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Extracellular vesicles in cancer and lung diseases
No full textExtracellular vesicles (EVs) are small mediators of cellular interactions, secreted by all cell types, and abundantly found in body fluids. They specifically package a wide variety of bioactive molecules, such as proteins, nucleic acids, or metabolites, which are often altered in the context of diseases.In lung diseases and particularly sarcoidosis, a granulomatous disease with unknown etiology, EVs have been shown to have an altered protein signature. In Study I, EVs originating from sarcoidosis patients were used to stimulate monocytic cells, which secreted more pro-inflammatory cytokines than healthy controls, suggesting a role of EVs in sustaining a pro-inflammatory environment. Study II focused on the characterization of the metabolomic content of EVs, comparing sarcoidosis to two other lung diseases (chronic obstructive pulmonary disease, COPD, and a variant of Myositis, anti-synthetase syndrome, ASyS). In line with clinical manifestations, patients with sarcoidosis and ASyS showed similarity in their EV metabolic profile, further separated from COPD and healthy controls. Interestingly, some pathways were specifically enriched in sarcoidosis EVs, unraveling manifestations of a disrupted metabolism detected in EVs.Besides their role in disease progression, EVs can also be used as markers to help guide diagnosis. Study III investigated urinary EVs from patients with urinary bladder cancer and healthy controls, characterized by proximity extension assay. A protein signature specific for bladder cancer patients was identified and additional proteins were correlated with muscle-invasiveness. Furthermore, a classifier was able to distinguish muscle-invasive samples from the rest with an accuracy of 92% based on the EV protein profile, paving the way for future EV biomarker studies in urinary bladder cancer.Finally, Study IV focused on improving the use of EVs as cancer immunotherapy. Combining antigen-loaded EVs from bone marrow derived dendritic cells, with checkpoint blockade inhibitors (anti-PD1 and anti-PD-L1) did not improve the treatment of established tumors, but using the EVs as a prophylactic cancer vaccine had a synergistic effect with anti-PD-L1 therapy, inducing an anti-tumor response in a checkpoint refractory melanoma mouse model.In conclusion, the work in this thesis focuses on the various roles of EVs in lung diseases and cancer by studying their function in disease progression, their cargo, or tuning their immune-stimulatory effect in a therapeutic setting.List of scientific papersI. Casper J. E. Wahlund, Gözde Güçlüler Akpinar, Loïc Steiner, Ahmed Ibrahim, Elga Bandeira, Rico Lepzien, Ana Lukic, Anna Smed- Sörensen, Susanna Kullberg, Anders Eklund, Johan Grunewald, Susanne Gabrielsson. Sarcoidosis exosomes stimulate monocytes to produce pro- inflammatory cytokines and CCL2. Scientific Reports. 10, 15328 (2020). https://doi.org/10.1038/s41598-020-72067-7II. Loïc Steiner, Hasnat Noor, Ralph Evaristo Claret Monte, Elga Bernardo Bandeira De Melo, Chantal Reinhardt, Carl Wengse, Maria Eldh, Begum Horuluoglu, Anders Linden, Lena Palmberg, Ingrid Lundberg, Susanna Kullberg, Carl Wengse, Gözde Güçlüler Akpinar, and Susanne Gabrielsson. BALF extracellular vesicles from patients with Sarcoidosis and Anti- synthetase Syndrome exhibit metabolic similarities, differing from those in patients with Chronic Obstructive Pulmonary Disease and healthy individuals. [Manuscript]III. Loïc Steiner, Maria Eldh, Annemarijn Offens, Rosanne E. Veerman, Markus Johansson, Tammer Hemdan, Hans Netterling, Ylva Huge, Abdul-Sattar Aljabery Firas, Farhood Alamdari, Oskar Liden, Amir Sherif and Susanne Gabrielsson. Protein profile in urinary extracellular vesicles is a marker of malignancy and correlates with muscle invasiveness in urinary bladder cancer. Cancer Letters. 609, 217352 (2025). https://doi.org/10.1016/j.canlet.2024.217352IV. Rosanne E. Veerman, Gözde Güclüler Akpinar, Annemarijn Offens, Loïc Steiner, Pia Larssen, Andreas Lundqvist, Mikael C. I. Karlsson, Susanne Gabrielsson. Antigen-Loaded Extracellular Vesicles Induce Responsiveness to Anti-PD-1 and Anti-PD-L1 Treatment in a Checkpoint Refractory Melanoma Model. Cancer Immunology Research. 11 217-227 (2023). https://doi.org/10.1158/2326-6066.cir-22-0540</p
Circulating and resident memory T cell functions in viral diseases
No full textA typical viral infection begins with the activation of the innate immune response, which recognizes viral components and initiates early defense mechanisms. This, in turn, enhances antigen presentation and stimulates the adaptive immune response, ultimately leading to infection resolution and the establishment of immunological memory. Memory T cells are central to long-term immunity and can be broadly classified into circulating and tissue-resident memory T cells (TRM), each playing distinct roles in immune surveillance. The coordination of immunity between these memory subsets is critical for effective control of both acute and chronic infections.This thesis explores the dynamics of circulating and tissue-resident memory T cell responses against viral infections, with the goal of increasing our understanding of effective human immunity and advancing vaccine development and immunotherapeutic strategies.In Study I, we investigate the antiviral and immunosurveillance function of CXCR5+ mCD8+ T cells in human blood and tonsil tissue, with a specific focus on Epstein- Barr virus (EBV) infection. We identified CXCR5 as a marker for CD8+ T cell tissue residency in human tonsil and observed that CD8+ T cells targeting antigens from the latent phase of the infection are predominantly localized in tonsil, the primary site of EBV reservoir.In Study II, we present a comprehensive analysis of the HIV immune response and HIV reservoir in the blood and gastrointestinal (GI) tract of people living with HIV (PLWH). Our findings indicate that CCR5+ CD4+ T cells exhibiting a TRM phenotype are depleted in the GI tract of HIV-infected individuals. Furthermore, we observe a larger HIV reservoir in the GI tract compared to blood, and note a tendency for its contraction in the presence of HIV-specific memory CD8+ T cells.In Study III and IV, we present the development of robust adaptive immunity against SARS-CoV-2 post-infection, and the effects of COVID-19 vaccination on the immune response to SARS-CoV-2 infection.List of scientific papersI. Rivera-Ballesteros, O., Cai, C., Sekine, T., Nilsén, V., Adamo, S., R. Müller, T., Constanz, C., Kammann, T., Mouchtaridi, E., Gao, Y., Akhirunnesa, M., J. M. Raineri, E., Stamper, C., Marchalot, A., Wild, N., Brownlie, D., Llewellyn-Lacey, S., Tibbitt, C., Michaëlsson, J., Marquardt, N., Mjösberg, J., Jorns, C., K. Sandberg, J., Driving, J., A. Price, D., & Buggert, M. CXCR5+ CD8+ T cells in tonsils mark a tissue- resident subset with elevated specificity for latent EBV antigens. [Manuscript]II. Rivera-Ballesteros, O., Kieri, O., Cai, C., Birk, M., Hedström, A., Nowak, P., & Buggert, M. Resident and circulating T cell characteristics and viral reservoir dynamics across the gastrointestinal tract in diverse people living with HIV. [Manuscript]III. Sekine, T *. , Perez-Potti, A *. , Rivera-Ballesteros, O *. , Strålin, K., Gorin, J .- B., Olsson, A., Llewellyn-Lacey, S., Kamal, H., Bogdanovic, G., Muschiol, S., Wullimann, D. J., Kammann, T., Emgård, J., Parrot, T., Folkesson, E., Akber, M., Berglin, L., Bergsten, H., Brighenti, S., . . . Buggert, M. (2020). Robust T Cell Immunity in Convalescent Individuals with Asymptomatic or Mild COVID-19. Cell, 183(1), 158- 168.e114. https://doi.org/https://doi.org/10.1016/j.cell.2020.08.017IV. Cai, C., Gao, Y., Adamo, S., Rivera-Ballesteros, O., Hansson, L., Österborg, A., Bergman, P., Sandberg, J. K., Ljunggren, H. G., Björkström, N. K., Strålin, K., Llewellyn-Lacey, S., Price, D. A., Qin, C., Grifoni, A., Weiskopf, D., Wherry, E. J., Sette, A., Aleman, S., & Buggert, M. (2023). SARS-CoV-2 vaccination enhances the effector qualities of spike-specific T cells induced by COVID-19. Sci Immunol, 8(90), eadh0687. https://doi.org/10.1126/sciimmunol.adh0687*These authors contributed equally to this work.</p
Prevalence for indications and outcome of cardiac resynchronisation therapy in specific patient groups
No full textBackground. The cardiac resynchronisation therapy (CRT) is well established. Several randomised clinical trials have proven its efficacy and framed the population that benefits the most from its utilisation. The presence of symptomatic heart failure (HF), in particular HF with reduced ejection fraction (HFrEF) and a certain grade of intraventricular conduction delay identified at the ECG as a prolonged Q, R, and S waves (QRS) duration or right ventricular paced rhythm indicates a possible benefit provided by the CRT. Despite these well-known results, everyday clinical experience and observational studies show how, in real-world practice, there is a substantial delay and lack of CRT use.Aims. The common aim of the project was to understand, describe and identify the underuse of CRT to help construct a foundation for improvement and further study the implementation of CRT.In particular, the first study focused on describing the state of the art of CRT utilisation in different populations and countries, comparing information from various data sources.The second study also looked at the implementation of CRT from the perspective of a more defined but unselected population.The third study wanted to examine the impact of a device implant on patients' quality of life.The final study aimed to describe the subpopulation with HF and a high percentage of right ventricular pacing (RVP) who also have proved to benefit from CRT implants.Materials. The first study consisted of a cross-sectional analysis of three data sources: the European Society of Cardiology (ESC) HF-Long Term Registry (ESC-HF-LT), the Swedish Heart Failure Registry (SwedeHF) and the second European Society of Cardiology survey on CRT (ESC- CRT Survey II).The other three studies used data from the National implantable cardioverter defibrillator (ICD) and Pacemaker (PM) registry.Study II combined it, thanks to the national personal registration number that every Swedish subject has, with the National Patient Registry and the Cause of Death Registry together with the regional electrocardiogram (ECG) database (MUSE).Study IV used data from the ICD and PM Registry, the National Patient Registry and the Cause of Death Registry linked with the Longitudinal integrated database for health insurance and labour market studies (LISA) from the Statistic of Sweden and The National Prescribed Drug Registry.Study I. "What determines who gets Cardiac Resynchronization Therapy in Europe? A comparison between ESC-HF-LT registry, SwedeHF registry and ESC-CRT Survey II" Three large data sources were compared at the patient level (the ESC-CRT survey II, 11,088 patients; the ESC-HF-LT registry, 1,031 patients; and the SwedeHF registry, 5,008 patients). All patients in the ESC-CRT survey II were implanted. In ESC-HF-LT, 36% had a CRT indication, of which 47% had CRT. In SwedeHF, the corresponding percentages were 30% and 25%. The median age of patients with CRT or CRT indication was comparable for the ESC-CRT survey II and ESC-HF-LT registry (70 years and 68 years, respectively) and lower compared to the SwedeHF registry (76 years). The ESC-CRT survey II and ESC-HF-LT registry are representative of a more specialised healthcare system compared to the broader enrolment pool of the SwedeHF registry (University hospitals 63%, 80%, 30% respectively, CRT implanting centres 100%, 86%, 46% respectively).In the ESC-HF-LT registry, the predictors of CRT were atrial fibrillation (AF), prior HF hospitalisation, and New York Heart Association (NYHA) class. In the SwedeHF registry, besides the previously mentioned factor, with the exception of prior HF hospitalisation, age, previous myocardial infarction, non-smoking, enrolment at a university hospital and follow-up at HF centre/Hospital were associated with CRT use. In SwedeHF, above median income and higher education level were also independently associated with the use of CRT.Study II. "Prognosis of CRT-treated and CRT-untreated unselected population with LBBB in Stockholm County"We collected 5,359 patients with a first ECG with QRS > 150ms and left bundle branch block (LBBB) morphology in the Stockholm region. The median age was 76 years, 36% were female. At the time of index ECG, 41% had a previous history of HF and 27% developed HF. Among 1053 patients with a class I indication for CRT, only 60% received the CRT with a median delay of 137 days and it was associated with a lower risk of death (hazard ratio (HR): 0.45 95% 95% confidence intervals (CI): 0.36-0.57), cardiovascular death (CVD) (HR: 0.47 95% CI: 0.35-0.63) and HF hospitalisation (HR: 0.56 95% CI: 0.48-0.66). The age of over 75 years and the diagnosis of dementia and chronic obstructive pulmonary disease were predictors of CRT non-use, while having a pacing/defibrillator device independently predicted CRT use.Study III. "Health-related quality of life in a large cohort of patients with cardiac implantable electronic devices - a registry-based study" In 2019, 1,479 patients implanted with a cardiac implantable electronic device completed the EuroQol Group Association five-dimension questionnaire (EQ-5D) before and after one year of the implant. Of those, 80% received a PM, 10% an ICD, 5% a cardiac resynchronization therapy pacemaker (CRT-P) and 6% a cardiac resynchronization therapy defibrillator (CRT-D). The median age was 77 years, with a prevalence of females ranging from 38% in the PM group to 17% in the ICD group. The EuroQoL visual analogue scale (EQ-VAS) and the EQ-5D index significantly increased in patients with PM and CRT-P (EQ-VAS +2.8, standard deviations (SD) 23 and +5.8, SD 24.9; EQ-5D index +0.019, SD 0.114 and +0.051, SD 0.125) while only the EQ-5D index increased in patients with ICD (+0.002, SD 0.104). After adjusting for age, sex and health-related quality of life (HRQoL) at baseline, the presence of a defibrillator was associated with lower EQ-VAS (-3.4, 95% CI -6.7; - 0.1 and -4.8, 95% CI -8.8; - 0.7) and EQ-5D index (-0.018, 95% CI -0.035; - 0.0003 and -0.025 95% CI -0.046; - 0.004) at follow-up compared to PM.Study IV. "Management and clinical outcomes in patients with heart failure and a high percentage of right ventricular pacing. A nationwide registry-based study".Out of 220,752 patients with HF from 2011 to 2021, 5,558 (2,5%) had a high burden of RVP (inferred from the presence of III° AV-block at pacemaker implantation) with a higher prevalence of males (63% vs 54%), hypertension (70% vs 65%), chronic kidney disease (20% vs 16%), ischemic aetiology (53% vs 43%). The exposed to a high percentage of RVP had a higher risk of CVD and HF hospitalisation (HR 1.08 95% CI 1.03-1.13 and HR 1.25 95% CI 1.19-1.30). Only a minority of those exposed were upgraded to CRT. High Age and hypertension were independently associated with a lower probability of upgrading to CRT therapy, while male sex and high-level education were associated with a higher probability of upgrade.Conclusions. This thesis and its component studies suggest that: 1. There is a large heterogeneity in CRT utilisation based on population characteristics, data sources and clinical or socio- economical factors. 2. Despite strong evidence of CRT efficacy, its underutilisation is alarming, and further study and actions to improve patient management should be undertaken. 3. Patients' perspectives should be considered in therapeutic decisions. 4. Outcomes of specific populations, such as those with HF and a high percentage of RVP, are poor and further need the implementation of beneficial therapies like CRT.List of scientific papersI. Gatti, Paolo, Cecilia Linde, Lina Benson, Tonje Thorvaldsen, Camilla Normand, Gianluigi Savarese, Ulf Dahlström, Aldo P. Maggioni, Kenneth Dickstein, och Lars H. Lund. "What Determines Who Gets Cardiac Resynchronization Therapy in Europe? A Comparison between ESC-HF-LT Registry, SwedeHF Registry, and ESC- CRT Survey Il". European Heart Journal. Quality of Care & Clinical Outcomes 9, nr 8 (22 december 2023): 741-48. https://doi.org/10.1093/ehjqcco/qcad024II. Gatti, Paolo, Stefan Lind, Ingibjörg Kristjánsdóttir, Ava Azari, Gianluigi Savarese, Matteo Anselmino, Cecilia Linde, och Fredrik Gadler. "Prognosis of CRT-Treated and CRT-Untreated Unselected Population with LBBB in Stockholm County". Europace: European Arrhythmias, Pacing, and Cardiac Electrophysiology: Journal of the Working Groups on Cardiac Pacing, Arrhythmias, and Cardiac Cellular Electrophysiology of the European Society of Cardiology 25, nr 7 (04 Juli 2023): euad192. https://doi.org/10.1093/europace/euad192III. Gatti, Paolo, Carolin Nymark, Fredrik Gadler. "Health-related quality of life in a large cohort of patients with cardiac implantable electronic devices - A registry-based study". PLOS ONE 19(12): e0314978. https://doi.org/10.1371/journal.pone.0314978IV. Gatti, Paolo, Lina Benson, Gianluigi Savarese, Matteo Anselmino, Cecilia Linde, Lars H. Lund, Fredrik Gadler. "Management and clinical outcomes in patients with heart failure and a high percentage of right ventricular pacing. - A nationwide registry- based study". [Manuscript]</p
Microwave ablation as treatment of benign uterine disease
No full textBACKGROUND AND AIMSUterine fibroids and adenomyosis are common benign gynecological conditions with possible negative impact on women's lives. Hysterectomy is often recommended when medical treatment is ineffective, and the patient has no further desire for pregnancy. The use of minimally invasive methods as treatment for uterine diseases has been evolving rapidly the last 10-15 years, and patients wishing to preserve their uterus are increasing in numbers. Microwave ablation (MWA) is minimally invasive and has been used in clinical routine in Danderyd Hospital for many years, to treat malignant tumors in other organs than the uterus. Focus on minimizing symptoms without risks of invasive surgery, is of high value both for patients and health care resources. Even though published studies on MWA treatment of fibroids and adenomyosis, mainly from China, have showed promising results with low time requirements and few complications, this treatment modality is largely unknown in Europe.The aim of this thesis was to evaluate effectiveness, acceptability, safety, and long-term effects of MWA treatment of symptoms related to fibroids and adenomyosis in women without desire to preserve fertility.METHODS AND MAIN RESULTSStudy I is a randomized controlled trial comparing MWA and uterine artery embolization (UAE) for symptoms related to uterine fibroids. Patients were randomized to MWA (n=17) or UAE (n=17) treatment and filled in two validated questionnaires before and after treatment. Uterine fibroid-quality of life (UFS- QoL) questionnaire includes symptom severity score (SSS) and health related quality of life score (HR-QoL). Pictorial bleeding assessment chart (PBAC) evaluates amount of menstrual blood loss. Primary outcome was fibroid volume difference six months after treatment measured on MRI. Secondary outcomes included difference in symptoms (SSS), quality of life (HR-QoL), bleeding during menstruation (PBAC), postoperative pain, hospitalization, sick leave, and acceptability. Median fibroid volume reduction was 42% (IQR 14-63) in the MWA group and 62% (IQR 35-80) in the UAE group without significant difference between the groups (p=0.29). Symptoms and bleeding decreased, and quality of life increased in both groups at follow-up without significant difference between the groups. Acceptability was high and did not differ between groups. Patients treated with MWA had shorter hospitalization (1 day compared to 2, pIn study II long-term effect of MWA on fibroid shrinkage and symptom reduction was studied as well as fibroid characteristics that could predict more successful treatment effect. Of 17 MWA treated patients from study I, 16 were included (one had entered menopause). MRI was performed before, after six months and at long-term (16-36 months), and fibroid volume was measured. Patients filled in the same questionnaires as Study I at all timepoints. Fibroid location in uterus was registered and shrinkage was correlated to vascularization and T2 signal intensity (SI) on MRI. Continuous shrinkage was noted in 83% of treated fibroids from six months to long-term follow up, with median shrinkage of 77% at long-term. Compared to baseline 82% of patients reported symptom improvement. Symptoms increased between the six-month follow-up and long-term, but no change in quality of life during that time period was observed. Preoperative vascularization and high T2 SI predicted better treatment effect.Study III is a prospective interventional cohort study on effectiveness and acceptability of MWA on symptoms related to uterine fibroids. A total of 123 patients were included and treated with MWA but 10 were lost to follow up. Primary outcome was symptom reduction (SSS) and increase in quality of life (HR- QoL) six months after MWA. Secondary outcomes included difference in menstrual bleeding, fibroid volume, hospitalization, postoperative pain, and acceptability. Symptoms decreased by 37% (pIn study IV 20 patients with symptomatic adenomyosis were randomized to MWA or UAE. Adenomyosis was confirmed on ultrasound and MRI and patients filled in the validated questionnaires before and six months after treatment. Primary outcome was symptom reduction (SSS) at follow-up. Secondary outcomes included quality of life, menstrual bleeding, dysmenorrhea, uterine volume, hospitalization, return to daily activities, use of pain medication and acceptability. Symptom reduction was seen in both groups at follow-up, by 36% in the MWA group (p=0.007) and 47% (p=0.067) in the UAE group but without significant difference between groups (p=0.755). Both groups had significantly higher quality of live, less bleeding and reduced dysmenorrhea after treatment but there was no significant difference between the groups. The MWA group had significantly shorter hospitalization (p=0.004), quicker return to daily activities (p=0.005) and used less pain medication postoperatively (p=0.029).CONCLUSIONMicrowave ablation is a promising treatment alternative for patients with symptoms from uterine fibroids and adenomyosis who seek uterus preservation. We could not confirm the superiority of MWA in shrinking fibroid size compared to UAE nor regarding symptom reduction, but absence from work, hospitalization and pain was less prominent in the MWA treated patients. Within the studies presented in this thesis one serious complication occurred. Acceptability was high. Fibroids treated with MWA continued to shrink over time and highly vascularized fibroids and submucosal fibroids responded better to the treatment. Further studies are needed to evaluate the effect of MWA in patients with impaired fertility.List of scientific papersI. Ultrasound guided microwave ablation compared to uterine artery embolization treatment for uterine fibroids - a randomized controlled trial. Jonsdottir G, Beermann M, Lundgren Cronsioe A, Hasselrot K, Kopp Kallner H. International Journal of Hyperthermia. 2022;39(1):341-347. @ copyright 2022, reprinted by permission of Informa UK Limited, trading as Taylor & Taylor & Francis Group. https://doi.org/10.1080/02656736.2022.2034991II. Long term follow-up of uterine fibroids treated with microwave ablation: an up to 3-year observational study of volume, regrowth, and symptoms. Beermann M, Jonsdottir G, Cronsioe A, Hasselrot K, Kopp Kallner H. International Journal of Hyperthermia. 2022;39(1):1158-1163. @ copyright 2022, reprinted by permission of Informa UK Limited, trading as Taylor & Taylor & Francis Group. https://doi.org/10.1080/02656736.2022.2109764III. Ultrasound guided microwave ablation treatment of uterine fibroids: clinical response and patient acceptability. Jonsdottir G, Beermann M, Lantz E, Nikodell A, Lundgren Cronsioe A, Hasselrot K, Kopp Kallner H. Acta Obstet Gynecol Scand. Published online 19 December 2024. https://doi.org/10.1111/AOGS.15041IV. Symptom improvement in adenomyosis patients after ultrasound guided microwave ablation or uterine artery embolization, a randomized controlled pilot study. Jonsdottir G, Lantz E, Beermann M, Paschou M, Kopp Kallner H, Hasselrot K. [Submitted]</p
Airway management in emergency anaesthesia
No full textBackgroundAirway management in critically ill patients, particularly rapid sequence induction and intubation (RSI) for emergency anaesthesia, remains a high-stakes and time-critical procedure associated with significant morbidity and mortality. Maximizing first-pass success (FPS) is a critical quality target, as multiple intubation attempts correlate with increased adverse events. Current global guidelines stress the need for a systematic approach to technical execution, patient physiology, operational logistics, and human factors to refine safe practices. The Scandinavian Helicopter Emergency Medical Service (HEMS) system, which is staffed by highly experienced anaesthesiologists, operates under challenging constraints, necessitating research that validates adaptable techniques and effective team dynamics. Historically, prehospital guidelines have advocated for 360-degree access outside the vehicle, potentially increasing critical on-scene time. Furthermore, contemporary practice has explored the use of alternative adjuncts for emergency anaesthesia, such as high-flow nasal oxygen (HFNO) for preoxygenation and prolonging the safe apnoea time, that can further mitigate these risky procedures. However, robust, multicentre evidence supporting operational changes, such as in-cabin intubation or quantifying the influence of the airway assistant, has been sparse. This thesis sought to contribute empirical evidence across these domains. The first phase of this doctoral project focused on evaluating the safety profile of HFNO as an alternative preoxygenation strategy within the emergency surgical population. The next trial addressed logistical constraints in prehospital care, specifically testing whether intubating within the confined space of a vehicle could match the success rates of traditional exterior procedures. Finally, we utilized the same dataset to explore human factors, specifically analysing whether the professional designation of the assisting provider correlated with procedural outcomes.MethodsThis thesis comprises three clinical studies, Study I ("PRIOR2"), a prospective, randomized controlled, international multicentre trial conducted across six centres in Sweden and Switzerland (n=349). Patients who underwent RSI for emergency surgery were randomized 1:1 to receive preoxygenation with HFNO or a tight-fitting facemask. The primary outcome was the incidence of oxygen saturation (SpO2) less than 93% from the start of preoxygenation until one minute after tracheal intubation. Study II ("PHASTER"), a prospective, observational, international multicentre study involving 12 HEMS bases across Scandinavia (n=422 drug-assisted tracheal intubations). This study was designed as a noninferiority trial to compare FPS and complication rates when intubation was performed in-cabin (in a helicopter or ambulance) versus outside. The primary outcome was the FPS rate. Noninferiority was defined by a margin (Δ) of -4.5%. Propensity score matching was used to adjust for confounding factors related to the observational nature of the location choice. Study III (PHASTER Subgroup Analysis), a retrospective subgroup analysis of Study II data (n=422) investigating the influence of the airway assistant's professional background, anaesthetist (anaesthesiologist or nurse anaesthetist) vs. nonanaesthetist (e.g., other physician, other nurse or paramedic), on FPS and complication rates. Binary logistic regression was used to calculate adjusted odds ratios (aORs) for the outcomes, adjusting for covariates such as initial patient condition, VL use, and operator experience.ResultsStudy I: No difference was detected in the primary outcome, desaturation within one minute of intubation. Five patients (2.9%) in the HFNO group desaturated below 93%, whereas six patients (3.4%) in the facemask group desaturated (p=0.77). No difference was detected in the incidence of gastric regurgitation or desaturation between office hours and on-call hours. There was a greater incidence of desaturation in the Switzerland cohort (7%) than in the Sweden cohort overall (1.6%) (p = 0.009).Study II: The FPS rate was 89.2% for in-cabin procedures and 86.3% for outside procedures. The confidence interval for the difference did not include the noninferiority margin (Δ= -4.5) and therefore successfully met the predefined criteria for noninferiority. Intubations performed in the helicopter cabin resulted in a significantly shorter mean on-scene time (27 minutes vs. 32 minutes, p=0.004).Study III: FPS was nearly identical between the anaesthetist-assisted (88.1%) and nonanaesthetist-assisted (87.8%) groups. The assistant profession was not independently associated with FPS (aOR 1.05, 95% CI 0.54-2.12) or overall complication rates (aOR 1.79, 95% CI 0.66-5.39).ConclusionsThis thesis validates essential strategies for increasing the standard of emergency airway management. The results of Study I support technical efficacy and flexibility. HFNO is deemed a functionally equivalent and as good alternative to facemask preoxygenation during RSI, offering crucial technical flexibility, particularly for physiologically compromised patients, by supporting the strategy of continuous apneic oxygenation. Study II highlights logistical efficiency since the in-cabin intubation procedure is noninferior to outside intubation in terms of FPS and safety while achieving a significantly shorter on-scene time. This provides evidence-based justification for adapting HEMS SOPs to maximize logistical efficiency without compromising core safety metrics. Study III adds perspectives on team resilience. In highly experienced, protocol-driven emergency medical systems, team performance and system governance are dominant predictors of success, as the professional background of the airway assistant does not independently influence outcomes. Taken together, these results support a flexible, patient- and context-tailored approach to RSI, prioritizing FPS through meticulous techniques, optimized logistics, and sustained investment in multidisciplinary team processes and systemic governance.List of scientific papersI. Preoxygenation using high-flow nasal oxygen vs. tight facemask during rapid sequence induction. A. Sjöblom, J. Broms, M. Hedberg, Å. Lodenius, A. Furubacke, R. Henningsson, A. Wiklund, S. Nabecker, L. Theiler, M. Jonsson Fagerlund. Anaesthesia, 2021; 76: 1159-62. https://doi.org/10.1111/anae.15426II. Prehospital tracheal intubations by anaesthetist-staffed critical care teams: a prospective observational multicentre study. J. Broms, C. Linhardt, E. Fevang, F. Helliksson, G. Skallsjö, H. Haugland, J. Knudsen, M. Bekkevold, M. Tvede, P. Brandenstein, T. Hansen, A. Krüger, L. Rognås, HM. Lossius, M. Gellerfors. British Journal of Anaesthesia, 2023 1;131(6):1102-11. https://doi.org/10.1016/j.bja.2023.09.013III. The impact of airway assistants on prehospital endotracheal intubations - a subgroup analysis of data from anaesthesiologist-staffed helicopter critical care teams. J. Broms, M. Günther, C. Svensén, A. Krüger, L. Rognås, M. Gellerfors. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 2025, Nov 25. https://doi.org/10.1186/s13049-025-01515-y</p
Efficient integration of human skin single-cell RNA sequencing data
No full textSkin is one of the largest organs in the human body and serves a multitude of functions. As a protective barrier, it shields the body from external harms such as dehydration, microorganisms, injury, and ultraviolet radiation. Skin also provides structural support, enables sensation through a network of nerves, and regulation of body temperature via sweating. An imbalance of cell types and associated signals can lead to disease. Skin composition and microanatomy across the body varies in thickness, hair growth, sebaceous and sweat gland density, microbiota exposure and disease susceptibility. However, a comprehensive unified view of cell types representing skin across the body is currently lacking. The overarching aim of this thesis is to establish a consensus nomenclature of normal human skin, which requires building an integrated human skin cell atlas and performing comprehensive analyses based on this atlas. Reference mapping is an important utility of atlases. However, many reference mapping methods have explicit or implicit forceful behaviour during mapping. For a more direct and unbiased reference mapping, we developed a de novo deep learning-based method scSEA, that enables virtual incremental computability for embeddings.In Paper I, we reanalysed 24 individual scRNA-seq datasets of normal human skin cells from various publications using a unified analysis pipeline. We harmonized all metadata and cell annotations of these 24 datasets and made the data available within "Skin Explorer", an interactive web tool and online data repository.In Paper II, we established a molecular and spatial atlas of human skin fibroblasts from healthy skin and 23 skin diseases and compared these with fibroblast data from 14 diseases across other tissues, revealing shared disease-related fibroblast subtypes across tissues.In Paper III, we used mouse and ex vivo human skin models, as well as bulk and single-cell transcriptomics to dissect the role of miR-149 in skin inflammatory response.In Paper IV, we integrated 463,503 cells from 145 donors and 24 studies to annotate their cell types, subtypes and cell states. The resulting integrated human skin cell atlas (iHSCA) serves as the basis for the human cell atlas version 1 reference and consensus nomenclature of healthy human skin.In Paper V, we developed a deep learning-based method scSEA (single cell Semi-supervised Embedding Aligner) that enables virtual incremental computation for embeddings to enable the mapping of new cells onto existing representations with the possibility of discovering new cell types for a more direct and unbiased reference mapping.List of scientific papersI. Hao Yuan*, Nil Campamà Sanz*, Rebecca E. Wagner, Linda Roessler, Elizabeth Heinmäe, Anaguli Yeerken, Alexandra Are, Karl Annusver, Maria Kasper. Skin Explorer: an interactive single-cell RNA-seq resource for healthy human skin. Journal of Investigative Dermatology, 2025, in press. https://doi.org/10.1016/j.jid.2025.08.025II. Lloyd Steele, Bayanne Olabi, Kenny Roberts, Pavel V. Mazin, Simon Koplev, Catherine Tudor, Benjamin Rumney, Chloe Admane, Treasa Jiang, Donovan Correa-Gallegos, Keerthi Priya Chakala, Aljes Binkevich, Nusayhah Hudaa Gopee, Alexander Predeus, Martin Prete, Elena Winheim, Karl Annusver, Agnes Forsthuber, Luc Francis, Sophie Frech, Clarisse Ganier, Thomas Layton, Yingzi Liu, Hao Yuan, Johann E. Gudjonsson, Beate M. Lichtenberger, Satveer Mahil, Jagdeep Nanchahal, Edel A. O'Toole, Maksim V. Plikus, Yuval Rinkevich, Emanuel Rognoni, Catherine H. Smith, Sarah A. Teichmann, Maria Kasper, April R. Foster, Mohammad Lotfollahi, Muzlifah Haniffa. A single cell and spatial genomics atlas of human skin fibroblasts reveal shared disease-related fibroblast subtypes across tissues. Nature Immunology, 2025;26(10):1807-1820. https://doi.org/10.1038/s41590-025-02267-8III. Longlong Luo, Hao Yuan, Ankit Srivastava, Karl Annusver, Nupur Khera, Piyal Saha, Roxane Prieux, Kunal Mahapatra, Evelyn Kelemen, Menil Dholakia, Jan Cedric Freisenhausen, Milena Petkova, Taija Makinen, Gunnar Pejler, Maria Kasper, Andor Pivarcsi, Enikö Sonkoly. A microRNA-mediated epithelial checkpoint limits inflammatory amplification in barrier immunity. [Manuscript]IV. Hao Yuan, Axel Almet, Yingzi Liu, Rebecca Wagner, Adaikalavan Ramasamy, Gokce Oguz, Nil Campamà Sanz, Karl Annsuver, Michaela Mueller, Elizabeth Heinmäe, Agnes Forsthuber, Sabina Gansberger, April Foster, Lloyd Steele, Clarisse Ganier, [HCA Bionetwork Skin], Malte D. Luecken, Fiona M. Watt, Ines Sequeira, Beate M. Lichtenberger, Andrew Ji, Muzlifah Haniffa, Johannes Griss, Carlos Clavel#, Maksim Plikus#, Maria Kasper#. Hierarchical Single-Cell Reference and Consensus Nomenclature for Healthy Human Skin. [Manuscript]V. Hao Yuan, Karl Annusver, Maria Kasper. scSEA: a single cell semi-supervised embedding aligner for effective reference mapping. [Manuscript]* These authors have contributed equally.# Co-corresponding authors.</p
Outcomes after endovascular aortic aneurysm repair
No full textBackgroundAortic aneurysms are life threatening conditions, most often affecting the abdominal and descending thoracic segments. Endovascular aortic repair offers better short-term outcomes, even in emergency cases; however, evidence on its cardiac effects, complications, and long-term survival patterns remain limited.MethodsFor Studies I and IV, data were collected from local hospital records and the Swedish Vascular Registry (Swedvasc). In Studies II and III, data from the National Patient Register (NPR) in Sweden including diagnostic and operative codes, all-cause mortality, and causes of death were linked to the registry. Study I investigated outcomes after endovascular repair of ruptured descending thoracic aortic aneurysms (rDTAA) in 140 patients in six university hospitals in Sweden. Study II analysed early and late major adverse cardiovascular events (MACE) in 8641 patients treated with endovascular aortic repair for ruptured and non-ruptured (intact) abdominal (rAAA/iAAA) and thoracic aortic aneurysm (rTAA/iTAA). In study III, the time distribution and trends of mortality after open or endovascular repair for rAAA were examined in 3927 patients in Sweden. Changes in echocardiography findings before and after aortic aneurysm repair in 83 patients treated at single center were evaluated in study IV.ResultsIn study I, estimated survival rate was 80.0% at one month, 71.7% at three months, and notably decreasing to 31.9% at five years. 45% of cohorts had a major complication within 30 days post TEVAR. Stoke, renal failure, major bleeding and previous aortic surgery were associated with mortality. Study II showed that within 90 days incidence of MACE was 10.2% of patients treated with TEVAR for iTAA and 26.7% after repair of rTAA. Otherwise, MACE rates after EVAR were 3.7% for iAAA and 26.9% for rAAA. No long-term difference in MACE was observed between TEVAR and EVAR, either after ruptured or intact aneurysm repair. Female sex was associated with a higher long-term risk of MACE in both intact and ruptured aneurysm groups. In study III, the overall postoperative mortality at 30 and 90 days was 28.9% and 33.2%, respectively. For EVAR, mortality rates were 20.9% and 25.7%, while for OSR they were 31.4% and 35.5%. Ninety-day postoperative mortality showed a significant improvement over time (OR 0.70; 95% CI 0.57-0.87; P=0.001). Most deaths (43.4%) occurred within 48 hours after surgery (EVAR 43.3%; OSR 43.4%), with an additional 16.3% occurring between 2 and 5 days (EVAR 12.5%; OSR 17.2%). Study IV reported postoperative cardiac events in 6.0% of patients at 30 days and 8.4% at 90 days. Over the follow up period, 51% had at least one postoperative cardiac event. Significant differences were observed between pre and postoperative measurements for LVEF (P=0.004), MAPSE (P=0.002), E wave velocity (P=0.001), TI vmax (P=0.008), and TAPSE (P=0.029), while other echocardiographic parameters showed no change. Age (HR 1.08; 95% CI 1.04-1.12) and pulmonary disease (HR 2.02; 95% CI 1.18-3.47) were associated with an increased risk of cardiac events or mortality. Only one echocardiographic parameter left ventricular posterior wall thickness in diastole (LVPWd) was significantly associated with a lower risk of cardiovascular events and mortality (HR 0.68; 95% CI 0.48-0.97).ConclusionsEndovascular repair demonstrates favorable short-term results for both thoracic and abdominal aortic aneurysms. However, long-term survival remains poor, especially among patients treated for ruptured aneurysms. Cardiovascular complications are common after both non-ruptured and ruptured aortic aneurysm repair. These observations highlight the importance of improved risk assessment, systematic follow-up, and the inclusion of cardiac evaluation as a routine part of post-aneurysm management.List of scientific papersI. Outcome After Endovascular Repair of Ruptured Descending Thoracic Aortic Aneurysm: A National Multicentre Study. Hammo S, Larzon T, Hultgren R, Wanhainen A, Mani K, Resch T, Falkenberg M, Forssell C, Sonesson B, Pirouzram A, Roos H, Hellgren T, Khan S, Hoijer J, Wahlgren CM. Eur J Vasc Endovasc Surg. 2019 Jun;57(6):788-794. Epub 2019 Mar 22. https://doi.org/10.1016/j.ejvs.2018.10.029II. High Risk of Early and Late Cardiovascular Events After Endovascular Aortic Aneurysm Repair. Hammo S, Grannas D, Wahlgren CM. Ann Vasc Surg. 2022 Oct; 86:320-327. Epub 2022 apr 26. https://doi.org/10.1016/j.avsg.2022.04.028III. Time Distribution of Mortality After Ruptured Abdominal Aortic aneurysm repair. Hammo S, Grannas D, Wahlgren CM. Ann Vasc Surg. 2022 Oct; 86:313-319. Epub 2022 Mar. https://doi.org/10.1016/j.avsg.2022.01.035IV. Changes In Cardiac Function Assessed With Transthoracic Echocardiography in Patients Undergoing Abdominal Aortic Aneurysm Repair. Hammo S, Bari R, Pikwer A, Yan J, Maret E, Wahlgren CM. Accepted for publication in Journal of Cardiovascular Echography, August 7, 2025. [Accepted]</p
Women’s perceptions of emergency visits with Swedish health care workers following rape
No full textThe focus of this study is on women’s perceptions of emergency visits with Swedish healthcare workers following rape. An online questionnaire was distributed and respondents included 106 women, aged 18–64 years old. Results show that raped women generally perceived their encounters as empathic, validating, and trustful. However, women seeking care at the specialised unit reported a higher quality in encounters. Questions were perceived as more relevant and empathic and as less blaming and intrusive if the questions had been explained. Higher quality in encounters correlated to perceptions of the gynecological examination as more safe and caring, and as less intrusive. Quality of encounters explained a significant amount of the variance in level of trust in healthcare. The study confirms earlier studies of the importance of quality of encounters with professionals after a sexual assault. This knowledge should be taken into consideration when planning future care for victims of rape.</p
Fertility concerns and fertility preservation in adolescent and adult men with cancer
No full textLong-term survival among young men with cancer have improved markedly in recent decades, shifting focus from life-saving treatments to long-term quality of life and reproductive health. Cancer treatments such as chemotherapy, radiotherapy, and surgery can impair spermatogenesis and fertility. Although sperm cryopreservation is the only established fertility preservation method for men, semen quality may be compromised already at diagnosis. Moreover, long-term reproductive outcomes and the psychosocial consequences of impaired fertility—such as distress and uncertainty about future parenthood—remain insufficiently understood. This thesis aimed to investigate biological and psychosocial aspects of fertility in men diagnosed with cancer, with a particular focus on patients with testicular cancer, the most common malignancy in young adult males.In Study I, 182 men with clinical stage I testicular cancer, recruited from two Swedish oncology centers between 2001 and 2006, were prospectively followed for five years to assess sperm quality after adjuvant treatment. Semen samples were collected at baseline (post-orchiectomy but before adjuvant therapy) and at 6, 12, 24, 36, and 60 months. The adjuvant treatments included radiotherapy (25.2 Gy in 14 fractions), chemotherapy with one cycle of bleomycin, etoposide, cisplatin or one cycle of carboplatin (AUC 7). One group was managed with surveillance (i.e. no adjuvant treatment). The study found no long-term effect in sperm concentration or total sperm count between men receiving adjuvant treatment and those managed with surveillance.Study II was an observational cohort study including 1,252 post pubertal males with either malignant or severe non-malignant diseases requiring gonadotoxic treatment, referred for sperm cryopreservation at the Reproductive Medicine Clinic, Karolinska University Hospital, between 2009 and 2020. The study compared semen parameters prior to treatment between men with malignant diagnoses and those with non-malignant conditions and comparisons were made to a reference group of known fertile men. Results showed that men with malignancies had significantly lower sperm concentration, motility, and total sperm count at referral compared to patients in the reference group. However, the men in the severe non-malignant group also had lower sperm quality than the reference group, highlighting the vulnerability of fertility potential even before treatment initiation in both groups.Study III was a cohort study of 1,378 adolescents and young adults diagnosed with cancer referred for sperm cryopreservation to the Reproductive Medicine Centre, Karolinska University Hospital, between 1988 and 2020. Clinical data from the fertility preservation program were linked to Swedish population-based registers to evaluate long-term reproductive outcomes. The study found that a substantial proportion of men became fathers, predominantly through natural conception. For those who did not achieve pregnancy naturally, assisted reproductive technologies proved successful.In Study IV, 193 men aged 18-39 years with testicular cancer, diagnosed between 2016 and 2017 and included in the Swedish Fertility and Sexuality Following Cancer (Fex-Can) Cohort, were investigated regarding fertility-related distress in relation to treatment intensity. Fertility-related distress was assessed using the Reproductive Concerns After Cancer (RCAC) scale at 1.5, 3, and 5 years post-diagnosis. While most men reported low levels of distress over time, a notable minority—particularly those who received more intensive treatment—experienced persistent or fluctuating distress, especially regarding the health of potential offspring. These findings highlight the need for ongoing psychosocial support for this group of survivors.Together, these studies provide a comprehensive perspective on both biological and psychosocial aspects of fertility in young male cancer patients and survivors. They emphasize the importance of early fertility preservation information, and the provision of long-term psychosocial support tailored to individual needs.List of scientific papersI. Weibring K, Nord C, Ståhl O, Eberhard J, Sandberg K, Johansson H, Arver S, Giwercman A, Cohn-Cedermark G. Sperm count in Swedish clinical stage I testicular cancer patients following adjuvant treatment. Ann Oncol. 2019;30(4):604-611. https://doi.org/10.1093/annonc/mdz017. PMID: 30798330.II. Weibring K, Lundberg FE, Cohn-Cedermark G, Rodriguez-Wallberg KA. Sperm quality in 1252 Adolescents and Young Adults (AYAs) Undergoing Fertility Preservation Due to Cancer or Non-malignant Diseases. J Adolesc Young Adult Oncol. 2024. https://doi.org/10.1089/jayao.2024.0068. PMID: 39069896.III. Weibring K, Lundberg FE, Cohn-Cedermark G, Rodriguez-Wallberg KA. Parenthood in a Swedish prospective cohort of 1,378 adolescents and young adults banking semen for fertility preservation at time of cancer diagnosis. Front Endocrinol. 2024; 15:1502479. https://doi.org/10.3389/fendo.2024.1502479. PMID: 39720258.IV. Weibring K, Rodriguez-Wallberg KA, Ullemar V, Ståhl O, Wettergren L, Lampic C. Long-term impact of treatment intensity on fertility-related distress in young survivors of testicular cancer - A population-based longitudinal study. Manuscript - under review. [Submitted]</p
Epidemiology, methodology, and biomarkers for lung cancer
No full textLung cancer is the leading cause of cancer-related death and among the most diagnosed cancers worldwide. Although mortality has declined in recent decades with reduced smoking prevalence, lung cancer remains a major public health challenge. Reducing its burden requires precise risk stratification, targeted screening of high-risk populations, and robust molecular biomarkers for early detection and personalized treatment.In this thesis, we integrate epidemiology, biomarker discovery, and methodology development to address the challenges of early detection, molecular stratification, risk prediction, and precision oncology. We aim to: (1) develop tools to identify clinically actionable gene fusions to resolve tumor heterogeneity and to inform targeted therapies (Study I); (2) develop advanced sequencing methods for ctDNA-based ultra-sensitive mutation detection to improve early diagnosis (Study II); (3) quantify lung cancer risk in patients with interstitial lung disease (ILD) using a sibling design, to inform screening strategies (Study III); and (4) provide a practical, reproducible protocol for SplitFusion to guide users in its implementation (Study IV).In Study I, we developed SplitFusion, an ultra-sensitive algorithm for detecting clinically actionable gene fusions (e.g., ALK, ROS1, RET, and NTRK) from low- quality RNA-seq data. Leveraging the library optimization from anchored multiplex PCR (AMP) and an optimized read-splitting strategy with functional annotation and filtering, SplitFusion sensitively and accurately captures low- frequency fusions in highly degraded formalin-fixed paraffin-embedded (FFPE) samples. By resolving fusion-driven tumor heterogeneity, SplitFusion improves the molecular stratification of patients to guide targeted therapies.In Study II, we developed BLAST-Seq (Bi-Strand Linear Amplification and Single-strand Target enrichment) for non-invasive early cancer diagnosis. The method enables ultra-sensitive detection of circulating tumor DNA (ctDNA) by a novel library design, with a custom computational error-suppression algorithm, incorporating UMI-based consensus calling and stringent filtering. BLAST-Seq achieved high analytical sensitivity compared with orthogonal ddPCR validation, and reliably identified driver mutations from low-input materials and at low variant allele frequencies (VAFs), enhancing early detection and minimal residual disease (MRD) monitoring.In Study III, we evaluated the association between interstitial lung disease (ILD) and lung cancer to refine screening strategies for high-risk populations. Using the Swedish nationwide registers as a large population-based cohort and a sibling-controlled design, we demonstrate that ILD significantly increases the risk of incident lung cancer, among all major histological subtypes. Thereby we define a critical smoking-independent high-risk group that may benefit from enhanced surveillance.In Study IV, we established a standardized and reproducible protocol for the implementation of the SplitFusion pipeline. This protocol provides comprehensive, step-by-step guidance on the required software environment, input data formats, and specific command-line instructions. It aims to offer a user-friendly framework that facilitates the consistent and reliable application of SplitFusion in both research and translational settings.In summary, this thesis advances precision oncology in lung cancer by integrating epidemiological risk identification with cutting-edge molecular diagnostics. By combining ultra-sensitive mutation detection and fusion profiling, this work provides a comprehensive framework to improve prevention, early detection, and individualized therapy.List of scientific papersI. Weiwei Bian*, Baifeng Zhang*, Zhengbo Song*, Binyamin A Knisbacher*, Yee Man Chan, Chloe Bao, Chunwei Xu, Wenxian Wang, Athena Hoi Yee Chu, Chenyu Lu, Hongxian Wang, Siyu Bao, Zhenyu Gong, Hoi Yee Keung, Zi-Ying Maggie Chow, Yiping Zhang, Wah Cheuk, Gad Getz, Valentina Nardi, Mengsu Yang, William Chi Shing Cho, Jian Wang, Juxiang Chen, Zongli Zheng. SplitFusion enables ultrasensitive gene fusion detection and reveals fusion variant- associated tumor heterogeneity. Patterns, Volume 6, Issue 2, 101174. https://doi.org/10.1016/j.patter.2025.101174II. Firaol Tamiru Kebede*, Weiwei Bian*, Chenyu Lu, Siyu Bao, Weimin Ye, William Chi Shing Cho, Zongli Zheng. Sensitive Cancer Detection Using Circulating Cell-Free DNA. [Manuscript]III. Hui Xu, Li Yin, Weiwei Bian, Mingqiang Kang, Hans-Olov Adami, Weimin Ye. Interstitial Lung Disease and Risk of Lung Cancer. JAMA Netw Open. 2025;8(7):e2519630. https://doi.org/10.1001/jamanetworkopen.2025.19630IV. Weiwei Bian, Binyamin A. Knisbacher, Yee Man Chan, Chen Zhao, Zongli Zheng. Protocol for sensitive detection of gene fusions from RNA-seq data using SplitFusion. [Manuscript]* Equally contributed</p