Swedish Centres Research Articles

P003 SUMMER TRIAL: MESH VERSUS SUTURE REPAIR IN SMALL UMBILICAL HERNIAS IN ADULTS: A STUDY PROTOCOL FOR A PROSPECTIVE, RANDOMIZED, DOUBLE-BLIND, MULTICENTER CLINICAL TRIAL

Abstract Aim A gold standard procedure for small umbilical hernia repairs is still lacking today. There is an increasing evidence that mesh could be advantageous in lowering recurrence rates. A question remains with regard to optimal anatomical positioning of the mesh. We hypothesize that the use of an onlay-mesh can reduce recurrence rates without increasing complications compared to a simple-suture repair. Material and Methods A prospective, national, multicenter, randomized, double-blind clinical trial comparing a standardized 4x4 cm onlay mesh to a conventional suture repair will be conducted. 288 patients with a primary elective umbilical hernia ≤ 2 cm from 7 participating Swedish surgical centers will be enrolled. Intraoperative randomization will take place. Trial participants and follow-up clinical surgeons will be blinded to the assigned allocation. The primary outcome assessed will be postoperative recurrence at 1 and 3 years. Secondary outcomes assessed will be postoperative complications at 30 days and pain 1 year after surgery. Results 140 participants are included since February 2020 and 95 participants are randomized. Conclusions How to best repair a small umbilical hernia continues to be debated. A small onlay-mesh may become an easy and a safe method of choice to reduce recurrence rates in small umbilical hernia defects. This trial design should allow for a good assessment of differences in recurrence rate with due to the large sample size and the adequate follow-up. Guidelines for small umbilical hernia repairs have stressed the need for reliable data to improve treatment recommendations. We can expect that this trial will have a direct implication on small umbilical hernia repair standards.

P036 IMPACT OF THE COVID-19 PANDEMIC ON HERNIA SURGERY IN A SWEDISH HEALTH-CARE REGION WITHOUT LOCKDOWN: A RETROSPECTIVE COHORT STUDY

AimDuring the COVID-19 pandemic, Swedish health care centers were restructured. This was accompanied by changes in the surgical programme. The aim of this study was to determine the effects of COVID-19 on emergency and elective hernia surgeries in a Swedish health-care region.Material and MethodsThis was a retrospective, observational cohort study. Data from inguinal and ventral hernia surgeries were retrieved from a medical database using procedure codes from all three hospitals in Region Jönköping County from March 1, 2019 to January 31, 2021. The participants were divided into two groups: COVID-19 group (March 1, 2020 - January 31, 2021) and reference group (March 1, 2019 - January 31, 2020). The incidence rate (IR) and relative risk (RR) of operations over different time frames were analyzed.ResultsA total 1351 participants met the inclusion criteria. 590 were operated during the COVID-19 period and 761 during the reference period. The IR of elective operations was decreased during the COVID-19 pandemic; 146 operations/100.000 population vs 192 operations/100.000 population during the reference period. RR was 0,76 (95% CI 0.6813-0.8545, p < 0.0001). Moreover, IR of emergency operations decreased insignificantly during the COVID-19 pandemic; 17,5 operations/100.000 population vs 19,4 operations/100.000 population during the reference period. RR was 0,9 (95% CI 0.6404- 1.2649, p 0.5441). No significant variations in the emergency operations have identified when different time frames were compared.ConclusionsThere is no evidence to support that COVID-19 pandemic has increased emergency hernia operations during the studied period despite the significant reduction of elective operations.

Outcomes of prolonged intensive care and rehabilitation at a specialized multidisciplinary center in Sweden.

Specialized clinics may improve the outcome for patients with prolonged intensive care stays. Admission may depend on diagnosis, need of respiratory support and more. We report the results from a Swedish specialized center with a multidisciplinary team approach to continued intensive care and simultaneous rehabilitation regardless of patients' primary diagnosis or ventilator need. All patients admitted and discharged from 2015 to 2018 were included. Demographics, diagnoses, ventilatory support requirement, discharge destination and survival were retrieved from the center´s quality registry. A total of 181 patients, mean age 61±16years, 64% men, were analyzed. A neurological diagnosis was the cause for hospitalization in 46% of patients. Of the 55 patients admitted to the center for weaning from mechanical ventilation, 89% were successfully weaned within a median of 25 (interquartile range (IQR) 16-45) days. Decannulation was intended in 117 patients of which 90% were successful within a median of 25 (IQR 13-43) days. Readmission to intensive care was 4%. Most patients were discharged to their home or to rehabilitation clinics with a lower level of care. In-clinic mortality was 3%. Survival beyond 1 and 2years after discharge was 79% and 70%, respectively. Patients with prolonged intensive care and complex medical needs treated at a specialized center in Sweden had weaning and decannulation rates comparable to or better than previously reported. Mortality was low, and most patients were discharged home or for further rehabilitation. This was achieved with a multidisciplinary team approach to continued intensive care and simultaneous rehabilitation.

A prospective multicenter study of visual response-evaluation by cystoscopy in patients undergoing neoadjuvant chemotherapy for muscle invasive urinary bladder cancer

Purpose To evaluate a method of transurethral visual response-staging in patients with urothelial muscle-invasive urinary bladder cancer (MIBC), undergoing neoadjuvant chemotherapy (NAC) and radical cystectomy (RC). Methods A prospective study at four Swedish cystectomy centers, cystoscopy was performed after final NAC-cycle for MIBC. Fifty-six participants underwent cystoscopy for visual staging of the tumor immediately pre-RC. Visual assessments were correlated to pathoanatomical outcomes post-RC. Results Seventeen tumors were classified as complete response (CR), i.e. pT0. Twenty-five patients had residual MIBC and 14 had non-muscle invasive residual tumors (NMIBC). Of the 39 patients with residual tumor, 25 were correctly identified visually (64%). Eleven patients were pN+. The diagnostic accuracy of cystoscopy to correctly identify complete response or remaining tumor was 70% (CI = 56–81%) with a sensitivity of 64% (CI = 47–79%), specificity 82% (CI = 57–96%), PPV 89% (CI = 74–96%) and NPV 50% (CI =38–61%). Twenty-eight cystoscopy evaluations showed signs of residual tumors and 3/28 (11%) were false positive. In 4/14 patients assessed having residual NMIBC the estimates were correct, 8/14 had histopathological MIBC and 2/14 had CR. In 11/14 patients (79%), the suggested visual assessment of MIBC was correct, 2/14 had NMIBC and 1/14 had CR. Twenty-eight cystoscopies had negative findings, 14 were false negatives (50%), when cystoscopy falsely predicted pT0. Among them there were eight patients with pTa, pT1 or pTis and six MIBC-tumors. In 17 patients with histopathological pT0, 14 were correctly identified with cystoscopy (82%). Conclusion Cystoscopy after the final NAC-cycle cannot robustly differentiate between NAC-responders and non-responders. Visually, negative MIBC-status cannot be determined safely.

Respiratory management for extremely premature infants born at 22 to 23 weeks of gestation in proactive centers in Sweden, Japan, and USA

Survival of preterm newborn infants have increased steadily since the introduction of surfactant treatment and antenatal steroids. In the absence of randomized controlled trials on ventilatory strategies in extremely preterm infants, we present ventilatory strategies applied during the initial phase and the continued ventilatory care as applied in three centers with proactive prenatal and postnatal management and well documented good outcomes in terms of mortality and morbidity in this cohort of infants.

The proactive approach to mother-infant dyads at 22-24 weeks of gestation: Perspectives from a Swedish center

The care of infants born at the lowest extreme of gestation requires dedication, skill, and experience. Most centers apply a selective approach where intensive care at these gestational ages is being offered to a varying proportion of infants depending on the views and experiences of the medical community, the individual physician, and the parents. Consequently, the outcomes differ dramatically with survival rates at 22-23 weeks ranging from 0 to greater than 50%. This paper presents the approach in a center with a long tradition of providing a comprehensive and uniformly active care to all mother-infant dyads from 22+0 weeks of gestation. Important features outlined include prenatal maternal referral and transfer, delivery room management, and initial intensive care.

Validity and reliability of the Swedish Functional Health Literacy scale and the Swedish Communicative and Critical Health Literacy scale in patients undergoing bariatric surgery in Sweden: a prospective psychometric evaluation study

ObjectivesThe aim was to psychometrically test and evaluate the Swedish functional health literacy scale and the Swedish communicative and critical health literacy scale in patients undergoing bariatric surgery.DesignA prospective cross-sectional...

Biosignatures to Optimize Adjuvant Radiation Therapy Use in Patients With DCIS With High Risk Clinicopathologic Features

There is an unmet need to identify women diagnosed with DCIS who have a low recurrence risk and could omit radiotherapy (RT) after breast conserving surgery (BCS), or an elevated recurrence risk after treatment with BCS plus RT.Pathology, clinical data, and FFPE tissue samples were evaluable for 485 women treated for DCIS with BCS with negative margins, with or without whole breast RT, at centers in Sweden, US and Australia. A subset with large tumor size (> 2.5 cm) &/or nuclear grade III DCIS was assessed (n = 250). A validated biosignature (Prelude, Laguna Hills CA) and a novel response subtype biosignature to RT after BCS were determined using protein biomarkers (p16/INK4A, Ki-67, COX-2, PgR, HER2, FOXA1, SIAH2) assayed on FFPE tissue. The two biosignatures classified women into three risk groups: Low risk, Elevated risk with a good response subtype (Rst) and Elevated risk with a poor Rst to RT after BCS. Ipsilateral breast tumor recurrence (IBTR) included DCIS or Invasive Breast Cancer (IBC) that was local, regional, or metastatic. Hazard ratios and 10-year risks were calculated using Cox proportional hazards and Kaplan-Meier analyses.Of 250 women with nuclear grade III DCIS and/or size > 2.5 cm, biosignatures classified 72% (n = 179) of patients into an Elevated risk group consisting of those with a good (n = 122) or a poor (n = 57) response subtype (Rst) to RT after BCS. The remaining 28% of women were classified into a low-risk group (n = 71). In the low-risk group (n = 71), women treated without RT had good 10-year outcomes with no (0%) 10-year IBC events, and derived no significant RT benefit (1%) in 10-year IBTR rates (IBTR P = 0.81). Of all women treated without RT (n = 102), those in the elevated risk group (good and poor Rst combined, n = 61) had significantly worse 10-year IBTR/IBC rates (31%/17%) than those in the low-risk group, (IBTR HR = 12, P = 0.01). Women treated with RT in the elevated risk group with a good Rst (n = 77) had significantly reduced 10-year IBTR/IBC rates of 5%/3%. However, no significant benefit to RT was noted for women within the elevated risk group with a poor Rst (n = 41) who had 10-year IBTR/IBC rates of 25%/20%. Of all women treated with RT in the elevated risk group (n = 118), those with a poor Rst had significantly worse outcomes than those with a good Rst (IBTR HR = 4.1, P = 0.035, IBC HR = 8, P = 0.053).In women with nuclear grade III DCIS &/or size > 2.5 cm, DCISionRT combined with a novel response subtype biosignature (Rst) identified an elevated risk group with two distinct subtypes of women: (1) a poor Rst that had high IBTR/IBC rates with or without RT and (2) a good Rst deriving significant benefit from adjuvant RT. Women in the corresponding low risk group had low 10-year IBTR/IBC rates and derived no significant benefit from adjuvant RT.

Scapular osseous free flap in head and neck reconstruction: An assessment of the postoperative function of the donor site

The scapular osseous free flap (SOFF) has become an important reconstructive option for complex head and neck defects. Postoperative donor site function is, however, an important consideration. The objective of this study was to prospectively investigate SOFF donor site morbidity and to relate the findings to hand dominance and neck dissection.Objective assessment included bilateral measurement of shoulder, elbow, and hand range of motion (ROM), hand strength, and distal nerve function in consecutive patients with head and neck cancer SOFF reconstruction at a tertiary referral center in Sweden between 2016 and 2019. The subjective function was assessed by the Disability of the Arm, Shoulder and Hand (DASH) questionnaire.Sixteen of 20 consecutive patients were evaluated (median follow-up 10 months [range 3-17]). Significant side differences in shoulder range of motion (ROM) (flexion, abduction, external and internal rotation) were observed for patients where the SOFF had been harvested from the same side as their dominant hand (n = 9; Ps ≤ 0.04). For patients where the SOFF was harvested from the non-dominant hand side, no significant shoulder ROM side differences were observed (n = 7; Ps ≥ 0.08). There were significant side differences in shoulder ROM for patients who underwent neck dissections (n = 12; Ps ≤ 0.03), not for the other four patients. Patients reported low but varying DASH scores (median 2.5, range 0-57).Postoperative donor site morbidity seems to be quite acceptable after SOFF surgery. The results indicate possible benefits of choosing the non-dominant hand side for the SOFF and that a neck dissection affects postoperative shoulder outcome. Further studies are however needed.

Deep Femoral Vein Reconstruction for Abdominal Aortic Graft Infections is Associated with Low Aneurysm Related Mortality and a High Rate of Permanent Discontinuation of Antimicrobial Treatment

Aortic prosthesis infection is a devastating complication of aortic surgery. In situ reconstruction with the neo-aorto-iliac system (NAIS) bypass technique has become increasingly used and is recommended in recent treatment guidelines. The main aim was to evaluate NAIS procedural outcomes when undertaken after previous open or endovascular aortic repair in Sweden. In this retrospective study, The National Quality Registry for Vascular Surgery (Swedvasc) was used to identify Swedish centres that offered the NAIS bypass procedure for aortic prosthesis infection between 2008 and 2018. Variables of special interest were procedural details, short and long term survival, renal and other complications, and the durtion of antimicrobial treatment. Forty patients (36 males, four females [mean age 69 years], 32 open repairs, seven endovascular aortic repairs [EVAR] and one fenestrated EVAR; 21 presented with aorto-enteric fistula) operated on with NAIS bypass were reviewed. The median time from the primary aortic intervention to the NAIS bypass procedure was 32 months (range 0 - 252 months). Mean ± standard deviation operating time was 645 ± 160 minutes, mean blood loss was 6 277 ± 6 525 mL, mean length of intensive care unit stay was 5.3 ± 3.7 days, and mean length of overall hospital stay was 21.2 ± 11.4 days. Thirty-five patients (88%) had a positive microbial culture; the most commonly isolated pathogen was Candida spp. The majority of patients survived for 30 days (n= 35 [88%]), and 33 (83%) and 32 (80%) patients survived for 90 days and one year, respectively. The number of surviving patients free from antimicrobial treatment at 90 days, six months, and one year was 19 (58%), 29 (88%), and 30 (94%). After a mean long term follow up of 69.9 ± 44.7 months, 20 patients were still alive. The NAIS bypass procedure offered reasonable survival and functional outcomes, and was associated with a high cure rate, defined as freedom from any antimicrobial treatment.

Patient empowerment: a way to improve the communication between young persons and healthcare providers

Abstract Background Through patient empowerment, it is possible to support persons with congenital heart disease (CHD) be autonomous, become actively involved in care and gain higher knowledge about their condition, treatment and/or lifestyle recommendations. Conceptual models suggest that patient empowerment is associated with other patient-reported outcomes (PROs). However, available evidence has not concluded whether patient empowerment is leading to improvements in other PROs or viceversa. Purpose The present study aimed to examine the direction of effects between patient empowerment and PROs in young persons with CHD. Methods As part of the STEPSTONES-CHD trial, adolescents with CHD from seven pediatric cardiology centers in Sweden were included in a longitudinal observational study (n=132). Data were collected when patients were 16 (T0) and 17 years old (T1). The Gothenburg Young Persons Empowerment Scale (GYPES) was used to measure patient empowerment on a scale from 15–75, which higher scores denoting a higher level of patient empowerment. Cross-lagged analyses between patient empowerment and PROs were undertaken. These analyses provide information related to the predominant direction of effects over time by comparing standardized betas. The model includes three types of relations, within time relations, which are the correlations between patient empowerment and variable X at T0 and T1. Autoregressive relations, which represent the prediction of patient empowerment or variable X at T1 by their respective value at T0. Cross-lagged is the last type of relation and it is the prediction of variable X at T1 by patient empowerment at T0 or the prediction of patient empowerment at T1 by variable X at T0. The model was replicated four times and the PROs included in the analyses were quality of life (linear analog scale), patient-reported sale (PedsQL generic 4.0), communicating with the healthcare provider (PedsQL cardiac 4.0) and transition readiness (RTQ). Results The sample comprised of 60.6% (n=80) boys. Overall, 13.2% (n=17) had a mild CHD, 62.0% (n=80) a moderate CHD and 24.8% (n=32) a complex CHD. The mean empowerment score was 52.6 (±10.7) at T0 and 53.2 (±11.7) at T1. We found a significant cross-lagged effect between patient empowerment and communication skills (β=0.28), signifying that a higher level of patient empowerment predicted a higher level of communication skills (see Figure 1). No other cross-lagged relationships were found. Conclusions Clinicians interested in improving the communication skills of their patients, may consider whether they can achieve this by targeting patient empowerment. Patient empowerment gives patients the tools they need in order to feel comfortable asking questions and expressing their needs in the care process. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Swedish Heart-Lung Foundation;Swedish Research Council for Health Working Life andWelfare;Swedish Children Heart Association;Swedish Research Council

Organizational and patient-level predictors for reaching key risk factor targets in cardiac rehabilitation after myocardial infarction – the perfect-CR study

Abstract Background The benefits of specific cardiac rehabilitation (CR) programme components on patient outcomes after myocardial infarction (MI) remain unclear, as does their relative predictive strength compared to patient-level predictors. Purpose To identify CR organizational and patient-level predictors for reaching risk factor targets at one-year post-MI. Methods This was an observational survey- and registry-based study. Data on CR organization at all 78 CR centres in Sweden was collected in 2016 and merged with individual patient data from nationwide registries (n=7549, median age 64 years, 24% females). Cross-validation resampled orthogonal partial least squares discriminant analysis identified predictors for reaching treatment targets for low-density lipoprotein-cholesterol (LDL-C&amp;lt;1.8 mmol/L), blood pressure (BP&amp;lt;140/90 mmHg) and smoking abstinence (yes/no). Predictors with Variables of Importance for the Projection (VIP) value &amp;gt;0.8 and 95% confidence intervals (CI) excluding zero, were considered meaningful. Results Of the 71 analysed organizational variables, 36 were identified as meaningful predictors for reaching LDL-C and 35 for BP targets (Figure 1). The strongest predictors (VIP [95% CI]) for LDL-C and BP were: offering psychosocial management at initial CR assessment 2.09 [1.70–2.49]; 2.34 [1.90–2.78], having a CR team psychologist 1.59 [1.28–1.91]; 2.00 [1.46–2.55], having extended CR centre opening hours 2.17 [1.95–2.40]; 1.51 [1.03–2.00], staff reporting satisfaction with CR centre facilities 1.55 [1.07–2.04]; 1.96 [1.64–2.28], having a medical director 1.71 [1.45–1.97]; 1.47 [1.07–1.87], nurses using protocols for antihypertensive and/or lipid lowering medication adjustment 1.58 [1.35–1.81]; 1.56 [1.03–2.08], having operational team meetings 1.36 [1.08–1.64]; 1.34 [0.99–1.70], and using audit data for quality improvement 1.00 [0.79–1.20]; 1.27 [0.99–1.56]. Offering pre-exercise-based CR (exCR) assessment and different modes of exCR were predictors for reaching both targets. The strongest patient-level predictor of reaching LDL-C target was low baseline LDL-C 3.90 [3.25–4.56], and for BP it was having no history of hypertension 2.93 [2.74–3.12]. Second, participation in exCR was the strongest predictor for both outcomes 1.60 [0.83–2.37]; 1.50 [1.15–1.86]. For smoking abstinence, 5 organizational variables were identified as meaningful predictors, the strongest being prescription of varenicline by the centre physicians 1.98 [0.13–3.84] (Figure 2). The strongest patient-level predictors were exCR participation 2.51 [2.24–2.79] and socioeconomic status variables e.g., income 1.67 [1.28–2.06], living with partner 1.47 [0.84–2.09] and education 0.80 [0.48–1.12]. Conclusion The study identified multiple CR organizational and patient-level predictors for reaching key risk factor targets one-year post-MI. The results might contribute to defining the optimal composition of comprehensive CR programmes. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): 1) The Swedish Research Council for Health, Working Life and Welfare (FORTE)2) The Swedish Heart and Lung Foundation (Hjärt Lung Fonden)

Improving smoking cessation after myocardial infarction by systematically implementing evidence-based treatment methods: a prospective observational cohort study

Abstract Background For smokers who suffer a myocardial infarction (MI), smoking cessation is the most effective measure to reduce recurrent event risk. Still, evidence-based treatment methods for aiding smoking cessation post-MI are underused. Purpose To compare the odds of smoking cessation at two-months post-MI before and after implementing a set of pre-specified routines for optimization of evidence-based treatment methods for smoking cessation, with start during admission. Methods Structured routines for early smoking cessation counselling and treatment optimization were implemented at six cardiac rehabilitation (CR) centres in Sweden. The routines included CR nurses providing current smokers hospitalized for acute MI with short consultation, written material, and optimal dosage of nicotine replacement therapy during admission, increasing early prescription of varenicline for eligible patients, and contacting the patients by telephone 3–5 days after discharge, after which usual care CR follow-up commenced. Centres were also encouraged to strive for continuity in nurse-patient care. Patient data was retrieved from the SWEDEHEART registry and medical records. Using logistic regression, we compared the odds for smoking cessation at two-months post-MI for currently smoking patients admitted with MI (a) before (n=188, median age 60 years, 23% females) and (b) after (n=195, median age 60 years, 29% females) routine implementation. Secondary outcomes included adherence to implemented routines and the association of each routine with smoking cessation odds at two-months. Results In total, 159 (85%) and 179 (92%) of enrolled patients attended the two-month CR follow-up, before and after implementation of the new routines. After implementation, a significantly larger proportion of patients (65% vs 54%) were abstinent from smoking at two-months (crude OR 1.60 [1.04–2.48], p=0.034) (Figure 1). Including only those counselled during admission (n=89), 74% (vs 54%) were abstinent at two-months (crude OR 2.50 [1.42–4.41], p=0.002). After the new routine implementation patients were counselled more frequently during admission (50% vs 6%, p&amp;lt;0.001), prescribed varenicline at discharge or during follow-up (23% vs 7%, p&amp;lt;0.001), and contacted by telephone during the first week post-discharge (18% vs 2%, p&amp;lt;0.001), compared to before implementation. Crude and adjusted associations between each routine and smoking cessation at two-months are shown in Table 1. Entering all routines into the regression model simultaneously, being prescribed varenicline before discharge or during follow-up had the strongest independent association with smoking abstinence at two-months (adjusted OR 4.09 [1.68–10.00], p=0.002). Conclusion Our results support that readily available methods for aiding smoking cessation can be implemented effectively in routine practice, with possible beneficial effects on smoking cessation for the high-risk group of smoking MI patients. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): The Swedish Heart and Lung AssociationPfizer AB

Preferences for Gender Affirming Treatment and Associated Factors Among Transgender People in Sweden

IntroductionGender affirming surgery of primary and/or secondary sex characteristics has been shown to alleviate gender dysphoria. A descriptive snapshot of current treatment preferences is useful to understand the needs of the transgender population seeking health care. This study aimed to describe preferences for gender affirming treatment, and their correlates, among individuals seeking health care for gender dysphoria in Sweden after major national legislative reforms.MethodsCross-sectional study where transgender patients (n = 232) recruited from all six Gender Dysphoria centers in Sweden 2016–2019, answered a survey on treatment preferences and sociodemographic, health, and gender identity-related information during the same time-period. Factors associated with preferring top surgery (breast augmentation or mastectomy), genital surgery, and other surgery (e.g., facial surgery) were examined in univariable and multivariable regression analyses in the 197 people without prior such treatment. Main study outcomes were preferences for feminizing or masculinizing hormonal and surgical gender affirming treatment.ResultsThe proportion among birth assigned male and assigned female patients preferring top surgery was 55.6% and 88.7%, genital surgery 88.9% and 65.7%, and other surgery (e.g., facial surgery) 85.6% and 22.5%, respectively. Almost all participants (99.1%) wanted or had already received hormonal treatment and most (96.7%) wished for some kind of surgical treatment; 55.0% wanted both top and genital surgery. Preferring a binary pronoun (he/she) and factors indicating more severe gender incongruence were associated with a greater wish for surgical treatment. Participants with somatic comorbidities were less likely to want genital surgery, while aF with lacking social support were less likely to want internal genital surgery, in the multivariable analyses.ConclusionsIn this sample of Swedish young adults seeking health care for gender dysphoria, preferences for treatment options varied according to perceived gender identity.Policy ImplicationsThe study findings underline the need for individualized care and flexible gender affirming treatment options. The role of somatic comorbidities should be further explored, and support should be offered to transgender people in need. There is an unmet need for facial surgery among aM.

Exploring the meaning, role and experiences of a patient-led social innovation for people affected by cancer: a new collaborative care model complementing traditional cancer rehabilitation in Sweden

ObjectiveKraftens Hus is the first support centre in Sweden designed by and for people affected by cancer, including patients, family, friends, staff members and local community representatives (collectively ‘stakeholders’). The...

Effects of Fluoxetine on Outcomes at 12 Months After Acute Stroke: Results From EFFECTS, a Randomized Controlled Trial.

The EFFECTS (Efficacy of Fluoxetine—a Randomised Controlled Trial in Stroke) recently reported that 20 mg fluoxetine once daily for 6 months after acute stroke did not improve functional outcome but reduced depression and increased fractures and hyponatremia at 6 months. The purpose of this predefined secondary analysis was to identify if any effects of fluoxetine were maintained or delayed over 12 months. EFFECTS was an investigator-led, randomized, placebo-controlled, double-blind, parallel group trial in Sweden that enrolled adult patients with stroke. Patients were randomized to 20 mg oral fluoxetine or matching placebo for 6 months and followed for another 6 months. The primary outcome was functional outcome (modified Rankin Scale), at 6 months. Predefined secondary outcomes for these analyses included the modified Rankin Scale, health status, quality of life, fatigue, mood, and depression at 12 months. One thousand five hundred patients were recruited from 35 centers in Sweden between 2014 and 2019; 750 were allocated fluoxetine and 750 placebo. At 12 months, modified Rankin Scale data were available in 715 (95%) patients allocated fluoxetine and 712 (95%) placebo. The distribution of modified Rankin Scale categories was similar in the 2 groups (adjusted common odds ratio, 0.92 [95% CI, 0.76–1.10]). Patients allocated fluoxetine scored worse on memory with a median value of 89 (interquartile range, 75–100) versus 93 (interquartile range, 82–100); P=0.0021 and communication 93 (interquartile range, 82–100) versus 96 (interquartile range, 86–100); P=0.024 domains of the Stroke Impact Scale compared with placebo. There were no other differences in secondary outcomes. Fluoxetine after acute stroke had no effect on functional outcome at 12 months. Patients allocated fluoxetine scored worse on memory and communication on the Stroke Impact Scale compared with placebo, but this is likely to be due to chance. URL: https://www.clinicaltrials.gov; Unique identifier: NCT02683213.

Crime Victims, Immigrants And Social Welfare: Creating The Racialized Other In Sweden

AbstractThis study explores the role of immigration and racialization in creating the first Swedish victim support centre in the early 1980s. The study is based on a qualitative content analysis of the archives of Victim Support Södertälje, the first lasting Swedish victim support centre, from 1983 to 1990. While many of the centre’s activities focused on crime prevention, it defined crime and victimization as the province of immigrant communities in Södertälje, and, notably, as outside—and aberrant from—the imagined racial community of Sweden. Thus, victim support centres were one of the mechanisms to continue to defend the ideals of the Swedish welfare state, but to do so in ways that prevented incursions within Swedish racial homogeneity from the outside.

Meaningful recognition: An imperative for nurse manager well-being.

Meaningful recognition: An imperative for nurse manager well-being.

Onlay mesh repair for treatment of small umbilical hernias ≤ 2 cm in adults: a single-centre investigation

PurposePrevious studies on the repair of small umbilical hernias have suggested a lower recurrence rate with mesh compared to suture repair. An important question is in what anatomical position the mesh should be placed. The purpose of this study was to investigate the outcome of using a standardized 4 × 4 cm onlay-mesh for umbilical hernias ≤ 2 cm.MethodsA retrospective study was conducted at a single centre in Sweden on all umbilical hernia repairs during 2015–2019. The follow-up time was at least four months. Patients were identified using the hospital medical database. Repairs performed with suture or a sublay, ventral patch and laparoscopic mesh positioning were excluded. The patient’s demographics, comorbidities, intra—and post-operative details were considered. The primary outcome was surgical site complications within 30 days. The secondary outcome was a recurrence.Results80 patients were repaired with a small onlay-mesh for an umbilical hernia ≤ 2 cm. The median (range) follow-up time was 29.0 (4.3–50.1) months. The median age was 46 (26–76) years old. The median body mass index was 28 (19–38) kg/m2. The male to female ratio was 2:1. 4 patients were identified with a surgical site post-operative complication; three with seromas and one with a superficial wound infection. 3 of these were given antibiotics. 2 patients were treated with wound openings bedside. There were no registered cases of recurrence.ConclusionsRepairing small umbilical hernias with a small onlay-mesh was safe with a low surgical site complication rate. Randomized trials are needed to assess whether mesh can reduce recurrences in umbilical hernia repairs ≤ 2 cm.

Control computerized tomography in neoadjuvant chemotherapy for muscle invasive urinary bladder cancer has no value for treatment decisions and low correlation with nodal status

Background Control computerized tomography (cCT) is routinely used in many cystectomy centres before the final treatment cycle in patients with muscle-invasive urinary bladder cancer (MIBC) undergoing neoadjuvant chemotherapy (NAC). This is for evaluating response or nonresponse to NAC treatment. In a real-world retrospective cohort, we intended to evaluate the frequency of changed individual treatment strategies following cCT and to investigate any discrepancies between cCT-results on nodal staging and final pN-stages. Methods We performed a retrospective data-based, multicenter study of 242 MIBC-patients, staged cT2N0M0-cT4aN0M0, having undergone NAC and radical cystectomy (RC) between 2008 and 2019 at four Swedish cystectomy centres. Statistical analysis was performed using IBM SPSS statistics 26. Results Overall, 139/242 patients were examined with cCT. Six patients were staged as progressive at cCT and 5/139 (3.6%) underwent a change of previously planned treatment strategy. 2/6 patients with suspected progression (33%) did not change strategy and underwent all preplanned NAC-cycles plus RC. Only 1/6 patients assigned as progressive at the cCT, showed progression in the postoperative pathology specimen. In total 133/139 patients were considered being without progress on cCT, yet 28/133 (21%) presented with nodal progression at postoperative pathology examinations. Only 1/29 patients with histopathologically verified nodal dissemination were detected with cCT, thus 28/29 (96.6%) with pN + were undetected. The sensitivity for cCT to predict pTNM was 17% CI [0%–64%] and the specificity was 78% CI [71%–86%]. Conclusions CCT prior to the final treatment cycle of NAC in MIBC, leads to a low percentage of treatment strategy changes and cCT cannot accurately predict pN-status.