopoulou. In-Depth Analysis of Protein-Coding and Non-Coding Transcriptomes in Ovarian Cortical Follicles from Children and Adults Reveals Differential Genome Regulation and Unexpected Interfollicular Heterogeneity. [Submitted]IV. Jasmin Hassan, Loren Méar, Tianyi Li, Katri Knuus, Marjut Otala, Valentina di Nisio, Ilmatar Rooda, Anastasios Damdimopoulous, Timo Tuuri, Sebastian Gidlöf, Judith Menezes, Johan Malmros, Petra Byström, Mikael Sundin, Cecilia Langenskiöld, Hartmut Vogt, Per Frisk, Cecilia Petersen, Cecilia Lindskog, Andres Salumets, Kirsi Jahnukainen, Pauliina Damdimopoulou. Single Cell Map of Human Ovarian Cortex from Birth to Reproductive Maturity. [Manuscript]</p
The role of inflammatory cells in sarcoidosis and asthma
No full textImmuno-homeostasis refers to maintaining a delicate balance between immune responses and tolerance. It relies on the harmonious interplay of various inflammatory cells, including macrophages, monocytes, dendritic cells, T cells, mast cells, etc. These cells maintain immune surveillance and response mechanisms, ensuring effective defense against pathogens while preventing excessive inflammation, and minimizing tissue damage. The respiratory system faces unique challenges in maintaining immune homeostasis due to constant exposure to airborne particles, allergens, and pathogens. Disruption of respiratory immune homeostasis may lead to chronic inflammatory disorders such as sarcoidosis and asthma, leading to impaired lung function. This thesis delves into the role of inflammatory cells in the pathogenesis of pulmonary sarcoidosis and allergic asthma.The first part focuses on elucidating the distribution, transcriptional profiles, and functions of mononuclear phagocytes (MNPs) in pulmonary sarcoidosis. Analysis revealed an elevation of CD14+CD16+ monocytes/monocyte-derived cells in the blood and bronchoalveolar lavage cells of sarcoidosis patients. RNA sequencing revealed markedly pro-inflammatory profiles in MNPs from sarcoidosis patients compared to those from healthy controls. Particularly, monocytes/monocyte-derived cells exhibited heightened expression of genes associated with inflammation and TNF signaling. Notably, TNF production by pulmonary monocytes at diagnosis was predictive of patients at risk of developing severe disease (Paper Ⅰ). Furthermore, respiratory MNPs were found to induce potent pathogenic IFN-γ production by Th1 cells (Paper Ⅱ). These findings highlight the significant contribution of MNPs to sarcoidosis pathogenesis.The second part aimed to study the role of airway-infiltrating inflammatory cells in allergic asthma pathophysiology. This project hypothesized that airway inflammation in asthma causes phenotypic alterations of the resident mast cells and the airway smooth muscle cells. Firstly, monensin was identified as an effective approach to decreasing mast cell populations and alleviating mast cell-related antigen-induced bronchoconstriction in both guinea pigs and humans. This highlights the pivotal role of mast cell hyperplasia in the development of airway hyperresponsiveness and inflammation in allergic asthma (Paper Ⅲ). Additionally, by overcoming post-mortem bronchoconstriction in guinea pig small airways, the study reveals guinea pig intralobular bronchi closely resembling human respiratory features. Combining this newly established guinea pig intralobular bronchi model with the modified guinea pig asthma in vivo model, it was found that allergic airway inflammation amplified mast cell responses (Paper Ⅳ), providing further insights into the pathophysiology of allergic asthma.List of scientific papersI. Lepzien R, Liu S, Czarnewski P, Nie M, Österberg B, Baharom F, Pourazar J, Rankin G, Eklund A, Bottai M, Kullberg S. Monocytes in sarcoidosis are potent tumour necrosis factor producers and predict disease outcome. European Respiratory Journal. 2021 Jul 1;58(1). https://doi.org/10.1183/13993003.03468-2020 II. Lepzien R, Nie M, Czarnewski P, Liu S, Yu M, Ravindran A, Kullberg S, Eklund A, Grunewald J, Smed-Sörensen A. Pulmonary and blood dendritic cells from sarcoidosis patients more potently induce IFNγ-producing Th1 cells compared with monocytes. Journal of Leukocyte Biology. 2022 Apr;111(4):857-66. https://doi.org/10.1002/JLB.5A0321-162R III. Liu J, Nie M, Dong C, Säfholm J, Pejler G, Nilsson G, Adner M. Monensin inhibits mast cell mediated airway contractions in human and guinea pig asthma models. Scientific reports. 2022 Nov 7;12(1):18924. https://doi.org/10.1038/s41598-022-23486-1 IV. Nie M, Liu J, Xiang Y, Wong A, Hendriks E, Nilsson G, Säfholm J, Adner M. Induction of allergic airway inflammation amplifies mast cell response in guinea pig intralobular bronchi. [Manuscript]</p
Studies on obesity-related dysfunction in insulin-target tissues : insulin receptor isoforms and intraocular in vivo liver imaging
No full textObesity, caused by poor dietary habits and sedentary lifestyle, has brought on a global health crisis. This condition affects over one-third of adults and largely increases the risk of developing metabolic diseases, such as type 2 diabetes and steatotic liver disease. Insulin is a central hormone in regulating metabolism and insulin receptors are ubiquitously expressed. In mammals, the insulin receptor (IR) has two isoforms, IR-A and IR-B, which differ in structure and function and trigger different signalling pathways within the cell. The first half of this thesis focuses on studying the IR isoforms and their role in metabolic dysfunction. Insulin resistance has been associated with variations in IR isoform expression, however, the mechanisms behind tissue/cell type-specific changes in metabolic disease are poorly understood. Using mouse models of obesity/diabetes we report IR isoform expression patterns in different tissues. We further investigated a shift in IR isoform ratio in perigonadal adipose tissue, and found tissue remodeling and immune cells infiltration to be responsible, rather than a change in IR isoform expression in adipocytes. We also worked to identify novel and isoform-specific IR interaction partners, to understand more about the intracellular signalling triggered by the receptors. The second half of this thesis focusses on the liver, a key player in metabolic regulation. The liver is inaccessible for optical imaging and there is a lack of high-resolution non-invasive imaging techniques. Addressing this need, we developed a novel in vivo imaging platform to monitor liver function longitudinally at cellular resolution. We use the anterior chamber of the mouse eye as a transplantation site for liver spheroids, which engraft on the iris. The cornea acts as a natural body window and allows repeated imaging of the same cells over time. We show that the liver spheroids in the eye retain hepatocyte-specific and liver-like features and perform typical hepatic functions. Importantly, we show that in feeding graft-bearing animals an obesogenic diet, the intraocular grafts developed hepatosteatosis, thereby reporting on endogenous liver function. Thus, we foresee this new technology could provide a unique tool to study steatotic liver disease in both basic and pre-clinical settings.List of scientific papersI. Moruzzi, N., Lazzeri-Barcelo, F., Valladolid-Acebes, I., Moede, T., Paschen, M., Leibiger, B., Berggren, P. O., & Leibiger, I. B. (2021). Tissue-specific expression of insulin receptor isoforms in obesity/type 2 diabetes mouse models. Journal of cellular and molecular medicine. 25(10), 4800–4813. https://doi.org/10.1111/jcmm.16452 II. Lazzeri-Barcelo, F., Leibiger, B., Beusch, C. M., Sabatier, P., Zubarev, R. A., Leibiger, I. B., Berggren, P. O., & Moruzzi, N. BioID-mediated identification of novel IR interaction partners. [Manuscript]III. Lazzeri-Barcelo, F., Oliva-Vilarnau, N., Baniol, M.,Leibiger, B., Bergmann, O., Lauschke, V. M., Leibiger, I. B., Moruzzi, N., & Berggren, P. O. (2024). Intraocular liver spheroids for non-invasive high-resolution in vivo monitoring of liver cell function. Nature communications. 15(1), 767. https://doi.org/10.1038/s41467-024-45122-4 IV. Lazzeri-Barcelo, F., Ciardo, P., Leibiger, B., Leibiger, I. B., Berggren, P. O., & Moruzzi, N. (2024). In Vivo Imaging of Liver Spheroids Engrafted in the Anterior Chamber of the Mouse Eye. J Vis Exp. (205), e66234. https://doi.org/10.3791/66234 </p
Immune cell-derived adipokines : role in white adipose tissue function and link to metabolic health
No full textThe white adipose tissue (WAT) is home to a vast array of immune cells that control local homeostasis and metabolism by engaging in intricate crosstalk with adipocytes and their precursors through secreted factors (adipokines). In the obese WAT, these immune cells adopt a pro-inflammatory profile, resulting in a state of chronic low-grade inflammation that can perturb local and systemic metabolic function. This thesis aimed to study physiological and pathological aspects of the interplay between immune cellderived adipokines and processes pertaining to the expansion and metabolic function of the WAT.A postprandial induction of the pro-inflammatory cytokine interleukin (IL)-1b was previously demonstrated in macrophages of the WAT, but not other tissues, hinting to a possible involvement in local energy handling. Therefore, in study I, we employed in vivo and in vitro models to investigate a physiological, metabolic role of IL-1b in the WAT. To our surprise, IL-1 signaling was of minor importance in mature adipocytes. Instead, we identified adipocyte precursors as the major target of IL-1b in the WAT, where it stimulated the formation of new fat cells, a process linked to preserved metabolic health during obesity development. Strikingly distinct effects caused by acute and chronic treatments led us to propose that postprandial surges in IL-1b has a physiological role in promoting healthy WAT expansion but that this effect may be lost in the chronically inflamed obese WAT.Study II set out to identify WAT-secreted factors involved in cardiometabolic diseases of non-obese individuals. An adipokine screen identified the chemokine CCL18 as significantly elevated in cardiometabolic disease groups compared to healthy controls (all non-obese). Further explorations led us to conclude that CCL18 recruits CD4+ T cells and activates them to secrete interferon g and transforming growth factor b1, which in turn stimulate lipolysis of adipocytes, thereby contributing to cardiometabolic disease through release of fatty acids into circulation.Women generally display a healthier metabolic phenotype than men. Whether differences in WAT inflammatory status may account for this is unknown. The antiinflammatory cytokine IL-10 was previously shown to be elevated in WAT of obese women. Study III explored possible sex differences in WAT production of this cytokine. IL-10 secretion and IL-10-producing macrophages were elevated in WAT of obese women, but not men, with type 2 diabetes. Estrogens had no direct effect on IL-10 expression in vitro. This reveals a sex-specific regulation of IL-10 production in obesity, which may provide women with relative protection from obesity-associated inflammation.Overall, this thesis has provided new insights on the complex role of immune cellderived adipokines in metabolism and expansion of the WAT under different contexts, and how this may be linked to metabolic health.List of scientific papersI. IL-1b promotes adipogenesis by directly targeting adipocyte precursors. Hofwimmer K*, de Paula Souza J*, Subramanian N, Rachid L, Méreau H, Zhao C, Vujičić M, Wernstedt Asterholm I, Böni-Schnetzler M, Meier DT2, Donath MY#, Laurencikiene J#. *Shared first authors; #Shared last authors. [Manuscript]II. Adipose tissue specific CCL18 associates with cardiometabolic diseases in non-obese individuals implicating CD4+ T cells. Subramanian N, Hofwimmer K, Tavira B, Massier L, Andersson DP, Arner P, Laurencikiene J. Cardiovasc Diabetol. 2023 Apr 12;22(1):84. https://doi.org/10.1186/s12933-023-01803-w III. Sex-specific regulation of IL-10 production in human adipose tissue in obesity. Subramanian N, Tavira B, Hofwimmer K, Gutsmann B, Massier L, Abildgaard J, Juul A, Rydén M, Arner P, Laurencikiene J. Front Endocrinol (Lausanne). 2022 Oct 13:13:996954. https://doi.org/10.3389/fendo.2022.996954 </p
