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Introduction: European legislation on orphan medicinal products, Regulation (EC) No. 141/2000 of the European Parliament and of the Council, entered into force in April 2000. Although the prevalence of rare diseases is low according to legislation (less than 5/10,000), 18–30 million people in the European Union (EU) are affected by rare diseases. The introduction of orphan medicine legislation has increased the number of orphan medicines developed but the fairness of the legislation has also raised concern and criticism. The literature review of this Master ́s thesis provides an overview of rare diseases, orphan medicines and EU orphan medicine legislation. The aim of the empirical study was to investigate the evolution of orphan medicine selection during European legislation on orphan medicinal products in 2000–2022. In more detail, aims were to describe the evolution of orphan medicine selection, the approved indications for orphan medicines and the number of orphan medicines approved for children. Methods: The research material was orphan medicines that received a marketing authorisation during the EU orphan drug legislation. This material was collected from the European Commission's Community Register of orphan medicinal products and the European Commission's Community Register of not active orphan medicinal products. Qualitative document analysis was used as the research method, where information on orphan medicines were quantified. Results and conclusions: In the 10-year review of orphan medicine development, the number of new orphan medicine products approved for the market doubled, being 63 products between 2001 and 2010 and 127 products between 2011 and 2020. In the latter 10-year period of the review, the focus of approved indications for orphan medicines shifted slightly from orphan medicines developed for the treatment of cancers (36%) to orphan medicines developed for the treatment of inborn errors of metabolism or immune disorders (43%). In the 10-year reviews, the relative share of orphan medicines approved for children decreased from 55 percent in 2001– 2010 to 40 percent in 2011–2020. Based on the results of the study, the fairness and targeting of the benefits of the orphan medicine legislation should be further investigated. Orphan medicine legislation should encourage the development of medicines for rare diseases for which there is no treatment at all, and for the population most affected, in other words children.

With advancing age the kidneys undergo anatomical and physiological changes. The most significant physiological changes are decreased renal blood flow and glomerular filtration rate (GFR). GFR is declined approximately in two thirds of the aged. Dosages of drugs eliminated mainly by the kidney should be adjusted carefully in patients with renal insufficiency. Nevertheless, according to earlier studies renal insufficiency among elderly patients is underdiagnosed and renal function is often overlooked when prescribing. Serum creatinine level is used as a screening test for renal dysfunction. However, it is a poor measure among elderly patients. Instead, calculated GFR should be the preferred method in estimating kidney function among this patient group. The aim of this study was to assess if comprehensive medication review can improve the quality of drug therapy among aged nursing home residents with impaired renal function. The data consisted of 153 comprehensive medication reviews (CMRs) conducted by Farenta Oy. CMR case reports were used to assess intervention recommendations made by pharmacists because of renal insufficiency, other kidney-related findings and resulting medication-related interventions. In addition, the prevalence of renal insufficiency, degree of renal insufficiency diagnoses and relationship between serum creatinine and estimated GFR were assessed. Clinical significance of the interventions was not assessed. The mean age of patients was 82,4 years. The estimated GFR was available for 145 patients (94,8%). 86,9% (n=126) had declined renal function (GFR<80 ml/min). Of these, serum creatinine levels were within normal range or under in 73,8% of all patients with renal insufficiency. Physicians had documented 4,8% of renal insufficiency cases in clinical patient files. Pharmacists identified inappropriate drugs due to renal function in 34,9% (n=44) of the patients with renal insufficiency. In total, pharmacists made 71 intervention recommendations. Physicians approved 60,6% of the pharmacists' recommendations as made. At least one intervention recommendation was approved as made in nearly one fourth (23,0%) of the patients with renal insufficiency. The most common drug-related intervention was changing the drug (25,4 %). Cardiovascular drugs accounted for 33,8% of the intervention recommendations, nervous system drugs 19,7 %. According to this study renal insufficiency among aged nursing home residents is common but underdiagnosed. Approximately one third of patients with renal insufficiency are using inappropriate medicines or dosages. These drug-related problems can be indentified and resolved during the comprehensive medication review procedure.

There is a great demand of cultured human hepatocytes for hepatotoxicity studies, drug testing, disease modelling and liver transplantation purposes. The current gold standard, primary human hepatocytes (PHHs), suffer from poor availability and high variability. Furthermore, PHHs are short-lived in in vitro cultures. Pluripotent stem cell (PSC)-derived hepatocyte-like cells (HLCs) have emerged as potential substitutes for PHHs in in vitro studies. PSCs are widely available, and additionally allow studies of hepatogenesis and open possibilities for personalized medicine. However, obtaining HLCs with mature hepatocyte functions in vitro has turned out to be challenging, and the differentiated cells have remained immature compared to PHHs. In vivo, hepatic differentiation and maturation of PSCs is guided by cues from the environment. Mimicking the 3D cellular environment in vitro has already shown encouraging results, but today, HLCs are still awaiting to fulfil their promise as a new gold standard. The aim of this study was first to select a new working human PSC line for in vitro hepatic differentiation and maturation. Hepatic differentiation and maturation of the selected cell line, embryonic stem cell line ESI-017, was next studied in five different 3D culture conditions (spheroids in suspension culture, four different hydrogels: Matrigel, collagen type I, mixture of Matrigel and collagen type I and alginate) with the aim to find the most favourable culture condition for later studies. For this, the PSCs were first differentiated to definitive endoderm cells and then to hepatoblasts in 2D cultures, on Matrigel- and laminin-521-coated plates, respectively. The PSC-derived hepatoblasts were then transferred for 16 days to the different 3D culture conditions for hepatic maturation. Of the conditions, suspension culture and mixture of Matrigel and collagen type I -hydrogel were estimated most promising and were selected for further studies. Hepatic maturation of the PSC-derived HLCs was estimated by analysing protein and mRNA expression levels of key marker genes, such as CYP3A4, AAT, MRP2, HNF4A, ALB, AFP, CK-8/18 and CK-19 by immunofluorescence staining and qPCR, respectively, and by cell morphology. Based on cell morphology and noticeable level of CYP3A4 expression, suspension culture shows most potential of the studied conditions in hepatic maturation of PSC-derived hepatoblasts. However, given that expression level of many other hepatocyte marker genes in these HLCs remained low compared to PHHs or human fetal liver samples, it is evident that adjustments to protocol and culturing conditions are still needed.

Review of the literature: The purpose of the review is to go through what is known about mechanisms of actions of different neurotrophic factors (GDNF, neurturin, CDNF and MANF) and how they are transported within the brain. Neurotrophic factors are endogenous and secreted proteins which have a pivotal role in the development and maintenance of neurons. They support the survival of neurons and they can help them to recover from different injuries. Due to these functions neurotrophic factors might be beneficial for the treatment of neurodegenerative disorders like Parkinson's disease. There are a great deal of studies that clearly show the neuroprotective and neurorestrorative function of GDNF and neurturin on dopaminergic neurons. They are also studied in clinical studies with Parkinson's patients but the results have been partly contradictory. The signalling route of GDNF and neurturin via RET tyrosinekinasereceptor is fairly well known but the other mechanisms of action of these factors needs to be studied further. CDNF and MANF constitute a novel, evolutionarily conserved family of neurotrophic factors. They are shown to have neuroprotective and neurorestrorative actions on dopaminergic neurons both in vitro and in vivo in a rodent model of Parkinson's disease. The mechanisms of action of CDNF and MANF are not quite clear at the moment. There are two different domains in their structure both of which are likely to carry different functions. The N-terminal domains of these proteins are close to saposins, lipid and membrane binding proteins, some of which are shown to have neurotrophic and anti-apoptotic effects. The C-terminal domain of MANF, in turn, is structurally close to the SAP-domain of Ku70-protein which binds Bax in the cytoplasm and thus inhibits apoptosis mediated by Bax. CDNF and MANF might protect neurons both via intracellular mechanisms and extracellularly acting like a secreted neurotrophic factor. CDNF and GDNF are transported retrogradially from striatum to substantia nigra. MANF, unlike the others, is transported from striatum to the frontal cortex. MANF and CDNF are shown to have better diffusion properties in the brain parenchyma than GDNF. Experimental part: We studied, by means of microdialysis, the effects of CDNF, MANF and GDNF on the dopaminergic neurotransmission of naive rats within the striatum. Neurotrophic factors (10 µg) and PBS as a negative control were injected into the left striatum in stereotaxic surgery. After this rats recovered one week before the first mircodialysis. The second mircodialysis was performed three weeks after the surgery. The samples were collected from the left striatum of freely moving rats. During the microdialysis neurotransmission was stimulated by replacing the perfusion solution with hypertonic potassium solution and with amphetamine solution. The concentration of dopamine, DOPAC, HVA and 5-HIAA was measured from the dialysate samples. In vivo TH-activity experiment was carried out for three rats in each group. NSD1015 was injected i.p.after which rats were decapitated and their striatums were dissected. The concentration of L-DOPA, dopamine and metabolites on the treated and untreated hemisphere were analyzed from the tissue samples. The amount of L-DOPA in the striatum after NSD1015-treatment indicates how active TH-enzyme is. There were no significant differences in the concentrations of dopamine and metabolites during the baseline. MANF and CDNF increased the release of dopamine from the nerve terminals compared to GDNF and PBS one week after the surgery. Three weeks after the surgery there was still significant increase in the release of dopamine in MANF group compared to GDNF group. Also the dopamine-DOPAC-turnover was increased significantly in MANF group compared to GDNF and PBS groups one week after the surgery. DOPAC/HVA -ratio was significantly smaller in GDNF group than in other groups one week after the surgery. These findings suggest that MANF potentiates dopaminergic neurotransmission most drasticly. The effects of MANF seem to last longer time than the effects of other neurotrophic factors. CDNF seems to increase the release of dopamine from the nerve terminals as well. The potentiation of dopaminergic neurotransmission could be due to increased biosynthesis of dopamine or due to the potentiation of the function of nerve terminals. In the results of the TH-activity experiment there was a trend according to which L-DOPA is synthesized less after the neurotrophic factor treatment that after the PBS treatment. This suggests that neurotrophic factors might decrease the activity of TH-enzyme.

In Finland the elderly residents of long-term care facilities are often prescribed a lot of medications, especially psychotropic drugs. It also happens that a patient or a resident has to be physically or chemically restrained. Chemical restraining can be defined in many ways, for example as using a drug - usually an antipsychotic - to restrict the freedom or movement of a patient and to control his or her behavior. In nursing homes the staff is in a key position when it comes to deciding on the use of chemical restraining or PRN medication. A legislation to guarantee the self-determination of a patient and to define how physical restraining can be used is now being prepared in Finland. Only a few studies on chemical restraining from a nurses' point of view have been made so far. Thus, the aim of this study is to provide more information on the level of knowledge, the attitudes and perceptions of nurses regarding chemical restraining and the effect of those on deciding whether to use chemical restraints or not. Three focus groups with nurses were conducted in Hyvinkää nursing homes (n=13). The groups were recruited both by e-mail and directly from the wards. The focus group discussions were digitally audiotaped and transcribed verbatim. The content of the transcripts was then analyzed using a constant comparative method. According to the study most of the antipsychotics used in long-term care were used daily. However, it is not uncommon for the nurses to be unsure about their knowledge on the use of medicines. It is thus important to help the nursing staff to increase their knowledge and skills in pharmacology. The nurses also wished to get extra training for treating people with dementia. The concept of chemical restraining is quite ambiguous, and the use of chemical restraints is a complex ethical issue because the reasons for and effects of administering it vary depending on the situation. The study shows that the chemical restraining is most often considered justified when it is used to ensure the safety of a patient, relieve anxiety or to keep the working conditions of the staff tolerable. Also a shortage of manpower and a request by the family can influence the decision on using chemical restraints. The lack of proper common guidelines causes confusion and wide variation in the use of chemical restraints. Many interviewees were hoping for more open discussion and cooperation on using chemical restraining. The nurses also mentioned many alternatives to rely on instead of using chemical restraints, such as soothing, comforting and creating a safe feeling for the patients, daily routines and stimulus. One of the key factors for taking to these instead of chemical restraints are the manpower resources in the facilities. Educating the staff can also help them to find more options for chemical restraining and make staff members recognize new or remember forgotten routines for caring for the patients without using psychotropic drugs.

Medication-related errors have been identified as the single most important risk factor for patient safety across the world. According to previous research, medication errors are common in nursing homes. However, the existing data on medication errors in Finnish nursing homes is scarce, although the challenges and defects in nursing home care services, including drug treatments, are well known. Furthermore, nursing home residents are typically characterized by old age, multimorbidity and polypharmacy. Therefore, they are particularly vulnerable to potential adverse events caused by medication errors. The aim of this study was to investigate the rates and causes of medication errors reported in nursing homes and evaluate their impact on medication safety. Additionally, the proportions of potentially inappropriate medication (PIMs) and high-risk medication involved in the medication errors were determined. The data of the study consisted of 251 medication errors reports that were submitted to the safety incident report system (HaiPro) in nursing homes located in Central Uusimaa healthcare and social welfare joint municipal authority (Keusote) in 2019. Quantitative analysis of the data provided an overview of the medication errors that had occurred in nursing homes and the medicines most commonly involved in them. Content analysis and simplified root cause analysis enabled to study more in-depth the contributing factors of medication errors and potential risks associated with the medication process in nursing homes, as well as the possibilities of preventing similar errors in the future. James Reason's human error theory and in particular its system perspective was applied as a theoretical framework in this study. Medication errors were reported regularly in nursing homes during the follow-up period of the study. The most frequent medication error type was administration error. The majority of these errors were medication omissions, followed by the wrong time of administration and administration to the wrong patient. The most common drug classes causing medication errors were antithrombotics, opioids, antidementia drugs, diuretics, antipsychotics, antidiabetics, and antidepressants. Nearly a quarter of the reported medicines were high-risk medications, most commonly opioids, antithrombotics, or antidiabetic drugs. PIMs accounted for approximately 13% of all medications in the data. Errors were most often caused by unsafe medication practices, communication problems, and deficiencies in the work environment such as excessive workload or time pressure. A significant part of the medication errors were related to transdermal medication patches. The study also showed that the quality of medication error reporting in nursing homes is in part insufficient and should be improved so that the reports can be better used for learning purposes. The results of the study provide valuable additional information on medication errors in Finnish nursing homes and their contributing factors. The information can be used to improve medication safety practices in nursing homes. Safe and uninterrupted medication use process is a goal that should be pursued not only in health care but also in social welfare services such as nursing homes.

Diacylglycerol (DAG) is a lipid second messenger, which activates classical and novel protein kinase C (PKC) isozymes at the plasma membrane. Abnormalities in PKC signaling have been linked to several diseases, and defective PKC function connects to multiple pathophysiological components of Alzheimer’s disease. However, aimlessly activating all PKC isozymes with synthetic ligands can be problematic, since the activation of certain isozymes can also promote unwanted processes. There are indications that DAGs with varying degrees of acyl chain saturation may have different and specific PKC activating abilities. Thus, understanding how the structural differences in DAGs relate to their behavior at the lipid bilayer may be beneficial for the development of new, isozyme-specific ligands of PKC. The aim of this master’s thesis was to compare the orientation, positioning and dynamics of two unsaturated DAG molecular species, 1,2-dioleoyl-sn-glycerol (DOG) and 1-stearoyl-2-docosahexaenoyl-sn-glycerol (SDG) in glycerophospholipid bilayers using conventional molecular dynamics (MD) simulations and umbrella sampling. The glycerophospholipid bilayers were composed of either 1-palmitoyl-2-oleoyl-sn-glycero-3-phosphatidylethanolamine (POPE) or 1-stearoyl-2-docosahexaenoyl-sn-glycero-3-phosphatidylethanolamine (SDPE), representing the glycerophospholipid environment in the inner leaflet of the plasma membranes in peripheral tissues and in brain tissue, respectively. Both DAG molecular species displayed very dynamic behavior in all systems, with wide distributions of glycerol moiety tilt angles and acyl chain conformations. Multiple occurrences of transbilayer movement (flip-flop) of DAGs was observed during the MD simulations in all systems. In POPE bilayers, SDG was observed to position closer to the aqueous interface compared to DOG, with larger values of solvent accessible surface area (SASA) of the glycerol moiety and the sn-3 hydroxyl group. In SDPE bilayers, no significant difference in this regard was observed between the DAG molecular species. Although potential of mean force (PMF) profiles did not reveal any major differences in the energetically favoured position of the hydroxyl group between the DAG molecular species, the calculations exposed that the dynamics of DOG are affected more by the surrounding lipid environment compared to SDG. Based on these results, it is probable that while the solvent accessibility and overall position of DAGs is affected by the length and degree of saturation of their acyl chains, there are also other mechanisms and processes causing the differing levels of PKC activation yielded by different DAG molecular species.

Human embryonic stem cells (hESCs) and human induced pluripotent stem cells (hiPSCs) have two unique properties: the self-renewal capacity and the broad developmental potential. They both have their advantages and disadvantages, but the current perception is that hESCs and hiPSCs complement rather than replace each other. New scientific problems and ethical challenges will arise because stem cell research is developing rapidly. The potential of hiPSC and hESC technologies in drug discovery is tremendous. The human pluripotent stem cell (hPSC)-derived cells have a potential to replace a part of the current preclinical toxicity and efficacy screening tests and to prevent misrouted drug development and use for lead optimization at phases before clinical trials. The hPSC-based disease models can also narrow the gap between traditional animal models and clinical trials. One major challenge is the differentiation process of hPSCs into cells of the relevant tissue. The recent study of our laboratory shows that the liver cell-deried acellular matrix (ACM) promotes the hepatic commitment of hESCs. To create chemically defined, xeno-free and feeder-free culture matrices for the differentiation of the hESCs into hepatocyte-like cells (HLCs), the ECM components of the ACM were characterized. The results suggest that the ACM contains fibronectin, laminins. After the characterization, the object was to identify which of the ECM proteins are essential and effective in the differentiation. A three-step differentiation protocol with differenent ECM protein solutions was used to produce HLCs. The hESCs were first induced into definitive endoderm (DE) cells. The DE cells were committed to the bipotential hepatic progenitors positive for HNF4α and AFP. Finally the progenitors were differentiated into HLCs. The mRNA expression of albumin, CK8, CK18, AAT, and BCRP was increased in HLCs. All the derived HLCs were albumin positive. The hESCderived HLCs showed hepatic morphology, cytoplasmic vacuole characteristics, and functional albumin secretion. The chemically defined matrices showed a supportive role in the differentiation of the hESCs into HLCs. This study establishes an efficient, chemically defined, xeno-free system to produce HLCs as a cell source for pharmaceutical and developmental studies.

Polypharmacy and age-related changes in pharmacodynamics and pharmacocinetics may lead to drug-related problems in elderly patients. Accurate medication reconciliation and medication review on admission may help to control drug-related problems and optimize drug therapy in elderly patients. Several models have been developed to reconciliate and review medications at this point of care. A Finnish model can be developed on the basis of the se models. The aim of this study was to develop a tool for medication reconciliation and medication review on admission for ward pharmacists’ use in the Lahti city hospital. The tool was developed with an action research method in cooperation with the multiprofessional study group. A preliminary tool was developed through doctors’ (n = 2), nurses’ (n = 3) and ward pharmacists’ (n = 2) interviews, a literature review and the expertise of the multiprofessional study group. The preliminary tool was piloted twice in the Lahti city hospital. After the first pilot a view changes were made to the too l by the experiences of the ward pharmacists. Doctors (n = 3) who worked at the study ward during the first pilot were interviewed to find out their views on the medication reconciliation and medication review process so that their views could be taken into consideration in the development of the final version of the tool. After second pilot ward Pharmacists (n = 2), researchers (n = 2) and an expert of geriatrics from the study group took part in a group conversation. Through the group conversation and doctors’ interviews was developed the final version of the tool. The developed tool contains sections for patient’s background information, patient interview, medication reconciliation, drug-related problems, proposed medication changes and doctor’s decisions on the proposed changes. Also instructions of the medication reconciliation and medication review process were developed for ward pharmacists. The developed tool will be used in an intervention study in the Lahti city hospital. In the future a new version of the tool could also be developed to be used in other hospitals in Finland to reconciliate and review medications at the time of hospital admission.