Matrix Metalloproteinases and their Tissue Inhibitors as Biomarkers in Ulcerative Colitis and Crohn s Disease

Matrix metalloproteinases (MMPs) represent a family of 23 metalloendopeptidases, collectively capable of degrading all components of the extracellular matrix. MMPs have been implicated in several inflammatory processes such as arthritis, atherosclerosis, and even carcinomas. They are also involved in several beneficial activities such as epithelial repair. MMPs are inhibited by endogenous tissue inhibitors of matrix metalloproteinases (TIMP). In this study, MMPs were investigated in intestinal mucosa of inflammatory bowel diseases (IBD), chronic intestinal disorders. The main focus was to characterize mucosal inflammation in the intestine, but also cutaneous pyoderma gangrenosum (PG), to assess similarites with IBD inflammation. MMPs and TIMPs were mainly examined in colonic mucosa, in adult Crohn s disease (CD), and paediatric CD, ulcerative colitis (UC), and indeterminate colitis (IC). Ileal pouch mucosa of proctocolectomized paediatric onset IBD patients was also investigated to characterize pouch mucosa. The focus was on finding specific MMPs that could act as markers to differentiate between different IBD disorders, and MMPs that could be implied as markers for tissue injury, potentially serving as targets for MMP-inhibitors. All examinations were performed using immunohistochemistry. The results show that immunosuppressive agents decrease stromal expression of MMP-9 and -26 that could serve as specific targets for MMP-inhibitors in treating CD. In paediatric colonic inflammation, MMP-10 and TIMP-3 present as molecular markers for IBD inflammation, and MMP-7 for CD. MMP expression in the the pouch mucosa could not be classified as strictly IBD- or non-IBD-like. For the first time, this study describes the expression of MMP-3, -7, -9, -12, and TIMP-2 and -3 in pouch mucosa. The MMP profile in PG bears resemblance to both intestinal IBD inflammation and cutaneous inflammation. Based on the results, MMPs and their inhibitors emerge as promising tools in the differential diagnosis of IBD and characterization of the disease subtype, although further research is necessary. Furthermore, the expression of several MMPs in pouch has been described for the first time. While further research is warranted, the findings contribute to a better understanding of events occurring in IBD mucosa, as well as pyoderma gangrenosum.

Patient doses in ct, dental cone beam ct and projection radiography in Finland, with emphasis on paediatric patients

Diagnostic radiology represents the largest man-made contribution to population radiation doses in Europe. To be able to keep the diagnostic benefit versus radiation risk ratio as high as possible, it is important to understand the quantitative relationship between the patient radiation dose and the various factors which affect the dose, such as the scan parameters, scan mode, and patient size. Paediatric patients have a higher probability for late radiation effects, since longer life expectancy is combined with the higher radiation sensitivity of the developing organs. The experience with particular paediatric examinations may be very limited and paediatric acquisition protocols may not be optimised. The purpose of this thesis was to enhance and compare different dosimetric protocols, to promote the establishment of the paediatric diagnostic reference levels (DRLs), and to provide new data on patient doses for optimisation purposes in computed tomography (with new applications for dental imaging) and in paediatric radiography. Large variations in radiation exposure in paediatric skull, sinus, chest, pelvic and abdominal radiography examinations were discovered in patient dose surveys. There were variations between different hospitals and examination rooms, between different sized patients, and between imaging techniques; emphasising the need for harmonisation of the examination protocols. For computed tomography, a correction coefficient, which takes individual patient size into account in patient dosimetry, was created. The presented patient size correction method can be used for both adult and paediatric purposes. Dental cone beam CT scanners provided adequate image quality for dentomaxillofacial examinations while delivering considerably smaller effective doses to patient compared to the multi slice CT. However, large dose differences between cone beam CT scanners were not explained by differences in image quality, which indicated the lack of optimisation. For paediatric radiography, a graphical method was created for setting the diagnostic reference levels in chest examinations, and the DRLs were given as a function of patient projection thickness. Paediatric DRLs were also given for sinus radiography. The detailed information about the patient data, exposure parameters and procedures provided tools for reducing the patient doses in paediatric radiography. The mean tissue doses presented for paediatric radiography enabled future risk assessments to be done. The calculated effective doses can be used for comparing different diagnostic procedures, as well as for comparing the use of similar technologies and procedures in different hospitals and countries.

Tablettien soveltuvuus annosjakeluun

Koneellinen annosjakelu on kasvava lääkehuollon osa-alue, jossa lääkkeet pakataan koneellisesti pieniin annoskertakohtaisiin pusseihin kahden viikon erissä. Aikaisemmin lääkevalmisteiden soveltuvuutta koneelliseen annosjakeluun ei ole systemaattisesti tutkittu. Tutkimus tehtiin yhteistyössä Espoonlahden apteekin annosjakeluyksikön kanssa ja sen tavoitteena oli määrittää annosjakeluprosessin kannalta optimaaliset ominaisuudet annosjaeltavalle tabletille rikkoutumisten ja siirtymien vähentämiseksi. Rikkoutuminen on lääkevalmisteen murentumista, puolittumista tai muuta rikkoutumista annosjakelun aikana. Siirtymä on lääkevalmisteen jakelu väärään annospussiin. Prosentuaalisesti rikkoutumisia ja siirtymiä on jakelumäärästä hyvin vähän, mutta määrällisesti paljon ja koko ajan enemmän koneellisen annosjakelun yleistyessä. Rikkoutumiset ja siirtymät aiheuttavat paljon lisätyötä pussien korjaamisen takia, joten niiden määrää on pyrittävä vähentämään. Lisäksi tavoitteena oli selvittää lääkkeiden valmistajilta kysyttävissä olevat asiat lääkevalmisteiden ominaisuuksista ja säilyvyydestä, jotta voitaisiin päätellä valmisteen soveltuvuus koneelliseen annosjakeluun kirjallisen tiedon perusteella. Tutkimuksen tulosten perusteella rikkoutumisten ja siirtymien vähentämiseksi optimaalinen tablettivalmiste annosjakeluun on pienehkö tai keskisuuri, päällystetty, luja ja jakouurteeton ja optimaalinen ilman suhteellinen kosteustaso annosjakeluyksikön tuotantotiloissa olisi noin 30 – 40 %. Lääkkeiden valmistajilta kysyttäviä seikkoja ovat koon, päällysteen, murtolujuuden ja jakouurteen lisäksi valmisteen säilyvyys alkuperäispakkauksen ulkopuolella sekä valmisteen valo-, lämpö- ja kosteusherkkyys. Rikkoutumisten ja siirtymien lisäksi tutkittiin myös kosteusherkän asetyylisalisyylihappovalmisteen (Disperin 100 mg) säilyvyyttä 25 °C ja 60 % RH olosuhteissa, koska tuotantotilojen ilman kosteustasoa ei ole säädelty. Säilyvyystutkimuksen kesto oli neljä viikkoa. Se on riittävä, koska se on enimmäisaika, jonka tabletit ovat annosjakeluprosessin yhteydessä pois alkuperäispakkauksestaan ennen käyttöä. Tabletteja säilytettiin avoimessa alkuperäispakkauksessa (purkki), suljetussa alkuperäispakkauksessa, annosjakelukoneen kasetissa ja kahdessa erilaisessa annospussissa (uusi ja käytössä oleva materiaali). Tulosten mukaan annosjakelukoneen kasetti suojaa kosteudelta yhtä huonosti kuin avoin purkki. Uusi pussimateriaali sen sijaan suojaa kosteudelta paremmin kuin tällä hetkellä käytössä oleva materiaali. Raman -spektroskopiamittausten perusteella asetyylisalisyylihappotableteissa ei ehdi neljän viikon seurannan aikana tapahtua asetyylisalisyylihapon hajoamista salisyylihapoksi. Kosteus heikentää tablettien murtolujuutta, mikä saattaa aiheuttaa enemmän rikkoutumisia. Kosteustaso olisi hyvä olla säädettävissä vakioksi tuotantotiloissa tai purkaa tabletit kasetteihin mahdollisimman lähellä jakelua rikkoutumisten ehkäisemiseksi, etenkin ilman kosteustason ollessa korkea. Lisäksi tutkittiin lääkevalmisteen lämpöherkkyyttä koska annosjakelukoneen saumauslaite altistaa annospussit noin 75 °C lämmölle, jos annosjakelukone pysäytetään kesken työn. Tutkimus tehtiin XRPD:llä, jolla voidaan säätää näytteen lämpötilaa. Lämpöherkkyystutkimusten perusteella 75 °C lämpö ei ehdi tunnin aikana aiheuttaa muutoksia karbamatsepiinitabletissa (Neurotol 200 mg). Tuloksista selvisi, että tutkitun valmisteen sisältämä karbamatsepiini ei kuitenkaan ole lämpöherkin muoto, joten muita lämpöherkkiä lääkevalmisteita tulisi tutkia lisätiedon saamiseksi lämmön vaikutuksista.

Health-related quality of life, symptoms and comorbidity in inflammatory bowel disease

Health-related quality of life (HRQoL) measurement has become an important outcome in treatment trials and in health policy decisions. HRQoL can be measured by using generic or disease-specific tools. Generic instruments can be used for comparing health status among patients in different health states and conditions but they do not focus specifically on the issues relevant in a particular disease. Disease-specific tools may be more responsive to changes within a specific condition. In earlier studies, impairment of HRQoL has been evident in patients with inflammatory bowel disease (IBD), especially when the disease is active. Data about the impact of comorbidity or demographic characteristics of the patients on HRQoL are partly controversial. This study, which comprised 2913 adult IBD patients, examined HRQoL using the disease-specific IBDQ and the general 15D instruments. The 15D scores of IBD patients were compared with scores of a gender and age matched general population sample. Frequency of IBD symptoms and arrangement of therapy were studied and compared with those of IBD patients in an earlier European study. Furthermore, data of other chronic diseases of the patients were obtained from the Social Insurance Institution s reimbursement register and comorbidity of IBD patients was compared with that of age and gender matched controls. --- Of the respondents, 37% reported that they suffered from disturbing IBD symptoms weekly. In 17% of the patients, the symptoms greatly affected the ability to enjoy leisure activities, and 14% stated that these symptoms greatly affected their capacity to work. Despite that, the great majority (93%) of patients expressed satisfaction with their current treatment, which exceeded the rate observed in the other European patients. The mean IBDQ score was 163, as the possible range is 32-224, and disease activity was strongly correlated with HRQoL. Older age, comorbid diseases, and female gender were also related to impairment of HRQoL. Lower HRQoL scores were seen also in newly-diagnosed patients and in those with a history of surgery, especially after stoma or ileal pouch-anal anastomosis (IPAA) operation. The range of 15D scores was 0.30-1.00, with mean of 0.87. As with the IBDQ, disease activity, older age and history of surgery were correlated with the score. Both the newly-diagnosed patients and patients with a long-lasting disease had lower scores than average even after adjusting for age. The 15D scores of IBD patients were significantly lower than those of the control group. A strong correlation was seen between the 15D and the IBDQ scores. Comorbidity with other chronic diseases was observed in 29% of IBD patients. Connective tissue diseases, chronic obstructive pulmonary diseases, pernicious anaemia, and coronary heart disease (CHD) were significantly increased in patients with IBD. Especially female IBD patients appeared to be at increased risk for CHD, and patients who reported weekly IBD symptoms had a higher risk for having other chronic diseases in addition to IBD. Comorbidity impaired HRQoL, as measured with both generic and disease-specific tools. In conclusion, HRQoL is impaired in IBD patients. An understanding of predictors of HRQoL will help to recognise patients who will need special support.