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Phalangeal fractures : epidemiology and new methods for treatment
No full textFinger fractures are very common and might affect hand function. Most finger fractures are treated non-surgically with plaster casts or immediate mobilization. Some, more complex, fractures need surgery to restore functionality. Surgery afflicts a new trauma to the already injured finger and give rise to soft tissue adhesions which restricts movement. This thesis aimed at describing the epidemiology of finger fracture and to evaluate different treatment methods.In Paper I data from the Swedish Fracture Registry (SFR) which is a national quality registry that collects data from all orthopaedic trauma centres in Sweden, were analysed. 21 341 finger fractures were described regarding anatomical distribution, cause, treatment, age distribution, and result in terms of patient related outcome measures (PROMs). The most common finger fracture was one in the proximal phalanx of the 5th finger. Fall accidents were the most common cause of fracture. The mean age at injury was 40 years (38 for men, 43 for women). 86% of finger fractures in adults were treated non-operatively. Finger fractures did not affect hand function or quality of life and there were no relevant differences in PROM between fracture type, treatment, or gender.Paper II was an interim, non-inferiority analysis of a randomised controlled trial comparing percutaneous pinning and plaster immobilization versus non-surgical treatment using a custom-made orthosis and early mobilization of fractures in the proximal finger phalanx. A total of 42 fractures in 42 patients were included in the analysis. Baseline characteristics, including age, sex, and fracture displacement, were comparable between groups. There was no significant difference in the primary outcome, total active range of motion (TAM of the injured finger at 12 months. Non-surgical treatment with a custom-made splint and early mobilization was not inferior to surgical fixation.To overcome the problem with soft tissue adhesions to osteosynthesis material in fracture surgery, a newly developed anti-adhesive moldable coating over metal plates was tested in Paper III. Using a rabbit model, coated plates were compared with bare plates regarding movement in rabbit toe joints. Macroscopically there were less adhesions around the coated plates. Joint movement in toes with coated plates was significantly better compared to bare plates. Coated plates were also easier to remove due to less soft tissue ingrowth.In Paper IV another application of the material from study III was evaluated. Screws on either side of a fracture line was connected with the soft composite material. After curing with high energy light, a rigid osteosynthesis was achieved. Maximum load and bending rigidity of the custom-made plate was tested on porcine bones with transverse and multifragmented fractures. In a human cadaver model with fractures of the proximal phalanges the method proved stable enough for finger flexion movement. A rat femur fracture model showed that the material did not interfere with bone healing nor affected the surrounding soft tissues in a negative way.In conclusion, most finger fractures are treated non-surgically and they usually do not have a large impact on patient reported outcomes. Some displaced fractures of the proximal phalanx can be treated non-surgically. The material described in Papers III and IV has promising features for fracture treatment in fingers, but further research is needed.List of scientific papersI. Alfort H, von Kieseritzky J, Wilcke M. "Finger fractures: Epidemiology and treatment based on 21341 fractures from the Swedish Fracture register." PLOS One. 2023 Jul 14;18(7):e0288506. https://doi.org/10.1371/journal.pone.0288506II. Alfort, H., von Kieseritzky, J. and Wilcke, M. "Percutaneous Pinning vs. Orthosis and Early Mobilization for Proximal Phalanx Fractures: A Randomized Controlled Trial - An interim analysis of 42 fractures". 2025. [Manuscript]III. von Kieseritzky J, Alfort H, Granskog V, Hutchinson D, Stenlund P, Bogestål Y, Arner M, Håkansson J, Malkoch M. "DendroPrime as an adhesion barrier on fracture fixation plates: an experimental study in rabbits." J Hand Surg Eur Vol. 2020 Sep;45(7):742-747. https://doi.org/10.1177/1753193420932477IV. Hutchinson, D. J., V. Granskog, J. von Kieseritzky, H. Alfort, P. Stenlund, Y. Zhang, M. Arner, J. Håkansson, M. Malkoch, "Highly Customizable Bone Fracture Fixation through the Marriage of Composites and Screws." Adv. Funct. Mater. 2021, 31, 2105187. https://doi.org/10.1002/adfm.202105187</p
Offspring exposure to Crohn's disease during pregnancy and association with milder psychiatric regulatory disturbances in childhood
No full textIntroduction: Prenatal exposure to inflammatory states has been suggested to influence offspring neurodevelopment. The aim was to investigate if offspring exposure to maternal Inflammatory bowel disorder (IBD), or specifically the IBD disorder Crohn's disease, during gestation is associated with neurodevelopmental or psychiatric disorders in childhood.Material and methods: We conducted a population-based registry study in Finland. All live births from 1996 until 2014 in Finland were included and followed up until December 2018. Exposure was maternal IBD or Crohn's disease. Outcome was a broad range of neurodevelopmental and psychiatric disorders in offspring. Cox proportional hazards regression was applied to assess association. Sensitivity analyses included assessing, for example, exposure to severe episode of IBD or Crohn's disease, the outcome psychotropic medication for the children, and influence from perinatal risk factors.Results: Of the participants (N = 1 105 997), 0.55% (N = 6067) were exposed to maternal IBD 0.18% (N = 1959) to maternal Crohn's disease. Among the children exposed to IBD or the subgroup Crohn's disease, 6.3% or 7.3%, respectively, had received an outcome diagnosis during the follow-up. There were higher risks for Sleeping disorders HR = 1.77 (95% CI, 1.13-2.78), Other feeding disorders HR = 1.83 (95% CI, 1.19, 2.19), and Incontinence HR = 1.42 (95% CI, 1.02-1.97) in children exposed to maternal Crohn's disease compared to unexposed children. This was supported by even higher point risk estimates for Incontinence HR = 2.43 (95% CI, 1.34-4.38) and Other feeding disorders HR = 2.83 (95% CI, 1.35-5.91) in offspring where the mother was hospitalized for Crohn's disease during pregnancy. Furthermore, there was a higher risk of dispensed antipsychotic, anxiolytic, hypnotic, and/or sedative medications for children with maternal Crohn's disease HR = 1.38 (95% CI, 1.03-1.85). These associations were not explained by cesarean section, preterm birth, or small birth size.Conclusions: Offspring exposed to maternal Crohn's disease during pregnancy had modestly higher risks of early sleeping, continence, and feeding disturbances. The exposure had no detectable association with any of the other psychiatric disorders studied.</p
PET imaging of neurodegenerative markers in Alzheimer's disease
No full textAlzheimer's disease (AD) is a neurodegenerative disorder resulting in neuron loss and dementia. Pathophysiological changes take place years before clinical symptoms appear. The association of these brain changes with the development of the clinical syndrome of AD is not known in detail. Biomarkers for in vivo detection of early pathophysiological change in AD are needed for early diagnosis and may also have potential as targets for therapy and for monitoring of disease-modifying treatments. The overarching aim of the thesis projects was to explore the potential of positron emission tomography (PET) imaging of amyloid deposits, neuroinflammation and neuron loss for early detection of neurodegenerative changes in AD.The 18-kDa translocator protein (TSPO) is a biomarker of activated microglia and neuroinflammation in neurodegenerative disorders. In study I, 7 control subjects and 9 mild AD patients were examined with the high affinity second generation TSPO radioligand [18F]FEDAA1106 and an ECAT EXACT HR PET system. Binding of [18F]FEDAA1106 to TSPO in mild AD was not different from the binding in control subjects, neither in global grey matter nor in regional grey matter. The results may have been influenced by a TSPO gene polymorphism that was not known when the study was designed and conducted, resulting in an unknown prevalence of high and low affinity binders in the sample. The results may also have been influenced by the relatively high nonspecific binding of [18F]FEDAA1106, not allowing for detection of increased specific signal in the AD patients compared to the healthy controls. The conclusion of the study was that TSPO imaging with [18F]FEDAA1106 does not have potential for in vivo detection of microglial activation in mild AD.The serotonin 1A (5-HT1A) receptor is expressed at high levels in entorhinal cortex, hippocampus and amygdala, regions that are vulnerable to early neuron loss in AD. In study II, 8 control subjects and 7 mild AD patients were examined with the sensitive and specific 5-HT1A radioligand [11C]WAY100635 and the ECAT EXACT HR PET system as an approach to evaluate neurodegenerative changes in vivo. AD patients had lower binding of [11C]WAY100635 than control subjects in amygdala, entorhinal cortex and hippocampus. Our findings corroborate and extend previous results of decreased 5-HT1A binding in the medial temporal lobe in samples including moderate-severe AD patients, and we conclude that PET using [11C]WAY100635 has potential for sensitive assessment of neurodegeneration in mild AD.Accumulation of amyloid beta peptide (Aβ) deposits in the cerebral cortex is considered as an initiating step on the pathogenic pathway leading to AD. In study III, 10 elderly subjects with subtle longitudinal decline in episodic memory function and 10 age-matched subjects with stable episodic memory function were recruited from the population-based Betula study and examined with [11C]AZD2184, an Aβ radioligand with high sensitivity, and a high-resolution research tomograph (HRRT). We hypothesized that episodic memory decline, regarded as an early cognitive marker of AD, would predict cortical Aβ deposits. Contrary to our hypothesis, the binding of [11C]AZD2184 was higher in the stable group than in the declining group. The three highest individual binding potential values in the stable group were observed in carriers of the ApoE4 allele. We concluded that subtle episodic memory decline alone does not seem to predict Aβ pathology and may be caused by other underlying pathologies in this cohort.Results from post-mortem studies suggest that brain Aβ deposits appear in a sequence from isocortical to allocortical to subcortical regions. The early regional distribution of Aβ deposits, however, needs more detailed study in vivo. In study IV, 8 cognitively unimpaired (CU) subjects, 8 mild cognitive impairment (MCI) and 8 AD patients were examined with [11C]AZD2184 and the HRRT system. The main aim was to compare the presence of isocortical, allocortical and subcortical Aβ deposits with the results from previous post-mortem studies. Isocortical Aβ was detected in two thirds of the sample (3 CU, 5 MCI, 8 AD) and this group was the focus of the subsequent analysis. In these Aβ-positive subjects (n=16), Aβ was detected in striatum, thalamus and allocortex in 15, 14 and 10 subjects, respectively. We concluded that Aβ deposits seem to be widespread in early AD and that high contrast PET can be used for detailed study of the appearance of Aβ, which has implications for improved diagnostics and monitoring of disease-modifying treatments.List of scientific papersI. Varrone A, Mattsson P, Forsberg A, Takano A, Nag S, Gulyás B, Borg J, Boellaard R, Al-Tawil N, Eriksdotter M, Zimmermann T, Schultze- Mosgau M, Thiele A, Hoffmann A, Lammertsma AA, Halldin C. In vivo imaging of the 18-kDa translocator protein (TSPO) with [18F]FEDAA1106 and PET does not show increased binding in Alzheimer's disease patients. Eur J Nucl Med Mol Imaging. 2013 Jun;40(6):921-31. Epub 2013 Feb 22. PMID: 23436070. https://doi.org/10.1007/s00259-013-2359-1II. Mattsson P, Cselényi Z, Andrée B, Borg J, Nag S, Halldin C, Farde L. Decreased 5-HT1A binding in mild Alzheimer's disease-A positron emission tomography study. Synapse. 2022 Jun;76(7-8):e22235. Epub 2022 May 28. PMID: 35587913; PMCID: PMC9285435. https://doi.org/10.1002/syn.22235III. Mattsson P, Forsberg A, Persson J, Nyberg L, Nilsson LG, Halldin C, Farde L. β-Amyloid binding in elderly subjects with declining or stable episodic memory function measured with PET and [11C]AZD2184. Eur J Nucl Med Mol Imaging. 2015 Sep;42(10):1507-11. Epub 2015 Jun 27. PMID: 26115835. https://doi.org/10.1007/s00259-015-3103-9IV. Mattsson P, Cselényi Z, Forsberg Moren A, Freund-Levi Y, Wahlund LO, Halldin C, Farde L. High Contrast PET Imaging of Subcortical and Allocortical Amyloid-β in Early Alzheimer's Disease Using [11C]AZD2184. J Alzheimers Dis. 2024;98(4):1391-1401. PMID: 38552111; PMCID: PMC11091650. https://doi.org/10.3233/jad-231013</p
Sexual and mental health among young male forced migrants in Stockholm : needs, links, and responses
No full textBackgroundFor young male youth, forced migration experiences often involves a heightened risk for sexual and mental health challenges as well as poor outcomes due to limited access to services and knowledge gaps. Consequently, they may have specific sexual and mental health needs in the host country that are seldom fully addressed. Much of the current research on sexual and reproductive health and rights primarily focuses on the experiences of women leaving a significant gap in understanding the diverse perceptions and experiences of young male forced migrants, their associated sexual and mental health needs, and how these two domains are interlinked. Additionally, there is a lack of research exploring the perspectives of health care professionals, regarding their experiences and capacity to address these needs, and their experiences of cross- cultural training designed to improve knowledge and quality of care.Aim The overarching aim of this thesis is two-fold. The first aim is to gain a deeper understanding of the sexual and mental health needs of young male forced migrants, the connection between these two domains, and how to address these needs from the perspectives of young Eritrean, Syrian, and Afghan men and healthcare professionals in the Stockholm region, Sweden. The second aim is to evaluate Comprehensive Cross- Cultural Training (CCCT) for mental health care professionals about refugees and asylum seekers mental health and care in Stockholm.MethodsData were gathered from two research projects. The first project comprised three studies (Studies I-III), which employed an exploratory qualitative approach using semi- structured interviews, while the second project (Study IV) applied a concurrent embedded mixed-method research design, combining both quantitative and qualitative data. A total of 32 semi-structured interviews were conducted with young male forced migrants originally from Syria, Eritrea and Afghanistan (aged 16-28 years) between June 2019-October 2020 in the Stockholm region, using theoretical sampling (data used for study I and II). For Study III, nine interviews with healthcare professionals were carried out using snowball sampling. Qualitative data from Study I was analyzed using constructivist grounded theory, while Study II and III employed inductive qualitative content analysis. In Study IV, for the quantitative sub-study, pre-and post- questionnaires were used including 17-items assessing perceived knowledge. The qualitative sub-study comprised six focus group discussions (FGDs). For Study IV, nested sampling was used while heterogeneous purposive sampling was employed for the FGDs. Quantitative data were analyzed using t-tests and factor analysis whereas qualitative data were analyzed using thematic content analysis.ResultsIn Study I, we found that sexual and mental health needs of young men evolved over time, reflecting an individual process of change, including attitudinal shifts. Across Studies I-III, six key areas of sexual and mental health needs were identified: needs related to recent forced migration experiences, understanding changing norms, navigating romantic and sexual relationships, needs related to knowledge gaps and building skills, the need for and seeking information and healthcare and using services and interacting with healthcare professionals.A multitude of factors influenced the process of change and the fulfillment of sexual and mental health needs. Facilitating factors included attending school and receiving sexuality education, support in adapting to the Swedish society, and experiencing enjoyable relationships. Constraining factors involved restrictive parental values, exposure to discrimination and stigma, and negative narratives about young male refugees. Furthermore, in Study II having a supportive female partner was found to facilitate sexual communication, including discussion about safer sexual practices, sexual transmitted infection (STI) status, testing, condom use, and accessing local services. In Study III, sexual and mental healthcare providers emphasized the importance of an integrated approach to care but noted limitations in service provision and in meeting the needs of young men with forced migration experiences. They also highlighted the need for specific training. In Study IV, participants of the cross-cultural training reported enhanced perceived knowledge and new perspectives in relation to the content. From the FGDs, it was revealed that refugee patients were perceived as a challenging group to care for, but the cross-cultural training promoted empathy towards this patient population and strengthened their professional role.ConclusionsThis thesis aims to contribute to an extended understanding of sexual and mental health needs of young male forced migrants, how sexual and mental health are interlinked, and potential approaches to address them. It incorporates perspectives from both the young male themselves and health professionals in the Stockholm region, offering a broader view of needs.To effectively respond to these needs, it is crucial to first understand their nature, the interconnection of sexual and mental health, the process of change, and influencing factors. While navigating a new social context, young male forced migrants would benefit from ongoing support, guidance, knowledge, and practical skill development related to sexual and mental health. These insights should inform public health and educational interventions targeting youth, as well as healthcare practices, including the training and support of public health and health care professionals. Educational interventions for refugee and asylum-seeking youth groups should consider migration experiences and related challenges, be culturally sensitive and tailored, and integrate both sexual and mental health components.In the context of service delivery, sexual and mental health needs, and their interconnection, are not being effectively addressed. This underscores the importance of continuously supporting health professionals, both organizationally and individually, to acquire cross-cultural knowledge, skills, tools, and practices. It also highlights the need to consider forced migration experiences, adopting reflective approaches, and including young men in care decisions, allowing time to build trust.List of scientific papersI. Tewelde McDonald J, Fayzi B, Laktinah M, Ekström AM, Salazar M. 'Sweden has changed me': a qualitative study exploring the sexual health needs and associated mental health aspects of young male former unaccompanied minors, asylum seekers and refugees in Region Stockholm, Sweden. BMJ Open 2024;14:e080514.https://doi.org/10.1136/bmjopen-2023-080514II. Tewelde McDonald J, Fayzi B, Laktinah M, Ekström AM, Salazar M. Attitudes, perceived knowledge, experiences and needs regarding condom use, STIs, transactional sex, and sexual healthcare among young male forced migrants in Stockholm, Sweden: a qualitative study [Manuscript]III. Karimah F, Tewelde McDonald J, Stålgren M, Salazar M. Healthcare providers' perceptions of mental and sexual health needs of young males with forced migration experiences in Stockholm, Sweden [Manuscript]IV. McDonald JT, Dahlin M, Baarnhielm S. Cross-cultural training program on mental health care for refugees - a mixed method evaluation. BMC Med Educ. 2021 Oct 15;21(1):533. PMID: 34654412; PMCID: PMC8520228https://doi.org/10.1186/s12909-021-02965-5</p
Anchored or adrift? : social connection, health, and loneliness in later life
No full textPeople aged 80 and older are the fastest-growing segment of the population, yet they remain underrepresented in research and are often portrayed through a lens of isolation and loneliness. Social connectedness, the ways individuals interact with and experience their social world, is a fundamental aspect of human life. In later life, changes in health, family, and social roles can reshape opportunities for connection. More people are now reaching older ages with higher levels of functional ability, lower rates of dementia, and more peers alive. Yet despite the importance of social connectedness in very old age, it remains underexplored.The aim of this thesis was to further our understanding of social connectedness in later life through patterns of change over time and associations with health and wellbeing. The first two studies established trends over time in light of changing conditions for social connectedness.Study I described trends in social participation among the oldest old (77+) in Sweden using the Swedish Panel Study of the Living Conditions of the Oldest Old (SWEOLD, 2002-2021). Leisure and informal participation increased until 2014 but declined in 2021, likely due to the COVID-19 pandemic, while formal participation rose slightly. Although one third of older adults reported low participation levels, overall participation increased over time. These changes could partly be attributed to compositional shifts in education and functional ability, reflecting broader societal and health developments.Study II described how friendship contact changed across cohorts using data from individuals born between 1905 and 1984, aged 15-97. The data was collected between 1968 and 2021 in the Swedish Level of Living survey (LNU) and SWEOLD. Friendship contact decreased across the life span, plateauing in midlife. Later-born cohorts reported more frequent contact, but these differences diminished in the oldest ages. Cohort differences in contact with relatives were not found. These patterns suggest that friendships may become increasingly important across cohorts, while old age may level out such differences.The next two studies examined relationships between social connectedness, health and wellbeing.Study III examined whether different types of social relationships (partners, children, relatives, friends, and weak ties) show distinct associations with life satisfaction, while considering the psychosocial pathways of perceived emotional and practical support, and loneliness using SWEOLD 2021. Close family relationships, partners and children, showed the strongest associations with life satisfaction. Relationships with children were directly and positively associated with life satisfaction and showed indirect associations through social support. Positive indirect associations with partners operated through social support and loneliness, while the direct association was equal in size and negative. Friendships were associated with life satisfaction through emotional support and reduced loneliness, whereas relationships with other relatives and weak ties showed no significant associations. These patterns suggest that different types of relationships fulfil distinct emotional and practical functions in very old age.Study IV investigated loneliness trajectories surrounding the onset of mobility limitations using longitudinal data from the Survey of Health, Ageing and Retirement in Europe (SHARE) for adults aged 65+. Loneliness increased following onset, particularly for those with persistent limitations, while individuals who recovered showed stabilised levels. Those with high neighbourhood attachment had lower loneliness prior to onset but steeper increases over time. This study highlights the potential negative impact of mobility limitations on social connectedness.Together, the four studies provide a multifaceted understanding of social connectedness in later life. Older adults today are generally more socially active and maintain more diverse networks than previous generations, yet experiences of connectedness remain heterogeneous and sensitive to health decline and social context. Different relationship types serve distinct emotional and practical purposes, and maintaining connection depends on both individual capacities and supportive environments. This thesis shows that very old age is not defined by inevitable isolation and loneliness, but by the ongoing negotiation of connection within changing personal and structural conditions.List of scientific papersI. Augustsson, E; Fors, S; Rehnberg, J; Lennartsson, C; Agahi. N. (2024) 20-year trends in the social participation of the oldest old. Scandinavian Journal of Public Health. 14034948241261720. https://doi.org/10.1177/14034948241261720II . Augustsson, E; Celeste, RK; Fors, S; Rehnberg, J; Lennartsson, C; Agahi, N. (2025). Friends and Trends: Friendship across life phases and cohorts. Archives of Gerontology and Geriatrics, 135, 105872. https://doi.org/10.1016/j.archger.2025.105872III. Augustsson, E; Celeste, RK; Dahlberg, L; Lennartsson, C; Agahi, N. Social relationships and life satisfaction among the oldest old: differentiating psychosocial pathways. [Submitted]IV. Augustsson, E; Fors, S; Dahlberg, L; Lennartsson, C; Agahi, N. Trajectories of loneliness in relation to mobility limitations and neighbourhood context. [Submitted]</p
Promoting change in secure settings : adaptation and evaluation of the adolescent community reinforcement
No full textBackgroundAdolescents in secure care constitute one of the most vulnerable groups in society, commonly contending with intersecting adversities, substance use, and involvement in severe crime. Also, they are in a setting where personal freedom is restricted. Despite the complexity of their needs and the high risk of continuing a destructive pathway into adulthood, few interventions have been rigorously evaluated or tailored for delivery in closed secure settings in Sweden. The Adolescent Community Reinforcement Approach (A-CRA), originally developed for outpatient services, has demonstrated effectiveness in promoting abstinence and prosocial behaviour in community contexts, but had not previously been tested within secure care.AimsThe main objective of this thesis was to examine A-CRA in secure settings from multiple perspectives: adolescents' and therapists' experiences, feasibility in the secure environment, potential processes of change it engages, and what outcomes it yields in comparison with treatment-as-usual. More specifically, the effectiveness of A-CRA on social, emotional, and behavioural problems, substance use, and prosocial behaviour.MethodsFour interlinked studies were conducted:I. Therapists' experiences of conducting A-CRA in secure care were explored and specifically how treatments were perceived, how A-CRA was adapted to the secure setting, and potential facilitators and barriers in delivery. Interviews were analysed using qualitative content analysis with an inductive approach (N = 7).II. A potential novel change process for A-CRA in secure care was investigated through a mixed-methods study of adolescents' goal-talk. First, content analysis with a deductive approach was used to develop a coding manual using a Relational Frame Theory framework, and second, the association between the coded goal talk and change in A-CRA was investigated (N = 12).III. Feasibility, acceptability and preliminary treatment effects was investigated through a mixed methods randomised trial comparing A-CRA as an addition to treatment-as-usual (TAU) with TAU alone and investigating adolescents' experiences of undergoing A-CRA in secure care through interviews (N = 42).IV. Randomised controlled trial evaluating the effectiveness of A-CRA in secure care by comparing A-CRA + treatment-as-usual (TAU) with TAU alone (N = 84).ResultsI. Therapists reported that A-CRA was useful in secure care with only minor adaptations. The programme’s flexibility and scope for individual tailoring were viewed as enhancing engagement, and a strong therapeutic alliance was considered essential to success.II. Among adolescents receiving A-CRA, goal-related verbal behaviour (goal-talk) was feasible to identify, code, and analyse. Appetitive goal-talk showed strong associations with reduced substance use and with movement towards personally endorsed values.III. A-CRA proved feasible and acceptable in secure care, with a 77% completion rate. Adolescents generally described positive treatment experiences. Registry indicators suggested lower relapse to substance use in A-CRA + TAU (54%) than in TAU (92%), whereas rates of serious norm-violating behaviour were similar across conditions. Recruitment and randomisation procedures were workable, however, administering paper self-reports led to substantial missing data.IV. In the definitive trial, both A-CRA + TAU and TAU yielded improvements in emotional, social, and behavioural problems, alongside gains in prosocial behaviour. Differences between groups were not clearly distinguishable in the full sample. In the completer sub-sample, adolescents receiving A-CRA + TAU showed greater improvement in emotional symptoms and conduct problems than those receiving TAU alone.ConclusionsA-CRA can be delivered in secure care with minor adaptations and is perceived as acceptable and helpful to adolescents and therapists. Notably, the flexibility of A-CRA, allowing therapists to tailor sessions to adolescents' specific goals and needs, was seen by therapists and adolescents to increase engagement, which is often difficult to maintain in compulsory secure care. Measuring goal-talk is a promising approach to capturing proximal change processes in this context. Across studies, A-CRA achieved effects comparable to those typically observed in outpatient delivery, however, the evidence does not indicate a clear advantage over other CBT-based treatments currently provided in secure care.ImplicationsPolicy and service implications include that A-CRA is perceived as helpful by therapists and adolescents and that treatment can be delivered as intended with smaller adaptations. Furthermore, A-CRA decreases problem behaviours in secure settings. Lastly, that flexibility and focus on individual goals as part of treatment seems to foster engagement and motivation for change towards prosocial pathways for adolescents within compulsory, secure care, where personal freedom is already very restricted.List of scientific papersI. Mälarstig, I., Tyrberg, M. J., Lundgren, T., & Alfonsson, S. (2023). Experiences of conducting a substance use disorder treatment, A-CRA, in compulsory institutional care for youth-The challenge of promoting openness in a closed, temporary setting. Children and youth services review, 148, 106850. https://doi.org/10.1016/j.childyouth.2023.106850II. Mälarstig, I., Törneke, N., Lundgren, T., Alfonsson, S., & Tyrberg, M. J. (2025). "Finding your values is important. You only die once."- Analysing goal-talk in incarcerated adolescents struggling with substance use from a Relational Frame Theory perspective. Journal of Contextual Behavioral Science, 100947. https://doi.org/10.1016/j.jcbs.2025.100947III. Mälarstig, I., Spännargård, Å., Garke, M. Å., Tyrberg, M., Lundgren, T., & Alfonsson, S. (2025). Adolescent Community Reinforcement Approach in Secure care for Adolescents with Substance Use and Severe Norm-Violating behavior: A Randomised Feasibility Trial. [Submitted]IV. Mälarstig, I., Spännargård, Å., Garke, M. Å., Sahlin, H., Lundgren, T., & Alfonsson, S. (2025). The effectiveness of the Adolescent Community Reinforcement Approach in secure care for adolescents with substance use and severe norm-violating behavior: A randomised controlled trial. [Manuscript]</p
Design and integration of AI solutions in oncology and healthcare infrastructures : bridging the gap between AI innovation and clinical practice
No full textArtificial intelligence (AI) is driving major changes across numerous fields, with healthcare emerging as one of the areas with the greatest potential for impact. In medical imaging, AI has the potential to enhance patient care through personalized treatment planning and early disease detection, while simultaneously supporting clinicians by optimizing their workload, and automating complex tasks such as radiological image analysis. Over the past decade, substantial progress has been made in medical AI research, leading to highly accurate and robust models in controlled experimental settings. However, bringing these AI tools into everyday clinical use has proven challenging. Despite many scientific breakthroughs, only few AI systems are currently being adopted in clinical settings.This PhD thesis focuses on understanding why that gap exists, and how to bridge it. The work explores the technical, organizational, and ethical barriers that slow down AI adoption in healthcare, and proposes new ways to make AI more practical, transparent, and trustworthy in clinical environments.A key result of this research is MAIA, a collaborative platform designed to bring together doctors, radiologists, and AI researchers. MAIA provides a shared space where experts can jointly develop and test AI tools under realistic clinical conditions. By combining research methods with everyday medical workflows, MAIA helps accelerate the transition from experimental AI models to clinical tools. The platform has been successfully deployed in both research and hospital environments, demonstrating its effectiveness in accelerating the integration of AI into medical practice.Building on this foundation, the thesis also introduces MONet, a framework that makes it easier to adapt and reuse state-of-the-art medical image segmentation models for different healthcare applications. It enables smooth integration of AI into various clinical settings, from federated learning across different institutions to human-in-the-loop smart annotation tools, ensuring that research innovations can be efficiently transferred into real-world practice.Finally, as a methodological contribution to the field, the thesis investigates the incorporation of anatomical and contextual prior knowledge into existing deep learning frameworks, with the goal of improving model interpretability and anatomical awareness. These methods were evaluated on different clinical tasks, such as lung lobe segmentation on chest CT, breast cancer treatment response prediction, and lymphoma segmentation on whole-body PET/CT, with the findings suggesting that the relevance of anatomical priors is task-dependent and can vary significantly across contexts.In summary, the thesis work aims to contribute to bridging the gap between AI research and clinical implementation by developing collaborative infrastructures, adaptable frameworks, and methodological insights that support the trustworthy, transparent, and effective integration of AI technologies in medical imaging practice.List of scientific papersPaper A. Simone Bendazzoli, Sanna Persson, Mehdi Astaraki, Sebastian Pettersson, Vitali Grozman, Rodrigo Moreno. MAIA: A Collaborative Medical AI Platform for Integrated Healthcare Innovation. [Accepted; Preprint] https://doi.org/10.48550/arXiv.2507.19489Paper B. Simone Bendazzoli, Mehdi Astaraki, Antonios Tzortzakakis, Andréas Abrahamsson, Björn Engelbrekt Wahlin, Sofia Brunori, Maria Holstensson, Rodrigo Moreno. MONet-FL: Extending nnU-Net with MONAI for Clinical Federated Learning. In: Zamzmi, G., et al. Bridging Regulatory Science and Medical Imaging Evaluation; and Distributed, Collaborative, and Federated Learning. MICCAI 2025. Lecture Notes in Computer Science, vol 16135. Springer, Cham. https://doi.org/10.1007/978-3-032-05663-4_10Paper C. Simone Bendazzoli, Emelie Bäcklin, Örjan Smedby, Birgitta Janerot-Sjoberg, Bryan Connolly, Chunliang Wang. Lung vessel connectivity map as anatomical prior knowledge for deep learning-based lung lobe segmentation. Journal of Medical Imaging, vol. 11, no. 04, Jul. 2024. https://doi.org/10.1117/1.jmi.11.4.044001Paper D. Simone Bendazzoli, Mehdi Astaraki, Yanbo Li, Rodrigo Moreno, Örjan Smedby, Hong Lu, Chunliang Wang. Designing Radio-dynamics Features for PCR Prediction in Breast DCE-MRI. [Manuscript]Paper E. Simone Bendazzoli, Antonios Tzortzakakis, Andreas Abrahamsson, Björn Engelbrekt Wahlin, Örjan Smedby, Maria Holstensson, Rodrigo Moreno. Anatomy-Aware Lymphoma Lesion Detection in Whole-Body PET/CT. [Manuscript]</p
Nerve injury in the arm and hand : epidemiology, rehabilitation interventions and clinical outcome
No full textPeripheral nerve injuries affecting the arm and hand can lead to significant functional impairments, limiting the performance of daily activities and negatively impacting quality of life. Due to the intricate anatomy of essential motor and sensory functions in the arm and hand, nerve injuries give rise to complex clinical challenges. Despite advances in surgical techniques and rehabilitation interventions, results are often suboptimal and differ substantially. This thesis comprises five studies. The overall aim was to investigate incidence and outcomes, evaluate current rehabilitation regimens and refine rehabilitation strategies after peripheral nerve injuries in the arm and hand, in order to enhance functional recovery. Through outcome evaluation, qualitative studies and in-depth understanding of participants' experiences, along with the exploration of innovative rehabilitation approaches, this thesis seeks to contribute to the development of more effective, evidence-based rehabilitation protocols tailored to the unique individual.Paper I investigated the epidemiology, demographics and postoperative care in 1004 patients treated surgically for a digital nerve injury between 2012 and 2018, identified through the Swedish Hand Surgery registry (HAKIR). The study showed no change in incidence of digital nerve injuries during the study period. Considerable variation in utilization of healthcare resources was evident. Few participants underwent postoperative sensory assessments, and only two-thirds received rehabilitation targeting nerve specific interventions. The findings highlight the need for standardized postoperative care, including rehabilitation and assessment protocols after digital nerve injury.Paper II investigated subjective and objective outcomes in 86 (matched-pairs) patients who underwent surgical repair of an isolated digital nerve injury. Two groups were formed, based on the affected digit: those with injuries to the thumb or little finger (border digit group), and those with injuries to the index, middle, or ring finger (middle finger group). Participants were assessed 3-10 years post-repair. Hand function indicated no significant difference between injury to border digits or central fingers; however, grip strength was significantly lower following central finger injuries. Tactile discrimination and touch perception yielded best outcomes in participants under 44 years of age. Neuropathic pain was identified in a large proportion of participants; 19 (44%) in the border digit injury group and 24 (56%) in the central fingers injury group. Participants reported a low level of disability in the upper extremity as evaluated by the Quick Disabilities of the Arm, Shoulder and Hand score. Numbness and cold sensitivity were the symptoms graded as worst after digital nerve injury. Rather than indicating outcome differences based on injury location, this study suggests that similar rehabilitation approaches are appropriate regardless of which specific finger that is injured. A particular focus on sensory rehabilitation targeting cold intolerance and pain treatment is important.Paper III explores and describes the experience of rehabilitation after a traumatic brachial plexus injury (TBPI). Transcripts from five focus group discussions with 21 participants treated for a TBPI were coded and analysed with a qualitative content analysis. The discussion guide contained questions regarding the experience of rehabilitation. The results indicate a wide gap in access to health care with an overarching theme, "a fight on their own" to receive a tailored rehabilitation approach. Three themes emerged 1) Lack of tailored rehabilitation in a life-changing situation, 2) Crucial prerequisites for engagement in rehabilitation, and 3) Life will never be the same. This study highlights the importance of competent and committed rehabilitation staff in ensuring active patient engagement and the successful implementation of holistic, person-centred rehabilitation across all stages of care. The participants lacked access to peer interaction, up-to-date technology and rehabilitation that emphasized activity and participation. Participants experienced rehabilitation after TBPI to primarily focus on joint movement and hand exercises, emphasizing motor function recovery through repetitive movements and home training. In addition, they experienced that the impact extended beyond the arm to affect one's entire life and mental state. As a result, rehabilitation was considered most effective when provided by an interdisciplinary team with a person-centred approach.Paper IV explored patients' physical activity level before and after a nerve injury in the arm and hand. A qualitative interview study with 20 participants, 1-3 years after a nerve injury was conducted with content analysis. Results indicate that physical activity was altered and generally decreased after a nerve injury in the arm and hand. This was evident regardless of the location and severity of the nerve injury. The greatest barriers for being physically active were identified among patients with no prior exercise habits or insufficient support from healthcare providers. The period immediately after surgery was the most inactive period. Greater difficulties in resuming previous activities were observed among those for whom the injury had been a dramatic experience. Previously inactive individuals often faced barriers too significant to overcome independently, highlighting the need for targeted support to facilitate physical activity following upper extremity nerve injuries.Paper V is a pilot study exploring the feasibility of an aerobic exercise program, performed on a stationary bike, after peripheral nerve injuries in the arm and hand. The primary outcome of the study was to assess the acceptability of the intervention. Secondary outcome measures explored study recruitment rate, feasibility in pre- and post-intervention testing, and acceptability of assessing the outcome measures related to sensation, pain and hand function. Further, the study explored serum levels of Brain Derived Neurotrophic Factor, BDNF and oxygen uptake capacity, VO2max. The study also explored pain and sensory functions. The cycling intervention proved to be safe and feasible, but the intervention required adjustments and pain monitoring. Patient reported outcomes evaluating disability and hand function improved over the study period. BDNF levels were detectable and increased from baseline to the end of the intervention, remaining elevated six weeks after the intervention ended. We conclude that intervention and outcome measurements must be tailored to injury level. Further studies are needed to explore the effects of physical activity and BDNF levels on sensory and motor function, as well as on pain.List of scientific papersI. Incidence, demographics and rehabilitation after digital nerve injury: A population-based study of 1004 adult patients in Sweden. Linda Evertsson, Carin Carlsson, Christina Turesson, Melih Selcuk Ezer, Marianne Arner, Cecilia Mellstrand Navarro. PLoS One. 2023 Apr 7;18(4):e0283907. https://doi.org/10.1371/journal.pone.0283907II. Long-term subjective and objective outcomes after digital nerve repair: a cohort study. Linda Evertsson, Anders Björkman, Christina Turesson, Marianne Arner, Cecilia Mellstrand Navarro. J Hand Surg Eur. 2025 May;50(5):649-658. https://doi.org/10.1177/17531934241286116III. A fight on your own - experiences of rehabilitation after traumatic brachial plexus injuries. Linda Evertsson, Helena Millkvist, Stina Sjerén, Lena Rosenberg, Ingeborg Nilsson. Disabil Rehabil. 2025 Aug;47(17):4506-4514. https://doi.org/10.1080/09638288.2025.2452371IV. Navigate physical activity after a nerve injury in the arm and hand. [Manuscript]V. Pilot/feasibility study using physical activity as intervention after a nerve injury in the arm and hand. [Manuscript]</p
Improving access to medical abortion and uptake of effective contraceptives
No full textIntroduction: Contraceptive prevention is a key factor to avoid an unintended pregnancy. Several studies have shown that an increased uptake of Long-Acting Reversible Contraceptive methods (LARCs) reduce unintended pregnancies and abortions. LARCs are the most effective methods, as they are not user- dependent, compared to short-acting methods. Surveys show that women in Sweden consider effectiveness as the most important factor when choosing a contraceptive. However, use of less effective methods is often seen. In comparison to similar European countries, abortion rates in Sweden are among the highest and the unmet need of contraception in Sweden 17.2%.Contraceptive counselling can facilitate prevention, although consistent and clear recommendations on how to provide counselling is lacking. Medical treatment with mifepristone and misoprostol for medical abortion is effective and safe. Treatment can be self-managed at home in the first trimester. However, clear evidence is lacking on very early medical abortion (VEMA) before a pregnancy is confirmed on ultrasound. Abortion providers may therefore delay care until a pregnancy is visualized. Telemedicine abortion provides a way to reduce barriers and expand access to safe abortion care, however there are no randomized trials from high income settings.Aim: The overall aim of this thesis is to provide evidence on models that can contribute to expanded access to medical abortion in very early gestation (before confirmed intrauterine pregnancy) and following telemedicine consultation. In addition we aimed to evaluate if a structured contraceptive counselling model can increase women's use of highly effective contraceptive methods.Method: We conducted one retrospective cohort study and two randomized trials. In study I the efficacy of abortion was retrospectively evaluated in patients seeking medical abortion with an unconfirmed intra-uterine pregnancy (IUP) compared to women with confirmed IUP. In study II women seeking care at abortion clinics, youth or maternal health clinics were randomized to structured contraceptive counselling (SCC) or contraceptive counselling according to routine (i.e no clear/specified structure) to evaluate the effect on LARC uptake and continuation. In study III patients seeking early medical abortion (Results: Study I showed no significant difference in abortion efficacy after VEMA compared to standard care (efficacy 98.2 vs 97.1%) No difference was seen in ongoing pregnancies, and interventions (additional misoprostol and surgical aspiration) for incomplete abortion was significantly less after VEMA. In Study II LARC uptake increased after SCC and LARC use was higher at 12 months follow- up compared to those who received routine counselling. At abortion clinics, at 12 months, pregnancy rates were significantly lower after receiving SCC. Among women initiating a LARC method no effect on continuation rates could be seen between groups at the 12 month follow-up. In study III telemedicine consultation was non-inferior to standard medical abortion care (98.2 vs 98.2%). Conclusion:Medical abortion treatment before confirmed IUP is effective and safe and should be offered to patients seeking abortion in very early gestation. The risk for ectopic pregnancy needs to be acknowledged, therefore a structured clinical protocol should be implemented if VEMA is offered. Structured contraceptive counselling provides a valuable tool in increasing the uptake of LARC methods and reduce unintended pregnancies. Telemedicine abortion is an effective and safe alternative to standard in-clinic care.List of scientific papersI. Efficacy and safety of very early medical termination of pregnancy: a cohort study Bizjak I, Fiala C, Berggren L, Hognert H, Sääv I, Bring J, Gemzell- Danielsson K. BJOG. 2017 Dec;124(13):1993-1999https://doi.org/10.1111/1471-0528.14904II. Increasing uptake of long-acting reversible contraception with structured contraceptive counselling: cluster randomized controlled trial (the LOWE trial) Emtell Iwarsson K*, Envall N*, Bizjak I, Bring J, Kopp Kallner H, Gemzell-Danielsson K. BJOG. 2021 Aug;128(9):1546-1554https://doi.org/10.1111/1471-0528.16754III. Contraceptive uptake and compliance after structured contraceptive counselling - secondary outcomes of the LOWE trial Bizjak I, Envall N, Emtell Iwarsson K, Kopp Kallner H, Gemzell- Danielsson K. Acta Obstet Gynecol Scand. 2024 May;103(5):873-883.https://doi.org/10.1111/aogs.14792IV. A Randomized Trial on Efficacy of Telemedicine Abortion Isabella Bizjak*, Karin Brandell*, Ninni Mannerberg, Anette Aronsson, Amanda Cleeve & Kristina Gemzell Danielsson. [Manuscript]*Shared first author</p
Joint effect of sleep duration and sleep quality on self-rated health among Canadian adults: estimating relative excess risk due to interaction from a nationwide survey.
No full textBACKGROUND: Self-rated health (SRH) is a globally recognized measure of health status. Previous studies have established that inadequate sleep duration and trouble falling asleep combinedly has a greater negative impact on health than either factor alone. This study aims to investigate the excess relative risk due to the interaction between short sleep duration and trouble sleeping on SRH. METHOD: We used the 2017-18 Canadian Community Health Survey (CCHS) publicly used microdata file. SRH was measured on a 5-point Likert scale from poor to excellent and dichotomized into "Good or Better" and "Fair or Poor." Sleep duration was categorized into "Less than 7 h" and "More than 7 h," while trouble sleeping was categorized as "Yes" or "No." A joint variable derived from these created four groups: "no sleep issues," "fewer sleeping hours (</p