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Midwize : a midwife-led intervention to improve the quality of care during labour and childbirth in Uganda
No full textBackground and aimDespite global efforts, gaps in the quality of maternal and newborn care during labour and birth persist, both worldwide and in Uganda. These gaps are partly driven by the underuse of evidence-based midwifery practices, which negatively impact maternal and neonatal outcomes. This thesis explores how midwife-led quality improvement interventions in Uganda can integrate evidence-based midwifery practices during labour and birth and improve women's and newborn health outcomes.MethodThe thesis comprises four papers: I) a qualitative exploration of systemic barriers to midwife-led care in Eastern Africa, II) a qualitative study on the co-creation process of the midwife-led quality improvement intervention in Uganda, and III) a quantitative observational study examining intervention uptake, and IV) women's and newborns' health outcomes, including perineal injuries and Apgar scores.Data for Papers I and II were collected through focus groups, observations, and interviews, while Papers III and IV used observations and structured questionnaires with women. Data were analysed using inductive and deductive content analysis, descriptive statistics, and binary logistic regression to explore uptake, outcomes, and associations.The intervention was implemented at a public hospital in Kampala and targeted three midwifery practices with an evidence-to-practise gap: dynamic birth positions, intrapartum support, and perineal protection. A group of midwives, known as the Midwize Ambassadors, led the intervention while receiving mentorship in quality improvement methods and clinical midwifery skills.ResultsThe results indicate that systemic barriers, including professional hierarchies, weak organisational and leadership structures, and gender disparities, limit midwives' ability to lead and deliver quality care. These barriers may be mitigated by fostering role models, mandating midwives to lead clinical care improvements, creating platforms for experience-sharing and ensuring midwives have access to leadership and decision-making roles (I). Co-creating the midwife-led quality improvement intervention involved a four-step process, including a needs assessment that guided the selection of the improvement areas and informed the roles, responsibilities, dose, and strategies of the intervention (II). The midwife-led quality improvement intervention led to significant and sustained increases in the use of the evidence-based midwifery practices. Dynamic birth positions increased from 0% to 79%, intrapartum support from 0% to 62%, and perineal protection from 62% to 92% (III). Simultaneously, maternal and neonatal outcomes improved, with reduced perineal injuries among women and higher Apgar scores at five minutes for newborns (IV). Mechanisms contributing to the increased uptake of the improvement areas included co-creating the intervention to ensure broad engagement, using a train-the-trainer approach, having a team of champions (the Midwize Ambassadors) lead the intervention, peer mentoring to share skills and foster greater involvement, information sharing with women and birth companions through various formats and stages, active involvement of birth companions, and regular updates to staff and policy representatives, all underpinned by a structured QI method that promoted continuous learning and adaptability.ConclusionMidwife-led quality improvement interventions in Uganda can help bridge the gap between evidence and practice during labour and birth while enhancing care quality and improving maternal and newborn outcomes. The positive outcomes of this intervention were driven by co-creation with broad engagement across sectors and professions, midwifery leadership development and empowerment of both midwives and women, peer learning, and collaboration with hospital colleagues, all within a structured quality improvement method. Future research should focus on scaling and adapting similar interventions in diverse settings to extend its benefits to more women, newborns, midwives and healthcare systems.List of scientific papersI. Blomgren, J., Gabrielsson, S., Erlandsson, K., Wagoro, M. C. A., Namutebi, M., Chimala, E., Lindgren, H. (2023). Maternal health leaders' perceptions of barriers to midwife-led care in Ethiopia, Kenya, Malawi, Somalia, and Uganda. Midwifery, 124, 103734. https://doi.org/10.1016/j.midw.2023.103734II. Blomgren, J., Wells, M. B., Erlandsson, K., Amongin, D., Kabiri, L., Lindgren, H. (2023). Putting co-creation into practice: lessons learned from developing a midwife-led quality improvement intervention. Global Health Action, 16(1), 2275866. https://doi.org/10.1080/16549716.2023.2275866III. Blomgren, J., Lindgren, H., Amongin, D., Erlandsson, K., Lundberg, C., Kanyunyuzi, A. E., Muwanguzi, S., Babyrie, V., Ogwang, K., Aineomugasho, D., Namutosi, C., Wells. M. B. (2024). Midwife-Led Quality Improvement: Increasing the Use of Evidence-Based Birth Practices in Uganda. Midwifery, 104188. https://doi.org/https://doi.org/10.1016/j.midw.2024.104188IV. Blomgren, J., Wells, M. B., Amongin, D., Erlandsson, K., Wanyama, J., Afrifa, D. A., Lindgren, H. (2025). Improving Apgar scores and reducing perineal injuries through midwife-led quality improvements: an observational study in Uganda. BMC Public Health, 25(1), 19. https://doi.org/10.1186/s12889-024-21137-w</p
Exploiting advances in quantitative computed tomography to improve dose calculation in radiotherapy
No full textThe work of this thesis had the overall aim to help improve dose-calculation accuracy in individualized radiotherapy treatment planning. To achieve this, we explored computed tomography (CT), using single-energy CT (SECT) and multi- energy CT (MECT) methods to derive patient material properties used for the treatment-planning dose calculations, and also compared results using analytical versus Monte Carlo (MC) dose algorithms. We focused on proton therapy as these aspects are generally more influential for charged-particle radiation, although some findings will transfer to radiotherapy more broadly. All standard energy-integrating CT scans were performed on a SOMATOM Definition AS+ scanner (Siemens Healthineers, Forcheim, Germany). The calibration phantom used was a 062M and the anthropomorphic head phantom was a 731-HN, both manufactured by CIRS (CIRS/SunNuclear, Norfolk, VA, USA).In the first study, we evaluated three published and two newly proposed parametrization models for stoichiometric SECT calibration of CT number to proton stopping-power ratio (SPR). Each model was calibrated on the Definition scanner using the calibration phantom and 11 tissue substitute materials, two of which included trace amounts of barium (Z=56). Model performance was assessed under two scenarios: (1) standard calibrations for each model and protocol using the measured CT numbers, and (2) simulations of 10 000 calibrations per model and protocol where the input CT numbers were randomized around the measured values. Both scenarios were also repeated with virtual removal of barium content from the calibrators. The results showed that all models yielded similar outcomes in both scenarios when barium was excluded. However, when barium was present, differences emerged between the models. One model in particular exhibited larger SPR deviations in scenario 1 and greater variability in scenario 2 compared to the reference model. Notably, the two newly proposed models demonstrated the least sensitivity to the presence of barium across both scenarios, indicating improved robustness to trace high-Z elements in calibration materials.Noisy dual-energy CT (DECT) images have been reported to compromise the accuracy of proton dose calculations; the second study aimed to develop an iterative DECT reconstruction algorithm that simultaneously produces accurate material properties and supresses image noise. A 140 kV/80 kV protocol combination was used on the Definition scanner, with each protocol calibrated using the same phantom and methods as in study 1. We solved for relative electron density (RED) and effective atomic number (EAN), from which proton SPR could be derived, denoting the model K-DECT. The iterative algorithm developed to solve K-DECT, denoted prior-image constrained denoising (PIC-D), incorporated penalty functions to supress image noise. PIC-D demonstrated efficient noise suppression, and with well-tuned penalties, introduced only minor bias in absolute quantities - evaluated using both the calibration phantom and the anthropomorphic head phantom.Study 3 investigated whether first-generation clinical photon-counting CT (PCCT) could improve material characterization in a human-like head geometry compared with DECT and SECT. Both the calibration phantom and the anthropomorphic head phantom were scanned on a NAEOTOM Alpha (Siemens Healthineers Forchheim, Germany) PCCT scanner as well as on the Definition scanner using SECT and DECT protocols. A method was developed to derive RED/EAN from a set of eight virtual monoenergetic images (VMIs). For PCCT and DECT, SPR was computed from RED/EAN, while SECT relied on a stoichiometric look-up table. The results showed that PCCT generally produced narrower pixel value distributions within each material and enabled superior material characterization compared to both DECT and SECT - though this was not consistent across all combinations of quantities and phantom materials. Additionally, the findings suggested that SPR may not be the most suitable metric for evaluating performance in image-derived material properties.In Study 4, we evaluated the dosimetric impact of two types of cranial titanium implants on proton beam dose distributions, with two primary aims: (1) to quantify the limitations of an analytic dose-calculation algorithm in a clinical treatment planning system (TPS) when implants are present, and (2) to assess the impact when the same algorithm uses SPR maps derived from standard clinical SECT images to represent the test geometry. The test geometry consisted of the calibration phantom combined with physical samples of two implants - a CranioFix (Aesculap AG, Tuttlingen, Germany) and a titanium mesh implant (OssDsign, Uppsala, Sweden) - scanned using SECT on the Definition scanner. A virtual ground-truth geometry was constructed using CAD models of the implants, with material properties derived from tabulated compositions. Proton treatment plans were generated and calculated using the pencil beam algorithm in the Eclipse v16.1 TPS (Varian, Siemens Healthineers, Palo Alto, USA) for both the ground-truth and CT-based geometries. Additionally, Monte Carlo simulations of the plans were performed using TOPAS for the ground-truth geometry. The results showed that the Eclipse pencil beam algorithm failed to accurately model dose distributions in the shadow regions of the implants, as validated against the Monte Carlo results. Dose inhomogeneities were consistently underestimated for both implant types, and a shorter end-of-range was predicted behind the CranioFix. Furthermore, poor CT representation of the implants, and coarse dose-matrix resolution, significantly compromised the accuracy of TPS-based dose calculations.List of scientific papersI. Ödén J, Zimmerman J, Poludniowski G. Comparison of CT-number parameterization models for stoichiometric CT calibration in proton therapy. Physica Medica-European Journal of Medical Physics. 2018 Mar;47:42-9. https://doi.org/10.1016/j.ejmp.2018.02.016II. Zimmerman J, Thor D, Poludniowski G. Stopping-power ratio estimation for proton radiotherapy using dual-energy computed tomography and prior-image constrained denoising. Medical Physics. 2023;50(3):1481-95. https://doi.org/10.1002/mp.16063III. Zimmerman J, Poludniowski G. Assessment of Photon-Counting Computed Tomography for Quantitative Imaging in Radiation Therapy. International Journal of Radiation Oncology*Biology*Physics. 2025 Apr 1;121(5):1316-27. https://doi.org/10.1016/j.ijrobp.2024.11.069IV. Zimmerman J, Carlsson Tedgren Å, Poludniowski G. The influence of metal cranial implants on proton therapy dose distributions: a simulation study. [Manuscript]</p
Pneumococcal meningitis : from the pathogenesis of disease to the development of novel therapeutics
No full textBacterial meningitis is a life-threatening inflammation of the meninges caused by a bacterial infection in the brain. The global burden of disease is mainly found in low-income countries, where a case-fatality rate of 50% is reported. In contrast, in high-income countries, the incidence is lower, but stable, with a case fatality rate of 7-30%. Accessibility to good health care practice is crucial for outcomes, and the delayed onset of treatment correlates with an increased risk of mortality and neurological sequelae. The most common cause of bacterial meningitis is the Gram-positive bacterium Streptococcus pneumoniae, the pneumococcus, which is associated with an increased risk of death, complications, and long-term neurological sequelae, the latter observed in approximately 50% of survivors. Bacterial presence in the brain causes a vast neuroinflammatory response, which aims to clear the infection, but is inefficient and becomes detrimental. The prolonged presence of the bacterium, its toxin, and the neuroinflammatory process leads to neuronal damage, ultimately causing neurological sequelae in patients. Antibiotic treatment is given to clear the infection; the success of this treatment relies on the sensitivity of the pneumococcal strain to antibiotics. This poses a significant threat in clinics, as antimicrobial resistance is on the rise. In addition, in some countries, administration of dexamethasone is recommended to reduce neuroinflammation, although dampening of the inflammatory response has given inconsistent results. Importantly, despite successful treatment, the incidence of mortality and long-term neurological sequelae remains high, highlighting the need for new treatment strategies to improve outcomes of pneumococcal meningitis.In order to develop new therapies, knowledge of the pathogenesis of the disease is crucial. In paper I, we demonstrated that S. pneumoniae invades the brain in a temporal, but not in a spatial pattern, with all brain regions equally affected by using, for the first time in the field, 3D whole brain imaging. The host responded dynamically, with neuronal damage observed early in the disease. We further indicated the importance of neutralising the pneumococcal toxin pneumolysin for future therapies. In paper II, we investigated the innate immune response to pneumococcal meningitis and the importance of microglia, the main innate immune cell in the brain parenchyma, in the generation of this response. Our results demonstrated that the microglial population inhibited the infiltration of peripheral monocytes and neutrophils into the brain, which was detrimental as the infiltration of peripheral immune cells in the brain increased protection in mice depleted of microglia, by reducing the bacterial load and lowering cytokine release. Furthermore, the expansion of neutrophilic and monocytic populations in the periphery also contributed to the clearance of the pneumococcus and reduced the levels of cytokines in the absence of resident microglia.The antibiotic resistance observed among pneumococcal strains must be addressed by developing new antimicrobial peptides. In paper III, we demonstrated how the bacteriophage-derived lytic enzyme cpl-1, a pneumococcal endolysin, could, due to its efficient and fast antimicrobial activity, make B-lactam and macrolide-resistant pneumococcal strains susceptible to antibiotics again. This had neuroprotective effects in vitro and dramatically increased survival in vivo, thereby highlighting the potential of cpl-1 as an adjuvant treatment in antibiotic-resistant pneumococcal meningitis cases.In paper IV, we isolated bioengineered human extracellular vesicles to address the major challenges in current treatment strategies of pneumococcal meningitis: the release of pneumolysin and the neuroinflammation. We demonstrated that treatment with rabies viral glycoprotein-expressing extracellular vesicles, which target acetylcholine receptors on neurons, increased survival in the bacteremia- derived meningitis model, due to its capacity to enter the brain parenchyma, where it sequestered and neutralised pneumolysin, protected neurons, and reduced inflammation.In conclusion, this thesis focused on the host response to infection and the potential of new treatment strategies in improving the outcome of pneumococcal meningitis.List of scientific papersI. Spatio-temporal brain invasion pattern of Streptococcus pneumoniae and dynamic changes in the cellular environment in bacteremia-derived meningitis.Farmen, K., Tofino-Vian, M., Wellfelt, K., Olson, L., & lovino, F. Neurobiology of Disease, 195, 106484, (2024). https://doi.org/10.1016/j.nbd.2024.106484II. Microglial Depletion is Protective in Experimental Bacterial Meningitis Due to an Expansion of Neutrophils and Monocytes.Farmen, K., Tofino-Vian, M., Benito Cuesta, I., Sarlus, H., Harris, R. A., & lovino, F. [Submitted]III. Bacteriophage-derived endolysins restore antibiotic susceptibility in ß- lactam-and macrolide-resistant Streptococcus pneumoniae infections.Vander Elst, N., Farmen, K., Knorr, L., Merlijn, L., & lovino, F. Molecular Medicine, 31(1), 170, (2025). https://doi.org/10.1186/s10020-025-01226-1IV. Bioengineered extracellular vesicles dampen inflammation, increase survival, and neutralise pneumolysin in experimental pneumococcal meningitisFarmen K., Tofino-Vian, M., Mamand D.R., Liang X., Zhou H., Hou W.Q.V., Andaloussi E.S., Wiklander P.B.O., & Iovino F. [Submitted]</p
In vitro modeling of tumor-stroma-crosstalk in pancreatic cancer leads to new insights into drug resistance and discovery
No full textPancreatic ductal adenocarcinoma (PDAC) remains a devastating disease despite decades of research. The 5-year-survival rate of PDAC patients remains at a dismal 11%(1) and worse still has not significantly improved over time. One key component which sets PDAC apart is the special role of the stromal cells in the tumor and the dense and restrictive extracellular matrix (ECM) which partially derives from them.Given the importance of the stromal component of PDAC, this research project aimed to investigate the role of stromal cells in drug-cancer-cell-interactions, as well as include the tumor-stroma-crosstalk when screening for tumor suppressive drugs.Paper I serves as an introduction to the cell culture models and their application in PDAC and discusses the benefits and drawbacks of different of them.Paper II describes a global assessment of the impact of crosstalk in PDAC. By choosing cell lines from human and mouse we could differentiate the RNA expression changes in the cancer cells and in the stromal cells. A key protein identified in this study was cellular communication network factor 1 (CCN1) which was further investigated inPaper III. Panc1-CCN1-KO cell lines were created and characterized. These newly established cell lines were more resistant to Gemcitabine. This increased resistance could be linked to the correlated downregulation of the Gemcitabine-metabolizing enzyme deoxycytidine kinase (DCK). Restoring CCN1 expression also restored DCK expression suggesting involvement in the same signaling pathway.Paper IV describes a newly developed method for spheroid viability, suited for the application in a high throughput drug screen. This image-based assay classifies treatment outcomes based on morphological features. This assay was further trained to identify shifts in apparent cell morphology shifts.Paper V describes the preliminary results of the high throughput screen (HTS). The results were selected based on targeting Panc1 cells over human pancreatic stellate cells (hPSCs) with the newly developed screening tool described in Paper IV. The compound CAY10581 showed synergistic effects with Gemcitabine in preliminary experiments.List of scientific papersI. Gündel B, Liu X, Lohr M, Heuchel R. Pancreatic Ductal Adenocarcinoma: Preclinical in vitro and ex vivo Models. Front Cell Dev Biol. 2021;9:741162. https://doi.org/10.3389/fcell.2021.741162II. Liu X, Gündel B, Li X, Liu J, Wright A, Löhr M, Heuchel R. 3D heterospecies spheroids of pancreatic stroma and cancer cells demonstrate key phenotypes of pancreatic ductal adenocarcinoma. Translational oncology. 2021;14(7):101107. https://doi.org/10.1016/j.tranon.2021.101107III. Gündel B, Liu X, Pfützenreuter A, Engelsberger V, Weiskirchen R, Löhr J-M, Heuchel R. The Crosstalk Analysis between mPSCs and Panc1 Cells Identifies CCN1 as a Positive Regulator of Gemcitabine Sensitivity in Pancreatic Cancer Cells. Int J Mol Sci. 2024;25(17):9369. https://doi.org/10.3390/ijms25179369IV. Gündel B, Gündel A, Axelsson H, Timpone A, Löhr M, Heuchel R. Applying an automated image analysis to quantify pancreatic cancer spheroid viability and classify morphology in a high throughput drug screen. [Manuscript]V. Gündel B, Heffinger L, Timpone A, Axelsson H, Gündel A, Löhr M, Heuchel R. Reporting on the outcomes of a phenotypic high throughput screen on Panc1/hPSC heterospheroids. [Manuscript]</p
Predictive extrapolation : a framework to reduce uncertainty around long-term treatment effects of innovative cancer therapies
No full textImmuno-oncology (IO) is a novel cancer treatment that activates the immune system to target tumor cells. IO has demonstrated a superior efficacy in clinical trials, including patients with metastatic non-small cell lung cancer (mNSCLC). However, assessing the cost-effectiveness of IO is challenging due to uncertainty around IO real-world impacts and its long-term treatment benefits beyond the trial period. Standard parametric distribution (SPD) models, commonly used for survival extrapolation, may have limitations in survival projections based on solely the immature trial data. Furthermore, although the treatment landscape for mNSCLC has evolved, the costs associated with novel treatments remain insufficiently understood. This thesis aims to address these challenges and explore methodological solutions applicable to health economic evaluations of novel treatments.Paper I investigated treatment patterns following the introduction of IO for mNSCLC and its impact, using the Flatiron Health oncology database comprising over 10,000 patients. The study compared real-world overall survival (rwOS) between patients receiving IO and those treated with chemotherapy (CT), using propensity score matched cohorts. The HR for rwOS was 0.887 (95% CI: 0.850- 0.978) in the first-line therapy and 0.775 (95% CI: 0.737-0.875) in the second-line therapy after adjusting for crossover effects. IO was associated with statistically significant survival benefits sustained over several years, though uncertainty increased with longer follow-up. These findings support the clinical effectiveness of IO in real-world practice while highlighting challenges in long-term outcome evaluation.Paper II evaluated survival extrapolation methods in 11,224 patients with HER2- positive breast cancer using the National Breast Cancer Register in Sweden. SPD models were compared to a novel modelling approach using excess hazard (EH) models with or without a cure assumption. An EH model is a method to implement the relative survival framework by incorporating background mortality in modelling to prevent unrealistic survival projections. Survival models were developed by stage based on truncated datasets to reflect immature trial data, and compared to Kaplan-Meier data observed up to 15 years. Extrapolations were then extended over a 50-year horizon to assess between-model variance in restricted mean survival time (RMST). EH cure models closely aligned with observed mid-term survival in stage I - III, while EH no cure models performed better in stage IV. In long-term survival projections, SPD models produced implausible estimates in early-stage cancer, exceeding survival in the general population. EH models substantially decreased between-model variance for RMST, for instance, by 93.7% using EH no cure models and 83.5% using EH cure models, compared to SPD models in stage II. These results suggest that the greater internal consistency of EH models may reduce structural uncertainty in long-term survival extrapolation based on immature data.Paper III examined treatment cost trends in 17,107 patients initially diagnosed with mNSCLC in Sweden from 2011 to 2020, using data from the National Registers. Patients were grouped by diagnosis period and treatment type including EGFR- targeted, ALK-targeted, IO, and CT drugs alone. The use of IO increased sharply after 2016, overtaking CT drugs alone by 2019, while EGFR- and ALK-targeted therapies showed gradual uptake. First-year mean costs rose from €26,640 in 2011-2013, €37,199 in 2014 - 2016 to €61,053 in 2017-2020, mainly due to increased costs of IO drug and inpatient care. IO patients had the highest first- year mean cost (€105,287), with costs declining in subsequent years. In contrast, costs for other groups remained relatively stable beyond the first year.Paper IV assessed cost-effectiveness using a partitioned survival model comparing pembrolizumab with CT in mNSCLC, based on digitally reconstructed data derived from the KEYNOTE-024 study. SPD and EH models were fitted to both the 11-month interim and the 5-year update data. With the interim data, exponential and log-normal models performed equally well in terms of the AIC and the BIC, but only log-normal projections aligned with the 5-year data. However, the SPD log-normal models projected long survival tails, deemed overly optimistic. In contrast, the EH log-normal models provided plausible extrapolations with tapering tails. EH models yielded consistent ICERs across data maturities, as SEK 412,611 per QALY using the interim data and SEK 458,946 per QALY using the update data, and reduced uncertainty compared to SPD models in probabilistic sensitivity analyses.The research highlights the challenges and advantages of using EH models compared to SPD models, notably in achieving more consistent long-term survival extrapolation and reducing uncertainty in ICER estimation. The findings also emphasize the importance of understanding long-term real-world treatment benefits and substantial costs of novel treatments.List of scientific papersI. Long-term real-world survival of immunotherapy compared to chemotherapy for metastatic non-small cell lung cancer: a propensity score-matched analysis. Kim K, Sweeting M, Jönsson L, Wilking N. Thorac Cancer. 2025 Jan;16(1):e15535. https://doi.org/10.1111/1759-7714.15535II. General population mortality adjustment in survival extrapolation of cancer trials: exploring plausibility and implications for cost- effectiveness analyses in HER2-positive breast cancer in Sweden. Kim K, Sweeting M, Wilking N, Jönsson L. Med Decis Making. 2024 Oct;44(7):843-853. https://doi.org/10.1177/0272989x241275969III. Cost of treatment of metastatic non-small lung cancer in Sweden, 2011-2023. Kim K, Sweeting M, Wilking N, Jönsson L. [Manuscript]IV. A re-evaluation of cost-effectiveness of immunotherapy in advanced non-small cell lung cancer, using excess hazard models, in a case study of the KEYNOTE-024 trial. Kim K, Sweeting M, Wilking N, Jönsson L. [Manuscript]</p
Applying novel methods to study long-term exposure to air pollution and temperature and annual mortality in India
No full textBACKGROUNDIndia is particularly affected by environmental exposures such as ambient air pollution and non-optimal temperature. These risk factors could be linked to a major burden on public health. The evidence from India on mortality burden due to long-term exposure to air pollution and ambient temperature is limited. It is crucial to identify areas that are most vulnerable to ambient air pollution and to identify the extent of mortality burden due to ambient air pollution and temperature, especially when the resources are scarce to address these issues. AIM The aim of the thesis was to apply novel methods to study the long-term exposure to air pollution and temperature on annual mortality in India.METHODS Data sources All of the three included studies were based on Indian data at national level.Exposure: Ambient air pollution (PM2.5) and ambient temperature were derived from previously developed nationwide machine-learning models at 1 km x 1 km spatial resolution from 2008 to 2019.Outcome: For Study II & III, we collected district level annual counts of mortality from the national register for births and deaths between 2009 and 2019. Study I was a descriptive study and did not include any health outcome.CovariatesWe used district level variable like gross domestic product (GDP) per capita and proportion of women literacy, proportion of households using clean cooking fuel, median age, proportion of households with electricity, relative humidity, precipitation and proportion of people aged 60 and older. We also adjusted for quarterly average temperature in Study II and annual average PM2.5 in Study III as confounders.Statistical analysesIn Study I, we conducted a geospatial analysis on gridded annual PM2.5 averages using Getis-Ord Gi* statistics for every year to classify hot and cold spots from 2008 to 2019. Then we analyzed the temporal trends of the identified hotspots to categorize them as consistent, emerging and declining hotspots and the population exposed. We also explored if the identified hotspots were included in the National Clean Air Programme (NCAP), a national effort focused on reducing the ambient air pollution levels.In Study II & III, we conducted quasi-experimental studies using a modified version of the Difference-In-Differences (DID) approach. For the main exposure of interest, in Study II, we used ambient air pollution (district level annual averages), and in Study III we used ambient temperature (district level quarterly averages and annual counts of episodes of extremes of heat and cold). We used generalized additive models with quasi-Poisson distribution with interactive fixed effects for the spatial unit and time trends in both Study II & III. The analysis was conducted on a national level for Study II and climate zone-specific for Study III. The spatial unit of analysis was administrative divisions (collection of districts) in Study II and districts in Study III.RESULTSOur results (Study I) highlighted areas of the country with consistently higher levels of air pollution compared to the spatial neighbors and emerging hotspots with a concerning trend and the significant levels of population exposure. The results have alerted us to areas of declining hotspots which could be serve as examples for the country for any policies or interventions. From our analysis we found that additional cities could be included in the NCAP. Further, in Study II, we observed an increased mortality risk of 8.6% for with every additional 10 ug/m3 increment of annual average PM2.5 corresponding to an attributable burden of 3.8 million deaths (in comparison to Indian National Ambient Air Quality Standards) and 16.6 million deaths (in comparison to revised WHO guidelines) throughout the study period. We also observed a near linear exposure-response function for PM2.5 and mortality. In Study III we studied the relationship between long-term ambient temperature exposure and mortality and found that some climatic zones demonstrated increased risk for mortality while others did not display a clear pattern of increased risk for quarterly temperatures. The increased annual mortality risk for annual counts of extreme heat and cold episodes was also specific to some climate zones and not uniform across the country. We also observed an effect modification by socio-economic status, with higher risk for mortality by increasing quarterly temperature among poorer districts.CONCLUSIONSTo conclude, the three constituent papers of this thesis quantify on the extent of population exposure to air pollution as well as the mortality risk and burden from long-term exposure to air pollution and temperature in India using novel methods. The methods used in thesis allowed us to fully utilize the mortality data and other covariates available at the national level, albeit lack of individual-level data and differing spatial and temporal availability of the covariates, to elucidate the complex relationship of long -term exposure to air pollution and temperature on mortality. The results clearly indicate higher mortality risk for increasing levels of air pollution and a significant burden of mortality above the Indian National Ambient Air Quality Guidelines. Finally, the results indicate varying levels of increased risk for mortality across different climate zones for increasing quarterly temperatures and episodes of heat and cold extremes. Our findings indicate a need for stricter regulatory standards and targeted interventions to improve public health.List of scientific papersI. Jaganathan S, Rajiva A, Amini H, de Bont J, Dixit S, Dutta A, Kloog I, Lane KJ, Menon JS, Nori-Sarma A, Prabhakaran D, Schwartz J, Sharma P, Stafoggia M, Walia GK, Wellenius GA, Prabhakaran P, Ljungman P, Mandal S. Nationwide analysis of air pollution hotspots across India: A spatiotemporal PM2.5 trend analysis (2008-2019). Environ Res. 2025 Jan 1;264(Pt 1):120276. Epub 2024 Nov 5. PMID: 39510231; PMCID: PMC11790316.https://doi.org/10.1016/j.envres.2024.120276II. Jaganathan S, Stafoggia M, Rajiva A, Mandal S, Dixit S, de Bont J, Wellenius GA, Lane KJ, Nori-Sarma A, Kloog I, Prabhakaran D, Prabhakaran P, Schwartz J, Ljungman P. Estimating the effect of annual PM25 exposure on mortality in India: a difference-in-differences approach. Lancet Planet Health. 2024 Dec;8(12):e987-e996. PMID: 39674205; PMCID: PMC11790315.https://doi.org/10.1016/S2542-5196(24)00248-1III. Jaganathan S, Stafoggia M, Rajiva A, Mandal S, Dixit S, de Bont J, Wellenius GA, Lane KJ, Nori-Sarma A, Kloog I, Prabhakaran D, Prabhakaran P, Schwartz J, Ljungman P. Long-term exposure to ambient temperature and mortality risk in six climatic zones of India: a difference-in-differences approach. [Manuscript]</p
Systematic profiling of protein function and drug response mechanisms in lymphoid leukemias
No full textCancer biology is characterized by complexity, because disease progression depends on the interplay of molecular components that shape phenotypes collectively. To advance our understanding of cancer biology and overcome remaining therapeutic limitations, it is necessary to deeply and systematically account for this molecular plasticity.For the most prevalent lymphoid leukemia malignancies in children and adults, respectively, acute lymphoblastic leukemia (ALL) and chronic lymphocytic leukemia (CLL), most patients can access relatively successful treatments. But standard therapies fall short for many patients, who continue to experience both poor treatment outcomes and complications of over-treatment. These under-served patients have a wide range of phenotypic and treatment-linked variability, and traditional approaches fall short of the power needed to systematically apply these insights productively. Applications that improve our understanding of protein variation specifically are critical, because proteins impact not only biology but also drug affinity and targeting.The overall aim of the thesis was to investigate the functional and molecular plasticity of the proteome in lymphoid leukemia, with the goal of expanding precision therapy opportunities across the disease spectrum through proteogenomic and functional proteomics approaches.Study I: We assembled a biobank of 49 commercially available childhood ALL cell lines (and 2 Epstein-Barr virus transformed B-cell lines). These were profiled using proteomics and transcriptomics, and drug responses were quantified for 528 oncology-related drugs suitable for repurposing applications. Molecular phenotypes were linked with drug sensitivity measurements and evaluated within the context of the other cell lines to identify therapeutic correlations and lineage-dependent effects. The primary aim was to perform multi-omic analyses of childhood ALL cell lines, identifying potential therapeutic candidates and their mechanistic associations. The outcome was a resource of cell line models with associated molecular phenotypes that can be used to infer potential sensitivities to targeted drugs.Study II: We conducted thermal proteome profiling with deep peptide coverage in 20 B-cell precursor ALL cell lines. Using a graph-based model and the Leiden community detection algorithm, we clustered peptides according to their physical properties, which was inferred from thermal stability. This approach enabled the detection of functional proteoform groups, in which peptides from the same gene could be distinguished as separate proteoforms. The primary aim was to infer proteoforms from bottom-up proteomics data using thermal proteome profiling and to link differential results to disease biology and drug sensitivity.Study III: Using the approach from Study Il for functional proteoform group detection, we systematically profiled ibrutinib target proteins. We distinguished between functional proteoform groups to better understand biologically relevant aspects of drug response. In a CLL patient cohort, profiled using proteomics, we linked specific peptides indicative of ibrutinib target proteins to annotate treatment associated phenotypes and ex vivo drug response. The primary aim was to refine the target landscape of ibrutinib, a key treatment in CLL known to have polypharmacology, and to explore the implications of proteoform variability in treatment response.Study IV: To better understand what leads to bryostatin-1 sensitivity in MEF2D-rearranged (MEF2Dr) ALL, following up on a drug sensitivity finding observed in Study I, we profiled bryostatin-1 interactions and signaling in responsive and resistant B-cell precursor ALL cell lines. We tested the hypotheses built from broad multi-omics data with specific assays and chemical proteomics approaches, quantifying the effects of PKCδ activation, ERK phosphorylation, histone remodeling processes, and calcium signaling. The primary aim was to investigate the rationale of this selective vulnerability and to explore how pre-B-cell receptor signaling thresholds may differ in ALL.By leveraging proteomics technologies, we systematically detected associations with drug responsiveness and enhanced the functional interpretation of this data by enabling the identification of functional proteoform groups. Together, we identified correlations between molecular phenotypes and drug responses in ALL cell lines, identifying bryostatin-1 as a therapeutic candidate in the MEF2Dr subtype and associating mediators of pre-B cell negative selection with drug susceptibility. Functional proteoform groups were resolved from bottom-up proteomics data using thermal proteome profiling, and could be linked to disease biology through differential co-aggregation and associations with drug sensitivity. Investigation of ibrutinib's target landscape implicated additional targets that perform immunomodulation and cellular processes such as Golgi and endosomal trafficking and glycosylation. Variability in proteoform profiles among CLL patients could be linked with treatment status and ex vivo response, suggesting complex biological effects linked to off-target engagement. Collectively, this work empowers nuanced detection of proteome features and introduces an approach that streamlines prioritization of therapeutic targets. Our findings emphasize that recognizing the spectrum of drug affinities and targets modulated by proteoform variability is crucial for improving the precision and efficacy of targeted therapies. Ultimately, this research contributes to efforts in developing more effective and personalized treatment strategies for leukemia patients.List of scientific papersI. Integrative multi-omics and drug response profiling of childhood acute lymphoblastic leukemia cell lines. Leo, I. R .* , Aswad, L .* , Stahl, M .* , Kunold, E., Post, F., Erkers, T., Struyf, N., Mermelakas, G., Joshi, R. N., Gracia-Villacampa, E., Östling, P., Kallioniemi, O. P., Pokrovskaja-Tamm, K., Siavelis, I., Lehtio, J., Vesterlund, M., Jafari, R .. et al. Nature Communications 13, 1691 (2022). * Equal contribution https://doi.org/10.1038/s41467-022-29224-5II. Deep thermal profiling for detection of functional proteoform groups. Kurzawa, N., Leo, I. R., Stahl, M., Kunold, E., Becher, I., Audrey, A., Mermelakas, G., Huber, W., Mateus, A., Savitski, M., Jafari, R.. Nature Chemical Biology 19, 962–971 (2023). https://doi.org/10.1038/s41589-023-01284-8III. Functional proteoform group deconvolution reveals a broader spectrum of ibrutinib off-targets. Leo, I. R., Kunold, E., Audrey, A., Tampere, M., Eirich, J., Lehtiö, J., Jafari, R.. Nature Communications 16, 1948 (2025). https://doi.org/10.1038/s41467-024-54654-8IV. Epigenomic mechanisms link MEF2D fusions to toxicity of pre-BCR signaling in leukemia. Leo, I. R., Post, F., Struyf, N., Mermelekas, G., Qi, X., Pokrovskaja-Tamm, K., Joshi, R., Erkers, T., Lehtio, J., Jafari, R .. (2025) [Manuscript]</p
Speech, communication, and neuroimaging in Parkinson's disease : characterisation and intervention outcomes
No full textMost individuals with Parkinson's disease (PD) experience changes in speech, voice or communication. Speech changes often manifest as hypokinetic dysarthria, a motor speech disorder that may result in restrictions in communicative participation and motivates rehabilitation. HiCommunication is a novel group intervention designed to improve speech and communication in PD, addressing challenges in retaining and transferring improvements obtained during intervention to situations outside the clinic.The aim of this thesis was to characterise dysarthria and evaluate the efficacy of the HiCommunication intervention in individuals with mild to moderate PD. This comprehensive approach included acoustic and auditory-perceptual assessment of speech, disease-related measures, cognitive assessments, and neuroimaging. Additionally, it explored the feasibility of using real-time monitoring in a randomised controlled trial (RCT) to assess speech and voice changes in daily life after intervention.This thesis consists of four studies that were part of the EXPANd trial, an RCT including 95 participants with mild to moderate PD. The aim was to study the link between behavioural changes obtained in intervention and possible structural and functional brain changes. Participants were assessed pre- and post- intervention using a comprehensive test battery that included recordings of speech and voice, clinical dysarthria assessment, a neuropsychological test battery, assessments of balance and motor impairment, and structural and functional magnetic resonance imaging (MRI). Six-month follow-up speech and voice recordings were also performed.Paper I was a cross-sectional study based on data obtained from assessment pre-intervention. Auditory-perceptual listener ratings of text reading were performed by two experienced speech and language pathologists specialising in motor speech disorders. Participants were rated on overall speech impairment, articulation, voice function, and prosody, and classified into three groups: no dysarthria, mild dysarthria, and moderate dysarthria. Structural and resting-state functional MRI were analysed using Voxel-Based Morphometry and fractional Amplitude of Low Frequency Fluctuations, respectively. Non-parametric Kruskal- Wallis tests were used to examine differences between the dysarthria severity groups. Significant differences were observed in voice sound level, degree of dysphonia, and motor symptom severity. Exploratory analyses showed that dysarthria was associated with decreased regional spontaneous resting-state brain activity in the right postcentral gyrus and superior frontal gyrus, and increased activity in the right inferior occipital gyrus and cerebellum exterior/fusiform gyrus. Decreased gray matter volume in the right superior and middle temporal cortices correlated with lower scores on global cognition, language, and executive functions.Papers II and III were longitudinal studies comparing HiCommunication to an active control intervention, utilising data from all participants across all time points. Acoustic analysis and auditory-perceptual listening assessment by experienced speech and language pathologists focused on speech domains affected by hypokinetic dysarthria: general impression, voice and breathing, articulation, and prosody. Additionally, resonance was assessed using only auditory-perceptual listening assessment. Spectral dynamic causal modeling and the parametric empirical Bayes methods were applied to resting-state functional MRI data to describe effective connectivity changes in a speech- related network. Statistical analyses of acoustic and auditory-perceptual outcomes included all participants (intention-to-treat) with imputed missing values and complementary per-protocol analyses of intervention completers. In intention-to-treat analysis, significant group-by-time interaction effects favouring HiCommunication were found post-intervention for the acoustic outcomes voice sound level in text reading and monologue, Acoustic Voice Quality Index, and Harmonics-to-Noise Ratio. HiCommunication completers also showed statistically significant improvements in the auditory-perceptual parameters imprecise articulation and vocal fry. However, these changes were not maintained at follow-up after 6 months. Immediately post-intervention, a majority of HiCommunication participants showed a clinically relevant increase in voice sound level. Effective connectivity analysis revealed a significant decrease in inhibitory self-connectivity in the left supplementary motor area and increased connectivity from the right supplementary motor area to the left paracentral gyrus after HiCommunication compared to the active control intervention.Paper IV was a feasibility study including 23 participants from the EXPANd trial. Voice use in daily life was registered with the portable voice accumulator (PVA) VoxLog for 4-7 days before and after intervention. The VoxLog registers voice sound level, phonation time, and levels of environmental noise, allowing analysis of voice use in relation to different environmental noise levels. Process feasibility results indicated challenges in data collection due to low inclusion rates, compliance issues, technical problems, and participants' difficulties understanding and following instructions. Recommendations for future protocols include adding a midway check-up, more detailed activity diaries, and repetition of instructions. The need for user-friendly, smartphone-based PVAs was highlighted. Scientific feasibility results indicated that data from PVAs provide valuable information on voice use in daily life, complementing studio recordings. This data offers insights into voice use across different levels of environmental noise and information on phonation time, i.e., the amount of time the person spends using their voice.Data from studies in this thesis show that voice symptoms are the most prominent feature of dysarthria in mild to moderate PD and that the HiCommunication intervention improves these symptoms, with clinically relevant increases in voice sound level for many participants. The findings also suggest potential functional brain changes related to dysarthria severity and altered connectivity in a speech-related network following intervention. Replication of these results in further RCTs, other settings, and broader PD populations is essential. It is important to interpret the neuroimaging results cautiously, as these studies were exploratory. The next step is to implement HiCommunication in routine healthcare. Furthermore, there is a need to assess the clinical relevance of changes through self-reported outcome measures, establish the minimal clinically important difference for acoustic outcomes, and develop novel PVAs for registering voice sound level in relation to environmental noise. Incorporating PVAs when studying intervention outcomes could enhance ecological validity by capturing real-life voice use, ensuring that observed improvements translate into meaningful changes in everyday communication.List of scientific papersI. Steurer, H., Schalling, E., Franzén, E., & Albrecht, F. (2022). Characterization of mild and moderate dysarthria in Parkinson's disease: Behavioral measures and neural correlates. Frontiers in Aging Neuroscience, 14, 870998. https://doi.org/10.3389/fnagi.2022.870998II. Steurer, H., Albrecht, F., Gustafsson, J. K., Razi, A., Franzén, E., & Schalling, E. (2024). Speech and neuroimaging effects following HiCommunication: a randomized controlled group intervention trial in Parkinson's disease. Brain Communications, 6(4), fcae235. https://doi.org/10.1093/braincomms/fcae235III. Steurer, H., Körner Gustafsson, J., Franzén, E., & Schalling, E. (2025). Auditory-perceptual analysis of speech outcomes following HiCommunication intervention in Parkinson's disease - a secondary analysis of a randomized controlled trial. [Manuscript]IV. Steurer, H., Körner Gustafsson, J., Franzén, E., & Schalling, E. (2024) (published online 2022). Using portable voice accumulators to study transfer of speech outcomes following intervention - A feasibility study. Journal of Voice, 38(4), 965.e1-965.e13. https://doi.org/10.1016/j.jvoice.2021.10.016</p
Bell's palsy in pregnancy and puerperium
No full textPregnancy-associated Bell's palsy (Bell's palsy in pregnancy and puerperium, i.e., the first 6 weeks after childbirth) is thought to be more common than in the general population. Still, incidence numbers differ as earlier study populations have been small. The reason for this supposed higher incidence remains unclear. The most commonly discussed hypotheses are that either edema, due to excessive body fluid caused by pregnancy, or herpes simplex reactivation, due to pregnancy-associated immunosuppression, cause damage of the facial nerve. Additionally, some studies have reported a poorer prognosis among women with Bell's palsy associated with pregnancy, whereas another study indicated a more favorable prognosis. Co-morbidities, such as gestational hypertension, preeclampsia, high BMI, and low Apgar score, are more common among women with pregnancy-associated Bell's palsy in some studies. In contrast, others could not show this association. No prior studies have investigated the degree of depression, facial disability, or quality of life in women with pregnancy- associated Bell's palsy.Study I is a retrospective study in which women who developed Bell's palsy during pregnancy or puerperium between 2005 and 2015 in Stockholm were recruited. Women with Bell's palsy without connection to pregnancy served as controls. Women with Bell's palsy in pregnancy had poorer facial outcomes than women with Bell's palsy in puerperium or without connection to pregnancy.Study Il is a prospective study where 31 women with Bell's palsy in pregnancy and puerperium were included as they were referred in the acute phase to the Ear, Nose, and Throat Department at the Karolinska University Hospital in Stockholm between the years 2005 to 2015. As comparison served 31 pregnant and puerperal women without Bell's palsy during the same time period. Patient- reported depression scores did not differ significantly between groups. The patient's experience of facial function and quality of life did not correlate to the physician's grading of facial functioning.Studies III and IV are based on data from the National Board of Social Health and Welfare in Sweden. Study III investigated maternal risk factors associated with Bell's palsy during pregnancy and puerperium. High BMI, geographical origin from Asia, Africa, and South America, multiple pregnancy, preeclampsia, and gestational diabetes were associated with pregnancy-associated Bell's palsy.Study IV investigated neonatal risk factors, showing that women with Bell's palsy in pregnancy did not have a higher risk of adverse neonatal outcomes. In comparison, women with adverse neonatal outcomes had a higher risk for Bell's palsy in the puerperium. The incidence of pregnancy-associated Bell's palsy in Sweden between 2005 and 2015 was calculated to be 171.6 per 100,000 pregnancies, compared with the general population, where earlier studies have reported an incidence of 23-53 per 100,000 per year.In conclusion, Bell's palsy is more common in pregnant and puerperal women than in the general population. A higher degree of depression could not be shown among these women, but larger study groups are needed to draw further conclusions about the psychological burden of the disease. Several maternal risk factors were associated with pregnancy-associated Bell's palsy. Bell's palsy during pregnancy did not increase the risk of adverse neonatal outcomes, but adverse neonatal outcome increased the risk of developing Bell's palsy after delivery, during puerperium.List of scientific papersI. Lansing, L., Wendel, S.B., Hultcrantz, M. and Marsk, E. (2023). Bell's Palsy in Pregnancy and Postpartum: A Retrospective Case-Control Study of 182 Patients. Otolaryngol Head Neck Surg. 168: 1025-1033. https://doi.org/10.1002/ohn.188II. Lansing L, Brismar Wendel S, Wejde Westlund E, Marsk E. A longitudinal study of facial function, quality of life, and depression in Bell's palsy during pregnancy and puerperium. Sci Rep. 2024 Oct 22;14(1):24890. https://doi.org/10.1038/s41598-024-75552-5III. Lansing L, Marsk E, Brismar Wendel S. Risk factors for pregnancy- associated Bell's palsy: a nationwide population-based register study. [Submitted]IV. Lansing L, Marsk E, Brismar Wendel S. A nationwide population- based register study of neonatal outcomes in pregnancy associated Bell's palsy. [Submitted]</p
Microrna and retroperitoneal lymph node dissection : advances in testicular cancer treatment
No full textBACKGROUNDTesticular germ cell tumor (TGCT) is the most common malignancy in young men, with an excellent five-year survival rate over 95%. Metastatic TGCTs can be cured by either chemotherapy, radiation or retroperitoneal lymph node dissection (RPLND), either solitary or in combination. Current research focuses on refining treatments and minimizing side effects. Over the past decade, the novel biomarker microRNA 371a-3p has demonstrated promising performance with high sensitivity and specificity for germ cell tumors (GCT), however, excluding teratomas. RPLND is a complex surgical procedure associated with certain morbidity, requiring substantial surgical experience for optimal outcomes. A global trend is emerging toward surgery as primary treatment for select patients with limited disease burden. The collaboration within the Swedish and Norwegian Testicular Cancer Group (SWENOTECA) enables populationbased studies on a relatively rare condition.AIMSPaper I, to evaluate miR-371a-3p levels in TGCT patients undergoing orchiectomy and in healthy blood donors using digital droplet PCR (ddPCR).Paper II, to assess miR-371a-3p levels in GCT patients undergoing RPLND using ddPCR and to evaluate the marker’s ability to predict viable cancer.Paper III, to report the outcomes for the first 62 patients in Sweden and Norway with low-stage, low-volume metastatic seminoma receiving RPLND as first-line treatment.Paper IV, to assess post-operative outcomes in a population-based cohort of metastatic GCT patients who underwent RPLND over a five-year period, in the context of centralization and wide-ranging adoption of robot-assisted procedures.METHODSPaper I is first part of the binational prospective multicenter study SWENOTECA-MIR. 180 TGCT patients and 50 healthy blood donors were analyzed for miR-371a-3p before and after orchiectomy, using ddPCR. The performance of ddPCR was compared to the quantitative PCR (qPCR) made by others to detect miR-371a-3p. Results were stratified by tumor subtype, tumor size, and clinical stage (CS), and levels of miR-371a-3p were statistically analyzed across the groups. Performance of the miR-371a-3p test was compared to conventional tumor markers.Paper II is the third part of the SWENOTECA-MIR study. 114 patients (86 nonseminomas, 28 seminomas) underwent open or robot-assisted RPLND from 2017 to 2022. miR-371a-3p levels were analyzed in pre- and post-operative samples using ddPCR. The cohort was categorized into primary and postchemotherapy RPLND groups and further subdivided into seminomas and nonseminomas. Statistical comparisons were made between pre- and postoperative miR-371a-3p levels, with optimism-corrected performance metrics assessed against conventional serum tumor biomarkers.Paper III describes the outcomes of a prospective population-based cohort. 62 seminoma patients from Norway and Sweden were operated between 2019 and 2022. Patients with lymphadenopathy £ 3 cm, primary CS IIA/B or CS I with relapse, underwent uni- or bilateral template RPLND, either open or robotassisted. Outcome measures included surgical complications according to the Clavien-Dindo classification, and Kaplan-Meier survival estimates for 24-month progression-free survival (PFS) and overall survival (OS).Paper IV is a prospective, population-based, observational multicenter study including all GCT patients who underwent RPLND in Sweden from 2018 to 2022. The cohort comprised 217 patients, with 175 nonseminomas and 42 seminomas. Unilateral and bilateral primary (P) RPLND and post-chemotherapy (PC) RPLND were performed, either open or robot-assisted. Primary outcomes included intra- and post-operative complications, loss of antegrade ejaculation, and histopathological findings of viable cancer or teratoma.RESULTSIn Paper I, ddPCR demonstrated high performance in detecting miR-371a-3p, with a sensitivity of 89% for the entire cohort. Sensitivities for CS I seminomas and CS I nonseminomas were 87% and 89%, respectively. Sensitivity for CS I–IV seminomas was 89%, and for CS I–IV nonseminomas, it was 90%. The specificity for the cohort was 100%, with a positive predictive value (PPV) of 100% and a negative predictive value (NPV) of 55%. In comparison, AFP demonstrated 52% sensitivity and b-HCG 51%, in nonseminomas. Linear regression indicated an association between tumor size and miR-371a-3p levels across the entire cohort (R² = 0.159, p In Paper II, all seminoma patients (n = 24) undergoing primary RPLND had normal conventional markers, with six having received adjuvant treatment prior to surgery. miR-371a-3p demonstrated a sensitivity of 74%, specificity of 100%, PPV of 100%, and NPV of 21% for detecting viable tumor. miR-371a-3p levels decreased significantly after surgery (p = 0.001). In the nonseminoma group (n = 18) undergoing primary RPLND, 22% had elevated conventional markers, and three patients had received prior adjuvant treatment. For primary nonseminoma patients, miR-371a-3p demonstrated a sensitivity of 34%, specificity of 88%, PPV of 67%, and NPV of 62%. No significant association was observed between stage or prior adjuvant treatment and miR-371a-3p outcome. In the postchemotherapy group (n = 72), miR-371a-3p sensitivity was 9%, and it dropped to 0% when seminoma patients (n = 4) were excluded. Teratomas and benign histology yielded essentially negative results.In Paper III, 33 patients (53%) had CS I with relapse during surveillance, six patients (10%) had CS I with relapse after adjuvant chemotherapy, and 23 patients (37%) had initial CS IIA/B disease. Post-operative analysis confirmed metastatic seminoma in 58 patients (94%), with a median largest diameter of 18 mm (IQR: 13–24). Robot-assisted RPLND was performed in 40 patients (65%). Clavien-Dindo III complications occurred in three patients (5%), and no grade ³ IV complications were observed. Eighteen patients (29%) received adjuvant chemotherapy after surgery. The median follow-up was 23 months (IQR: 16–30), with recurrence occurring in six patients (10%) after a median of 8 months (IQR: 4–14). PFS was 90% (95% CI: 0.86–1), and OS was 100% at 24 months.In Paper IV, the cohort experienced intra-operative complications in 8% of unilateral and 0% of bilateral P-RPLND procedures, with renal injury being the most common event. For PC-RPLND, the rates were 0% for unilateral and 8% for bilateral templates. Post-operative complications were more frequent with bilateral templates (P-RPLND: 40% vs. 26%, p = 0.3; PC-RPLND: 49% vs. 18%, p = 0.0), with Clavien-Dindo ≥ IIIb complications in 2% of P-RPLND cases and 3% of PC-RPLND cases. Loss of antegrade ejaculation was more common after bilateral templates (P-RPLND: 60% vs. 31%, p = 0.07; PC-RPLND: 53% vs. 38%, p = 0.09). Viable cancer was found in 95% of seminomas and 52% of nonseminomas for primary procedures, while nonseminoma PC-RPLND showed 11% viable cancer, 50% teratoma, and 39% benign nodes. Robot-assisted procedures were not associated with higher rates of intra-operative or post-operative complications, nor increased loss of antegrade ejaculation. Patients who underwent robotic procedures had shorter hospital stays, and conversions to open surgery occurred in 10%.CONCLUSIONSPaper I: miR-371a-3p using ddPCR showed 89% sensitivity and 100% specificity in TGCTs, outperforming conventional biomarkers. It decreased postorchiectomy, with less reduction seen in metastatic patients.Paper II: miR-371a-3p had superior performance over conventional markers in seminomas undergoing primary RPLND (74% sensitivity, 100% specificity) but was less effective in nonseminomas and post-chemotherapy patients.Paper III: Primary RPLND appears to be a safe and effective treatment for selected metastatic seminomas, offering low complication and relapse rates, and potentially reducing long-term risks compared to conventional chemotherapy and radiotherapy.Paper IV: Centralized RPLND procedures are associated with low complication rates, with robotic surgery further improving certain outcomes. In PC-RPLND, rates of teratoma and viable cancer increased, with fewer benign findings. Careful patient selection and outcome monitoring are crucial.List of scientific papersI. Serum miR371 in testicular germ cell cancer before and after orchiectomy, assessed by digital-droplet PCR in a prospective study Myklebust MP, Thor A, Rosenlund B, Gjengstø P, Karlsdottir A, Brydøy M, Bercea B S, Olsen C, Johnson I, Berg M I, Langberg C W, Andreassen K E, Kjellman A, Haugnes H, Dahl O Scientific Reports, 2021 Aug 2: 11:15582. https://doi.org/10.1038/s41598-021-94812-2II. miR-371a-3p Predicting Viable Tumor in Patients Undergoing Retroperitoneal Lymph Node Dissection for Metastatic Testicular Cancer: the SWENOTECA-MIR study Thor A, Myklebust MP, Grenabo Bergdahl A, Lundgren P-O, Skokic V, Almås B, Haugnes H, Tandstad T, Akre O, Cohn-Cedermark G, Dahl O, Kjellman A Journal of Urology, 2024 Nov; 212(5):720-730. https://doi.org/10.1097/JU.0000000000004164III. Primary Retroperitoneal Lymph Node Dissection as Treatment for Low-volume Metastatic Seminoma in a Population-based Cohort: the Swedish Norwegian Testicular Cancer Group Experience Thor A, Negaard H, Grenabo Bergdahl A, Almås B, Melsen Larsen S, Lundgren P-O, Gerdtsson A, Halvorsen D, Johannsdottir B, Jansson A K, Hellström M, Wahlqvist R, Langberg C W, Hedlund A, Akre O, Glimelius I, Ståhl O, Haugnes H, Cohn-Cedermark G, Kjellman A/ Tandstad T European Urology Open Science, 2024 Jun 11:65:13-19. https://doi.org/10.1016/j.euros.2024.05.006IV. Complications and clinical outcomes of retroperitoneal lymph node dissection in a centralized population-based cohort: insights from the SWENOTECA group Thor A, Grenabo Bergdahl A, Abniki A, Almås B, Melsen Larsen S, Gerdtsson A, Habberstad A, Halvorsen D, Lundgren P-O, Akre O, Cohn-Cedermark G, Kjellman A. 2024 [Manuscript] </p