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HIF2α negatively regulates MYCN protein levels and promotes a low-risk noradrenergic phenotype in neuroblastoma.
No full textNo description supplied</p
Inguinal hernia : optimizing surgical treatment
No full textInguinal hernia is among the most common general surgical conditions, with a lifetime risk of up to 27% in men and 3% in women. Surgical repair remains the only definitive treatment, and in Sweden, approximately 16,000 inguinal hernia repairs are performed annually. Over recent decades, advances in surgical techniques—particularly the introduction of mesh-based repairs and minimally invasive approaches—have led to significantly reduced recurrence rates. Consequently, the focus of clinical and scientific interest has shifted from recurrence to optimizing patient-centered outcomes. One such key outcome is chronic postoperative inguinal pain (CPIP), a condition that can severely impact quality of life and has been reported in up to 30% of patients following hernia repair. A more elusive complication is infection involving the mesh. Fortunately, mesh infections are rare and have therefore been scarcely studied.For Study I the objective was to compare long-term postoperative pain following inguinal hernia repair using two established techniques: the Lichtenstein repair under local anesthesia (LLA) and total extraperitoneal endoscopic repair (TEP) under general anesthesia. A randomized controlled trial was conducted with 384 patients (193 TEP, 191 LLA). At one year postoperatively, 97.7% completed follow- up, including the Inguinal Pain Questionnaire (IPQ). CPIP was reported in 20.7% of the TEP group compared to 33.2% in the LLA group (p = 0.007). Severe pain was reported in 4 TEP and 6 LLA patients. Pain limiting physical activity was noted in 5 TEP (2.7%) and 14 LLA (7.5%) patients (p = 0.034).In Study II the aim was to assess the cost-effectiveness of LLA versus TEP for primary inguinal hernia repair in men, utilizing data from the aforementioned RCT. Health economic outcomes and sick leave data were analyzed. Among 374 patients (189 LLA, 185 TEP), median operating time was longer for LLA (70 minutes) compared to TEP (60 minutes; p The aim in Study III was to evaluate how intraoperative management of the three inguinal nerves during open anterior mesh repair influences the risk of developing CPIP. Data from 34,115 patients in the Swedish Hernia Register (2012–2017) who completed a postoperative PROM one year after surgery were analyzed. Pain that could not be ignored was reported by 25.9%, and pain interfering with daily activities by 15.7%. Multivariable ordinal regression analysis showed no significant association between identification or preservation of any of the three inguinal nerves and the risk of CPIP, after adjustment for anesthesia type, sex, age, and emergency surgery.Study IV aimed to investigate the incidence, treatment, and potential risk factors for mesh infection following inguinal hernia repair. A case-control study was conducted based on 12,375 hernia repairs recorded in the Swedish Hernia Register across three hospitals between 2005 and 2020. Infectious complications were reported in 177 cases (1.43%), of which 26 (0.21%) were classified as mesh infections. These were primarily managed conservatively with antibiotics and drainage; no cases required the removal of mesh.From these studies it can be concluded that TEP repair is associated with a significantly lower risk of CPIP compared to LLA, without incurring additional cost, and should therefore be considered the preferred technique for primary inguinal hernia repair. When open anterior repairs are performed, careful tissue handling is essential and pragmatic nerve resection did not increase the risk of persistent pain. Finally, mesh infections are rare and, when they do occur, are typically manageable without the need for mesh removal.List of scientific papersThis thesis is based on the following papers, they will be referred to by their roman numerals.I. Less pain one year after TEP compared to Lichtenstein using local anesthesia - data from a randomized controlled clinical trial. L. Westin, S. Wollert, M. Ljungdahl, G. Sandblom, U. Gunnarsson, U. Dahlstrand. Annals of Surgery, 2016, Volume 263, number 2: 240-3. PMID: 26079901. https://doi.org/10.1097/SLA.0000000000001289II. Health economic analysis of Total ExtraPeritoneal repair vs. Lichtenstein surgery for inguinal hernia - data from a randomized clinical trial. L. Westin, U. Gunnarsson, G. Sandblom, U. Dahlstrand. BJS Open, 2021, Volume 5, Issue 3. https://doi.org/10.1093/bjsopen/zrab026III. The impact of nerve management on the risk for persistent postoperative pain one year after open anterior mesh inguinal hernia repair. L. Westin, U. Gunnarsson, G. Sandblom, U. Dahlstrand. Accepted for publication in Hernia, October 2025. [Accepted]IV. Mesh infections following inguinal hernia repair - incidence, risk factors and treatment options from a Swedish cohort. L. Westin, U. Gunnarsson, G. Sandblom, U. Dahlstrand. [Manuscript]</p
Translational 3D spatiomolecular imaging in health and disease
No full textVolumetric microscopic imaging, also known as three-dimensional (3D) imaging, is an advanced approach that enables spatial visualization of molecular components such as proteins and RNAs within intact tissues. It provides an unbiased, panoramic view for investigating spatial heterogeneity and molecular organization in complex biological systems. To achieve deep imaging of large samples, tissue-clearing methods have been established to make biological specimens optically transparent, thereby greatly advancing the capability of 3D imaging. However, current methods remain limited in their ability to visualize RNA and to support multimodal molecular imaging. To date, most published 3D imaging studies have focused primarily on proteins-either through endogenous fluorescent reporters (e.g., CUBIC) or antibody-based labeling for spatial profiling of target proteins (e.g., iDISCO+) in whole tissues. This thesis aims to further develop and apply 3D imaging methods to translational research in health and disease.In Papers I and II, we developed and presented a whole-organ RNA detection method termed TRISCO (Tris buffer-mediated retention of in situ hybridization chain reaction signal in cleared organs). This method effectively preserves RNA integrity, enables uniform staining, and addresses transparency challenges associated with combining in situ hybridization with tissue clearing. Using TRISCO, we monitored the expression of immediate early genes in mouse brains following administration of the anti-obesity drug semaglutide. This application illustrates the potential of TRISCO for studying drug-induced gene expression changes at the spatial transcriptional level.In Paper III, the iDISCO+ method was applied to investigate microglia-myelin interactions in the mouse spinal cords. We found that myelin degeneration was particularly prominent in the dorsal column (DC), accompanied by molecular and functional alterations in DC microglia and an upregulation of TGF-ß signaling. Disruption of TGF-B signaling in microglia led to excessive microglial activation, loss of MBP+ myelin, and aggravated neurological deficits.In Paper IV, we applied 3D imaging to clinical upper tract urothelial carcinoma (UTUC) biopsies, enabling histopathological assessment without sectioning. We found that phosphorylated ribosomal protein S6 (pS6) served as a spatial biomarker for improving diagnosis and prognosis.In Paper V, we integrated and optimized the co-detection of RNA and protein method and named as ARO-DIIFCO (accelerated robust and operator-friendly technique for simultaneous 3D mRNA and protein detection). This method enables comprehensive dual-molecular mapping-of both mRNA and protein-at single-cell resolution, while reducing processing time by one-third compared to the previous protocol. Applying ARO-DIIFCO to a cohort of breast cancer patients, we demonstrate its potential for identifying personalized risk-associated features linked to disease progression.In summary, the 3D imaging strategies developed and applied in this thesis provide a translational framework for spatially resolving molecular landscapes, bridging fundamental biology with clinical applications.List of scientific papersI. Whole-Brain Spatial Transcriptional Analysis at Cellular Resolution. Shigeaki Kanatani, Judith C. Kreutzmann*, Yue Li*, Zoe West*, Lea Lydolph Larsen, Danai Vougesi Nikou, Ilse Eidhof, Abigail Walton, Songbai Zhang, Leslie Rubio Rodríguez-Kirby, Jacob Lercke Skytte, Casper Gravesen Salinas, Kimiharu Takamatsu, Xiaofei Li, Daisuke H. Tanaka, Dagmara Kaczynska, Keishiro Fukumoto, Razieh Karamzadeh, Yujiao Xiang, Naofumi Uesaka, Tsutomu Tanabe, Mikael Adner, Johan Hartman, Ayako Miyakawa, Erik Sundström, Gonçalo Castelo-Branco, Urmas Roostalu, Jacob Hecksher- Sørensen, and Per Uhlén. Science 2024. doi.org/10.1126/science.adn9947II. Whole-organ spatial transcriptional analysis at cellular resolution using TRISCO. Yue Li*, Abigail Walton*, Judith C. Kreutzmann, Lea Lydolph Larsen, Urmas Roostalu, Jacob Hecksher-Sørensen, Shigeaki Kanatani, Per Uhlén. Nature Protocols under revision 2025 [Accepted]III. TGF-B signaling mediates microglial resilience to spatiotemporally 1 restricted myelin degeneration. Keying Zhu, Yun Liu, Jin-Hong Min, Vijay Joshua, Jianing Lin, Yue Li, Judith C. Kreutzmann, Yuxi Guo, Wenlong Xia, Elyas Mohammadi, Melanie Pieber, Valerie Suerth, Yiming Xia, Zaneta Andrusivova, Jean-Philippe Hugnot, Shigeaki Kanatani, Per Uhlén, Joakim Lundeberg, Xiaofei Li, Stephen P.J. Fancy, Heela Sarlus, Robert A. Harris, Harald Lund. [Manuscript]IV. Three-Dimensional Imaging of Upper Tract Urothelial Carcinoma Improves Diagnostic Yield and Accuracy. Keishiro Fukumoto*, Shigeaki Kanatani*, Georg Jaremko, Zoe West, Yue Li, Kimiharu Takamatsu, Ibrahim Al Rayyes, Shuji Mikami, Naoya Niwa, Tomas Andri Axelsson, Nobuyuki Tanaka, Mototsugu Oya, Ayako Miyakawa, Marianne Brehmer, Per Uhlen. JCI Insight. 2024. //doi.org/10.1172/jci.insight.175751V. ARO-DIIFCO: Simultaneous 3D Mapping of mRNA and Protein to Aid Personalized Medicine in Breast Cancer. Yue Li, Shigeaki Kanatani, Ceren Boyaci, Stephanie Robertson, Wenchao Shao, Zoe West, Judith C. Kreutzmann, Songbai Zhang, Johan Hartman, Per Uhlén [Manuscript]*: These authors contributed equally to this study.</p
The effect of nicotinamide on retinal ganglion cell metabolism and mitochondria in glaucoma
No full textGlaucoma is the leading cause of irreversible blindness, affecting over 111 million people worldwide by 2040 (Tham et al., 2014a) and accounting for over 8% of all blindness cases, which equates to approximately 3.6 million individuals. The main risk factors are age, genetic, and elevated intraocular pressure (IOP). To date, the only available therapeutic strategy is the IOP reduction (eye drops, laser or surgical form) which role is to limit the retinal ganglion cells (RGCs) degeneration and the vision loss.In this work I compile three articles which collectively treats about biologic challenge faced by the RGCs during the neurodegenerative disease affecting the visual system. The RGCs are neuronal cells present in the retina which project axons to form the optic nerve (ON). This thesis focuses primarily on glaucoma, but another form of optic neuropathy, Leber's Hereditary Optic Neuropathy (LHON) is also studied. The critical point in both pathologies is the mitochondrial dysfunction leading to the metabolic failure. This translates by the RGCs vulnerability, a progressive dysfunction and eventually a cell death. In this context, a promising strategy have been identified: the nicotinamide (NAM) supplementation. NAM is an early precursor to nicotinamide adenine dinucleotide (NAD) NAD in the salvage pathway, previous research has shown neuroprotective capacities across different model.With an aging population and a longer life expectancy, we are likely to see a drastic increased number of patients presenting glaucoma, this stresses even more the necessity to improve the treatment.Paper I: Retinal Ganglion Cell Degeneration in a Rat Magnetic Bead Model of Ocular Hypertensive Glaucoma.In this study we use a previously published glaucomatous model: the rat beads model. This inducible ocular hypertensive model by magnetic microbeads injection in the anterior segment of the brown Norwegian rat constitutes a relevant glaucomatous pre-clinical tool to study the consequence of the IOP component. With highly relevant clinical feature met in patients such as the compartmentalized RGCs degeneration, the optic nerve head (ONH) excavation, the axoplasmic and vascular impairment, this model offers a great platform for the characterization and further understanding of the mechanical, molecular and metabolic processes lead by the elevation of the IOP in the glaucomatous pathology.Paper II: Nicotinamide provides neuroprotection in glaucoma by protecting against mitochondrial and metabolic dysfunction.This second article constitutes the continuity of paper I as we use the same model and further explore the impact of the ocular hypertension (OHT) on the RGCs specific mitochondria and the cellular metabolic changes taking place after the OHT induction. Using similar methodology, we study the impact of the metabolic disruption following the intravitreal injection of rotenone, a specific Complex I inhibitor, which leads to a severe metabolic deprivation. We detailed the impacts of these glaucomatous injuries throughout the visual track (RGCs soma, dendrites and axons) before to target the NAD, a co-factor necessary for the neuronal survival. NAD is known to decrease in retina in both animal models and glaucoma patients, and we demonstrate the neuroprotective effect of NAM under IOP and metabolic stressor when pre-treated. These finding support a neuroprotective action of NAM against different glaucomatous injuries, and more generally against neurodegenerative diseases.Paper III: Prophylactic nicotinamide treatment protects from rotenone-induced neurodegeneration by increasing mitochondrial content and volume.The LHON is driven by mutation affecting the gene which code for the mitochondrial Complex I, resulting into a progressive RGC dysfunction and eventually cell death. The RGCs are highly metabolically vulnerable and do not tolerate the mitochondrial dysfunction, unfortunately there are no treatment or neuroprotection, which leads to long-term vision loss. NAM is a NAD precursor, and it has been shown to have neuroprotective effect against mitochondrial and metabolic dysfunction in the scope of glaucoma. In this study, we model LHON with intravitreal injection of rotenone (a complex I inhibitor) in mice reporting model (MitoV), causing a drastic loss of RGCs. We then demonstrate the prevention of RGCs loss when mice are treated in a prophylactic manner with NAM and detail the mechanism of protection under complex I inhibition. NAM protects the mitochondria by increasing the total number of mitochondria and their cristae density. This well-established component with a safe profile is being tested for glaucomatous patients, and could hold some promises for other mitochondrial optic neuropathies as LHON to slower or prevent the progression of the neurodegenerative process.List of scientific papersI. Tribble JR, Otmani A, Kokkali E, Lardner E, Morgan JE, Williams PA; Retinal Ganglion Cell Degeneration in a Rat Magnetic Bead Model of Ocular Hypertensive Glaucoma. Translational vision science & technology. 2021;10(1):21. https://doi.org/10.1167/tvst.10.1.21II. Tribble JR, Otmani A, Sun S, Ellis SA, Cimaglia G, Vohra R, Jöe M, Lardner E, Venkataraman AP, Domínguez-Vicent A, Kokkali E, Rho S, Jóhannesson G, Burgess RW, Fuerst PG, Brautaset R, Kolko M, Morgan JE, Crowston JG, Votruba M, Williams PA., Nicotinamide provides neuroprotection in glaucoma by protecting against mitochondrial and metabolic dysfunction, Redox Biology, Volume 43, 2021, 101988, ISSN 2213-2317, https://doi.org/10.1016/j.redox.2021.101988III. Otmani A, Johannesson G, Brautaset R, Tribble JR, Williams PA. Prophylactic nicotinamide treatment protects from rotenone- induced neurodegeneration by increasing mitochondrial content and volume. Acta Neuropathologica Communications 12, 37 (2024).https://doi.org/10.1186/s40478-024-01724-z</p
Toward precision medicine : sex-specific effects of multi-drug therapies in mouse models of aging and Alzheimer's pathology
No full textAs the population ages and comorbidities rise, concurrent use of multiple drugs (≥5, polypharmacy) has become a major challenge in geriatric medicine. While often necessary to manage chronic conditions, polypharmacy is also associated with increased risks, including functional decline and cognitive impairment. Yet, the biological mechanisms underlying these effects, and how they are shaped by age, sex, and pathological background, remain poorly understood. Notably, common age-related comorbidities such as cardiovascular conditions, and depression are also risk factors for Alzheimer's disease and related dementias (ADRD), and medications prescribed for their management, including some antihypertensives and antidepressants, are being investigated as repurposed therapies to prevent or slow AD progression.This doctoral thesis aimed to investigate the impact of multi-drug therapies using mouse models of aging and AD-related pathology, focusing on sex-specific outcomes and mechanistic insights.In Papers I, II, and III, we administered polypharmacy regimens comprising cardiovascular, analgesic, and antipsychotic agents to resemble common multi- drug therapies in older adults in Sweden. The tested regimens included: combination #1 (metoprolol, simvastatin, aspirin, paracetamol, and citalopram) and combination #2 (enalapril, atorvastatin, aspirin, paracetamol, and citalopram). In addition, selected monotherapies (metoprolol, simvastatin, and citalopram) were evaluated for comparison with the multi-drug treatments (in Papers II and III).Papers I and II investigated the impact of these treatments in wild-type (WT) mice at different adult life stages. In young adult female WT mice (Paper I), long-term polypharmacy altered locomotion, and recognition memory, accompanied by downregulation of hippocampal synaptic proteins. In aged WT mice (Paper II), we identified pronounced sex-specific effects that varied depending on the drug combination. In males, both regimens induced negative outcomes on locomotor activity, stress-related responses, and cognitive functions, whereas females appeared more resilient. Serum metabolomic profiling, particularly in males exposed to combination #1, revealed a marked downregulation of metabolites including serotonin, lysophospholipids, ornithine, methionine, and other amino compounds linked to age-related pathways. In male mice, but not in females, these alterations were paralleled by a reduction in serotonergic receptor expression in the brain. Monotherapies recapitulated a small subset of outcomes induced by multi-drug regimens, highlighting the complexity of polypharmacy effects.Paper III extended these investigations to AppNL-G-F knock-in (APP KI) mice, a model of AD-like amyloid pathology. In males, combination #1 improved cognitive performance and reduced amyloid plaque load, amyloidogenic enzyme levels, and microglial marker expression in the brain. However, substituting two drugs within the same regimen abolished these benefits in males and even impaired memory and learning in females. In females, polypharmacy did not markedly affect molecular readouts, whereas some monotherapies altered glial proteins such as Iba1 and GFAP. Notably, in males receiving combination #1, we detected upregulation of metabolomic pathways commonly dysregulated in AD, including kynurenine, carnitines, and fatty acids, which may underlie the cognitive benefits observed. Remarkably, the same metabolite classes were strongly reduced in females receiving this treatment.In Paper IV, we compared the effects of a multimodal lifestyle intervention to a pharmacological intervention, in WT mice, as well as in CYP27A1 (CYP27Tg), and APP KI transgenic mice, models of cholesterol dysmetabolism and amyloid pathology. The lifestyle intervention improved memory in WT and APP KI mice, while proteomics revealed enhanced synaptic plasticity pathways in WTs and restoration of neuroinflammatory and immune processes in CYP27Tg mice despite limited cognitive effects. By contrast, the pharmacological intervention (atorvastatin and enalapril) did not influence behavior in WT mice but decreased memory performance in CYP27Tg and APP KI cohorts. Proteomic analysis showed a marked downregulation of proteins associated with synaptogenesis, synaptic plasticity, and glutamatergic signaling in CYP27Tg mice treated with pharmacological prevention, whereas the hippocampal proteome of WT and APP KI animals remained largely unaffected.Collectively, this thesis demonstrates that polypharmacy outcomes are shaped by age, sex, and disease background. Depending on drug composition and biological context, multi-drug regimens impaired or had beneficial effects on functional and cognitive abilities, influencing domains linked to aging and disease.These findings provide key insights into the molecular signatures of polypharmacy, informing precision medicine for aging and ADRD, and highlight the importance of sex and vulnerable groups when weighing harms and benefits.List of scientific papersI. Francesca Eroli, Kristina Johnell, Maria Latorre-Leal, Sarah N Hilmer, Jonas W Wastesson, Angel Cedazo-Minguez, Silvia Maioli. Long-term exposure to polypharmacy impairs cognitive functions in young adult female mice. Aging. 2021 Jun 2;13(11):14729-14744. https://doi.org/10.18632/aging.203132II. Francesca Eroli, Kristina Johnell, Patricia Rodriguez-Rodriguez, Maria Latorre-Leal, Jonas W Wastesson, Sarah N Hilmer, Angel Cedazo- Minguez, Silvia Maioli. Sex differences in vulnerability to polypharmacy drive cognitive, functional, and metabolic alterations in aged mice. [Manuscript]III. Francesca Eroli, Kristina Johnell, Zeynep Acararicin, Christina Tsagkogianni, Stefania Zerial, Saverio Lancia, Maria Latorre-Leal, Vilma Alanko, Sarah N Hilmer, Anna Matton, Jonas W Wastesson, Angel Cedazo-Minguez, Silvia Maioli. Commonly prescribed multi-medication therapies exert sex- specific effects on Alzheimer's disease pathology and metabolomic profiles in AppNL-G-F mice: Implications for personalized therapeutics in aging, Alzheimers Dement. 2025 Mar;21(3):e70081. https://doi.org/10.1002/alz.70081IV. Vilma Alanko, Francesca Eroli, Ákos Végvári, Alina Solomon, Tobias Hartmann, Per Nilsson, Miia Kivipelto, Silvia Maioli, Anna Matton. Mouse PAW: reverse-translation of the FINGER multimodal lifestyle trial improves memory and dementia-related mechanisms in female mice [Manuscript]</p
Body dysmorphic disorder in children and adolescents : advancing the assessment, treatment, and clinician training
No full textBackground: Body Dysmorphic Disorder (BDD) is a disabling mental health condition that typically begins in adolescence and causes significant distress and functional impairment. Despite its impact, research on BDD in young people remains limited, leaving important gaps in understanding and clinical care. BDD in youth is often overlooked in clinical practice, partly due to the absence of validated, age-appropriate assessment tools. Additionally, although cognitive– behavioural therapy (CBT) is effective for adults, evidence in children and adolescents remains scarce, particularly from large, real-world studies. Consequently, awareness of BDD in clinical settings remains low, and there is a shortage of trained clinicians to provide effective care, perpetuating underdiagnosis and inadequate treatment. Scalable training initiatives, such as online education programmes, offer a promising approach to enhance assessment, treatment delivery, and service capacity. There is therefore a need for targeted research in this area, alongside further evaluation of assessment tools and treatment strategies.Aim: The overall aim of this doctoral thesis was to advance the understanding of BDD in youth and to inform improvements in clinical care. Specifically, it comprised four interrelated studies. The first study aimed to examine the psychometric properties of the Appearance Anxiety Inventory (AAI), a selfreport measure of BDD symptoms, in a clinical youth sample. The second study aimed to evaluate the acute and long-term outcomes of multimodal treatment in BDD for youths and identify predictors of response. The third study aimed to develop and assess the feasibility and preliminary effects of a supervised online training programme in BDD for clinicians in child and adolescent mental health services (CAMHS). The fourth study explored the clinicians’ experiences of the training and its use in clinical practice. Methods: Study 1 included 182 adolescents with BDD referred to two specialist outpatient clinics in Stockholm, Sweden, and London, England, who were assessed with the AAI. The study examined the factor structure, reliability, and validity of the AAI, and tested its sensitivity to change in a subgroup receiving treatment (n = 79). Study 2 was an open trial including 140 adolescents at the same clinics who received multimodal treatment (i.e., a combination of CBT and medication when deemed necessary). Participants were assessed at baseline, post-education, and at 3-, 6-, and 12-month follow-ups. Mixed-effects regression and linear models were used to analyse outcomes and predictors. Study 3 involved 30 CAMHS clinicians in Sweden completing a 4–7-week supervised online training programme. Feasibility was assessed using descriptive statistics on acceptability, adherence, credibility, and satisfaction. Preliminary learning effects were evaluated using a custom BDD knowledge and conceptual skills test, alongside self-reported self-efficacy and application of learned content, with assessments at baseline, post-training, and six-month follow-up; analyses were conducted using descriptive statistics and mixed-effects regression models. Study 4 used semi-structured interviews with 12 clinicians, analysed with conventional content analysis. Results: Study 1 identified a three-factor structure of the AAI—threat monitoring, camouflaging, and avoidance—with good internal consistency (ω = 0.83) and adequate convergent validity, though divergent validity was more modest. The AAI was sensitive to treatment-related change and moderately correlated with symptom improvement. Study 2 demonstrated that a multimodal treatment approach (i.e., combining CBT and medication when indicated), delivered flexibly and tailored to individual needs (e.g., number and length of CBT sessions, home visits, booster sessions) in specialist outpatient clinics, resulted in substantial reductions in BDD symptoms from baseline to post-treatment (d = 2.08). By the end of treatment, 79% of participants met responder criteria, and 59% achieved full or partial remission. Improvements extended beyond core BDD symptoms, with large gains observed in global functioning, self-reported BDD and depressive symptoms, and impairment. These benefits were sustained over 12 months, with continued improvements in clinician-rated BDD symptoms. At the 12-month follow-up, 82.2% of participants remained responders and 68.3% were in remission, accompanied by further gains in clinician-rated global functioning and self-reported impairment. Higher baseline BDD symptom severity predicted poorer post-treatment outcomes, although no consistent predictors emerged at one-year follow-up. Study 3 demonstrated that the clinician training was feasible and well-received, with high credibility and satisfaction ratings. Clinicians improved in BDD knowledge, conceptual skills, and self-efficacy, and reported applying new skills in practice. Study 4 revealed positive clinician experiences and reported changes in clinical practice, while also highlighting areas for improvement such as practical skill training and peer support. Workplace context was also described influencing educational engagement and implementation. Conclusions: This thesis presents complementary insights for improving the identification and treatment of BDD in young people. It establishes the psychometric validity of a key assessment tool, supporting its use in clinical practice and research; indicates that a flexible, specialist-delivered multimodal treatment may be effective; and provides evidence for the feasibility and preliminary learning effects of online clinician training. While more rigorous research is needed to confirm and extend these effects, these efforts may be viewed as important steps toward strengthening clinical tools, enhance treatment delivery, and build service capacity to better address youth BDD in routine care.List of scientific papersI. Gumpert, M., Rautio, D., Monzani, B., Jassi, A., Krebs, G., Fernández de la Cruz, L., Mataix-Cols, D., & Jansson-Fröjmark, M. (2024). Psychometric evaluation of the appearance anxiety inventory in adolescents with body dysmorphic disorder. Cognitive Behaviour Therapy, 53(3), 254-266. https://doi.org/10.1080/16506073.2023.2299837II. Rautio, D., Gumpert, M., Jassi, A., Krebs, G., Flygare, O., Andrén, P., Monzani, B., Peile, L., Jansson-Fröjmark, M., Lundgren, T., Hillborg, M., Silverberg- Morse, M., Clark, B., Fernández de la Cruz, L., & Mataix-Cols, D. (2022). Effectiveness of multimodal treatment for young people with body dysmorphic disorder in two specialist clinics. Behavior Therapy, 53(5), 1037- 1049. https://doi.org/10.1016/j.beth.2022.04.010III. Gumpert, M., Rautio, D., Birovecz, A., Jolstedt, M., Lundgren, T., Fernández de la Cruz, L., Mataix-Cols, D., & Jansson-Fröjmark, M. (2025). Supervised online training of clinicians in the assessment and treatment of young people with body dysmorphic disorder: a feasibility study. Cognitive Behaviour Therapy, 54(6), 794-812. https://doi.org/10.1080/16506073.2025.2515526IV. Gumpert, M., Högberg Ragnarsson, E., Birovecz, A., Rautio, D., Lundgren, T., Fernández de la Cruz, L., Mataix-Cols, D., Jansson-Fröjmark, M., & Ingvarsson, S. Clinician experiences of an online clinical training to assess and treat body dysmorphic disorder in youth: A qualitative study. [Submitted]</p
Unraveling the phenotypic features and functional mechanisms of tumor-associated adaptive natural killer cells
No full textAdaptive natural killer (aNK) cells represent a specialized subset of NK cells that can form immunological memory, once thought to belong exclusively to, a group of adaptive immune cells, T and B cells. This discovery has fundamentally challenged the traditional dichotomy between innate and adaptive immunity, highlighting that NK cells are capable not only of rapid innate responses but also of long-term functional adaptation. While their role in viral infection is increasingly understood, including their contribution to long-lasting protection and recall responses, their presence, regulation, and antigen specificity in solid tumors remain less explored and thus represent an important knowledge gap in tumor immunology. In this thesis, we investigated aNK cells in the context of high-grade serous ovarian cancer (HGSOC). In study I, we found that tumor-infiltrating aNK cells are associated with enhanced autologous tumor killing, suggesting a direct role in tumor surveillance, and that naïve NK cells could be trained in vitro to possess immune memory-like behavior through exposure to tumor antigens, demonstrating that tumor-derived signals are sufficient to imprint memory-like features (Paper I). In study II, we used integrated single-cell transcriptomic and chromatin accessibility analysis to uncover key transcriptional regulators-PRDM1 and STAT2-and downstream target genes, CRCP and MTFP1, that define the epigenetic landscape of tumor-infiltrating aNK cells, providing mechanistic clue into how these cells acquire and maintain their unique identity in the tumor microenvironment (Paper II). In study III, we showed that aNK cells recognize non-canonical 9mer viral peptides presented by HLA-E (Paper III), and further discovered a novel tumor-derived peptide that also binds HLA-E and effectively trains aNK cells to generate enhanced memory responses against ovarian tumor cells, thereby establishing a direct link between tumor antigens and the induction of NK cell memory (Paper IV). Together, these findings deepen our understanding of peptide-driven memory in NK cells and reveal new opportunities for harnessing aNK cells in cancer immunotherapy, either through targeted manipulation of their regulatory networks or by exploiting tumor-associated peptides to potentiate durable antitumor response.List of scientific papersI. Sun Y, Rodgers-Furones A, Gultekin O; Khare S, Neo SY, Shi W, Galceran LM, Lam K-P, Dasgupta R, Fuxe J, Salehi S, Lehti K, Sarhan D. Adaptive NK Cells Exhibit Tumor-Specific Immune Memory and Cytotoxicity in Ovarian Cancer. Cancer Immunol Res, 2025 Jul 2;13(7):1080-1097. PMID: 40293356. https://doi.org/10.1158/2326-6066.cir-24-0852II. Sun Y, Wan M, Kolbeinsdottir S, Wang K, Khare S, Gultekin O, Salehi S, Lehti K, Dasgupta R, Foukakis T, Enge M, Sarhan D. Single-Cell Integration of Chromatin Accessibility and Transcriptomics Reveals Regulatory Networks in Ovarian Tumor-Infiltrating Adaptive NK Cells. bioRxiv. 2025 Sep 13. [Manuscript Preprint] doi: https://doi.org/10.1101/2025.09.13.676040III. Martín Almazán N, Sala BM, Sandalova T, Sun Y, Resink T, Cichocki F, Söderberg-Nauclér C, Miller JS, Achour A, Sarhan D. Non-classical HLA-E restricted CMV 15-mer peptides are recognized by adaptive NK cells and induce memory responses. Front Immunol. 2023 Sep 21;14:1230718. PMID: 37809084; PMCID: PMC10552778. https://doi.org/10.3389/fimmu.2023.1230718 IV. Sun Y, Kaminskiy Y, Branca R, Li S, Gultekin O, Govindajaran K, Salehi S, Lehtio J, Sarhan D. Recognition of Ovarian Tumor-Derived Non-canonical Peptide Induces Memory-Like Features in Natural Killer Cells. bioRxiv. 2025 Sep 15. [Manuscript Preprint] doi: https://doi.org/10.1101/2025.09.15.676162</p
Team resilience : exploring adaptive management of complexity in healthcare
No full textBackground: The research on safety in health care has during the last decades moved towards understanding how safety is managed as an integral part of everyday clinical work (ECW). Resilient healthcare (RHC) defines safety as an emergent property which is constantly present in teams everyday work, where normal variation and risks caused by the continuously changing healthcare system are managed. Safety is a dynamic non-event, and it infiltrates all levels and dimensions of an organization.A resilient organization has an intrinsic capacity to adjust its functioning prior to, during, or following expected and unexpected situations. Evidence of such adaptations could be identified by exploring how healthcare teams manage ECW in the complex adaptive system (CAS) of healthcare. Understanding the dynamics of team resilience and factors supporting it may provide knowledge on versatile strategies and opportunities to sustaining and enhancing patient safety in the frontline.Aim: The aim of this thesis is to deepen the understanding on how risks are proactively managed by healthcare teams – what resilience and sustaining safety look like in healthcare teams, and what factors support the proactive management of complex situations in everyday work.Methods: Thesis is comprised of four sub-studies. Both quantitative and qualitative methods from deductive and inductive approaches are used, in a descriptive research design, conducted in intraoperative anaesthesia care, in Sweden and in Finland.Study I observed the surgical team in situ, using a prospective, structured observation tool (WOMBAT). From 26 observation sessions and 169 observation hours the type and frequency of tasks, multitasking, interruptions and their causes, and interactions were described. Data was analyzed using descriptive statistics. Study was conducted in Sweden.Study II analyzed further data from study I, visualizing work as done (WAD) by mapping all phases of intraoperative anaesthesia care process, conducted by the registered nurse anaesthetists’ (RNA). 30 observation sessions including 73 observation hours were analyzed using descriptive statistics.Study III explored factors supporting anaesthesia teams in managing complex everyday situations during intraoperative anaesthesia care process. Individual interviews with anaesthesia nurses (n=9) and anaesthesiologists (n=6) were conducted using cognitive task analysis (CTA) on case scenarios constructed from studies I and II. The interviews were analyzed using the framework method. Study was conducted in Finland.Study IV investigated the conceptual structure, operationalization and contextualization of team resilience in healthcare. The phased principle-based concept analysis with quality criteria was used. Data was collected through scoping review and analyzed with reflexive content analysis.Findings: Study I elucidated WAD among the surgical team members in the CAS of an operating room (OR). Teams dealt with multitasking and interruptions. Task distribution reflected the interactions and constant adaptations. RNAs task intensity, multitasking, number of interruptions and contacts were the highest among the surgical team.Study II illustrated RNAs WAD and adaptations, comprising of phases with variation regarding the level of complexity through task intensity, task distribution, amount of multitasking, interruptions and interactions. Most intensive phases were anaesthesia induction and preparation for anaesthesia maintenance.Study III elucidated further, how safety is sustained during the expected and unexpected complex situations during intraoperative anaesthesia care. Safety was sustained in the team level through strategies, supported by organizational prerequisites. Management of complex situations benefits from high-quality teamwork and non-technical skills.Study IV described team resilience in healthcare being understood relatively consistently, but an unambiguous definition was lacking. Two aspects, systemic and team, composed a dualistic component of team resilience in healthcare, affecting both concept and characteristics in the definition. The presence of resilience skills and interactions between individuals completed the concept of team resilience, which previously has been broadly defined as an emergent system property. A new model and a theoretical definition were proposed.Conclusions: Everyday complexity in intraoperative anaesthesia care consists of multiple simultaneous processes in an interprofessional team, in addition to profession specific tasks, multitasking, interruptions and interactions, in the CAS of an OR. Exploring WAD during the intraoperative anaesthesia, a picture of a complex, dynamic process, including multiple moments of adaptations is elucidated.The concept team resilience in healthcare is multifaceted, embracing both systemic and team perspectives of resilience. This duality should be seen as a clarifying lens to further research, assisting in further operationalization of the concept. Team resilience is supported by active processes from both organization and team level strategies and actions.Team resilience is present as an intrinsic team capacity, but when a trigger for adaptation is identified, it changes to an active status, resulting in a possible reorganization of courses of action. These moments of adaptation should be identified as a safety potential situations for learning, how safety is proactively managed during everyday care.As the context of this thesis was in intraoperative anaesthesia care and previous studies explored team resilience mostly in hospital context, to further clarify the conceptual structure and position of team resilience in healthcare, the model presented in this thesis, underlying behavioural and systemic factors and adjacent concepts should be explored in various contexts, situations and types of teams.List of scientific papersI. Göras C*, Olin K*, Unbeck M, Pukk Härenstam K, Ehrenberg A, Tessma MK, et al. Tasks, multitasking and interruptions among the surgical team in an operating room: A prospective observational study. BMJ Open 2019;9:e026410. *Both authors contributed equally. https://doi.org/10.1136/bmjopen-2018-026410II. Olin K, Göras C, Nilsson U, Unbeck M, Ehrenberg A, Pukk Härenstam K, et al. Mapping registered nurse anaesthetists ' intraoperative work: tasks , multitasking , interruptions and their causes , and interactions: a prospective observational study. BMJ Open 2022;12:e052283. https://doi.org/10.1136/bmjopen-2021-052283III. Olin K, Klinga C, Pukk Härenstam K. Exploring everyday work as a dynamic non-event and adaptations to manage safety in intraoperative anaesthesia care: An interview study. BMC Health Services Research 2023 23:651. https://doi.org/10.1186/s12913-023-09674-3IV. Olin K, Hybinette K, Pukk Härenstam K. Exploring the concept of team resilience in healthcare - a phased principle-based concept analysis, and potentials for development. Theoretical Issues in Ergonomic Science 2025 1-21. https://doi.org/10.1080/1463922X.2025.2516518</p
Applications of engineered ligand biosensors to elucidate cancer biology and develop novel therapeutics
No full textDeveloping therapies to treat diseases requires a rigorous process involving conceptualization, design, and testing in biochemical assays, cell-based systems, and animal models, culminating in clinical trials to ensure safety and efficacy. However, understanding drug-target interactions within the complexity of living cells remains a significant challenge.This thesis introduces CeTEAM (Cellular Target Engagement by Accumulation of Mutants), a pioneering platform designed to address this gap. CeTEAM leverages destabilizing mutations to generate biosensors that illuminate drug binding and target engagement directly within the cellular environment. Unlike traditional methods focused solely on binding affinity, CeTEAM provides real-time insights into the functional consequences of drug interactions, such as effects on DNA repair or cell cycle progression. By combining high-throughput screening with live-cell imaging, CeTEAM offers a transformative approach to studying drug behaviour with unprecedented precision.Beyond its foundational development, this thesis demonstrates CeTEAM's versatility by applying it to characterize novel PROTACs (Proteolysis Targeting Chimeras), thereby offering new strategies for drug design and therapeutic innovation. As the first implementation of CeTEAM, this work highlights its potential to streamline drug discovery, improve our understanding of cellular drug responses, and accelerate the development of safer and more effective treatments.In Paper I, CeTEAM is presented as an innovative tool for real-time analysis of drug-target interactions in living cells. It is applied to distinguish on-target from off-target effects to profile PARP inhibitors (PARPi) based on their trapping efficacy and influence on DNA repair, and to explore the role of small molecules targeting MTH1 and NUDT15 in cancer biology. This work also demonstrates CeTEAM's scalability for high-throughput screening and its potential for in vivo applications, highlighting its value in optimizing therapeutic strategies and improving drug specificity.In Paper II, CeTEAM is employed as a dual-biosensor system for PARP1 and PARP2, enabling investigation of PARPi selectivity in living cells, overcoming the limitations of conventional in vitro assays. While most PARPi displayed limited selectivity between PARP1 and PARP2, certain compounds, such as AZD5305, showed marked specificity for PARP1, suggesting potential for reduced toxicity. Interestingly, niraparib exhibited a 10-fold higher selectivity for PARP1 over PARP2 in living cells, a difference that was not evident in earlier biochemical studies. We also infer ways of creating selective PARPi based on trends related to compound structures. The study also revealed a role for histone PARylation factor 1 (HPF1) in modulating PARPi binding and enhancing PARP-DNA trapping, a critical mechanism in cancer treatment. These findings emphasize the importance of evaluating drug interactions in physiologically relevant environments.In Paper III, targeted protein degradation (TPD) was investigated using a combination of CeTEAM and a complementary degradation assay, both playing central roles in the development and assessment of PROTACs targeting NUDT5, an enzyme involved in nucleotide metabolism and cancer. Using destabilized E3 ligase mutants for VHL and CRBN, CeTEAM enabled real-time tracking of PROTAC binding and degradation efficacy in live cells. Among the tested compounds, PROTAC-2 (P2), a VHL-based PROTAC, showed the highest degradation efficacy, whereas CRBN-based PROTAC variants were less effective. The study also identified critical lysine residues (K210, K218) essential for ubiquitination and degradation, emphasizing the significance of lysine positioning and E3 ligase choice in PROTAC design.Together, the work presented in this thesis illustrates how CeTEAM can revolutionize drug discovery by addressing key challenges in understanding drug- target interactions. By delivering real-time, cell-based insights and supporting the development of advanced therapeutic approaches like PROTACs, CeTEAM emerges as a powerful and flexible platform for refining treatment strategies. These findings open new avenues for creating more targeted, effective, and safer therapies, reinforcing the importance of innovative tools in tackling complex diseases such as cancer.List of scientific papersI. Nicholas C.K. Valerie, Kumar Sanjiv, Oliver Mortusewicz, Si Min Zhang, Seher Alam, Maria J. Pires, Hannah Stigsdotter, Azita Rasti, Marie-France Langelier, Daniel Rehling, Adam Throup, Matthieu Desroses, Jacob Onireti, Prasad Wakchaure, Ingrid Almlöf, Johan Boström, Luka Bevc, Giorgia Benzi, Pål Stenmark, John M. Pascal, Thomas Helleday, Brent D.G. Page, Mikael Altun. Coupling cellular drug-target engagement to downstream pharmacology with CeTEAM. Nat Commun 15, 10347 (2024). https://doi.org/10.1038/s41467-024-54415-7https://doi.org/10.1038/s41467-024-54415-7II. Maria J. Pires, Seher Alam, Alen Lovric, Emanuele Fabbrizi, Dante Rotili, Mikael Altun, Nicholas C.K. Valerie. Duplexed CeTEAM drug biosensors reveal determinants of PARP inhibitor selectivity in cells. Journal of Biological Chemistry, Volume 301, Issue 4 108361 (2025). https://doi.org/10.1016/j.jbc.2025.108361https://doi.org/10.1016/j.jbc.2025.108361III. Seher Alam*, Maria J. Pires*, Gabriel Tidestav, Ann-Sofie Jemth, Fredrik Klingegard, Rémi Caraballo, Massimiliano Gaetini, Eri van Berkum, Olov Wallner, Jonas Malmström, Per Arvidsson, Nicholas C.K. Valerie, Mikael Altun. Cell-based technologies for the development and assessment of targeted protein degraders. [Manuscript] * - these authors contributed equally to this studyItalics - corresponding authors</p
Bacteriophage-derived endolysins restore antibiotic susceptibility in β-lactam- and macrolide-resistant Streptococcus pneumoniae infections
No full textAbstract
Streptococcus pneumoniae, the pneumococcus, is a cause of major illness globally. Invasive pneumococcal disease (IPD) is characterized by pneumococci invading blood (bacteremia), lungs (pneumonia), or brain and cerebrospinal fluid (meningitis). Meningitis remains an important global health concern because half of the survivors experience long-term neurological damage. The antibiotics commonly used to treat pneumococcal infections are β-lactams and macrolides, however, S. pneumoniae is nowadays often resistant to one or several antibiotics, therefore novel antimicrobials are needed. Here, we found that the bacteriophage-derived cpl-1 endolysin showed consistent antibacterial activity against β-lactam- and macrolide-resistant pneumococcal clinical strains grown in human blood and human cerebrospinal fluid. Exploiting synergistic and additive mechanisms, supplementation of cpl-1 to either penicillin or erythromycin, as representatives for β-lactam and macrolide antibiotics, rescued human neuronal cells from the cytotoxicity of antibiotic-resistant pneumococcal infections. Finally, systemic administration of cpl-1 supplemented to penicillin in mice infected with penicillin-resistant pneumococci successfully reduced bacteremia, and, thanks to the efficient penetration across the blood–brain barrier, abolished bacterial load in the brain, resulting in increased (89%) survival accompanied by an asymptomatic course of infection. These findings strongly suggest that cpl-1 can enhance antibiotic susceptibility in β-lactam- and macrolide-resistant S. pneumoniae, serving as a valuable adjunct therapy to standard-of-care antibiotics for multidrug-resistant IPD.</p