Incidence, aetiology and injury characteristics of traumatic spinal cord injury in Stockholm, Sweden: a prospective, population-based update

OBJECTIVES: To update the incidence rate, aetiology and injury characteristics of acutely-injured adults with traumatic spinal cord injury in Stockholm, Sweden, using international standards of reporting. Study design: Prospective, (regional) populationbased observation. SUBJECTS: Forty-nine consecutively enrolled individuals. METHODS: A surveillance system of newly-injured adults with traumatic spinal cord injury was implemented for an 18-month period. The International Spinal Cord Injury Core Data Set was used to collect data on those who survived the first 7 days postinjury. RESULTS: After an 18-month period, 49 incident cases were registered, of whom 45 were included in this study. The crude incidence rate was 19.0 per million, consisting mainly of men (60%), and the mean age of the cohort was 55 years (median 58). Causes of injury were almost exclusively limited to falls and transport-related events, accounting for 58% and 40% of cases, respectively. The incidence has remained stable when compared with the previous study; however, significant differences exist for injury aetiology (p = 0.004) and impairment level (p = 0.01) in that more fall- and transport-related spinal cord injury occurred, and a larger proportion of persons was left with resultant tetraplegia, in the current study, compared with more sport-related injuries and those left with paraplegia in the previous study. CONCLUSION: The incidence rate appeared to remain stable in Stockholm, Sweden. However, significant changes in injury aetiology and impairment-level post injury were found, compared with the previous study. There remains a need for developing fall-related prevention strategies in rehabilitation settings as well as in population-based programmes

An open prospective study on the efficacy of Navina Smart, an electronic system for transanal irrigation, in neurogenic bowel dysfunction

Background: Transanal irrigation (TAI) has emerged as a key option when more conservative bowel management does not help spinal cord injured (SCI) individuals with neurogenic bowel dysfunction (NBD). Aim: To investigate the short-term efficacy and safety of an electronic TAI system (Navina Smart) in subjects with NBD. Design: We present an open, prospective efficacy study on Navina Smart, in individuals with NBD secondary to SCI, studied at three months. Population: Eighty-nine consecutive consenting established SCI individuals (61 male; mean age 48, range 18–77) naïve to TAI treatment were recruited from ten centres in seven countries. Subjects had confirmed NBD of at least moderate severity (NBD score ≥10). Methods: Subjects were taught how to use the device at baseline assisted by the Navina Smart app, and treatment was tailored during phone calls until optimal TAI regime was achieved. The NBD score was measured at baseline and at three months follow up (mean 98 days). Safety analysis was performed on the complete population while per protocol (PP) analysis was performed on 52 subjects. Results: PP analysis showed a significant decrease in mean NBD score (17.8 to 10, p<0.00001). In subjects with severe symptoms (defined as NBD score ≥14), mean NBD scores decreased (19.4 to 10.9, p<0.0001). The number of subjects with severe symptoms decreased from 41 (79%) subjects at baseline to 16 (31%) at three months follow-up. Device failure accounted for the commonest cause for loss of data. Side effects possibly related to the device developed in 11 subjects (12%). Discontinuation due to failure of therapy to relieve symptoms was reported by 5 subjects (6%). Conclusion: Navina Smart is effective for individuals with NBD, even those with severe symptoms; long-term data will follow. Whilst there were some device problems (addressed by the later stages of subject recruitment) the treatment was generally safe

An open prospective study on the efficacy of Navina Smart, an electronic system for transanal irrigation, in neurogenic bowel dysfunction

Background: Transanal irrigation (TAI) has emerged as a key option when more conservative bowel management does not help spinal cord injured (SCI) individuals with neurogenic bowel dysfunction (NBD). Aim: To investigate the short-term efficacy and safety of an electronic TAI system (Navina Smart) in subjects with NBD. Design: We present an open, prospective efficacy study on Navina Smart, in individuals with NBD secondary to SCI, studied at three months. Population: Eighty-nine consecutive consenting established SCI individuals (61 male; mean age 48, range 18–77) naïve to TAI treatment were recruited from ten centres in seven countries. Subjects had confirmed NBD of at least moderate severity (NBD score ≥10). Methods: Subjects were taught how to use the device at baseline assisted by the Navina Smart app, and treatment was tailored during phone calls until optimal TAI regime was achieved. The NBD score was measured at baseline and at three months follow up (mean 98 days). Safety analysis was performed on the complete population while per protocol (PP) analysis was performed on 52 subjects. Results: PP analysis showed a significant decrease in mean NBD score (17.8 to 10, p<0.00001). In subjects with severe symptoms (defined as NBD score ≥14), mean NBD scores decreased (19.4 to 10.9, p<0.0001). The number of subjects with severe symptoms decreased from 41 (79%) subjects at baseline to 16 (31%) at three months follow-up. Device failure accounted for the commonest cause for loss of data. Side effects possibly related to the device developed in 11 subjects (12%). Discontinuation due to failure of therapy to relieve symptoms was reported by 5 subjects (6%). Conclusion: Navina Smart is effective for individuals with NBD, even those with severe symptoms; long-term data will follow. Whilst there were some device problems (addressed by the later stages of subject recruitment) the treatment was generally safe

A Multicenter, Randomized, Open-Labeled, Parallel Group Trial of Sildenafil in Alcohol-Associated Erectile Dysfunction: The Impact on Psychosocial Outcomes

To examine the effect of sildenafil on erectile dysfunction (ED) and psychosocial outcomes in alcohol-dependent (AD) men, 108 men with these diagnoses were randomly assigned to either take sildenafil (50 mg) as add-on to standard treatment for AD, or the same treatment without sildenafil, for 12 weeks. Only 50 patients in sildenafil group and 51 in control group twice completed the International Index of Erectile Function (IIEF) and a battery of self-report questionnaires. IIEF scores and psychosocial functioning, self-esteem and support from friends improved only for sildenafil-treated patients (P < 0.001). The high effect sizes suggest that the observed benefits are unlikely to be a placebo effect, although their unspecific nature could not be ruled out. In men with ED associated with AD, sildenafil improves both ED and psychosocial outcomes. Further placebo-controlled clinical trial is warranted

Branschen är rund, men skolan är fyrkantig : En intervjustudie om förusättningar för lärande på yrkesutbildningar med inriktning mot film, tv- och media

Studien undersökte hur förutsättningar för lärande utformas inom ramen för arbetsplatsbaserat lärande inom film-/tv-mediabranschen. Dessa lärandemiljöer som undersöks från utbildningsanordnares perspektiv representerar olika typer svenska yrkesutbildningar vilka gemensamt har som mål att utbilda filmarbetare. På dessa utbildningar inkluderas moment av arbetsplatsbaserat lärande parallellt med utbildningsmoment förlagda på skolan. Studien använde sig av en kvalitativ metodansats och dess material har samlats in genom 8 semistrukturerade intervjuer med utbildningsanordnare. Resultatet har analyserats med hjälp av Wengers (1998) teori om Communities of Practice, perspektiv på formellt och informellt lärande (Malloch, 2010; Schugurensky, 2000; Olofsson, 2017) samt Ellströms (1992) kvalifikations-begrepp. Studiens resultat visar att det finns goda förutsättningar för lärande på arbetsplatsen för branschen i fråga, om tid och resurser finns. Dessa pedagogiska byggstenar som är arbetsplatsbaserat lärande är något som branschen tycker är ovärderliga. Huruvida står branschen inför stora utmaningar att tillsammans med utbildningsväsendet utforma ett anpassat "skoliferat" lärande ute på filminspelningar. Detta när uppfattningar om vad formella och informella utbildningsmoment kan innehålla skiljer sig. Målen med utbildningarna uppnås av en god tidig planering, möjligheter till kontinuerlig kommunikation mellan student, utbildningsanordnare och handledare samt olika former av uppföljningar som en möjlighet till reflektion. Framkommer gör också att de som skall agera handledare för eleverna inte behöver vara några pedagoger och därför finns det en utmaning att hitta tid och engagemang för att tydliggöra handledarnas ansvar och roll i utbildningsleden. Studien tittar på en bransch som är föremål för vidare forskning när det kommer planeringen och innehållet av arbetsplatsbaserat lärande inom yrkesutbildningar. Samt att, det vidare måste kunna finnas en accelererande flexibilitet i att kunna anpassa utbildningsmomentet efter världens syn på lärande parallellt med branschens önskemål

Branschen är rund, men skolan är fyrkantig : En intervjustudie om förusättningar för lärande på yrkesutbildningar med inriktning mot film, tv- och media

Studien undersökte hur förutsättningar för lärande utformas inom ramen för arbetsplatsbaserat lärande inom film-/tv-mediabranschen. Dessa lärandemiljöer som undersöks från utbildningsanordnares perspektiv representerar olika typer svenska yrkesutbildningar vilka gemensamt har som mål att utbilda filmarbetare. På dessa utbildningar inkluderas moment av arbetsplatsbaserat lärande parallellt med utbildningsmoment förlagda på skolan. Studien använde sig av en kvalitativ metodansats och dess material har samlats in genom 8 semistrukturerade intervjuer med utbildningsanordnare. Resultatet har analyserats med hjälp av Wengers (1998) teori om Communities of Practice, perspektiv på formellt och informellt lärande (Malloch, 2010; Schugurensky, 2000; Olofsson, 2017) samt Ellströms (1992) kvalifikations-begrepp. Studiens resultat visar att det finns goda förutsättningar för lärande på arbetsplatsen för branschen i fråga, om tid och resurser finns. Dessa pedagogiska byggstenar som är arbetsplatsbaserat lärande är något som branschen tycker är ovärderliga. Huruvida står branschen inför stora utmaningar att tillsammans med utbildningsväsendet utforma ett anpassat "skoliferat" lärande ute på filminspelningar. Detta när uppfattningar om vad formella och informella utbildningsmoment kan innehålla skiljer sig. Målen med utbildningarna uppnås av en god tidig planering, möjligheter till kontinuerlig kommunikation mellan student, utbildningsanordnare och handledare samt olika former av uppföljningar som en möjlighet till reflektion. Framkommer gör också att de som skall agera handledare för eleverna inte behöver vara några pedagoger och därför finns det en utmaning att hitta tid och engagemang för att tydliggöra handledarnas ansvar och roll i utbildningsleden. Studien tittar på en bransch som är föremål för vidare forskning när det kommer planeringen och innehållet av arbetsplatsbaserat lärande inom yrkesutbildningar. Samt att, det vidare måste kunna finnas en accelererande flexibilitet i att kunna anpassa utbildningsmomentet efter världens syn på lärande parallellt med branschens önskemål

Assisted reproduction technology in men with ejaculatory dysfunction with special reference to spinal cord injury

Background: Men afflicted by spinal cord injury (SCI), myelomcningocele (MMC) and testicular cancer (TC) with retroperitoneal Iymph node dissection (RPLND) share the problem of infertility due mainly, but not exclusively, to neurologic impairment. This problem has historically been neglected, partly due to lack of effective treatment, partly due to lack of appreciation of the importance of sexual and procreational issues for rehabilitation outcomes and quality of life. With the recent significant development of assisted reproduction technology (ART), investigation of the effectiveness of such methods when applied to these patients is of highest relevance in a holistic rehabilitative context. Aims: To evaluate the effectiveness of ART in infertile men with SCI, with particular reference to intracytoplasmic sperm injection (ICSI), and to compare it with previously published results using simpler methods. To evaluate the use of in vitro fertilization (IVF) and ICSI in men with anejaculatory infertility after TC/RPLND. To investigate if spermatogenesis in men with MMC is sufficient for ART. To evaluate the anaesthesiological management of electroejaculation (EEJ) in patients at risk for autonomic dysreflexia (AD). Patients and methods: Twenty-five couples with a SCI man underwent 53 ovum retrievals and 47 embryo transfers. Additionally, four frozen embryo replacements were carried out. (Papers I and III) Ten couples with a TC/RPLND man, with long-standing infertility due to anejaculation or retrograde ejaculation underwent EEJ under general anaesthesia (GA). The anterograde fraction was prepared and used for IVF. Additionally, one frozen embryo replacement was carried out. (Paper II) In nine men with MMC, retrieval of sperm was attempted by unassisted ejaculation, penile vibratory stimulation (PVS), EEJ in GA and/or testicular biopsy. (Paper IV) Thirty anejaculatory SCI men and 15 men with anejaculation due to TC/RPLND underwent 87 EEJ procedures in GA with assisted mask ventilation in a day surgery setting. (Paper V) Results Sixteen clinical pregnancies were established in the couples with a SCI man, leading to 12 deliveries (10 singletons and 2 duplex). Ten of the pregnancies were established after conventional IVF and six after ICSI. Spermatozoa were recovered in nine of ten TC/RPLND men. Sperm quality was variable and conventional IVF was considered impossible in three cases. Altogether six IVF treatment cycles in six couples resulted in five pregnancies, of which four resulted in a delivery and one resulted in a spontaneous abortion. One additional pregnancy was achieved after transfer of cryopreserved embryos. The fenilization rate (FR) was 54% (33/61) and the cleavage rate was 97% (32/33). No complications relating to the procedure was encountered. Two MMC men were able to achieve unassisted ejaculation. PVS was unsuccessful in the remaining seven subjects. In five subjects, EEJ yielded enough sperrn to make ICSI possible. In one case, testicular biopsy revealed spermatogenesis. Thus, in six of nine MMC men, fatherhood seemed possible. All 87 EEJ procedures gave ejaculation of semeo. Six episodes of hypenension occurred, all in subjects with SCI and a lesion at T6 or rostral. These episodes were successfully treated with calcium blockers. No adverse events occurred in the SCI group. Conclusions: A cumulative delivery rate of about 50% can be expected with assisted ejaculation and IVF/ICSI in couples with a SCI man where home insemination has been unsuccessful. IVF/ICSI is the method of choice if home insemination fails, if EEJ in GA is required, if semen quality is poor, or if there are concurrent female infertility factors. A high cumulative delivery rate can also be expected from EEJ and IVF/ICSI in anejaculatory men after TC/RPLND. Since semen retrieval in most instances requires EEJ in GA, IVF/lCSI is the method of choice. A sizeable proportion of men with MMC seems to have enough sperm for ICSI. The risk of severe hypertension and other complications from EEJ of SCI men in GA with assisted mask ventilation in a day surgery setting seems small, provided anaesthesia is managed by experienced staff. Our conclusion is that the safety of this procedure justifies its application in infertility treatment

Smart Grids - Model and Market

The Smart Grid technology has during the last decade been established as a way to create a greater flexibility on the electricity grid that will be needed as the development moves towards an increased share of renewable primary energy sources in the electricity production. One part of the Smart Grid technology is the ability to shift loads in time, to adapt to either price or emissions, known as Demand Response. This project, which was conducted at KTH in collaboration with the consulting corporation Capgemini, examines the economic, environmental and social aspects of the Demand Response technology.   In the project, three household products are used in a model that derives the potential savings in costs and emissions of CO2e. The results show that the actual savings measured in SEK are small, but that the savings measured in percent can be as high as 20 percent. Reduction of CO2e emissions is slightly lower. Furthermore, the study shows that the savings increase as more flexibility is given to the model and as the fluctuations of price increases. A scenario that includes more intermittent electricity production, and end users ready to commit to the technology,  is therefore vital for the success of the Demand Response technology. The results also show that an optimization cannot be done in such way that both minimize costs and CO2e emissions simultaneously.   A discussion on the strategic opportunities for Capgemini shows that focus should be on collecting, interpreting and compiling the large amounts of data that the technology will result in. There are also possibilities in peripheral services tied together with the Smart Grid technology, such as the development of a charging infrastructure for electric cars.Tekniken kring smarta elnät har under det senaste decenniet blivit etablerad som ett sätt att skapa en större flexibilitet på elnätet, vilket kommer att behövas allt eftersom utvecklingen går mot mer förnybara primärenergikällor i elproduktionen. En del av tekniken är förmågan att flytta laster i tid, för att anpassa sig till antingen pris eller utsläpp, vilket kallas efterfrågeflexibilitet. Detta projekt, som genomförts vid KTH i samarbete med konsultföretaget Capgemini, undersöker de ekonomiska, miljömässiga och sociala aspekterna av efterfrågeflexibilitet.   I projektet används tre hushållsprodukter i en modell som beräknar potentiella kostnadsbesparingar och möjliga reduktioner av CO2e-utsläpp. Resultaten visar att de faktiska besparingarna mätta i kronor är små, men att den procentuella besparingen kan vara så hög som 20 procent. Reduktionen av CO2e-utsläppen är något lägre. Dessutom visar studien att besparingarna ökar då modellen ges en större flexibilitet samt då fluktuationerna i elpriset ökar. Ett scenario som innefattar mer intermittent elproduktion och slutanvändare som är beredda att anamma tekniken är därför avgörande för efterfrågeflexibilitetens framgång. Resultaten visar också att en optimering inte kan göras på ett sätt som både minimerar kostnader och CO2e-utsläpp samtidigt.   En diskussion om de strategiska möjligheterna för Capgemini visar att fokus bör ligga på att samla in, tolka och sammanställa de stora mängder data tekniken kommer att medföra. Det finns också möjligheter i kringtjänster tätt sammankopplade med smarta elnät, såsom utveckling av en laddningsinfrastruktur för elbilar

The Stockholm spinal cord injury study 1. Medical problems in a regional SCI population

Out of a regional traumatic spinal cord injury population consisting of 379 individuals, 353 (93.1%) participated in the present study. Subjects were individually interviewed using semi-structured protocols. In addition, previous medical records were available for over 96% of subjects, and were used in all these cases to minimise recall bias. Cause of injury, prevalence of present medical symptoms and occurrence of medical complications in the post-acute, post-discharge phase were recorded. Neurological classification was verified by physical examination according to ASIA/IMSOP standards. Many subjects had experienced complications since discharge from initial hospitalisation, especially urinary tract infections, decubitus ulcers, urolithiasis, and neurological deterioration. Prevalence of medical symptoms was also high. More than 41% of subjects with spastic paralysis reported excessive spasticity to be associated with additional functional impairment and/or pain. Almost two-thirds of subjects reported significant pain, with a predominance of neurogenic-type pain. Bladder and bowel dysfunction were each rated by nearly 41% of subjects as a moderate to severe life problem. As expected, sexual dysfunction was also commonly reported. Prevalence of reported symptoms by general systems review was high, particularly fatigue, constipation, ankle oedema, joint and muscle problems, and disturbed sleep. However, lack of adequate normative data precludes comparison with the general population. The frequent occurrence of reported medical problems and complications support advocacy of comprehensive, life-long care for SCI patients. The commonly reported problems of neurogenic pain and neurological deterioration, in particular, require more attention, as these symptoms are not seldom ominous, either by virtue of their impact on quality of life, or because of underlying pathology