Faculty of Medicine


Recent Submissions

  • Turconi, Giorgio (2022)
    Glial cell line-derived neurotrophic factor (GDNF) is a protein that supports dopamine neurons and regulates multiple cellular processes in the brain and peripheral systems. Because of this, GDNF holds promising potential as a disease-modifying agent for several neurological disorders, including Parkinson’s disease. However, currently available tools used in basic and translational research to study GDNF bear several limitations and often results in side effects due to ectopic expression, hindering the discovery of new GDNF functions and the development of GDNF-based therapies. The main aim of this thesis was to investigate how endogenous GDNF regulates the motor function and cholinergic transmission in the brain using animal models generated in our laboratory where the level of endogenous GDNF can be constitutively or conditionally increased in a spatiotemporally controlled manner. The results presented in this thesis provide the rationale for future research on GDNF signaling as a drug target to treat currently incurable neurological conditions characterized by motor and cholinergic dysfunctions.
  • Ämmälä, Antti-Jussi (Helsingin yliopisto, 2022)
    ABSTRACT The Developmental Origins of Health and Disease (DOHaD) hypothesis states that several prenatal, perinatal, childhood, and adolescence factors may program the future health of an individual. These preprograming factors include maternal stress, anxiety, depression, or sleep during pregnancy or adverse life experiences in childhood or stress during adolescence. The programming processes may be changes in deoxyribonucleic acid (DNA) methylation or shortening of leukocyte telomere length (LTL). DNA methylation refers to an epigenetic mechanism that affects gene expression and is modified by external conditions. Telomere shortening is an event where the end of a chromosome shortens slightly in each cell division, ultimately leading to programmed cell death. Therefore, LTL is considered a marker for biological age. We studied this with a large birth cohort of newborns and calculated based on existing literature that our sample size was sufficient to detect previously reported findings. Despite sufficient statistical power, we could not replicate previous findings. Several reasons for this are discussed. Childhood is a phase of rapid brain development, and adverse events in early life are linked to a wide range of adverse health outcomes in adulthood. Several mechanisms behind this association have been proposed, among them LTL shortening. In turn, this shortening is also affected by current mental health disorders, stress, and lifestyle factors. We studied the effect of adverse life events (ACE) during childhood on adult LTL in a large, population-based nationally representative cohort of adults. Current mental disorders, stress, sleep, and various lifestyle and socioeconomic variables were considered. While current stress or mental health did not affect LTL, early adverse experiences had a cumulative effect on adult LTL, even when confounding factors were considered. This suggests that programming of cellular age can occur during childhood and persist into adulthood independent of later health and lifestyle. Adolescence is another phase where rapid brain development occurs and thus the brain is vulnerable to external and internal stressors. We explored this by studying epigenome-wide methylation in a sample of adolescent boys with or without depression and sleep disturbances. Due to the small sample size, we could not identify any significant genome-wide results. However, when the 500 best differentially methylated positions (DMP) were explored, a pathway related to synaptic pruning, the long-term depression (LTD) pathway, was identified as the most significant pathway. In a post-hoc analysis, a flattened slow-wave sleep dissipation, tiredness, and depression correlated with several individual sites in that pathway, suggesting that methylation changes in the LTD pathway may be one potential mechanism behind widespread adverse effects of sleep disturbances. Biological programming may occur in rapid phases of brain development and these effects may last for longer periods of time. However, careful methodological consideration is required to detect these effects.
  • Rantasalo, Mikko (Helsingin yliopisto, 2022)
    Aims Elective total knee arthroplasty (TKA) is one of the most common in-hospital surgeries for patients with knee osteoarthritis (OA) when conservative treatment has failed. In Finland, approximately 13,000 TKAs were performed in 2020. Given the projections that the incidence of TKA will increase, this causes a significant burden to health care, even though TKA is a cost-effective procedure. Despite enhancements in surgery and postoperative care, up to 20 percent of patients are dissatisfied following TKA. High-level evidence regarding the effects of a widely used surgical tourniquet, and spinal anesthesia (SA) or general anesthesia (GA) on patient recovery, patient-reported outcomes, and patient satisfaction with TKA remains scarce. This trial aimed to determine the optimal combination of tourniquet and anesthesia methods used during TKA regarding immediate recovery, patient-reported and functional outcomes, adverse events, and patient satisfaction with TKA in a 12-month follow-up. Methods We conducted a randomized trial comprising 404 patients aged 18–75 years with Kellgren-Lawrence Grade 3 or 4 OA, body mass index (BMI) ≤ 40, American Society of Anesthesiologists (ASA) Class I–III, and eligible for elective fast-track TKA. The trial was conducted in a single tertiary care arthroplasty center in Helsinki University Hospital between October 2016 and December 2019. We evaluated the effect of tourniquet (T) or no tourniquet (NT) use, and the effects of SA and GA on postoperative oxycodone consumption with patient-controlled analgesia (PCA) in the first 24 hours, surgical and tourniquet times, blood loss, postoperative pain and nausea, length of stay (LOS), adverse events, knee range of motion (ROM), patient-reported outcome measures assessed using the Oxford Knee Score (OKS), health-related quality of life (HRQoL) using the 15D tool (15D), prolonged pain using the Brief Pain Inventory short form (BPIsf), and patient satisfaction with TKA. Study I describes the previous literature and rationale for our study, as well as a rigorous and detailed research protocol and statistical analysis plan. Study II describes the in-hospital results of the studied regimens regarding postoperative oxycodone consumption with PCA in the first 24 hours as a primary outcome and postoperative pain and nausea, surgical blood loss, in-hospital complications, and LOS as secondary outcomes. Study III, comprising 391 patients, discusses the 3- and 12-month functional outcomes of the operated-on knees assessed with OKS as a primary outcome. Secondary outcome measures included operative and tourniquet times, adverse events, ROM, the proportion of patients reaching OKS minimal important change (MIC) and OKS patient acceptable symptom state (PASS), satisfaction with TKA and anesthesia methods, and HRQoL assessed with 15D. Study IV, a comparative retrospective analysis, describes the etiological factors and patient-reported outcomes on patients with a postoperative stiff knee who underwent manipulation under anesthesia (MUA) three months after TKA. The patients of Study IV comprised the prospective patient cohort of the original Studies II and III. Main results In Study II, comprising 395 patients, we found no significant differences between the groups regarding the cumulative oxycodone consumption in the first 24 hours postoperative. Additionally, pain at 24 hours postoperatively, blood transfusion rates, in-hospital complications, or LOS between the two-group (NT vs. T and SA vs. GA) or the four-group (NT/SA, T/SA, NT/GA, and T/GA) comparisons did not differ. Tourniquet use decreased blood loss, but it did not have a significant effect on blood transfusion rates. Postoperative nausea and vomiting (PONV) incidence was higher in the SA group than in the GA group but without affecting general recovery. In Study III, comprising 391 patients, in the two-group comparisons, the NT group reached OKS PASS more seldom than the T group (77.0% vs. 84.8%, odds ratio [OR] 0.59, 95% confidence intervals [CI] 0.35–0.997, p = 0.049). Surgical time, adverse events, total OKS, and 15D score at 12 months postoperatively did not differ regardless of tourniquet use. The SA group reported more substantial improvement in OKS (16.21 vs. 14.1, mean difference 2.13, 95% CI 0.55–3.71, p = 0.008) and 15D score (0.051 vs. 0.033, mean difference 0.016, 95% CI 0.003–0.030, p = 0.019). In addition, the SA group had a higher proportion of patients reaching OKS MIC (91.7% vs. 81.7%, OR 2.49, 95% CI 1.32–4.69, p = 0.005) and OKS PASS (86.0% vs. 75.7%, OR 2.00, 95% CI 1.18–3.39, p = 0.010), than the GA group. Satisfaction with the anesthesia method used during TKA was very high in both groups without significant difference. Surgical time, adverse events, and 15D score at 12 months postoperatively did not differ significantly. In the four-group comparisons, patients in the T/SA had the most substantial improvements in OKS (16.82) and the highest proportion of patients reaching OKS MIC (95.7%) and OKS PASS (92.6%). Regarding 90-day adverse events and 15D score at 12 months postoperatively, we found no significant differences between the four groups. In Study IV, we found a 10% incidence of MUA (39/391). A younger age, higher preoperative pain severity scores assessed using BPIsf, and higher postoperative in-hospital opioid consumption seemed to be prognostic factors for MUA. Patients with stiff knees gained significant ROM benefit from MUA performed at three months postoperative (mean gain of 39 degrees). The final OKS at 12 months after TKA in MUA patients was comparable to patients without postoperative stiff knees (42.0 vs. 43.0, p = 0.15). No MUA-related complications appeared. The final ROM at the 12-month follow-up in the MUA group was approximately ten degrees less (115 vs. 124, p = < 0.001) than in the no-MUA group. Conclusions We found the use of a surgical tourniquet and both anesthesia regimens safe in TKA without clinically significant differences in terms of surgical time, postoperative pain, the number of blood transfusions, LOS, adverse events, total OKS, and quality of life assessed using 15D at 12 months postoperatively. According to these results, a surgical tourniquet has no detrimental effect on the outcomes of TKA. The patients undergoing TKA benefit from SA in terms of improvements in OKS and 15D score. At the 12-month follow-up, T/SA resulted in the most substantial improvements in OKS and had the highest proportion of patients reaching OKS MIC and OKS PASS. Patients with postoperative stiff knee benefit from MUA performed three months postoperatively. In a 12-month follow-up, the patients who received MUA resulted in nearly comparable functional outcomes to patients who did not have postoperative stiff knee.
  • Pradhan, Barun (Helsingin yliopisto, 2021)
    Transposable elements (TEs) comprise almost half of the human genome because of their mobile activity during genome evolution. Although most families of TE are currently inactive in the human genome, one young TE family called Long Interspersed Nuclear Element (LINE)-1 is found to be active in germ cells, during embryonic development, and in diseases such as cancer, especially epithelial cancer types. LINE-1 is an RNA transposon (retrotransposon) which means it moves from one genomic location to another via an RNA intermediate by a process called retrotransposition. By following this replicative cycle, LINE-1 has already made more than 500,000 near-identical copies of itself and hence occupied 17% of the human genome. However, most of these copies have accumulated inactivating mutations and/or truncations and are retrotransposition-incompetent. The diploid genome in an individual is estimated to have only 80-100 potentially active LINE-1s. These potentially active LINE-1s are epigenetically silenced in normal cells. Widespread epigenetic modification during cancer alters this silencing mechanism and activates these LINE-1s which have the potential to generate mutagenic insertions in the genome. Detection of de novo LINE-1 insertions among more than 500,000 pre-existing LINE-1 copies remains challenging. To address this unmet need, we developed a novel PCR-based method that detects de novo insertions originating from one of the most active LINE-1 loci in the human genome (located within the TTC28 gene, hereafter referred to as TTC28 LINE-1). Compared to whole-genome sequencing (WGS), this approach is substantially more sensitive, identifying nearly three times more de novo TTC28 LINE-1 insertions in two colorectal cancer samples. Moreover, by taking advantage of long-read single-molecule sequencing, we were able to characterize de novo LINE-1 insertions in their entirety at nucleotide-level resolution. Using uterine leiomyoma as the disease model, we show that LDI-PCR is also suited for detecting DNA rearrangements in rearrangement-prone genomic regions with high sensitivity. Next, we traced the activity of TTC28 LINE-1 in a panel of ten high-grade serous ovarian carcinoma (HGSOC) cell lines, five of which were proficient for homologous recombination (HR), an error-free DNA double-strand break repair pathway, and the other five were HR-deficient. Although TTC28 LINE-1 mRNA was expressed in all HGSOC cell lines, HR-proficient HGSOC cell lines showed a higher frequency of de novo TTC28 LINE-1 insertions in comparison to HR-deficient cell lines. We speculate that the simultaneous loss of HR-mediated DNA repair and gain of LINE-1 activity (which generates DNA double-strand breaks as part of the insertional process) could be detrimental to HR-deficient cell lines. HR-proficient cell lines, in contrast, might tolerate LINE-1 activity and thus have accrued more de novo LINE-1 insertions. Altogether, this thesis provides a highly sensitive method to detect and characterize de novo LINE-1 retrotransposition events. By employing this approach, this thesis also demonstrates that LINE-1 retrotransposition is more frequent in HGSOC cell lines that are proficient in repairing DNA double-strand breaks by the HR pathway.
  • Raju, Sajan (Painosalama, 2019)
    The human microbiota, i.e. the microbes living in or on humans, plays an important role in health and disease. Lifestyle factors, such as diet and physical activity as well as environmental factors, and exposure to antimicrobials (AMs) are likely among the important factors shaping the microbiota. Several studies have reported that the gut microbiota may be associated with overweight and obesity. Fewer studies have investigated associations between body mass index (BMI) and the salivary microbiota. There is a worldwide epidemic of obesity and the number of overweight and obese people reached 1.9 billion in 2016. Overweight and obese children are likely to stay obese into adulthood and tend to develop diseases more frequently and at a younger age. Thus, identification of the associations between microbiota and body size in young individuals are of great importance. The increased use of AMs rises concern of increasing antibiotic resistance resulting in lack of treatment options for many diseases. Exposure to AMs affects the microbial diversity and composition in the gut microbiota, but less is known about salivary microbiota. Since AM use is frequent in children, it is vital to study its associations with saliva microbiota at this age. The objectives of this doctoral thesis were to develop cost effective protocols to assess the salivary microbiota profiles for large-scale epidemiological studies and, with the new protocol, to determine its association with body size and lifetime antimicrobial use in children. In this thesis, all in-house 16S amplicon assays produced similar salivary microbiota profiles for the individual samples, i.e. there was no superior protocol. Salivary microbiota profiles of Finnish children were gender-specific in terms of alpha- and beta-diversity and relative abundances of bacteria. A prominent finding was the decrease in the core bacteria in overweight and obese children. Lifetime AM exposure to saliva microbiota showed that Azithromycin use was associated with alpha-diversity in all children, and in girls. Microbiota dissimilarities were significant between children with low, medium and high number of AM user groups in all children with all AMs combined. Similar trend was significant with Azithromycin use, whereas Amoxicillin use affected the dissimilarity only in boys. This thesis suggests that the saliva microbiota is significantly associated with body size, antimicrobial use and gender in Finnish children. Thus, saliva microbiota profiles open new possibilities to study the potential roles of microbiota in weight development and management in children. In addition, the involuntary consequences of lifetime AM use are a concern and the importance of microbiota in the development of new therapeutic strategies should be emphasized in order to limit the use of AMs wisely. Studies have shown that the saliva microbiota is more resilient and stable than gut microbiota when exposed to antibiotics. Thus, the saliva-based screening of microbial biomarkers in health surveillance, and the associations with oral and general health status, may be considered feasible, simple, economical and easy to collect with high compliance for all age groups compared to faecal samples. However, further research on metabolic and functional potential of saliva microbiota is needed to fully understand the saliva microbiota – host relationship.
  • Matilainen, Sanna (2019)
    Leigh syndrome is a progressive mitochondrial encephalopathy manifesting in early childhood, with characteristic symmetric lesions of the brainstem and basal ganglia, and a spectrum of clinical findings. Often multi-organ manifestation is known to occur. The genetic background of Leigh syndrome is exceptionally wide, with over 75 known disease genes affecting mitochondrial function, in both the mitochondrial and nuclear genomes. The molecular characteristics of this clinically and genetically heterogenetic disease, however, remain largely unknown. In this study genetic diagnoses were found for patients with Leigh syndrome and the underlying molecular pathomechamisms were studied. The disease found in two families was caused by a novel Scandinavian founder mutation in SUCLA2, causing deficiency of succinyl-CoA ligase (SCL) of the TCA cycle, a central metabolic pathway. The substrate for the reaction catalyzed by SCL is succinyl-CoA, also serving as the substrate for succinylation, a recently characterized post-translational modification with yet unknown biological significance. These results show SCL deficiency to lead to increased protein succinylation via accumulation of succinyl-CoA in cell lines of patients. Metabolic disturbances caused by the succinylation of hundreds of target lysine residues, found on a wide range of metabolic proteins in nearly all cell compartments, propose succinylation as a mechanism for the simultaneous control of several metabolic pathways. Also, defects of the mitochondrial polynucleotide phosphorylase (PNPase) caused by PNPT1 mutations were established among the causative mechanisms of Leigh syndrome with next-generation sequencing in one patient with a progressive Leigh encephalomyopathy. Defective mitochondrial RNA metabolism due to loss of RNA degradation activity of PNPase is shown as a novel mechanism for mitochondrial disease. The paths to molecular diagnoses for the patients in this study portray the recent advancements of molecular and genetic diagnostics, which have developed dramatically with the era of next-generation sequencing methods. Genetic diagnoses were provided for patients with Leigh syndrome of unknown molecular etiology, crucial for the well-being of the families and treatment of the patients. Simultaneously, patient-derived cell lines and tissues with a disarrangement of mitochondrial metabolism were utilized to increase our understanding of the related metabolic pathways and mitochondrial metabolism.
  • Grotenfelt, Nora Elisabeth (Helsingin yliopisto, 2019)
    The global prevalence of gestational diabetes (GDM) is around 14%, with increasing numbers over the last decades. In 2017, 19% of all pregnancies in Finland were affected by GDM. Despite treatment, GDM is associated with several short- and long-term adverse health outcomes for both the mother and the child. The short-term effects include an increased risk of large-for-gestational-age babies, birth injuries, Caesarean sections, and neonatal hypoglycemia. The long-term consequences include an increased risk of type 2 diabetes for the mother, and an increased risk of overweight, obesity, metabolic syndrome, and type 2 diabetes for the offspring of GDM pregnancies. Over the recent years, several studies designed to reduce GDM have been published. So far the results are inconclusive. Moreover, there is a shortage of studies assessing the effects of prevention of GDM on the long-term health of the offspring. The aim of this study was to assess women at high risk for GDM considering their clinical characteristics, genetic variance, and time of GDM diagnosis, and to determine the effect of a lifestyle intervention aiming at GDM prevention on long-term offspring health outcomes. This thesis includes four studies. Studies I and II are substudies and Study II is a secondary study of the RADIEL GDM prevention trial, conducted in 2004-2008, assessing maternal outcomes until delivery. Study III includes assessment of neonatal data. In the original RADIEL trial, a total of 720 women with a body mass index (BMI) ≥ 30 kg/m2 and/or a history of GDM in a previous pregnancy were enrolled either before conception or in early pregnancy and allocated either to a lifestyle intervention or a conventional-care group. The intervention focused on both diet and physical activity. Study IV is a substudy of the RADIEL five-year follow-up study (2013-2017), into which all participants of the original RADIEL trial with a viable singleton pregnancy and at least one study visit during pregnancy were invited five years after delivery along with their children. We detected pronounced differences in GDM occurrence between participants with different clinical characteristics. In addition, the effect of the intervention on GDM occurrence differed according to genetic variance. The findings suggest that GDM is a heterogenous disorder, consisting of subgroups that differ markedly regarding both fenotype and genotype. Our lifestyle intervention, delivered by trained nurses to a heterogeneous group of high-risk women enrolled either in early pregnancy or before conception, was not associated with positive effects on metabolic health in the offspring. The value of these findings is the increased knowledge of GDM heterogeneity, useful when improving the screening of GDM and the targeting and cost-effectiveness of future interventions and treatment.
  • Koskinen, Suvi (Picaset Oy, 2019)
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  • Petäjä, Liisa (2019)
    Annually world-wide, 17.7 million people die of cardiovascular diseases. Cardiac surgery is performed to improve patients’ prognosis and alleviate their symptoms. However, these challenging procedures have inherent risks, including cardiac and renal injury. The objective of this study was to investigate, by biomarkers and risk models, cardiac surgery-related cardiac and renal morbidity, and their association with prognosis. A systematic search, review and meta-analysis were performed to find out the relationship of postoperative injury markers after coronary artery bypass grafting (CABG), and mortality. Additionally, two cohorts, 428 CABG and 220 other cardiac surgical patients, were enrolled to a prospective study. The associations of pre- and postoperative high-sensitivity troponin (hs-TnT) with postoperative major adverse events (MAE) and mortality were explored. Whether these biomarkers offer additive information for an established risk model, EuroSCORE II, was detected. Acute kidney injury (AKI) was defined by complete Kidney Disease: Improving Global Outcomes (KDIGO) criteria including serum creatinine and urine output (UO). The associations of AKI stages and the separate criteria with long-term mortality was assessed in the two cohorts as one. Finally, a recently published risk model predicting cardiac surgery-associated AKI (CSA-AKI), named AKI Risk Score, was validated in this cohort. The potential benefit of adding preoperative biomarkers, hs-TnT and N-terminal pro-B-type natriuretic peptide (NT-proBNP), to AKI Risk Score, was evaluated. Postoperative CK-MB releases after cardiac surgery were related to increased mortality until 3 years. Even though troponins seemed better predictors, the assays lack standardization, and this remains a problem in generalizing the results. Elevated preoperative hs-TnT determined the meaning of first postoperative day hs-TnT in all cardiac surgery. It was related to long-term mortality regardless of postoperative hs-TnT in cardiac surgery other than plain CABG. Adding hs-TnT to EuroSCORE II yielded to better prediction of MAE in all cardiac surgery, and to better prediction of half-a-year mortality in at least cardiac surgery other than plain CABG. AKIs, diagnosed by separate criteria of KDIGO, were all associated with 2.5-year mortality, even AKI diagnosed by only urine output. AKI by KDIGO stages was associated with increased mortality, related to severity. The excess mortality associated with AKI was not predicted by EuroSCORE-based risk of mortality or risk factors for AKI. AKI Risk Score performed acceptably in Finnish cardiac surgical patients. Adding preoperative biomarkers to the score yielded to no clear clinical benefit. A thorough analyses of the added value of the biomarkers, by risk assessment plot and estimation of net benefit, is warranted to reveal true potential of the biomarkers.
  • Semenova, Svetlana (2019)
    The neurotransmitter dopamine is involved in the regulation of diverse functions of the nervous system, from reward processing and motor control to cell proliferation. The zebrafish dopaminergic system is an outstanding research object for research on nervous system disorders, especially for neurodevelopmental and neurochemical studies. The present work was focused on the distinct roles of the tyrosine hydroxylase genes in the development of the zebrafish nervous system, and on the previously unexplored features of COMT enzymes and genes in the zebrafish. An antibody was generated to detect zebrafish TH2, a tyrosine hydroxylase that had remained overlooked for a long time. As the new antibody recognized both TH1 and TH2 proteins, it was used together with a validated commercial anti-TH1 antibody to map the entire dopaminergic network in the zebrafish brain and to characterize the responses of TH2-expressing cells to various stressful stimuli. TH2-expressing cell groups were found in the preoptic area (group 3b), paraventricular nucleus of the hypothalamus (group 8b) and nuclei of the lateral and posterior recesses of the caudal hypothalamus (groups 9b and 10b). Cells of groups 9b and 10b were intermingled with serotonin-containing cells, but no (serotonin+TH2)-immunopositive cells were detected. Chemical and social stress induced cell activation in distinct regions of the brain, including the caudal hypothalamus, as inferred from c-fos expression, but only a small fraction of TH2 cells was activated. Dopaminergic regulation of histaminergic neuron development was assessed in pharmacological and gene knockdown experiments. Knockdown of the th1 gene by morpholino oligonucleotide injection reduced histamine and orexin neuron numbers in zebrafish larvae, whereas th2 gene knockdown increased cell numbers in these populations. These opposite effects may be due to the different spatiotemporal expression patterns of the two th genes in the zebrafish.Wnt signaling was implicated in the regulation of cell numbers. Similar patterns of expression of zebrafish comt-a and comt-b genes and a broad distribution of COMT enzymatic activity in zebrafish tissues was demonstrated. High activity and expression levels were detected in the brain, liver, and kidney. Treatment with an inhibitor of COMT did not lead to increased dopamine concentrations in zebrafish larvae, but it shifted the balance of dopamine inactivation towards the oxidation pathway catalyzed by monoamine oxidase Dopamine degradation in the zebrafish was shown to have many features in common with that in other vertebrates. Anti-TH2 antibodies were developed and characterized as tools for imaging studies in zebrafish, and possibly in other fish species. Distinct roles of TH1- and TH2-producing cells in the regulation of brain development were revealed. The thesis demonstrated that enzymes with similar biochemical functions in dopamine synthesis but different spatiotemporal expression patterns may make fundamentally different contributions to the regulation of brain development.
  • Lahtela, Elisa (Picaset, 2018)
    Sarcoidosis is a systemic, granulomatous disease of unknown etiology. Clinical phenotypes range from resolved to persistent disease, leading to the hypothesis that sarcoidosis might not be one disease, but consists of several disease entities each with distinct genetic associations. Many immunological genes have been found to associate with sarcoidosis and many of these loci have been shown to be shared among other immune-mediated diseases. The strongest association is found for the Major Histocompatibility Complex (MHC) genes. In Finnish patients, subjects with good prognosis sarcoidosis are more likely to have the MHC markers HLA-DRB1*03:01 and/or HLA-DRB1*04:01-DPB1*04:01 haplotype, but no diagnostically applicable markers have been found. The overall aim of this thesis was to find genetic variants predisposing to different phenotypes of sarcoidosis, to help distinguish the disease phenotype at the early stages of the disease. This aim was assessed by candidate-gene analysis in the angiotensin converting enzyme (ACE) gene in chromosome 17 (I) and in the MHC II and III regions (II). Marker combination of the MHC and ACE was analyzed to evaluate more powerful prognostic markers (III) and finally, the study was extended throughout the genome by utilizing whole-exome sequencing (IV). In study I, the single nucleotide polymorphisms (SNPs) were genotyped from the ACE gene region. These SNPs included the tag SNP for insertion/deletion (I/D) polymorphism, previously known to associate with the prognosis of sarcoidosis. No association was detected with I/D genotypes, but a novel SNP (rs9905945) was found to be moderately associated with favorable disease. In study II, SNPS from the MHC II and III regions (AGER, LTA, TNF, BTNL2 and HLA-DRA) were genotyped and the study was conducted as a joint analysis in four study populations (Finnish, Swedish, Dutch and Czech). Due to high linkage disequilibrium (LD) in the MHC, the independent association from HLA-DRB1 alleles was evaluated and the functionality of these SNPs was assessed by expression quantitative trait loci (eQTL). Three SNPs in the HLA-DRA/BTNL2 region were found to associate with persistent disease and one SNP in the same region with resolved disease when compared to controls. In study III, the combination of previously found good prognosis HLA markers was assessed with the ACE SNP (I). The strongest association for good disease prognosis was found for a combination of either/or both HLA markers and ACE SNP. In study IV, whole-exome sequencing was conducted. A genetic region was found in chromosome 1p36.21 (AADACL3 and C1orf158), in which an association has recently been found in another WES study. In our study, these genes were found to associate with resolved disease. In conclusion, a novel SNP in the ACE gene was discovered with prospective, although moderate and population-specific association with favorable disease prognosis. Our findings further establish that polymorphisms in the HLA-DRA and BTNL2 in the MHC region have a role in sarcoidosis susceptibility. However, this study did not bring prognostic information to be used in clinical practice. Interestingly, the combination of the ACE SNP and the previously found HLA-DRB1 markers enhanced the accuracy for predicting disease course. The whole-exome analysis revealed genetic regions which associated with disease prognosis in Finnish sarcoidosis. Together all these studies further characterize genetic differences among Finnish sarcoidosis patients with different prognosis.
  • Koskinen, Hanna (Kela, 2018)
    This study examines the impact of the implementation of a generic reference price system on pharmaceutical prices and competition within the market. The focus is particularly on antipsychotic medications. Furthermore, the impact of reference pricing on previously implemented generic substitution is assessed. Antipsychotics and antidepressants were, in terms of value, among the fastest growing pharmaceutical groups in Finland at the turn of the 21st century. For antipsychotics, most of the cost growth resulted from the rise in the mean daily cost of treatment, whereas the main reason for antidepressant cost growth was the increased number of patients. The implementation of reference pricing decreased the daily cost of the studied antipsychotics. The decreases ranged from 30% to 66% in the short term and from 25% to 51% in the medium-to-long term. When the study was extended to other pharmaceutical groups, the average decrease was 35% at the end of the first year, 56% at the end of the second year and 60% at the end of the third year. However, there were large differences in the size of the decrease between groups. Being included in the reference price system had the largest decreasing impact on prices. However, the reference price system’s impact on prices appeared to be waning; the later an active substance was included in the system, the higher the price level remained. In addition, the impact of the reference price system on previously implemented generic substitution remained low, and 2.5 years after the implementation of the reference price system it was almost non-existent. Generic pharmaceutical markets are highly concentrated in Finland. In addition, there is an overall lack of transparency in the pharmaceutical distribution chain. Further research is needed on the barriers of entry and on the role different operators of the pharmaceutical distribution chain have in promoting price competition in the generic market sector.
  • Hafez, Ahmad (2018)
    Background: Management strategies for brain arteriovenous malformation (AVM) remain controversial. AVM resection is the optimal, definitive treatment, if performed with little risk of consequences and complications. The aim is to evaluate the features, surgical treatment, results, and outcomes of AVMs. Patients and methods: Six operative cases from the University of California, San Francisco, were selected to demonstrate the surgical technique used in and results of a contralateral anterior interhemispheric approach (CAIA) to medial frontal AVMs. We also analyzed the clinical and radiological data from a database of 805 consecutive patients. They were treated between 1942- 2014” and diagnosed with AVM at the Department of Neurosurgery of the Helsinki University Hospital, which served Southern Finland. We focused a defined subgroup of the whole study in each part of this study. A detailed analysis of 59 surgically-treated ruptured supratentorial AVMs was conducted, focusing on the time elapsed before surgery as a unique factor for the outcome. A novel Supplementary Spetzler-Martin Grading System (also known as Lawton-Young Grading Scale) was applied to predict outcomes of AVM surgery on 200 patients admitted between 2000- 2014; results were then compared to the more classical Spetzler-Martin scale. Results: A CAIA to access medial frontal AVMs is a safe alternative to the ipsilateral approach, in certain circumstances. Elapsed time (as a sole factor) between rupture and surgery did not affect early or final outcomes. Many other factors played more significant roles than timing in long-term outcomes for surgically-treated, ruptured supratentorial AVMs. For cases with poor final outcomes, associated aneurysms, high Hunt and Hess (H&H) grades, and more than 400cc of bleeding during surgery were significant factors. For predicting surgical outcome for AVMs, performance of the Supplementary Spetzler-Martin Grading System was superior to original Spetzler-Martin Grading Scale in short- and long-term follow-ups. Deep perforator supply, which is not part of either the scale, proved to be an important factor influencing outcomes. Conclusions: Microsurgery is the treatment of choice for a considerable number of brain AVMs. Certain locations and vascular features of brain AVMs could necessitate contralateral approaches. For ruptured AVMs, the elapsed time before surgery has no significant influence on the outcome. Application of the Supplementary Spetzler-Martin Grading System in patients with brain AVMs improves prediction of surgical outcomes better than the original Spetzler-Martin grading system.
  • Katajisto, Milla (Unigrafia, 2017)
    Chronic obstructive pulmonary disease (COPD), mainly caused by inhaling tobacco smoke, is very common an the main symptom is slowly proceeding dyspnoea, which often reduces a patient’s physical activity. Physical inactivity in COPD relates to poor prognosis and lower quality of life. Pulmonary rehabilitation (PR), based on exercising, has been proven to be an effective intervention among COPD patients. One of the aims of this study was to evaluate physical activity among Finnish COPD patients, to better understand the reasons behind activity or inactivity and their interest in exercise-based PR, in order to improve their care in the future. The patient cohort of the Chronic Airway Disease (CAD) study made it possible to study physical activity in relation to quality of life and severity of disease, among other characteristics. A questionnaire asking about exercise habits, daily activities and patient history regarding sports and rehabilitation was sent to all COPD study patients in spring 2010. The main result was that dyspnoea was more severe among the inactive patients, even when adjusted to the forced expiratory capacity in one second (FEV1). Dyspnoea was also the main subjective obstacle to exercising. The study patients had given their consent to allow the study of their registries for medication purchases. The reimbursement registry of the National social insurance office made it possible to track the study patients' COPD drug medication in the same year that their physical activity status was evaluated. Episodes of severe exacerbation and pneumonia were also of interest, in relation to medication and physical activity. The result of this investigation was that the maintenance medication did not differ significantly among active and inactive patients; however, inactive patients suffered more from severe exacerbations and needed more rescue medication, antibiotics and oral steroids. Only half of the patients reached the daily defined dose (DDD), a dose considered relevant in care. During 2010 to 2013, PR was started with special funding available for workers of the Helsinki and Uusimaa (HUS) district, to development of new type of care for patients. Patients with COPD from Helsinki university hospital, who had severe disease, were included and the majority of them had a history of hospital admissions. The primary aim of the third study of this thesis, was to evaluate the short-term and long-term results and also to evaluate the cost effectiveness. The patients performed well in the PR programme, their test results improved as expected, and the hospitalisation days during the year after PR were less than half of the number of hospitalisation days during the year before.The secondary aim was to gather information, which so far had been lacking, about the occurrence of serious exacerbations in the Helsinki; in this district. Data for every hospital admission with the COPD ICD-code year 2014 were collected from eMr and the patient’s COPD diagnosis and the cause of hospital stay was evaluated. The data showed that there were 437 patients with severe exacerbations; 3 out of 4 of whom were treated in city hospitals and none of them was offered PR. The rate of readmissions due to exacerbations was 50% and total mortality during the year was 41%.Understanding of the importance of physical activity or exercise-based PR in treatment for COPD is not sufficient in health care. Access to PR should be made possible for all patients in need, inparticular for patients with severe COPD exacerbations.
  • Haikala, Heidi (2017)
    MYC is a transcription factor and a proto-oncogene, which is overexpressed in almost 50% of all breast cancers. Cell cycle promoting oncogenic MYC supports the altered energetic needs of continuously proliferating cancer cells, since there is an immense requirement for nucleic acids, proteins, and lipids to support the cell division. MYC supports the metabolic switch by enhancing the main nutrient (glucose and glutamine) uptake, increasing glycolysis and glutamine utilization, as well as by instructing the normally ATP generating citric acid cycle to serve biosynthetic growth promoting reactions. In this study we found that the metabolic changes induced by MYC lead to decreased production of ATP and the consequent activation of a key cellular energy sensor protein AMP-activated kinase (AMPK). AMPK is a metabolic guardian, which instructs cells to perform catabolic reactions to restore the ATP levels. However, persistent AMPK activity directs MYC-transformed cells towards apoptotic cell death. We found that MYC-activated AMPK phosphorylated the tumor suppressor protein p53, which accumulated on the mitochondrial surface. In the mitochondria, p53 primed the cell death promoting protein BAK for apoptotic cell death induction, thus connecting MYC-driven metabolic transformation to apoptotic sensitivity. In addition, we discovered a novel synthetic lethal and potentially druggable interaction between MYC activation and inhibition of a small GTPase RhoA. We found that RhoA assists MYC to upregulate glutamine metabolism, which highlights the relevance of metabolism as a sweet spot for targeting oncogenic MYC. Furthermore, we found that supraphysiological, highly expressed MYC is globally repressing the transcriptional targets of serum response factor (SRF), a RhoA downstream target, thus exposing new pathways needed for cancer cell survival. In addition, the same study contributed to a finding that supraphysiological MYC represses a set of genes related to luminal identity of breast epithelial cells, which possibly affects the cell differentiation and apoptotic sensitivity in vivo. The described mechanisms suggest a possible answer to the old paradox why cancerous MYC expression levels, but not physiological MYC, sensitize cells to apoptosis. Finally we studied how the altered metabolism-derived sensitivity to apoptosis could be exploited as a potential therapeutic strategy to kill MYC expressing cancer cells. In a rationalized drug combination screen, we found that the pharmacological superactivation of AMPK is able to potentiate the anticancer activity of apoptosis targeting therapies, which usually do not show great efficacy in solid tumors as single agents. The described combination proved substantial efficacy against highly MYC expressing breast cancer models in vitro, in vivo and in ex vivo. Thus, we describe the first pharmacological MYC apoptosis activation strategy that could be easily translated to the benefit of breast cancer patients, and currently clinical trials to test the combination are under consideration. In addition to the described scientific findings, the ex vivo and in vivo preclinical research models of breast cancers developed during this study are likely to serve breast cancer research community by providing more predictive and more translationally relevant platforms for studies of breast cancer biology and drug discovery.
  • Boyd, Sonja (Unigrafia, 2017)
    Primary sclerosing cholangitis (PSC) is particularly common in the Nordic countries. Most (70-80%) PSC patients have concomitant inflammatory bowel disease (IBD). The majority of patients are male. Increased levels of serum cholestasis markers in IBD patients lead to PSC suspicion, and diagnosis is verified with magnetic resonance cholangiopancreatography or endoscopic retrograde cholangiography (ERC). PSC patients usually become symptomatic over time, and PSC may lead to liver fibrosis and finally to cirrhosis. Cholangiocarcinoma (CCA) develops in 7-13% of PSC patients. The prognosis of CCA is poor. Dysplasia of the bile ducts is thought to precede the development of CCA. Liver transplantation (LT) may be performed in end-stage PSC cirrhosis, but premalignant biliary changes may also be a partial indication for LT even if the patient is asymptomatic. At Helsinki University Hospital, PSC patients regularly undergo systematic dysplasia surveillance with ERC and brush cytology (BC) to detect dysplastic changes of the bile ducts and to determine disease progression. ERC changes are graded according to the modified Amsterdam ERC score. If suspicion of dysplasia is repeatedly seen in BC, patients are referred to liver surgeons for consideration of LT. Our aims were to evaluate the relevance of the screening protocol at PSC diagnosis and later during the disease course to identify risk factors for biliary neoplasia, and to evaluate the utility of ERC, BC and ploidy analysis of biliary epithelium in detecting biliary neoplasia. In their first, diagnostic ERC (n=261), 81% of PSC patients were asymptomatic, but 43% already had advanced ERC changes. Seven percent had malignancy or malignancy suspicion in BC. Those who had elevated liver enzymes and advanced ERC changes were most likely diagnosed with biliary neoplasia during follow-up. Female patients had milder ERC changes and a lower cumulative risk of biliary neoplasia. During the follow-up period (median 4.7 years), 2.7% were diagnosed with CCA and 3.1% with biliary dysplasia. Independent risk factors for biliary neoplasia were elevated extrahepatic ERC score, suspicious/malignant BC and elevated serum alanine aminotransferase. During surveillance (median 6 years) with ERC and BC, 3.8% out of 447 PSC patients were diagnosed with CCA, and 5.1% had dysplasia in the explanted liver. ERC score, male gender, elevated liver enzymes, serum tumour markers, suspicious BC and inflammation or aneuploidy in BC were risk factors for CCA. All patients with biliary neoplasia had intra- and extrahepatic ERC changes. 126 PSC patients underwent liver transplantation in Helsinki University Hospital during 1984-2012, and 28% of these LTs were due to neoplasia suspicion for asymptomatic patients. The combined sensitivity of BC and ploidy analysis to detect biliary neoplasia was 68% with 86% specificity. The ten-year survival of asymptomatic patients after LT was 91%. Screening and surveillance of PSC patients with ERC and BC may help find patients that are most prone to develop CCA. Patients with advanced extrahepatic ERC changes and elevated liver enzymes are most likely to be later diagnosed with CCA. On the other hand, patients with intrahepatic ERC changes only have a negligible CCA risk. If BC is repeatedly suspicious, even asymptomatic patients should be referred to evaluation of LT.
  • Räsänen, Minna (Helsingin yliopisto, 2017)
    Aims: Rectal cancer, one of the most common cancers worldwide, causes significant mortality. After curative rectal cancer surgery, local recurrences (LR) are detected in 4-10% and distant metastases in 20-31% of the patients. For diagnosing recurrence, the surveillance is recommended, but the optimal frequency, length and methods are not well established. This study analysed the pattern of rectal cancer recurrence, the usefulness of surveillance and the different surveillance instruments available. Nowadays, low colorectal or coloanal anastomosis is performed whenever possible because most patients prefer anus-preserving surgery over a permanent stoma. The covering stoma is used to facilitate anastomosis healing and to protect against fatal complications. In this study, we determined the cumulative risk of and the risk factors for failure of low colorectal or coloanal anastomosis. In locally advanced rectal cancer, when the tumour has invaded the adjacent organs, a multivisceral en bloc -resection is needed. In these resections, morbidity and mortality are higher than in standard resections. An attempt is made to decrease tumour size by neoadjuvant long-course (LC) chemoradiotherapy (CRT); the goal is to achieve clear resection margins. The oncological results of multivisceral resections for rectal cancer were evaluated, as were the risk factors for LR and survival. The response to CRT seen in response magnetic resonance imaging (MRI) and the histopathology report was analysed. In addition, the usefulness of the response seen in MRI and the pathological specimen in predicting curative resection, risk of LR and survival was investigated. Neoadjuvant short-course radiotherapy (SCRT) has been reported to diminish the rate of LR. Anyhow, meticulous total mesorectal excision (TME) surgery has good local control without RT in so-called good T2-T3N0-1 tumours , and the use of SCRT has been questioned in many countries because of side-effects and uncertainty of utility. The aim of this study was to determine, whether SCRT prevents LR in pT3N1-2 patients compared with those operated on without RT. Patients and methods: A total of 952 rectal cancer patients were operated on at Helsinki University Hospital between January 2005 and June 2014. Study I comprised 481 consecutive rectal cancer patients treated with radical intention during 2005-2011. Study II comprised all patients (n= 273) operated on with anterior resection (AR) combined with low colorectal or coloanal anastomosis and covering stoma during 2005-2011. The Study III population consisted of 94 patients, operated on because of locally advanced rectal cancer by multivisceral resection between 2005 and 2013. In Study IV, 151 patients operated on because of pT3N1-2 rectal cancer during January 2005-June 2014 were included. Of these 151 patients, 57 did not have radiotherapy (RT) before the operation and 94 had received short-course RT before surgery. Data were retrospectively collected from patient records. Results: Local recurrence occurred in 8.3% and distant metastases in 23.3% of patients treated with curative intention. The median time to recurrence was 1.3 years after operation, and 75% of recurrences were diagnosed during the first two postoperative years. Recurrences were detected significantly earlier by the follow-up visits than by symptoms. All of the surveillance instruments used, were equally useful for finding recurrences. Curative re-operation was possible in 41.1% of patients with disease recurrence. The colorectal or coloanal anastomosis was switched to a permanent stoma in 23 (8.5%) of 271 patients. Protective stoma was not closed in five patients (1.8%). Total permanent stoma rate was 10.3%. The risk factors for failure of low colorectal or coloanal anastomosis were tumour location under 6 cm from anal verge, coloanal anastomosis, early anastomotic complication, anastomotic fistula, anal incontinence, and LR. After multivisceral resection, LR occurred in 10.6%. The median time for detecting a recurrence was 1.4 years (0.7-5.2). The 5-year overall survival (OS) for the whole population was 51.8% and for curatively treated patients (n=83) 59.2%; the 5-year disease-free survival (DFS) for the latter group was 64.2%. A significant risk factor for LR and survival was R1 resection. Poor or no response in post-treatment MRI predicted LR and also seemed to predict DFS in curatively treated patients. Of patients having pT3N1-2 rectal cancer, LR occurred in altogether 11.3%. The rate of LR in the surgery only group was 14% and in the RT + surgery group 9.6%. Risk factors in univariate analysis for LR were tumour location under 6 cm from anal verge, positive circumferential resection margin (CRM), tumour perforation and mucinous histology. In multivariate analysis, the risk factors were tumour location under 6 cm from anal verge and positive CRM. The short-course RT did not prevent LR. Conclusions: The most intensive follow-up should fall within two to three years for all patients treated with curative intent, and thereafter, only patients with known risk factors for recurrence should be followed. The risk of permanent stoma after low anterior resection in our study population was low, most probably due to routine use of covering stoma. Multivisceral resection is safe and has an over 50% 5-year OS and almost 90% local control. Poor response for CRT in post-treatment MRI predicts LR and seems to be associated with decreased DFS in curatively treated patients. Achievement of R0 multivisceral resection is most important concerning LR and also survival. Short-course radiotherapy did not affect LR risk in pT3N1-2 rectal cancer patients. Larger studies allowing analysis of subgroups with different T3 classes and N1 and N2 groups separately are needed to evaluate the role of short-course neoadjuvant radiotherapy in T3N+ tumours.
  • Hilander, Taru (Hansaprint, 2017)
    Proteins, consisting of amino acids, work as building blocks in the cells. In addition, they carry out vast amounts of cellular functions. Accurate protein synthesis is thus crucial for the normal function of cells. The first step of protein synthesis is the charging of transfer-RNAs (tRNAs) with their cognate amino acids. Evolutionarily conserved and extremely old proteins, aminoacyl-tRNA synthetases (aaRSs), carry out this step and each amino acid-tRNA pair has its own synthetase for the task. However, in some cases the amino acids are so similar in size and structure that they cannot be separated well enough by the aaRSs. To avoid mischarging and the subsequent protein misfolding, some of the synthetases have an editing domain, which recognizes and hydrolyses incorrect amino acid-tRNA pairs. In addition, cells have other important quality control mechanisms to ensure protein homeostasis, the capacity of cells to maintain internal stability of the proteome. Patient mutations in genes connected to protein synthesis and quality control are found to cause different diseases, the mechanisms of which are not yet, however, well known. Research on these topics is thus important. The aim of this thesis was to study the molecular mechanisms of different tRNA-charging defects and protein quality control mechanisms in both protein-translating compartments of a eukaryotic cell, cytosol and mitochondria. The first part of the thesis describes the molecular mechanism and the clinical phenotype of a special cytosolic tRNA charging defect caused by mutations in SEPSECS gene. The corresponding protein is involved in charging of the 21st amino acid, selenocysteine, to its tRNA. We identified mutations in this gene and showed them to lead to a decreased amount of selenocysteine-containing proteins, selenoproteins, in the brain of a patient with a severe early onset encephalopathy. Our study also indicated increased protein oxidation in the patient brain. This study extends the clinical phenotypes connected to SEPSECS mutations, and indicates that selenoprotein synthesis defect can resemble mitochondrial disease with lactate elevation. In the second part of this thesis, the potential of an amino acid analogue of arginine, canavanine, to induce protein misfolding in mitochondria was studied. The results demonstrated that mitochondrial protein translation machinery does not distinguish canavanine from arginine. The amino acid analog was incorporated into mitochondrially encoded proteins causing protein instability and formation of aberrant polypeptides. Surprisingly, however, canavanine did not induce mitochondrial unfolded protein response (UPRmt), a previously described signalling pathway induced by accumulation of misfolded proteins inside mitochondria. The study showed that none of the protein quality control mechanisms were able to solve protein misfolding caused by canavanine, which led to a severe respiratory chain defect. Canavanine has been used previously in a large number of studies to induce cytosolic protein misfolding, but the impact of canavanine for mitochondrial function has been largely ignored. Canavanine can be used in future as a tool to study further the consequences of protein misfolding in mitochondria, and for studying how mitochondria solve stalled ribosomes, which was also detected to be a consequence of canavanine in our study. The goal of the third part of the thesis was to study UPRmt in an animal model. The purpose was to generate a mouse model that has a mutation in the editing domain of mitochondrial alanyl-tRNA synthetase, leading to amino acid mischarging and formation of unfolded proteins inside mitochondria in vivo. The result of the study indicated for the first time the importance of amino acid editing by a tRNA synthetase as an essential quality control mechanism in mammalian mitochondria. The work presented in this thesis provides new information concerning the mechanisms of different tRNA charging defects and their consequences for the cell and organism. Special emphasis was on mitochondrial function.
  • Porkholm, Mikaela (Unigrafia Oy, 2017)
    Although most children with cancer can be cured, every fifth patient still succumb from their disease. The need for new treatments and more refined diagnostic methods are thus understandable. Angiogenesis, the formation of new blood vessels, is an essential phenomenon in many malignancies. The first study in this thesis evaluated the role of two regulators of angiogenesis, vascular endothelial growth factor (VEGF) and angiopoietin-2 (Ang-2), during allogenic hematopoietic stem cell transplantation (HSCT) in 67 children. High levels of VEGF and Ang-2 in plasma samples collected after allogenic HSCT correlated with severe acute graft-versus-host disease (GVHD). High Ang-2 post-HSCT was associated with increased non-relapse mortality and, together with concomitantly high VEGF, correlated with inferior event-free survival. However, methodological challenges should prompt cautious interpretation of these results. The second study summarized results of the anti-angiogenic Angiocomb protocol in the treatment of pediatric diffuse intrinsic pontine gliomas (DIPGs). The survival of study patients (N = 41) did not differ from that of controls (N = 8), but the ability to attend school or daycare and walk was maintained for a longer time after the diagnosis in the study cohort. The Angiocomb protocol was generally well tolerated, with the most frequent adverse event being neutropenia. The third study explored the effect of the Extended Angiocomb protocol in a cohort of 17 heavily pre-treated children with high-risk or end-stage malignancies. Although a significant increase in Karnofsky-Lansky performance scores occurred in patients during therapy, the protocol was more toxic than anticipated. This underlines the importance of careful patient selection and close monitoring during metronomic therapy in heavily pre-treated patients. The fourth study analyzed genetic alterations by next-generation sequencing and protein expression and microvessel density (MVD) by immunohistochemistry in 26 DIPG tumor samples. 87% of the patients had mutations in H3-K27M, excluding two rarely encountered long-term survivors. One of the long-term survivors had an IDH1 mutation, an alteration formerly considered to be absent in DIPGs. Angiogenesis-related genes were altered in 40% of the patients, whereas MVD showed up to 6-fold variation. The clinical significance of these findings requires further studies in the future.
  • Järvinen, Riikka (Unigrafia, 2016)
    Non-muscle-invasive bladder carcinoma (NMIBC) should be treated with a transurethral resection of the bladder tumour (TURBT). The need for an adjuvant intravesical treatment is evaluated after TURBT and is based on various tumour characteristics. The aim of the adjuvant intravesical treatment is to reduce the number of recurrences and the risk of progression. This thesis consists of four individual FinnBladder (FB) studies that compared different intravesical regimens of chemo- and immunotherapy among patients with intermediate- or high-risk NMIBC. The present thesis analyses the long-term results of those studies. Patients in these studies belonged to the intermediate- or to the high-risk group of NMIBC. Patients in study I were treated with mitomycin C (MMC) or bacillus Calmette-Guérin (BCG) instillations for up to one year, whereas the patients in study II had one perioperative plus four weekly MMC instillations followed by MMC or alternating MMC and BCG instillations. The patients in study III had one perioperative MMC plus four weekly MMC instillations followed by either BCG or alternating BCG and interferon-α2b (IFN) instillations. The patients of study IV had one perioperative epirubicin (EPI) followed by BCG or combination of EPI and IFN. The follow-up times of the patients that were still alive were between 8.0 (study IV) and 19.4 years (study II). The median follow-up times of all patients were between 7.2 (study II) and 8.6 years (study III). In study I, we found that BCG significantly reduced the time to recurrence but had no effect on progression, disease specific survival or overall survival compared to MMC. In study II, we found no difference between the study groups (one perioperative MMC and four weekly MMC followed by BCG or alternating MMC and BCG). However, the risk of dying of BC appeared to be markedly lower than observed in the series of untreated patients. In study III, we found that one perioperative and four weekly MMC instillations followed by a monthly maintenance with BCG significantly reduced the probability of recurrence compared to maintenance with alternating BCG and IFN. In study IV, we found that one perioperative EPI administration followed by five weekly BCG and a 1- to 2-yr BCG maintenance treatment was significantly better in reducing recurrence than was a combination of EPI and IFN using the same schedule. Two subgroup analyses of our studies revealed a lower probability of recurrence in patients that had been treated with a single perioperative chemotherapy instillation compared to those without the single instillation. The risk of progression was very low in the best treatment groups of our studies after 10 years, which might question the benefit of a recommended life-long follow-up for all patients. Three out of four patients who progressed died of BC despite the relatively meticulous follow-up. Better methods are still needed to recognize the progression in NMIBC early enough to be able to lower the mortality of this disease.

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