Background Many risk factors for stroke are well characterized and might, at least to some extent, be similar for first-ever stroke and for recurrent stroke events. However, previous studies have shown heterogeneous results on predictors and rates of stroke recurrence. Patients who survive spontaneous intracerebral hemorrhage (ICH) often have compelling indications for antithrombotic (AT) treatment (antiplatelet (AP) and/or anticoagulant (AC) treatment), but due to controversy of the decision to treat, a large proportion of these patients are untreated. In the absence of evidence from randomized controlled trials (RCTs), there is need for more high- quality observational data on the clinical impact of, and optimal timing of AT in ICH survivors. The aims of this thesis were to assess time trends in stroke recurrence, to determine the factors associated with an increased risk of stroke recurrence – including socioeconomic factors – and to determine to what extent ICH survivors with and without atrial fibrillation (AF) receive AT treatment and to determine the optimal timing (if any) of such treatment.  Methods The population-based Monitoring Trends and Determinants of Cardiovascular Disease (MONICA) stroke incidence register was used to assess the epidemiology and predictors of stroke recurrence after ischemic stroke (IS) and ICH from 1995 to 2008 in northern Sweden. Riksstroke, the Swedish stroke register, linked with the National Patient Register and the Swedish Dispensed Drug Register, made it possible to identify survivors of first-ever ICH from 2005 to 2012 with and without concomitant AF to investigate to what extent these patients were prescribed AP and AC therapy. The optimal timing of initiating treatment following ICH in patients with AF 2005–2012 was described through separate cumulative incidence functions for severe thrombotic and hemorrhagic events and for the combined endpoint “vascular death or non-fatal stroke”. Riksstroke data on first-ever stroke patients from 2001 to 2012 was linked to the Longitudinal Integration Database for Health Insurance and Labour market studies to add information on education and income to investigate the relationship between socioeconomic status and risk of recurrence. Results Comparison between the cohorts of 1995–1998 and 2004–2008 showed declining risk of stroke recurrence (hazard ratio: 0.64, 95% confidence interval (CI): 0.52-0.78) in northern Sweden. Significant factors associated with an increased risk of stroke recurrence were age and diabetes. Following ICH, a majority (62%) of recurrent stroke events were ischemic.  The nationwide Riksstroke study confirmed the declining incidence, and it further concluded that low income, primary school as highest attained level of education, and living alone were associated with a higher risk of recurrence beyond the acute phase. The inverse effects of socioeconomic status on risk of recurrence did not differ between men and women and persisted over the study period. Of Swedish ICH-survivors with AF, 8.5% were prescribed AC and 36.6% AP treatment, within 6 months of ICH. In patients with AF, predictors of AC treatment were less severe ICH, younger age, previous anticoagulation, valvular disease and previous IS. High CHA2DS2-VASc scores did not seem to correlate with AC treatment. We observed both an increasing proportion of AC treatment at time of the initial ICH (8.1% in 2006 compared with 14.6% in 2012) and a secular trend of increasing AC use one year after discharge (8.3% in 2006 versus 17.2% in 2011) (p<0.001 assuming linear trends). In patients with high cardiovascular event risk, AC treatment was associated with a reduced risk of vascular death and non-fatal stroke with no significantly increased risk of severe hemorrhage. The benefit appeared to be greatest when treatment was started 7–8 weeks after ICH. For high-risk women, the total risk of vascular death or stroke recurrence within three years was 17.0% when AC treatment was initiated eight weeks after ICH and 28.6% without any antithrombotic treatment (95% CI for difference: 1.4% to 21.8%). For high-risk men, the corresponding risks were 14.3% vs. 23.6% (95% CI for difference: 0.4% to 18.2%). Conclusion Stroke recurrence is declining in Sweden, but it is still common among stroke survivors and has a severe impact on patient morbidity and mortality. Age, diabetes and low socioeconomic status are predictors of stroke recurrence. Regarding ICH survivors with concomitant AF, physicians face the clinical dilemma of balancing the risks of thrombosis and bleeding. In awaiting evidence from RCTs, our results show that AC treatment in ICH survivors with AF was initiated more frequently over the study period, which seems beneficial, particularly in high-risk patients. The optimal timing of anticoagulation following ICH in AF patients seems to be around 7–8 weeks following the hemorrhage.

Background: The risk of ischaemic stroke in patients with atrial fibrillation (AF) and mechanical heart valve (MHV) prostheses can be reduced by oral anticoagulation (OAC), which increases the risk of serious bleeding. The aims of this thesis were [1] to find out how effective and safe warfarin is where treatment quality is high, i.e. Sweden, with proportion of time that patients spend within the therapeutic range (TTR) &gt;70%, [2] whether there is evidence for administering low-molecular-weight heparin (LMWH) during temporary interruptions of OAC (bridging therapy), and whether non-vitamin K-dependent oral anticoagulants (NOACs) as a group, [3] or individually, [4] are more effective and safer than warfarin when used for stroke prevention in patients with AF. Materials and methods: All four studies were retrospective, based on the Swedish anticoagulation register Auricula, and done with merging of data from some or all of the National Patient Register, the Prescribed Drug Register, the Swedish Stroke Register (Riksstroke), and the Cause of Death Register. In studies 2–4, propensity score matching was performed to obtain treatment groups with similar risk profiles. Outcomes were defined as haemorrhages or thromboses requiring specialist care, or death. Haemorrhages were intracranial, gastrointestinal, or other. Thromboses were ischaemic stroke, systemic embolism, myocardial infarction, or venous thromboembolism (VTE). Study 1 described all patients on warfarin during 2006–2011, which was before the introduction of NOACs. Study 2 was a cohort study of all patients who had a planned interruption of warfarin during the same period. Study 3 included all 49,011 patients starting OAC for stroke prevention due to AF between 1 July 2011 and 31 December 2014, and study 4 all 64,382 patients with the same indication between 1 January 2013 and 31 December 2015. Results: Study 1 showed that for the 77,423 patients on warfarin with 217,804 treatment years, TTR was 77.4% for patients with AF, 74.5% with MHV, and 75.9% with VTE. Annual rates of intracranial bleeding were 0.38%, 0.51%, and 0.30%. In study 2, with 14,556 warfarin interruptions, the 30-day risk of a bleeding requiring specialist care was 0.64% for LMWH treated and 0.46% for controls. For patients with VTE as indication for OAC, bleeding rate with LMWH was significantly higher at 0.85% vs. 0.16% (hazard ratio 5.24, 95% confidence interval 1.39–19.77), but with no difference for patients with MHV or AF. The incidence of ischaemic complications was higher in the LMWH bridging group overall and for patients with MHV and AF, but not for patients with VTE. In study 3, for the 12,694 patients starting NOAC (10,392 treatment years) or matched warfarin patients (9,835 treatment years, TTR 70%) due to AF, annual incidence of ischaemic stroke and systemic embolism did not differ between the groups (1.35% vs. 1.58%), but risks of major bleedings and intracranial bleedings were significantly lower: 2.76% vs. 3.61% and 0.40% vs. 0.69%. In study 4, patients on individual NOACs (6,574 dabigatran, 8,323 rivaroxaban, 12,311 apixaban) were compared to 37,174 patients starting warfarin (in total 81,176 treatment years). No NOAC showed any difference in risk of ischaemic stroke or systemic embolism, but there were fewer intracranial bleedings, serious bleedings overall, and deaths for dabigatran and apixaban compared to warfarin. For patients starting rivaroxaban the risk of gastrointestinal bleeding was higher than for matched warfarin counterparts, with no significant differences in other bleeding risks, or mortality. Conclusions: Swedish warfarin treatment shows TTR levels that are high by international standards, correlating to low incidences of ischaemic and haemorrhagic events. LMWH bridging has not been proven beneficial, even for patients with MHV, meaning that bridging in general cannot be recommended. NOACs as a group were safer than high-quality warfarin treatment. Efficacy did not differ, even when comparing individual NOACs to warfarin, but there were fewer bleedings on dabigatran and apixaban. Although not more efficient than warfarin with a high TTR, NOACs should be the recommended first choice for OAC in AF, on the merit of lower bleeding risks. / <p>Finansiär: Forskning och Utveckling, Region Västernorrland</p>

This thesis presents a real time software program written in MATLAB using off-the-self MEMS sensors from Shimmer-Research®. Parallel to the software development, a proof of concept was conducted using the produced program to quantify stride length, stride length variance and stride time for patients diagnosed with Parkinson's disease. Results from testing showed that the system measured the mean stride length error to 2.4% of stride length and a standard deviation of 13.7% of stride length. Results from testing further showed a stride time error of 2.70% of individual stride times with a standard deviation of 1.89%. The system shows promise as a pedagogical, gait analysis training tool for physiotherapists as well as in academic teaching. The system is flexible and data processing functions can be readily re-programmed with other or additional processing features while maintaining user feedback, storage and plotting functionalities implemented in the current version of the program.

Children with phonological problems often come in contact with a speech and language pathologist for intervention. The intervention can be based on different theoretical frameworks, whereof non-linear phonology is one. The present study was carried out as a multiple single-case study with three participants aged 4;3-4;4 years. They had all been diagnosed with speech sound disorder but not yet been given any treatment. Before the intervention was started, three baseline measurements were made with the Swedish phonology test LINUS. The intervention took place once a week for five weeks and ended with two follow-up measurements. The first follow-up measurement occurred in connection to the last intervention and the other one after three weeks. The children’s caretakers filled in a questionnaire about their perception of the intervention at the last follow up measurement. Correctly produced segments and clusters in the words in LINUS were calculated and compared to the children’s productions at the base-line measurements. Percentage Phonemes Correct and Reliable Change Index were calculated to check whether any change was reliable. The targeted segments and clusters improved to a greater extent than other segments. Clusters demonstrated greater result regarding to the segments. The RCI-index was &gt;1,96 for all participants indicating that the results were reliable in terms of improved phonological ability. In the parental questionnaire, it was indicated that the caretakers thought that the treatment was valuable, that they perceived improvements in their children’s speech and that the children thought that the treatment was funny. The study shows that an intervention based on a nonlinear phonological analysis is effective and can be used clinically. / Barn som har fonologiska svårigheter kommer ofta till en logoped för utredning och eventuell intervention. Den logopediska utredningen och efterföljande intervention kan utgå från olika teoretiska ramverk, varav icke-linjär fonologi är ett. Föreliggande studie var en multipel fallstudie med tre deltagare i åldern 4;3-4;4 år. Deltagarna hade fått diagnosen fonologisk språkstörning men ännu inte erhållit någon behandling. Före interventionsstart gjordes tre baslinjemätningar med det svenska fonologiska bedömningsmaterialet LINköpingUnderSökningen (LINUS). Interventionen gavs sedan en gång i veckan i fem veckor och avslutades med två uppföljande mätningar. Den första uppföljande mätningen skedde i samband med sista behandlingstillfället och den andra uppföljande mätningen skedde efter tre veckor. Vårdnadshavarna till barnen fick vid sista uppföljande mätningen även fylla i en utvärdering om hur de upplevde behandlingen. Korrekt producerade segment och kluster i orden i LINUS beräknades och jämfördes med barnens produktion vid baslinjemätningarna. Percentage Phonems Correct och Reliable Change Index för deltagarnas samtliga bedömningar beräknades för att ta reda på om eventuell förändring var reliabel. De segment och kluster som utgjorde mål för interventionen förbättrades mer än andra segment och kluster. Kluster förbättrades i högre grad än enskilda segment. RCI-index var &gt;1,96 för samtliga deltagare, vilket innebär att förbättringen var reliabel. Baserat på vårdnadshavarnas utvärdering framkom det att behandlingen varit värdefull för dem, att de hörde en förbättring hos barnen samt att de upplevde att barnen fann behandlingen rolig. Studien visar att en intervention baserad på en icke-linjär fonologisk analys är effektiv och med fördel kan användas kliniskt.

Mantle cell lymphoma (MCL) is an aggressive B-cell malignancy with bad prognosis, which predominates in males with advanced age. However, studies of the endocannabinoid system and how it affects tumour behaviour provides the basis for designing innovative therapeutic strategies that could open new opportunities for treatment of patient with MCL. It has earlier been shown that the cannabinoid receptor ligand (R)-(+)-methanandamide (R-MA) induce cell death in MCL by accumulation of ceramide. Ceramide has a pro-apoptotic effect on the cell but could be metabolized by the enzymes glucosylceramide synthase (GCS) and sphingosine kinase 1 (SphK1) to molecules with pro-proliferative effect. Therefore, treatments with R-MA on Jeko-1 MCL cell line were performed in this study to determine interference in the proliferative behaviour as well as in the gene expression of the enzymes GCS and SphK1. In addition, treatments with chemotherapeutic substances, such as doxorubicin or cytarabine (Ara-C), and combinations of R-MA and chemotherapeutic substance, were performed for the same reason. Results showed that the proliferation behaviour of Jeko cells remained unaffected when treated with R-MA, in contrast to the decreased proliferative effects shown when treated with cytostatics or combinations of R-MA and cytostatics. Furthermore, a tendency for up-regulation of GCS and SphK1 expression was recognized when cells were treated with cytostatics or combination of cytostatics and R-MA, in contrast to cells treated with R-MA alone. Although, R-MA alone had a tendency for a small down-regulation of GCS expression, it contributed to a potential elevation of GCS expression when combined with Ara-C or doxorubicin. It is believed that the effect from upregulated levels of the metabolizing enzymes GCS and SphK1 is balanced by, earlier observed, up-regulations of the ceramide synthesis enzymes.

Bakgrund   The Gugging Swallowing Screen - Intensive Care Unit (GUSS-ICU) är ett screeningtest med syfte att fånga upp indikationer på sväljsvårigheter efter långvarig intubering hos inneliggande patienter på intensivvårdsavdelningar (IVA). I dagsläget finns det inget svenskt översatt och validerat screeningtest för omvårdnadspersonalen att använda vid bedömning av sväljförmågan efter extubering på IVA. Syfte Syftet med studien var att översätta det internationella screeningtestet GUSS-ICU till svenska för användning i en svensk intensivvårdspopulation. Vidare syftade studien till att utföra en pilotstudie av den svenska versionen på extuberade patienter på IVA. Metod En framåt-bakåtöversättningsmetod användes vid översättningen av screeningtestet GUSS-ICU. Översättningsprocessen omfattade tre steg: framåtöversättning, granskning och kommentarer från en expertpanel och en bakåtöversättning. I översättningsprocessen deltog två logopedstudenter, två handledare, en expertgrupp och en översättare. Expertgruppen bestod av 10 deltagare med olika professioner inom hälso- och sjukvården. Fem inneliggande patienter från IVA planerades delta i en pilottestning av den svenska översättningsversionen. En innehållsanalys genomfördes för att kunna jämföra samtliga översättningar. Syftet med jämförelsen var att identifiera skillnader i ord och satser samt kulturella och kontextuella skillnader. Resultat       Studien resulterade i en svensk översättning (GUSS-IVA) av screeningtestet GUSS-ICU. Analysen visade på skillnader i val av ord, koncept och satser mellan de olika översättningarna. Flertalet skillnader var ej betydelseskiljande utan analyserades istället som resultat av skillnader i erfarenhet, kunskap och språkbruk. Översättningsmetoden bidrog till språklig, kontextuell och kulturell anpassning av översättningen. Slutsats Den svenska versionen av GUSS-ICU stämmer bra överens med originalversionen och enbart ett fåtal skillnader observerades mellan översättningarna. Skillnaderna mellan bakåtöversättningen och originalversionen var inte betydelseskiljande, vilket tyder på att den svenska versionen mäter det den avser att mäta. Framtida studier behöver pilottesta och validera den svenska versionen av GUSS-ICU, innan testet kan implementeras i en svensk intensivvårdspopulation. / Validering av screeningtest för sväljsvårigheter för användning inom svensk vårdkontext

I dagens samhälle har användning av digitala medier ökat drastiskt och i fler områden. Användning av mobila pekskärmenheter har ökat successivt hos småbarn och förskolebarn, och åldern när barn först exponeras till dessa enheter har minskat. Till skillnad från en tidigare tidsperiod utsätts barn idag för en stor mängd stimuli från digital media under sina utvecklingsår. De kort- och långsiktiga effekterna av denna typ av exponering är fortfarande inte helt utforskade. Theory of Mind (ToM) är ett väsentligt område i utvecklingsprocessen hos barn. Vi har i denna studie undersökt barns ToM i en narrativ kontext, där vi bryter ner och analyserarderas yttranden och beteendemönster som visar ToM-förmåga både språkligt och interaktionellt. Multimodal interaktionsanalys låg som grund för analyserna i denna studie, där 45 barn speladesin när de berättar utifrån bilder i boken ”Frog, where are you?”. Resultatet redovisades både kvalitativt för att besvara frågan hur barn visar ToM-förmåga i ett narrativt sammanhang, och kvantitativt för att besvara frågan huruvida det finns en korrelation mellan ToM-förmåga ochdigital mediaanvänding. Det kvantitativa resultatet visade inget signifikant samband mellandigital mediaanvändning eller bokläsning och ToM-förmågan hos barn. Det kvalitativa resultatetvisar att barn integrerar flera olika kunskapsområden för att uppvisa sin ToM både språkligt ochinteraktionellt. / Currently, the use of digital media has increased significantly and has become dominant in manyareas in our society. The use of mobile touch screen devices has increased gradually in youngchildren and preschool children, and the age at which children are first exposed to these deviceshas decreased. Unlike earlier eras, children today are exposed to a substantial quantity of stimulifrom digital media during their developmental years. The short- and long-term effects of thistype of exposure are still not fully explored. Theory of Mind is an essential part of thedevelopmental process in children. In this study, we examined children's ToM in a narrative context, where we analyzed their statements and behavioural patterns that show ToM abilities both linguistically and interactively. Multimodal interaction analysis was the basis for the analyses in this study, where 45 children were recorded when they told a story called "Frog, where are you?". The results were reported qualitatively to answer the question of how children show ToM ability in a narrative context, and quantitatively to answer the question of whether there is acorrelation between ToM ability and children’s digital media use. The quantitative result showed no significant relation between digital media usage or book reading and children’s ToM ability.The qualitative result shows that children integrate several different areas of knowledge to present their ToM both linguistically and interactively, during the narrative activity.

Behovet av tolkar inom hälso- och sjukvården har ökat i takt med att antalet flerspråkiga individer ökar i dagens samhälle. Detta medför högre krav på sjukvården att upprätthålla kvalitén på god hälso- och sjukvård för alla. Logopeder kommer ofta i kontakt med flerspråkiga personer och är då i många av fallen i behov av tolkar vid utredningar eller behandlingar. I dagsläget finns det endast ett fåtal studier tillgängliga som beskriver de utmaningar i ett samarbete med logoped, som kan upplevas ur tolkens perspektiv. Syftet med studien är därmed att undersöka tolkars roll och få fram deras perspektiv av logopedisk utredning och behandling av flerspråkiga personer. Ökad kunskap om tolkens perspektiv skulle kunna tydliggöra de utmaningar och välfungerande arbetssätt som kan finnas och bidra till att förstärka samarbetet mellan tolk och logoped.Materialet för studien består av enkätsvar från 209 tolkar som arbetar i olika delar av Sverige. Information om tolkarna sammanställdes i tabeller för att kunna ge en överblick över bakgrundsinformation samt svar på ett antal fasta frågor om deras perspektiv och erfarenheter av tolkning inom logopediska aktiviteter. Många av de fasta frågorna hade också möjlighet till fritextsvar, vilket i hög grad utnyttjades av de tolkar som besvarade enkäten. Fritextsvarenanalyserades med tematisk analys. Resultatet påvisade att många av tolkarna överlag upplevde samarbetet med logopederna som positivt, men att det finns förbättringsområden. Det främst förekommande området var att tolkarna upplevde att logopederna inte hade tillräcklig kunskap över hur tolkarna bör utföra sitt yrke (utifrån yrkesetiska principer). En förbättrad förståelse förvarandras professioner skulle kunna öka den ömsesidiga förståelsen i samarbetet mellan tolk och logoped. Att kunna få ta del av de material som ska användas innan ett besök hos logopeden för att kunna förbereda sig, är något som tolkarna angav skulle kunna förbättra deras egen prestation och på så sätt även bidra till ökad patientsäkerhet. / The need for interpreters in health care has increased as the number of multilingual individuals increases in today´s society. This entails greater demands on healthcare services to maintain a high quality of healthcare for all. Speech therapists often encounter multilingual people and are then in many cases in need of interpreters during assessments or interventions. Currently, there are only a few studies available that describe challenges that may occur in collaborationsbetween interpreters and speech and language therapist, viewed from the interpreters’perspective. The purpose of this study is thus to investigate the role of interpreters and emphasise their perspective on speech and language therapy activities (e.g. assessment and intervention) for multilingual people. Increased knowledge of the interpreters’ perspective may reveal challenges, as well as identify well-functioning working methods that exist. Results of the study may contribute to strengthening the collaboration between interpreters and speech and language therapists.The material for the study consists of questionnaire responses from 209 interpreters from different parts of Sweden. To provide a comprehensive overview of their answers,information about the interpreters was compiled in tables. Free text answers were an accompanying option to many of the fixed questions. The interpreters' free text answers were analysed using thematic analysis. Overall, the results showed that many of the interpreters perceived the collaboration with the speech therapists as positive, but that there are areas for improvement. The most commonly addressed area was that the interpreters felt that the speech therapists did not have sufficient knowledge of how interpreters are required to perform their profession (by oath of conduct). An improved understanding of each other's professions might increase the degree of satisfaction in the collaboration between interpreter and speech and language pathologist. Getting access to the materials that are to be used for assessment or intervention, before the appointment to be interpreted, would provide the interpreter with a fair chance to prepare appropriately. This is something that a majority of the interpreters in the present study pressed would improve their own performance and thus also increase patient safety.

Bakgrund: Hjärnskakning är en vanlig diagnos och vissa patienter upplever att fysisk ansträngning utlöser symtom lång tid efter hjärnskakningen. En förändring i reglering av cerebralt blodflöde (CBF) har visats vara en potentiell orsak bakom detta. Konditionsträning under tröskeln för symtomexacerbation kan förkorta återhämtningstiden för patienterna. På Neurorehab vid Norrlands universitetsjukhus i Umeå identifieras tröskeln med ett stegrat arbetsprov på ergometercykel. Det finns inte någon studie där transkraniell doppler (TCD) använts för att mäta förändringar i cerebralt blodflöde (CBF) under detta arbetsprov. Syfte: Att undersöka genomförbarhet och klinisk relevans av att använda TCD för mätning av blodflödeshastighet i arteria cerebri media (ACMh), hos friska män, under stegrat arbetsprov. Metod: Sex friska och regelbundet aktiva män genomförde ett stegrat arbetsprov på ergometercykel under samtidig mätning av hjärtfrekvens, blodtryck, partialtryck end-tidal CO2 (PetCO2) och blodflödeshastighet i arteria cerebri media (ACMh, mätt med TCD). Smärta från TCD-utrustning och upplevd ansträngning skattades. Tidsåtgången för TCD-tillägget samt eventuell signalförlust noterades. Resultat: Fem studiedeltagare rapporterade ökad smärta (huvudvärk), skattad med Borg CR10 skala, från TCD-utrustningen. Total tidsåtgång för TCD-tillägget var 7 minuter och 40 sekunder i median (IQR, 5 minuter och 32 sekunder). Signalförlust uppstod för en studiedeltagare på vänster sida. PetCO2 och ACMh följdes åt under arbetsprovet bortsett från avvikelser vid två tillfällen. Slutsatser: Studien visar att mätning av ACMh med TCD är genomförbart och ger relevant information om hur CBF ter sig under genomförandet av stegrat arbetsprov. TCD-utrustningen orsakade smärta vilket kan vara problematiskt vid genomförande för personer med postkontusionellt syndrom.