Swedish National Quality Register Research Articles

One-year recovery from breast cancer: Importance of tumor and treatment-related factors, resilience, and sociodemographic factors for health-related quality of life.

AimThis study investigated the changes in health-related quality of life from diagnosis to 1 year after diagnosis in breast cancer (BC) patients and the influence of clinical, psychological, and sociodemographic variables. An additional aim was to explore the mediating and moderating effects of resilience on changes in health-related quality of life.MethodsA longitudinal population-based study was conducted in southern Sweden. Newly diagnosed BC patients filled in measures of health-related quality of life, resilience, and sociodemographic variables at diagnosis (N = 980) and 1 year post-diagnosis (N = 780). Clinical variables were extracted from the Swedish national breast cancer quality registry. Mixed-model analyses were performed.ResultsMost health-related quality of life outcomes declined from diagnosis to 1 year post-diagnosis. Role limitations due to emotional problems remained the same, whereas mental health improved. Lower health-related quality of life outcomes were associated with symptomatic detection and axillary dissection. Patients with a higher TNM stage and histologic grade and estrogen receptor (ER)-negative and human epidermal growth factor 2 (HER2)-positive status, who received chemotherapy, antibody therapy, or bisphosphonate therapy, had a steeper decline in outcomes. Changes in resilience were positively associated with all outcomes but did not mediate or moderate changes in any. Resilience at baseline moderated changes in bodily pain, vitality, and mental health, with higher baseline resilience being associated with a steeper decline, possibly due to floor or ceiling effects. Patients with lower socioeconomic status, educational level, and older age had a lower health-related quality of life.ConclusionPhysical health-related quality of life among breast cancer patients declined 1 year post-diagnosis, whereas mental health-related quality of life improved. Low resilient patients may be especially vulnerable at diagnosis. Biopsychosocial assessment at diagnosis can help identify patients who may require additional support. A multidimensional treatment plan should be started early to help overcome the problems in everyday activities.

A registry study of oral health problems and preventive interventions among older persons receiving municipal healthcare - PROSENIOR.

The aim was to identify planned and completed preventive interventions among older persons with oral health problems receiving municipal health care. A further aim was to determine the correspondence between oral health problems and planned preventive interventions among older persons with oral health problems receiving municipal health care. Cross-sectional register study. Oral health data from the Swedish national quality registry, Senior Alert, were extracted for 4,024 older persons (≥65 years) receiving municipal health care in a county in Southern Sweden. Data were statistically analysed. A large majority of older persons (97.4%) with assessed oral health problems had at least one planned preventive intervention, and approximately three quarters of the planned interventions were completed. There seemed to be a mismatch between type of oral health problems and preventive interventions as not all older persons had a planned preventive intervention related to their specific oral health problem.

The influence of pregnancy, parity, and mode of delivery on urinary incontinence and prolapse surgery—a national register study

The long-term effects of vaginal delivery, parity, and pregnancy on the pelvic floor remain uncertain and controversial issues. In comparison with studies using self-reported symptoms, surgical register data may offer a more valid means for evaluating the relative influence of these risk factors. This study used data from 3 high-quality nationwide registers, namely the Swedish National Quality Register of Gynecological Surgery, the Swedish Medical Birth Register, and the Total Population Register, to evaluate the contribution of vaginal and cesarean delivery, parity, and factors not related to childbirth to the long-term risk for reconstructive urogenital surgery. This was a register-based linkage study among women aged ≥45 years who underwent urinary incontinence or prolapse surgery from 2010 to 2017. This surgical cohort was divided into nulliparous women, women with ≥1 cesarean deliveries only, those with ≥1 vaginal deliveries, and according to the number of births. A corresponding reference group was constructed based on women born in 1960 from the Total Population Register (n=2,309,765). The Swedish Medical Birth Register was used to determine the rate of women with cesarean and vaginal delivery and their respective parity. Absolute and relative risk were presented per 1000 women with 95% confidence intervals. Pairwise differences were analyzed with Fisher exact tests and the Mann-Whitney U test for dichotomous and continuous variables. The trend between ≥3 ordered categories of dichotomous variables was analyzed with Mantel-Haenszel statistics. A total of 39,617 women underwent prolapse surgery and 20,488 underwent incontinence surgery. Among women with prolapse surgery, 97.8% had ≥1 vaginal delivery, 0.4% had ≥1 cesarean delivery only, and 1.9% were nullipara. Corresponding figures for those with incontinence surgery were 93.1%, 2.6%, and 4.3%, respectively. Women with vaginal deliveries were overrepresented in the prolapse surgery (relative risk, 1.23; 95% confidence interval, 1.22-1.24; P<.001) and incontinence surgery groups (relative risk, 1.17; 95% confidence interval, 1.15-1.19; P<.001). Nulliparous and cesarean delivered women were underrepresented in the prolapse surgery (relative risk, 0.14; 95% confidence interval, 0.13-0.15 and relative risk 0.055; 95% confidence interval, 0.046-0.065; all P<.001) and incontinence surgery groups (relative risk, 0.31; 95% confidence interval, 0.29-0.33 and relative risk, 0.40; 95% confidence interval, 0.36-0.43). The absolute risk for prolapse surgery was lowest after cesarean delivery (0.09 per 1000 women; 95% confidence interval, 0.08-0.11) and differed by a factor of 23 (absolute risk, 2.11 per 1000 women; 95% confidence interval, 2.09-2.13) from that after vaginal birth. The absolute risk for prolapse and incontinence surgery increased consistently with parity after vaginal births. This trend was not observed after cesarean delivery, which is on par with that of nulliparous women. The first vaginal birth contributed the highest increase in the absolute risk for pelvic organ prolapse surgery (6-fold) and stress urinary incontinence surgery (3-fold). The second vaginal birth contributed the lowest increase in the absolute risk for pelvic organ prolapse surgery (∼1/3 of the first vaginal birth) and for stress urinary incontinence surgery (∼1/10 of the first vaginal birth). Surgery for urinary incontinence and prolapse was almost exclusively related to vaginal parity. The risk for prolapse surgery increased consistently with parity after vaginal births but not after cesarean delivery, whereas the risk associated with cesarean delivery was on par with that of nulliparous women. Thus, cesarean delivery seems to offer protection from the need for pelvic organ prolapse and stress urinary incontinence surgery later in life.

Swefoot – The Swedish national quality register for foot and ankle surgery

BackgroundPopulation-based register data could be used to improve our knowledge of patients surgically treated for foot and ankle disorders. The quality register Swefoot was recently created to collect surgical and patient-reported data of foot and ankle surgery. This manuscript aims to describe the development and current use of the register. MethodsThe development of Swefoot started in 2014 and currently, data on 16 different diagnoses are collected in 49 units performing foot and ankle surgery. Registrations are performed by the surgeon and the patient. ResultsBetween 2014 and 2020 approximately 20,000 surgical procedures have been registered. 75.1% of the registered patients were women, 9.3% were smokers, 9.3% had a concomitant rheumatoid disease, and 18.4% a BMI larger than 30 kg/m2. ConclusionsThe Swefoot is a unique national register for foot and ankle surgery. It is by now possible to present demographic, surgical, and outcome parameters based on Swefoot.

Cold sensitivity and its association to functional disability following a major nerve trunk injury in the upper extremity-A national registry-based study.

AimsTo investigate self-reported cold sensitivity and functional disability after a repaired major nerve trunk injury in the upper extremity.MethodsWe identified 735 individuals with a major nerve trunk injury in the upper extremity, surgically treated with direct nerve repair or reconstructed with nerve autografts, in the Swedish national quality registry for hand surgery (HAKIR). Patient-reported symptoms, including cold sensitivity, and perceived disability were collected using two questionnaires (HQ-8 and QuickDASH) preoperatively, and at three and 12 months postoperatively.ResultsWe included 281 individuals, who had responded the questionnaires, where 197 (70%) were men (median age 34 [interquartile range 25–52] years) and 84 (30%) were women (median age 41 [25–55]). Cold sensitivity (scored 0–100) was the most prominent symptom 12 months postoperatively after an injured and repaired/reconstructed median (p<0.001) or ulnar (p<0.001) nerve, while individuals with a radial nerve injury showed milder symptoms. Concomitant injuries did not affect cold sensitivity scores. Individuals with ulnar nerve injuries scored higher in stiffness (p = 0.019), weakness (p<0.001) and ability to perform daily activities (p = 0.003) at 12 months postoperatively than median nerve injuries. Individuals with a median, ulnar or radial nerve injury with severe (>70) cold sensitivity had 25, 37 and 30 points higher QuickDASH scores, respectively (p<0.001), at 12 months postoperatively than individuals with mild (<30) cold sensitivity. There were no differences in QuickDASH score or cold sensitivity score at 12 months postoperatively between direct nerve repair or nerve reconstruction with nerve autografts. Neither age, nor sex, affected QuickDASH score at 12 months postoperatively.ConclusionCold sensitivity after surgery for a major nerve trunk injury in the upper extremity can be substantial with impaired ability to perform daily activities, where an ulnar nerve injury may have a worse outcome.

Association of Clinical and Demographic Characteristics With Response to Electroconvulsive Therapy in Mania

Knowledge of the effectiveness of electroconvulsive therapy (ECT) in the treatment of manic episodes is based on clinical experience, but empirical evidence is scarce. Moreover, prognostic factors associated with response to ECT in patients with mania are poorly understood. To investigate the response to ECT in patients with manic episodes. This nationwide, register-based observational cohort study was conducted using data from patients admitted to psychiatric departments in Sweden that reported data to the Swedish National Quality Registry for ECT (Q-ECT). Patients admitted to any hospital in Sweden and receiving ECT for a manic episode between 2012 and 2019 were considered for inclusion (605 individuals). The outcome, Clinical Global Impression Improvement scale (CGI-I) score, was available in 571 patients. Data from several national registers were combined to determine clinical and sociodemographic factors. Analysis of data occurred from April through September 2021. Patients treated with ECT for a mania were identified from the Q-ECT. Response to ECT was defined by a CGI-I score of 1 (very much improved) or 2 (much improved). Remission was defined as a Clinical Global Impression Severity scale (CGI-S) score of 1 (reference range or not ill) or 2 (minimally ill) within 1 week after ECT. Univariate and multivariable regression models were used to investigate associations of sociodemographic factors, psychopharmacology, and comorbidities with response. Among 571 patients with mania treated with ECT (211 [37.0%] men; median [IQR] age, 46 [31-59] years), 482 patients (84.4%) responded to ECT. Comorbid anxiety and obsessive-compulsive disorder (OCD) were associated with lower odds of response to ECT (adjusted odds ratio [aOR], 0.48; 95% CI, 0.25-0.90 and aOR, 0.17; 95% CI, 0.06-0.56, respectively). Patients who were markedly ill (aOR, 2.93; 95% CI, 1.23-7.00), severely ill (aOR, 2.60; 95% CI, 1.06-6.34), or among the most extremely ill (aOR, 7.94; 95% CI, 2.16-29.21) according to CGI-S score had higher odds of response than those with mild or moderate illness. This study found that ECT was associated with improvement for mania in clinical settings, with especially high response rates in patients with severe illness and those without comorbid anxiety or OCD.

Long-term incidence of endometrial cancer after endometrial resection and ablation: A population based Swedish gynecologic cancer group (SweGCG) study.

Minimally invasive methods to reduce menorrhagia were introduced in the 1980s and 1990s. Transcervical endometrial resection (TCRE) and endometrial ablation (EA) are two of the most frequently used methods. As none of them can guarantee a complete removal of the endometrium, there are concerns that the remaining endometrium may develop to endometrial cancer (EC) later in life. The primary aim was to analyze the long-term incidence of EC after TCRE and EA in a nationwide population. The secondary aim was to assess the two treatment modalities separately. The Swedish National Patient Registry and National Quality Registry for Gynecological Surgery were used for identification of women who had TCRE or EA performed between 1997-2017. The cohort was followed from the first TCRE or EA until hysterectomy, diagnosis of EC, or death. Follow-up data were retrieved from the National Cancer Registry and the National Death Registry. Expected incidence for EC in Swedish women was calculated using Swedish data retrieved from the NORDCAN project after having taken into account differences of age and follow-up time. Cumulative incidence of EC after TCRE and EA, was calculated. A standardized incidence ratio was calculated based on the expected and observed incidence, stratified by age and year of diagnosis. In total, 17 296 women (mean age 45.1 years) underwent TCRE (n=8626) or EA (n=8670). Excluded were 3121 who had a hysterectomy for benign causes during follow up. During a median follow-up time of 7.1 years (interquartile range 3.1-13.3 years) the numbers of EC were 25 (0.3%) after TCRE and 2 (0.02%) after EA, respectively. The observed incidence was significantly lower than expected (population-based estimate) after EA but not after TCRE, giving a standardized incidence ratio of 0.13 (95% confidence interval [CI] 0.03-0.53) after EA and 1.27 (95% CI 0.86-1.88) after TCRE. Median times to EC were 3.0 and 8.3 years after TCRE and EA, respectively. There was a significant reduction of EC after EA, suggesting a protective effect, whereas endometrial resection showed an incidence within the expected rate.

Pneumococcal urinary antigen testing for antimicrobial guidance in community-acquired pneumonia–A register-based cohort study

ObjectivesTo evaluate the effect of pneumococcal urinary antigen test (UAT) usage on broad-spectrum antibiotic treatment in community-acquired pneumonia (CAP). MethodsPatients admitted to 32 Swedish hospitals between 2011 and 2014 were retrospectively included from the Swedish National Quality Register of CAP. Using propensity score matched data, stratified by CRB-65 score, we studied the effect of performing UAT and of positive test results on treatment with broad-spectrum β-lactam monotherapy (BSBM) and antibiotics with coverage for atypical bacteria compared to narrow-spectrum β-lactam monotherapy (NSBM). ResultsUAT was performed for 4,995/14,590 (34.2%) patients, 603/4,995 (12.1%) of whom had positive test results. At day three, performing UAT was not associated with decreased use of BSBM (OR 1.07, 95% CI 0.94–1.23) but was associated with increased atypical coverage among patients with CRB-65 score 2 (OR 1.47, 95% CI 1.06–2.02). A positive UAT was associated with decreased BSBM use (OR 0.39, 95% CI 0.25–0.60) and decreased atypical coverage (OR 0.25, 95% CI 0.16–0.37), predominantly in non-severe CAP. At day one, performing UAT was associated with atypical coverage among patients with CRB-65 scores 2 (OR 2.60, 95% CI 1.69–3.98) and 3–4 (OR 3.69, 95% CI 1.55–8.79), and a positive test reduced the odds of BSBM treatment among CRB-65 score 3–4 patients (OR 3.49, 95% CI 1.02–12.0). ConclusionsPerforming UAT had no overall effect on decreasing the use of BSBM treatment by day three of hospitalization, yet non-severely ill patients with positive UAT results were less likely to be treated with BSBM and antibiotics with atypical coverage.

Improving lithium dose prediction using population pharmacokinetics and pharmacogenomics: a cohort genome-wide association study in Sweden

Lithium is the most effective treatment for bipolar disorder, resulting in strong suicide prevention effects. The therapeutic range of lithium, however, is narrow and treatment initiation requires individual titration to address inter-individual variability. We aimed to improve lithium dose prediction using clinical and genomic data. We performed a population pharmacokinetic study followed by a genome-wide association study (GWAS), including two clinical Swedish cohorts. Participants in cohort 1 were from specialised outpatient clinics at Huddinge Hospital, in Stockholm, Sweden, and participants in cohort 2 were identified using the Swedish National Quality Registry for Bipolar disorder (BipoläR). Patients who received a lithium dose corresponding to at least one tablet of lithium sulphate (6 mmol) per day and had clinically relevant plasma concentrations of lithium were included in the study. Data on age, sex, bodyweight, height, creatinine concentration, estimated glomerular filtration rate (eGFR), lithium preparation, number of tablets of lithium per day, serum lithium concentration, and medications affecting kidney function (C09 antihypertensives, C03 [except C03D] sodium-retaining diuretics, and non-steroidal anti-inflammatory drugs) were obtained retrospectively for several timepoints when possible from electronic health records, BipoläR, and the Swedish prescription registry. The median time between timepoints was 1·07 years for cohort 1 and 1·09 years for cohort 2. The primary outcome of interest was the natural logarithm of total body clearance for lithium (CLLi) associated with the clinical variables. The residual effects after accounting for age and sex, representing the individual-level effects (CLLi,age/sex), were used as the dependent variable in a GWAS. 2357 patients who were administered lithium (1423 women [60·4%] and 934 men [39·6%]; mean age 53·6 years [range 17-89], mainly of European descent) were included and 5627 data points were obtained. Age (variance explained [R2]: R2cohort1=0·41 and R2cohort2=0·31; both p<0·0001), sex (R2cohort1=0·0063 [p=0·045] and R2cohort2=0·026 [p<0·0001]), eGFR (R2cohort1=0·38 and R2cohort2=0·20; both p<0·0001), comedication with diuretics (R2cohort1=0·0058 [p=0·014] and R2cohort2=0·0026 [p<0·0001]), and agents acting on the renin-aldosterone-angiotensin system (R2cohort1=0·028 and R2cohort2=0·015; both p<0·0001) were clinical predictors of CLLi. Notably, an association between CLLi and serum lithium was observed, with a lower CLLi being associated with higher serum lithium (R2cohort1=0·13 and R2cohort2=0·15; both p<0·0001). In a GWAS of CLLi,age/sex, one locus was associated with a change in CLLi (rs583503; β=-0·053 [95% CI -0·071 to -0·034]; p<0·00000005). We also found enrichment of the associations with genes expressed in the medulla (p=0·0014, corrected FDR=0·04) and cortex of the kidney (p=0·0015, corrected FDR=0·04), as well as associations with polygenic risk scores for eGFR (p value threshold: 0·05, p=0·01), body-mass index (p value threshold: 0·05, p=0·00025), and blood urea nitrogen (p value threshold: 0·001, p=0·00043). The model based on six clinical predictors explained 61·4% of the variance in CLLi in cohort 1 and 49·8% in cohort 2. Adding genetic markers did not lead to major improvement of the models: within the subsample of genotyped individuals, the variance explained only increased from 59·32% to 59·36% in cohort 1 and from 49·21% to 50·03% in cohort 2 when including rs583503 and the four first principal components. Our model predictors could be used clinically to better guide lithium dosage, shortening the time to reach therapeutic concentrations, thus improving care. Identification of the first genomic locus and PRS to be associated with CLLi introduces the opportunity of individualised medicine in lithium treatment. Stanley Medical Research Institute, Swedish Research Council, Swedish Foundation for Strategic Research, Swedish Brain Foundation, Swedish Research Council, Söderström-Königska Foundation, Bror Gadelius Minnesfond, Swedish Mental Health Fund, Karolinska Institutet and Hospital.

Surgically Treated Carpal Tunnel Syndrome and Ulnar Nerve Entrapment at the Elbow in Different Occupations and their Effect on Surgical Outcome.

We investigated whether certain occupations were over-represented among surgically treated carpal tunnel syndrome and ulnar entrapment at the elbow, and if manual occupation affected surgical outcome. We included 9030 patients operated for CTS and 1269 for UNE registered in the Swedish National Quality Register for Hand Surgery (HAKIR) 2010-2016. Occupational data was retrieved from Statistics Sweden. Outcome was assessed using the QuickDASH questionnaire. In patients operated for CTS, there were more assistant nurses, attendants/care providers/personal assistants, nannies/student assistants, carpenters/bricklayers/construction workers, cleaners, nurses, and vehicle mechanics than in the general population. In the UNE population, assistant nurses and attendants/care providers/personal assistants were over-represented. Manual workers with CTS scored the preoperative QuickDASH higher than non-manual workers. Manual workers are overrepresented among surgically treated CTS and UNE. Manual workers with CTS have more symptoms preoperatively than non-manual workers.

MO758: Warfarin Treatment Quality and Outcomes in Patients with Non-Valvular Atrial Fibrillation and Chronic Kidney Disease Including Patients on Dialysis

Abstract BACKGROUND AND AIMS Warfarin has traditionally been the drug of choice for patients with atrial fibrillation and GFR &amp;lt; 30 mL/min. Observational studies have shown a lower risk of ischemic stroke with warfarin compared with no treatment, but also an increased risk of bleeding [1]. For patients on dialysis, the role of warfarin is less clear due to high bleeding risk and diverging data on stroke protection [2, 3]. Warfarin treatment quality can be calculated as time in therapeutic range (TTR). TTR ≥ 70% is considered lowering the risk of adverse events [4]. The impact of a patient’s individual TTR (iTTR) on ischemic stroke and bleeding is poorly investigated for patients with eGFR &amp;lt; 60 mL/min/1.73 m2 including patients on dialysis, and the aim is to study this further. METHOD A Swedish retrospective national cohort study investigating the risk of ischemic stroke and major bleeding in patients with non-valvular atrial fibrillation (NVAF) during warfarin treatment depending on iTTR (individual time in therapeutic range). Patients included have warfarin treated NVAF, eGFR &amp;lt; 60 mL/min or on dialysis, kidney transplant recipients excluded, between 2009 and 2018. Data extracted from Swedish high quality national health-care registries including Swedish Renal Registry for GFR-category, The Stroke Register for stroke-related outcomes and Auricula—the Swedish national quality register for AF and anticoagulation for warfarin treatment periods and INR measurements. ITTR is calculated in a 90-day Window and updated at each new INR value. The impact of iTTR is tested with the Cox regression and time-dependent covariates regarding risk for ischemic stroke, major bleeding (intracranial, gastrointestinal and other) and all-cause mortality. RESULTS At enrolment of 2421 patients (29.1% female) 22.1% had G3 (eGFR 59–30 mL/min/1.73 m2) 47.4% G4 (eGFR 15–29), 10.9% G5 (eGFR &amp;lt; 15) and 19.7% G5D (on dialysis). Mean iTTR for all patients was 64% (G3 71%, G4 66%, G5 61% and G5D 55%). The number of events, time on warfarin and event rates are found in Table 1. Adjusted analysis shows that a 0.2 unit increase of iTTR lowers the risk of major bleeding for all patients, patients in G3–G5 and patients on dialysis (G5D) {hazard ratio 0.69 [95% confidence interval (95% CI) 0.61–0.78], 0.65 (0.55–0.77) and 0.78 (0.62–1.0)} (Fig. 1). Increased iTTR by 0.2 units does not seem to have a significant effect on the hazard of ischemic stroke for all patients, G3–G5 and G5D [HR 0.72 (95% CI 0.51–1.00), 0.77 (0.49–1.19) and 0.70 (0.36–1.37)]. An ITTR increase of 0.2 units lowers the risk of all-cause mortality for all patients, G3–G5 and G5D [0.62 (0.55–0.69), 0.56 (0.48–0.65) and 0.75 (0.62–0.9)]. ITTR &amp;gt; 70% compared with &amp;lt;70% lowers the risk of major bleeding and all-cause mortality in all patients [HR 0.63 (0.52, 0.76) and HR 0.52 (0.44, 0.61) but no significant effect on ischemic stroke (HR 0.61 (0.37, 1.01)]. CONCLUSION Warfarin treatment quality worsens with decreasing GFR. Higher iTTR confers a lower risk of major bleeding and death for patients with NVAF and CKD, eGFR &amp;lt; 60 including dialysis. Conclusions cannot be made regarding the effect of iTTR and ischemic stroke due to few events. Patients with NVAF and chronic kidney disease including patients on dialysis on warfarin should be closely monitored to lower the bleeding risk.

Evidence-based digital support during 1 year after an Interdisciplinary Pain Rehabilitation Programme for persons with chronic musculoskeletal pain to facilitate a sustainable return to work: a study protocol for a registry-based multicentre randomised controlled trial

IntroductionChronic musculoskeletal pain (CMSP) severely affects the individual’s quality of life, functioning and ability to work, and comes with significant societal costs for sick leave and productivity loss. After rehabilitation,...

Trapeziectomy with or without a tendon-based adjunct: a registry-based study of 650 thumbs.

This study aimed to assess the outcomes after simple trapeziectomy and trapeziectomy with ligament reconstruction and/or tendon interposition based on data in the Swedish national healthcare quality registry for hand surgery (HAKIR). Six-hundred and fifty thumbs were included, and 265 were assessed up to 12months after operation. There was significant and clinically relevant improvement in patient-reported measures (pain on load, pain on motion without load, pain at rest, stiffness, weakness, and ability to perform activities of daily living and the Quick Disabilities of the Arm, Shoulder and Hand score) and objective measures (strength and thumb mobility) at 3 and 12months for all procedures. The use of the abductor pollicis longus tendon had better improvement in some respects compared with the use of flexor carpi radialis or extensor carpi radialis tendons. However, overall, the use of a tendon adjuncts yielded no better outcomes than simple trapeziectomy.Level of evidence: III.

Cold sensitivity, functional disability and predicting factors after a repaired digital nerve injury

To investigate self-reported cold sensitivity and functional disability after a repaired digital nerve injury. We identified 3204 individuals operated with digital nerve repair in the Swedish national quality registry for hand surgery (HAKIR). Patient-reported symptoms, including cold sensitivity and perceived disability, were examined using two questionnaires (HQ-8 and QuickDASH), three and 12 months postoperatively. Patients with diabetes (n = 48; 3%) were identified in the Swedish National Diabetes Register (NDR). Cold sensitivity (scored 0–100) was the most prominent symptom among 1553 included individuals (998 men, 555 women; median age 41 [IQR 27–54] years). In the regression analysis, flexor tendon injury, hand fracture and injury to multiple structures predicted worsened cold sensitivity (6.9, 15.5 and 25.0 points; p = 0.005, 0.046 and < 0.001) at 12 months. Individuals with moderate (30–70) and severe (> 70) cold sensitivity had higher QuickDASH scores at three and 12 months postoperatively than individuals with mild cold sensitivity (6.0 and 5.5; 19.8 and 21.0 points; p = 0.001). Flexor tendon injury, injuries to multiple structures and diabetes had significant effect on QuickDASH scores at three, but not at 12, months postoperatively. Cold sensitivity is common after a digital nerve repair and impacts self-reported disability. A concomitant injury, particularly multiple injuries, predicts postoperative cold sensitivity.

Long-term outcome after routine surgery for pelvic organ prolapse—A national register-based cohort study

Introduction and hypothesisPelvic organ prolapse (POP) is common, and women have an estimated 12–19% lifetime risk for needing POP surgery. Aims were to measure re-operation rates up to 10 years after POP surgery and patient-reported outcomes (PROMs) 5 years after a first-time operation for POP.MethodsThis is a cohort study using the Swedish National Quality Register for Gynaecological Surgery (GynOp). We retrieved information from 32,086 POP-operated women up to 10 years later. After validation, a web-based PROM questionnaire was sent to 4380 women who 5 years previously had standard POP surgery. Main outcome measures were reoperations due to a relapse of prolapse and PROMs 5 years after the primary operation.ResultsAmong women operated for all types of POP, 11% had re-operations 5 years later and an additional 4% 10 years later, with similar frequencies for various compartments/types of surgery. PROMs yielded a 75% response rate after 5 years. Cure rate was 68% for anterior, 70% for posterior, and 74% for combined anterior-posterior native repairs. Patient satisfaction exceeded 70%, and symptom reduction was still significant after 5 years (p < 0.0001).ConclusionsFollowing primary prolapse surgery, re-operation rates are low, even after 10 years. A web-based survey for follow-up of PROMs after POP surgery is feasible and yields a high response rate after 5 years. The subjective cure rate after primary POP operations is high, with reduced symptoms and satisfied patients regardless of compartment. Standard prolapse surgery with native tissue repair produces satisfactory long-term results.

Suicidal ideation and ECT, ECT and suicidal ideation: A register study.

ObjectiveAlthough electroconvulsive therapy (ECT) is anti‐suicidal, it is not known whether the presence of suicidal ideation (SI) at baseline predicts response and remission after ECT. The aim of the study was to analyze the impact of baseline SI on response and remission following ECT treatment in a large sample of patients with depression and to assess SI before and after ECT.MethodsThis population‐based register study used data from the Swedish National Quality Register for ECT and the Swedish Patient Register. Patients aged 18 years or older who had received ECT for a unipolar or bipolar depressive episode between 2011 and 2018 were included in the study. SI was defined as a score of ≥4 on the last item of the Montgomery–Åsberg Depression Rating Scale – Self Assessment (MADRS‐S). Using a logistic regression model, SI at baseline was used to predict response and remission following ECT, while controlling for depression severity, psychotic symptoms, presence of a comorbid personality disorder, age, sex, electrode position, unipolar or bipolar disorder, and number of previous suicide attempts at baseline.ResultsIn patients who exhibited SI at baseline, 53.7% (N = 632) of cases showed a response to ECT, whereas 68.4% (N = 690) of patients without SI showed a response. In addition, 27.2% (N = 320) of cases with SI achieved remission, whereas 48.5% (N = 489) of cases without SI achieved remission. The odds of achieving response and remission for patients with SI were 0.75 and 0.58 times, respectively, those for patients without SI. Of the 1178 patients with pre‐treatment SI, 75.64% (N = 891) exhibited no SI at the end of treatment. Moreover, in this subgroup, the presence of a personality disorder, higher MADRS‐S‐score, and younger age were associated with persistent SI.ConclusionThe presence of SI was associated with lower ECT response and remission rates. Nevertheless, depressive symptoms and SI were reduced in a large proportion of patients across both patient groups. Clinicians should be aware of the lower likelihood of achieving a successful outcome following ECT in younger patients who present with a non‐psychotic depressive episode, SI, and (suspected) personality disorders. More research is warranted regarding if these patients can achieve similar or better results with other treatments.

Preoperative Electrophysiology in Patients With Ulnar Nerve Entrapment at the Elbow-Prediction of Surgical Outcome and Influence of Age, Sex and Diabetes.

The impact of preoperative electrophysiology on outcome of surgical treatment in ulnar nerve entrapment at the elbow (UNE) is not clarified. Our aim was to evaluate influence of preoperative electrophysiologic grading on outcome and analyse how age, sex, and in particular diabetes affect such grading. Electrophysiologic protocols for 406 UNE cases, surgically treated at two hand surgery units reporting to the Swedish National Quality Register for Hand Surgery (HAKIR; 2010-2016), were retrospectively assessed, and graded as normal, reduced conduction velocity, conduction block or axonal degeneration. Outcome of surgery after primary and revision surgery was evaluated using QuickDASH and a doctor reported outcome measure (DROM) grading. No differences in QuickDASH or DROM were found between the four groups with different electrophysiologic grading preoperatively, or at three and 12 months or at follow up, respectively. When dichotomizing the electrophysiologic grading into normal and pathologic electrophysiology, cases with normal electrophysiology had worse QuickDASH than cases with pathologic electrophysiology preoperatively (p=0.046). Presence of a conduction block or axonal degeneration indicated a worse outcome by DROM grading (p=0.011). Primary surgeries had electrophysiologic more pronounced nerve pathology compared to revision surgeries (p=0.017). Cases of older age, men, and those with diabetes had more severe electrophysiologic nerve affection (p<0.0001). In the linear regression analysis, increasing age (unstandardized B=0.03, 95% CI 0.02-0.04; p<0.0001) and presence of diabetes (unstandardized B=0.60, 95% CI 0.25-0.95; p=0.001) were associated with a higher risk of a worse electrophysiologic classification. Female sex was associated with a better electrophysiologic grading (unstandardized B=-0.51, 95% CI -0.75- -0.27; p<0.0001). We conclude that older age, male sex, and concomitant diabetes are associated with more severe preoperative electrophysiologic nerve affection. Preoperative electrophysiologic grade of ulnar nerve affection may influence surgical outcome.

Vaginal vault prolapse and recurrent surgery: A nationwide observational cohort study.

In surgical repair of pelvic organ prolapse the recurrence rate is about 30% and the importance of apical support was recently highlighted. In surgical randomized controlled studies, the external validity can be compromised because the surgical outcomes often depend on surgical volume. Therefore, we sought to study outcomes of surgical treatment in patients with vaginal vault prolapse in a nationwide setting with a variety of surgical volumes. This is a nationwide cohort study. All patients with a vaginal vault prolapse undergoing surgery, between January 1, 2015 and December 31, 2018, were identified from the Swedish National Quality Register of Gynecological Surgery, GynOp. The primary outcome was the frequency of recurrent pelvic organ prolapse surgery within 2years postoperatively. Secondary outcomes included patient-reported vaginal bulging, operative time, estimated blood loss and 1-year postoperative complications. In 1812 patients with vaginal vault prolapse, 538 (30%) had a sacrospinous ligament fixation (SSLF) with graft, 441 (24%) underwent SSLF without graft, and 200 (11%) underwent minimally invasive sacrocolpopexy (SCP) or sacrocervicopexy (SCerP). A significantly higher proportion of patients undergoing recurrent pelvic organ prolapse surgery was seen in SSLF without graft than in SSLF with graft (adjusted odds ratio [aOR] 2.2, 95% CI 1.4-3.6). Patient-reported sensation of vaginal bulging 1year after surgery was higher in the SSLF group without graft than in the SSLF group with graft (aOR 1.9, 95% CI 1.3-2.8) and in the SCP/SCerP group (aOR 2.0, 95% CI 1.1-3.4). Finally, we found a significantly higher rate of complications 1year after surgery in SSLF without graft (aOR 2.3, 95% CI 1.2-4.2) and in SSLF with graft (aOR 2.2, 95% CI 1.2-4.2) compared with SCP/SCerP. In patients with vaginal vault prolapse, SSLF without graft was associated with a higher frequency of recurrent pelvic organ prolapse surgery compared with SSLF with graft, and a higher subjective relapse rate compared with SCP/SCerP and SSLF with graft. Additionally, the complication rate 1year after primary surgery was higher in SSLF both with and without graft than in SCP/SCerP.

Efficacy and safety of warfarin in patients with non-valvular atrial fibrillation and CKD G3-G5D.

ABSTRACTBackgroundObservational data comparing warfarin with no treatment for patients with non-valvular atrial fibrillation (NVAF) and severely reduced glomerular filtration rate (GFR) are conflicting and randomized controlled trials (RCTs) are lacking. Most studies do not provide information on warfarin treatment quality, making them difficult to compare.MethodsThis national cohort study investigates the risk of ischaemic stroke and major bleeding during warfarin treatment compared with no oral anticoagulants in patients with NVAF, GFR category 3–5 (G3–G5) or on dialysis (G5D), with kidney transplant recipients excluded, between 2009 and 2018. Data extracted from high-quality Swedish national healthcare registries, including the Swedish Renal Registry, AuriculA—the Swedish national quality registry for atrial fibrillation and anticoagulation—and the Stroke Registry.ResultsAt enrolment of 12 106 patients, 21.4% were G3, 43.5% were G4, 11.6% were G5 and 23.6% were G5D. The mean time in the therapeutic range was 70%. Warfarin compared with no treatment showed a lower risk for ischaemic stroke for G3 {hazard ratio [HR] 0.37 [95% confidence interval (CI) 0.18–0.76]}, G4 [0.53 (0.38–0.74)] and G5 [0.49 (0.30–0.79)] and an increased risk of major bleeding in G4 [HR 1.22 (1.02–1.46)], G5 [1.52 (1.15–2.01)] and G5D [1.23 (1.00–1.51)]. All-cause mortality was more than halved on warfarin compared with no treatment in all GFR categories.ConclusionsWarfarin treatment is associated with a lower risk of ischaemic stroke for patients with NVAF and G3, G4 and G5D at the cost of a higher risk of major bleeding for G4–G5D. Existing observational data are conflicting, stressing the need for RCTs on warfarin compared with no treatment in G4–G5D. Awaiting RCTs, it seems reasonable to treat selected patients on dialysis and NVAF with warfarin.

Sex Differences in Glioblastoma-Findings from the Swedish National Quality Registry for Primary Brain Tumors between 1999-2018.

Sex disparities in glioblastoma (GBM) have received increasing attention. Sex-related differences for several molecular markers have been reported, which could impact on clinical factors and outcomes. We therefore analyzed data on all patients with GBM reported to the Swedish National Quality Registry for Primary Brain Tumors, according to sex, with a focus on prognostic factors and survival. All glioma patients registered during 20 years, from 1 January 1999 until 31 December 2018, with SNOMED codes 94403, 94413, and 94423, were analyzed. Chi2-test, log-rank test, and Kaplan–Meier analyses were performed. We identified 5243 patients, of which 2083 were females and 3160 males, resulting in a ratio of 1:1.5. We found sex related differences, with women having diagnostic surgery at a significantly higher age (p = 0.001). Women were also reported to have a worse preoperative performance status (PPS) (<0.001). There was no gender difference for the type of surgery performed. For women with radical surgery, overall survival was slightly better than for men (p = 0.045). The time period did not influence survival, neither for 1999–2005 nor 2006–2018, after temozolomide treatment was introduced (p = 0.35 and 0.10, respectively). In the multivariate analysis including sex, age, surgery, and PPS, a survival advantage was noted for women, but this was not clinically relevant (HR = 0.92, p = 0.006). For patients with GBM; sex-related differences in clinical factors could be identified in a population-based cohort. In this dataset, for survival, the only advantage noted was for women who had undergone radical surgery, although this was clinically almost negligible.