<p>Inom hälso- och sjukvården spelar informationsteknologi en allt större roll för utvecklingen. Informationsteknologin har skapat nya förutsättningar där chansen till förbättrade vårdrutiner finns inom många områden genom att införa och utveckla användandet av telemedicin.</p><p>Då vi tror att den telemedicinska potentialen kommer att användas i större utsträckning i framtiden känner vi att det finns ett intresse för en utredning av redan existerande samarbeten inom telemedicin. Vi skrev denna uppsats med syftet att undersöka, identifiera och analysera vad som krävs för att möjliggöra ett effektivt telemedicinskt partnerskap inom sjukvården för att förbättra patientens vård, behandling och ta tillvara på de arbetsprocesser som skapas i och med ett telemedicinskt samarbete. Vi har analyserat två olika typer av telemedicinska samarbeten. Vi har genom en kvalitativ undersökning, främst genom intervjuer, grundligt undersökt två av de bestående nätverken för att sedan analysera dessa med hjälp av den modell vi har sammanställt från de teorier om nätverk som vi utgått ifrån.</p><p>Utifrån analysen om Konsensusnätverket är slutsatsen att samarbetet har lett till en förbättring av kvaliteten i behandlingarna. Utifrån detta kan det konstateras att nätverkets existens inte leder till en direkt effektivisering ur ett tidsmässigt perspektiv. Nätverket leder istället till ett optimalt patientomhändertagande som ur ett långsiktigt perspektiv leder till färre felbehandlingar och därmed indirekta kostnadsbesparingar. Slutsatsen vi dragit från Australiensamarbetena är att det främsta utbytet som ges till de medverkande parterna är en förbättrad kvalitet i arbetsförhållandena och därmed även röntgendiagnoserna.</p>

The aim of this doctoral thesis was to study the influence of memory, pain, age and education on the regional cerebral blood flow (rCBF), i.e. brain function, in early Alzheimer's disease (AD) and in chronic neck pain patients in comparison to healthy controls and in healthy elderly per se. This was done by optimizing single photon emission computed tomography (SPECT) as a method to study rCBF with the tracer Technetium-99m (99mTc) hexamethylpropyleneamine oxime (HMPAO) and by matching all image data to a brain atlas before evaluation. The rCBF-SPECT was evaluated and developed to obtain higher diagnostic accuracy in AD and in chronic neck pain patients it was used to study basic pain related cerebral processes in chronic pain of different origin. A new semimanual registration method, based on fiducial marker, suitable for investigations with low spatial resolution was developed. The method was used to reconstruct images with an improved attenuation and scatter correction by using an attenuation-map calculated from the patients' previously acquired CT images. The influence of age and education on rCBF was evaluated with statistical parametric mapping, SPM in healthy elderly. The main findings were age related changes in rCBF in regions close to interlobar and interhemispheric space but not in regions typically affected in early AD, except for the medial temporal lobe. The theory of a 'cognitive reserve' in individuals with a longer education was supported with findings in the lateral temporal lobe, a region related to semantic memory, and in the frontal lobe. A cross-sectional study of chronic neck pain patients showed extensive rCBF changes in coping related regions in a non-traumatic pain patients compared to both healthy and a pain group with a traumatic origin, i.e. whiplash syndrome. The whiplash group displayed no significant differences in rCBF in comparison with the healthy controls. This suggests different pain mechanisms in these groups. The AD-patients showed a significantly lower rCBF in temporoparietal regions including left hippocampus. These changes were associated to episodic memory performance, and especially to face recognition. The diagnostic sensitivity for AD was high. The face recognition test (episodic memory) was used in AD patients to improve the sensitivity of method, i.e. memory-provoked rCBF-SPECT (MP-SPECT). The results were compared to healthy controls and the reductions of rCBF in temporoparietal regions were more pronounced in mild AD during provocation. Memory provocation increased the sensitivity of AD-related rCBF changes at group level. If a higher sensitivity for AD at the individual level is verified in future studies, a single MP-SPECT study might then be of help to set diagnosis earlier. In conclusion rCBF in temporoparietal regions are associated to an impaired episodic memory in early AD. Changes in these regions do not have a strong connection to chronological age. The diagnostic sensitivity of rCBF-SPECT in AD is high and there is a potentially higher sensitivity if memory provoked investigations are used. The findings in this thesis have given an increased knowledge of underlying cerebral pain processing in non-traumatic and traumatic (whiplash) neck pain. Preliminary results supporting the theory of 'cognitive reserve' by showing a correlation between long education and preserved rCBF was found in healthy elderly.

Radionuclide molecular imaging is an emerging multidisciplinary technique that is used in modern medicine to visualise diseases at cellular and molecular levels. This thesis is based on five papers (I-V) and focuses on the development of site-specific radiolabelled recombinant anti-HER2 Affibody molecules and preclinical evaluations in vitro and in vivo of the labelled conjugates. This work is part of a preclinical development of an Affibody molecule-based tracer for molecular imaging of HER2 expressing tumours. Papers I and II report the evaluation of the Affibody molecule ZHER2:2395-C, site-specifically labelled with the radiometals 111In (for SPECT) and 57Co (as a surrogate for 55Co, suitable for PET applications) using a thiol reactive DOTA derivative as a chelator. Both conjugates demonstrated very suitable biodistribution properties, enabling high contrast imaging just a few hours after injection. Papers III and IV report the development and optimization of a technique for site-specific labelling of ZHER2:2395-C with 99mTc using an N3S chelating peptide sequence. 99mTc-ZHER2:2395-C demonstrated high and specific tumour uptake and rapid clearance of non-bound tracer from the blood, resulting in high tumour-to-non-tumour ratios shortly after injection, enabling high contrast imaging. In addition, in the study described in paper IV, freeze-dried kits previously developed for 99mTc-labelling were optimised, resulting in the development of a kit in which all the reagents and protein needed for labelling of ZHER2:2395-C with 99mTc were contained in a single vial. Paper V reports the evaluation of an anti-HER2 Affibody molecule, ABY-025, with a fundamentally re-engineered scaffold. Despite the profound re-engineering, the biodistribution pattern of 111In-ABY-025 was very similar to that of two variants of the parental molecule. It seems reasonable to believe that these results will also be applicable to Affibody molecules towards other targets. Hopefully, this work will also be helpful in the development of other small proteinaceous tracers.

The controlled lowering of core body temperature to 32°C to 34°C is defined as therapeutic hypothermia (TH). Therapeutic hypothermia has been shown to improve neurological outcome and survival in unconscious patients successfully resuscitated after cardiac arrest. Brain temperature is important for cerebral protection therefore methods for primarily cooling the brain have also been explored. This thesis focuses on the likelihood that intranasal cooling can induce, maintain and control cerebral hypothermia. The method uses bilaterally introduced intranasal balloons circulated with cold saline. Selective brain cooling induced with this method was effectively accomplished in pigs with normal circulation while no major disturbances in systemic circulation or physiological variables were recorded. The temperature gradients between brain and body could be maintained for at least six hours. Intranasal balloon catheters were used for therapeutic hypothermia initiation and maintenance during and after successful resuscitation in pigs. Temperature reduction was also obtained by combined intranasal cooling and intravenous ice-cold fluids with possible additional benefits in terms of physiologic stability after cardiac arrest. Rewarming was possible via the intranasal balloons. In these studies brain temperature was recorded invasively by temperature probes inserted in the brain. The fast changes in pig’s brain temperature could also be tracked by a non-invasive method. High-spatial resolution magnetic resonance spectroscopic imaging (MRSI) without internal reference showed a good association with direct invasive temperature monitoring. In addition the mapping of temperature changes during brain cooling was also possible. In awake and unsedated volunteers subjected to intranasal cooling brain temperature changes were followed by two MR techniques. Brain cooling was shown by the previously calibrated high-spatial resolution MRSI and by the phase-mapping method. Intranasal cooling reduced body temperature slightly. The volunteers remained alert during cooling, the physiological parameters stable, and no shivering was reported.

Inom hälso- och sjukvården spelar informationsteknologi en allt större roll för utvecklingen. Informationsteknologin har skapat nya förutsättningar där chansen till förbättrade vårdrutiner finns inom många områden genom att införa och utveckla användandet av telemedicin. Då vi tror att den telemedicinska potentialen kommer att användas i större utsträckning i framtiden känner vi att det finns ett intresse för en utredning av redan existerande samarbeten inom telemedicin. Vi skrev denna uppsats med syftet att undersöka, identifiera och analysera vad som krävs för att möjliggöra ett effektivt telemedicinskt partnerskap inom sjukvården för att förbättra patientens vård, behandling och ta tillvara på de arbetsprocesser som skapas i och med ett telemedicinskt samarbete. Vi har analyserat två olika typer av telemedicinska samarbeten. Vi har genom en kvalitativ undersökning, främst genom intervjuer, grundligt undersökt två av de bestående nätverken för att sedan analysera dessa med hjälp av den modell vi har sammanställt från de teorier om nätverk som vi utgått ifrån. Utifrån analysen om Konsensusnätverket är slutsatsen att samarbetet har lett till en förbättring av kvaliteten i behandlingarna. Utifrån detta kan det konstateras att nätverkets existens inte leder till en direkt effektivisering ur ett tidsmässigt perspektiv. Nätverket leder istället till ett optimalt patientomhändertagande som ur ett långsiktigt perspektiv leder till färre felbehandlingar och därmed indirekta kostnadsbesparingar. Slutsatsen vi dragit från Australiensamarbetena är att det främsta utbytet som ges till de medverkande parterna är en förbättrad kvalitet i arbetsförhållandena och därmed även röntgendiagnoserna.

A few abnormal cells found in a small piece of prostate tissue are most consequential for a man’s future. The prevalence of prostate cancer (PCa) is increasing globally. The main instigating factor for this cancer is not yet known, but it appears to be the consequence of many variables such as an increasingly older population, more frequent PSA-testing, and factors involving lifestyle. Prostate cancer screening, as an equivalent for breast cancer screening, has been suggested but unfortunately there are no accurate diagnostic tools available for this type of screening. The reason for this is simply that the prostate is one of the most difficult organs to diagnose and, consequently, PCa screening would generate far too many false-positive and false-negative results.  The prostate is not easily accessible as it is deeply-seated in the male pelvic area, wrapped around the urethra and surrounded by sensitive vital organs.  Furthermore, PCa is frequently multi-focal, and the cancer cells have a tendency of assimilating among normal cells and, thus, do not always form solid lumps.  Therefore, prostate tumors are often not felt by digital rectal examination (DRE) or identified by imaging.  The PSA-test is not reliable as it is more prostate-specific than cancer-specific.  Due to increasing prostate awareness, more early-stage and locally confined PCa are being detected. This is saving lives, although there is a high risk of over treatment and unnecessary side-effects.  The increased detection of PCa requires sophisticated diagnostic methods and highly skilled clinicians who can discern between indolent and aggressive cancers.  The current “gold-standard” for PCa diagnosis is biopsy grading by pathologists using the Gleason score system, which is a difficult task.  Therefore, innovative methods to improve the precision of prostate diagnosis, by increased biopsy sensitivity and tumor localization, are of essence. In light of these difficulties, the metabolomic approach using 1D and 2D high-resolution magic angle spinning (HRMAS) NMR spectroscopy combined with histopathology on intact prostatectomy specimens was evaluated in this research project.  The non-destructive nature of HRMAS NMR enables spectroscopic analysis of intact tissue samples with consecutive histological examinations under light microscope. Metabolomics aids in the unraveling and the discovery of organ-specific endogenous metabolites that have the potential to be reliable indicators of organ function and viability, extrinsic and intrinsic perturbations, as well as valuable markers for treatment response. The results may, therefore, be applied clinically to characterize an organ by utilizing biomarkers that have the capacity to distinguish between disease and health. The aim was to characterize the human and the rat prostate in terms of its intermediary metabolism, which I show here to differ between species and anatomical regions.  Furthermore, the aim is to seek the verification of HRMAS NMR derived metabolites which are known to be a part of the prostate metabolome such as, citrate, choline, and the polyamines which were performed, but also the identification of metabolites not previously identified as part of the local prostate metabolism, such as Omega-6, which was detected in tumors.  The extended aim was to elucidate novel bio-markers with clinical potential. In this study, the common phyto-nutrient, inositol, which appears to possess protective properties, was identified as being a potentially important PCa bio-marker for the distinction between the more indolent Gleason score 6 and the more aggressive Gleason score 7 in non-malignant prostate tissues with tumors elsewhere in the organ. Further studies in this area of PCa research are therefore warranted.

Cone Beam Computed Tomography (CBCT) är en relativt ny modalitet att användas inom ortopedin till olika typer av skador och användningen håller på att öka. Författarna till denna studien har under skolgången endast i liten omfattning stött på denna modalitet, vilket gjorde att deras intresse för att lära sig mer om den var stort. Syftet med den här studien var att sammanställa vilka fördelar och nackdelar modaliteten har vid frakturutredning i extremiteter. Metoden som användes till den här studien var en allmän litteraturstudie, där fakta samlades in från artiklar i olika databaser och även i kurslitteratur. Kvalitetsgranskningen gjordes av båda författarna enligt ett kvalitetsgranskningsprotokoll som var specialutformat för att passa studien bra.  I analysen sammanställdes informationen från artiklarna och kategoriserades för att göra resultatet mer lättöverskådligt. Resultatet visade på att fler frakturer hittas med hjälp av CBCT:n än vad det görs med konventionell röntgen. Detta gällde särskilt scaphoideum-, karpalbens-, och handledsfrakturer. Den visade sig även vara ett hjälpmedel gällande bedömning av instabil eller stabil fotled efter en viss typ av fotledsfraktur. Magnetisk resonans (MR) visade sig var något bättre än CBCT:n på att detektera scaphoideumfrakturer. Frakturdetekteringsförmågan hos CBCT:n var likvärdig som med den hos Multi Detector Computed Tompography (MDCT). Stråldosen ifrån CBCT:n visade sig vara högre än vid konventionell röntgen, men mindre än stråldosen från MDCT:n. CBCT:n var även billigare att köpa in och underhålla än MDCT:n. CBCT:n visade sig ha en vanlig typ av artefakter, som var beam-hardening artefakter och rörelseartefakter. Författarna till denna studien tror att CBCT:n kan vara ett bra komplement till konventionell röntgen vid olika frakturer i extremiteter, men mer forskning behöver göras då området fortfarande är relativt nytt och informationen är begränsad. / Cone Beam Computed Tomography (CBCT) is a relatively new modality to be used in orthopedic for various types of injuries and the usage is increasing. The authors of this study have only encountered this modality a little bit during school, which meant that their interest in learning more about it was big. The purpose of this study was to compile the advantages and disadvantages of this modality in fracture examination in extremities. The method used for this study was a general literature study, where facts were collected from articles in different databases and also in literature. The quality review was done by both authors according to a quality audit protocol that was tailor-made to suit the study well.  In the analysis, the information was compiled from the articles and categorized to make the result more easy to understand. The result showed that more fractures were found using CBCT than conventional X-ray. This was especially true of scaphoidum, carpal, and wrist fractures. It also proved to be an aid in assessing unstable or stable ankle after a certain type of ankle fracture. Magnetic resonance (MR) proved slightly better than the CBCT to detect scaphoid fractures. The fracture detection capability of the CBCT was similar to that of Multi Detector Computed Tompography (MDCT). The radiation dose from the CBCT was found to be higher than in conventional X-rays, but less than the radiation dose from the MDCT. The CBCT was also cheaper to buy and maintain than the MDCT. The CBCT proved to have a common type of artifacts, such as beam-hardening artifacts and movement artifacts. The authors of this study believe that the CBCT may be a good complement to conventional x-ray in various fractures in extremities, but more research needs to be done as this area is still relatively new and the information is limited.

Inledning: Bröstcancer är en vanlig cancerform hos kvinnor och årligen drabbas 1,5 miljoner kvinnor världen över. Screeningprogram och tidig upptäckt är två faktorer som leder till ökad överlevnad. För kvinnor där en ökad cancerrisk föreligger såsom förhöjd ärftlighet och BRCA-mutation rekommenderar socialstyrelsen att mammografiscreening kompletteras med MR. MR kan komplettera bröstdiagnostik till en mer individanpassad behandling. Syftet: Syftet med denna litteraturstudie var att beskriva hur bröstdiagnostik med magnetkamera (MR) inverkar på den kirurgiska behandlingen av bröstcancer. Metod: En litteraturstudie genomfördes, där 11 kvantitativa artiklar användes för att svara på studiens syfte. Resultat: Preoperativ MR detekterade ytterligare maligna lesioner som inte tidigare var kända vilket medförde en förändrad behandling till mer omfattande kirurgi såsom mastektomi och lumpektomi. MR visade generellt en överskattning av tumörstorlek vid bedömning av tumörutbredning. Utöver den redan diagnostiserade bröstcancern detekterades med MR ytterligare lesioner vilka ej var synliga vid mammografi både i det primära och det kontralaterala bröstet. MR i kombination med biopsi konstaterar maligna lesioner. Slutsats: Fakta tyder på att MR har hög sensitivitet men en lägre specificitet vid detektering av förändringar i bröstvävnaden. Resultatet är ej entydigt och behov finns av ytterligare studier inom ämnet. / Introduction: Breast cancer is a common form of cancer in women, annually, 1.5 million women are affected worldwide. Screening programs and early detection lead to increased survival. In women where there is increased cancer risk with increased heredity and in BRCA mutation, the National Board of Health recommends that mammography screening be supplemented with Magnetic resonance imaging (MRI). MRI can supplement breast diagnosis and can lead to a more personalized treatment. Purpose:The purpose of this literature study was to describe how breast diagnosis with MR affects the surgical treatment of breast cancer. Method: A literature study was conducted, where 11 quantitative articles were used to respond to the purpose of the study.Results: Preoperative MRI detected additional malignant lesions not previously known which resulted in a change in treatment for more extensive surgery such as mastectomy and lumpectomy. MRI generally showed an overestimate of tumor size in the assessment of tumor proliferation. In addition to the already diagnosed breast cancer, MR was detected additional lesions which were not visible in mammography in both the primary and the contralateral breast. MRI in combination with biopsy notes malignant lesions. Conclusion: Facts suggest that MRI has high sensitivity but a lower specificity in detecting changes in the breast tissue. The results are not unambiguous and there is a need for further studies on the subject.

Inledning: Varje år besöker mellan 12 000 och 14 000 kvinnor öppenvården till följd av våld i nära relation. Röntgensjuksköterskan ska arbeta med personcentrerad vård i enlighet med sin kompetensbeskrivning samt implementera ny kunskap för att utvecklas. Utifrån detta ansågs det betydelsefullt att beskriva kunskapsläget inom området bemötande av kvinnor utsatta för våld. Syfte: Syftet var att beskriva vad som är viktigt att ta hänsyn till vid bemötande av kvinnor på röntgen utsatta för våld i nära relation och hur detta kan tillämpas i det korta mötet. Vilken kunskap om bemötandet av kvinnor utsatta för våld i nära relation finns beskriven i litteraturen? Metod: Studien utfördes som en litteraturöversikt med 12 vetenskapliga artiklar som kvalitetsgranskades, analyserades och resultatet presenterades i form av kategorier. Resultat: Sex kategorier som beskriver bemötandet och vad som påverkar hur bemötandet upplevs av kvinnorna. Bemötande, kunskap, attityder, stöd, hinder och att förhålla sig professionell. I resultatet framkommer stora brister i bemötandet av dessa kvinnor, där de hjälpsökande istället skuldbeläggs, vilket ger kvinnorna ytterligare skamkänslor. De utsatta kvinnorna är dessutom rädda att dömas av personalen och skyddar sig från dessa attityder genom att dölja våldet.  Kunskap efterfrågas av både utsatta och personal. Det framkommer attityder bland hälso- och sjukvårdspersonal som lägger skulden på kvinnorna. Kvinnorna efterfrågar stöd och personalen påtalar behovet av rutiner som stöd för att kunna ge ett gott bemötande. Hinder för att kunna bemötas kan vara frågor såsom svårigheter att kunna söka vård eller att mannen för kvinnans talan. Professionellt förhållningssätt visar sig svårgenomfört bland annat på grund av att känslor var svårhanterliga i mötet med kvinnorna. Konklusion: Det är viktigt att röntgenavdelningarna tar fram riktlinjer och rutiner för ett gott bemötande. Kunskap och samtal kring detta bör vara prioriterat för att minska negativa attityder och inspirera till förbättringsarbete som kan utveckla röntgensjuksköterskans profession. / Introduction: Every year between 12,000 and 14,000 women visit health care in relation to intimate partner violence. The radiology nurse ought to work with person centered care in accordance with their competence description and implement new knowledge to develop. Based on this, it was considered important to describe knowledge of encounter with the women. Purpose: The purpose was to describe what to consider when health personnel encounter women exposed to intimate partner violence in the radiology department and how this can be applied in the short meeting. What knowledge is described concerning encounter with the women? Method: The study was conducted as a literature review consisting of 12 scientific articles that were quality reviewed, analyzed and presented. Results: Six categories described the encounter and how the treatment of women was experienced. Encounter, knowledge, attitudes, support, obstacles, and professional conduct. The results revealed major shortcomings in the treatment of these women, when seeking help they were blamed, given a feeling of guilt and shame. The women were also afraid to be valued by the staff and protected themselves by concealing the violence. Knowledge was required by both groups. There were attitudes among healthcare professionals who blamed the women. The women demanded support and the staff wanted routines to support a good encounter. Obstacles to be treated can be issues such as difficulties in seeking care or because of the husband, who speaks for the woman. Professional approaches appeared to be difficult, among other things, since the emotions were difficult to handle in the encounter with the women. Conclusion: It is important for the radiology departments to develop guidelines and procedures to achieve a good encounter. Knowledge and discussions should be prioritized to reduce negative attitudes and inspire improvement work, that can develop the radiology nurse's profession.

Slutna cylinderformade MRT-kameror ger bilder av patienten i liggande position men studier visar att ländryggen beter sig annorlunda under den belastning som en sittande eller stående position innebär. Syfte: Syftet med denna litteraturstudie var att sammanställa kunskap om diagnostik av ländrygg med hjälp av öppen MRT-kamera som tillåter belastade bilder i viktbärande position. Metod: Studien genomfördes som en allmän litteraturstudie, med 16 inkluderade vetenskapliga artiklar. Resultat: Belastning såväl som extension av ländryggen kan påverka flertalet av ländryggens strukturer. Vid belastade bilder upptäcktes fler fall av spinal stenos, spondylolistes, nervkompression och facettcystor. Flertalet studier visade dock på mer smärta vid bildtagning i belastad position. Slutsats: Belastade bilder kan vara mer fördelaktigt än icke-belastade för att upptäcka patologi, samtidigt som extension och flexion är viktiga faktorer anatomiskt vid diagnostisering av ländryggssmärta. / Closed cylindrical MRI cameras provide images of the patient in a supine position, but studies show that the lumbar spine behave differently in a sitting or standing position with axial load. Objective: The purpose of this literature overview was to compile knowledge of lumbar diagnosis using open MRI camera that allows loaded images in weight-bearing positions. Methods: A literature overview including 16 articles. Results: Weight-bearing position as well as extension of the lumbar spine can affect many of the lumbar structures. Weight-bearing position revealed more cases of spinal stenosis, spondylolisthesis, nerve compression and juxtafacet cysts. However, the majority of studies showed imaging in the weight-bearing position to be more painful. Conclusion: Weight-bearing MRI may be more advantageous than non-weight-bearing to detect pathology. Extension and flexion are also important factors in the diagnosis of the lumbar spine.