Women with abnormal Pap smear result: a qualitative study of Swedish healthcare professionals' experiences.

A Papanicolaou (Pap) smear can be used to detect pre-cancerous cellular changes, so that they can be treated before they develop into cervical cancer. When the results of a Pap smear test are abnormal, women need further investigation, treatment and follow-up. Healthcare professionals (HCPs) are in a position to care for these women with abnormalities. The aim of this study was to explore the experiences of HCPs in caring for women with abnormal Pap smear results. In total, 20 HCPs from two counties in south-eastern Sweden participated in individual interviews, based on two open-ended questions. Interviews were recorded, transcribed verbatim and analysed using content analysis. The results showed that HCPs experienced that abnormal Pap smear results created anxiety in women, who often sought information from the Internet as a way to cope. Furthermore, the HCPs thought that it was a problem that women chose not to attend investigation, treatment and follow-ups. However, information about the seriousness of abnormal Pap smear results causes women to participate. It is a challenge for HCPs to inform in a reassuring manner. Finally, HCPs should collaborate with women to meet their information needs and to also provide support regarding finding and filtering reliable information on the Internet.

Impact of a fast-track surgery programme for pancreaticoduodenectomy.

BACKGROUND: Fast-track (FT) programmes are multimodal, evidence-based approaches to optimize patient outcome after surgery. The aim of this study was to evaluate the safety, clinical outcome and patients' experience of a FT programme after pancreaticoduodenectomy (PD) in a high-volume institution in Sweden. METHODS: Consecutive patients undergoing PD were studied before and after implementation of the FT programme. FT changes included earlier mobilization, standardized removal of the nasogastric tube and drain, and earlier start of oral intake. Patient experience was evaluated with European Organization for Research and Treatment of Cancer QLQ-C30 and QLQ-PAN26 questionnaires 2 weeks before and 4 weeks after surgery. RESULTS: Between 2011 and 2014, 100 consecutive patients undergoing PD were studied, of whom 50 received standard care (controls), followed by 50 patients treated after implementation of the FT programme. The nasogastric tube was removed significantly earlier in the FT group, and these patients were able fully to tolerate fluids and solid food sooner after PD. Delayed gastric emptying was significantly reduced in the FT group (26 versus 48 per cent; P = 0.030). Overall morbidity remained unchanged and there were no deaths in either group. Postoperative length of hospital stay was reduced from 14 to 10 days and hospital costs were decreased significantly. Health-related quality-of-life questionnaires showed similar patterns of change, with no significant difference between groups before or after surgery. CONCLUSION: The FT programme after PD was safe. Delayed gastric emptying, hospital stay and hospital costs were all reduced significantly. Although patients were discharged 4 days earlier in the FT group, this did not influence health-related quality of life compared with standard care.

Predicting risk for large-for-gestational age neonates at term: a population-based Bayesian theorem study.

OBJECTIVES: To evaluate the prediction of large-for-gestational age (LGA) term neonates using the routine third-trimester ultrasound examination and to investigate whether the prediction could be further improved by adding information on maternal characteristics. METHODS: Information on 56,792 singleton term pregnancies with a routine ultrasound examination at 32-34 weeks' gestation was retrieved from a population-based perinatal register. Estimated fetal weights (FW) were expressed as gestational age-specific standard deviation scores (Z-scores). The prediction of LGA was assessed by receiver-operating characteristics (ROC) curves, with LGA defined as birth weight Z-score > + 2. The data set with complete clinical information (n = 48,809) was divided into a development and a validation set. Using the development set, multiple logistic regression analysis was performed to identify maternal characteristics associated with LGA. The odds ratios obtained were converted into likelihood ratios. These were then applied to the validation set and the probability for LGA for each infant was estimated using the Bayesian theorem. RESULTS: The FW Z-score showed a high predictive ability for LGA (area under the ROC curve (AUC) 0.89 (95% CI, 0.89-0.90)). Prediction was further improved by using the model that included both FW Z-scores and maternal variables (AUC 0.91 (95% CI, 0.90-0.92)) (P for difference < 10(-6) ). The corresponding AUC for a model including maternal characteristics only was 0.74 (95% CI, 0.73-0.76). CONCLUSIONS: Routine third-trimester ultrasound FW estimation is effective in the prediction of LGA neonates at term. The prediction of LGA might be further improved by using a model including maternal characteristics.

Impact of maternal characteristics on fetal growth in the third trimester: a population-based study.

OBJECTIVES: To investigate the association between maternal characteristics and fetal growth during the third trimester of pregnancy. METHODS: Using a population-based perinatal register, 48809 term singleton pregnancies were identified for which a routine ultrasound examination in the third trimester had been performed between 1995 and 2009. Fetal and infant weight were expressed as gestational age-specific standard deviation scores (z-scores) using a Swedish ultrasound-based reference curve. The growth of each fetus was assessed using the difference between the birth-weight z-score and the fetal-weight z-score estimated at the ultrasound examination, adjusted for gestational age, and divided by the time elapsed between the ultrasound examination and delivery. Analyses were performed using multivariable linear and polynomial regression analyses. RESULTS: Positive associations were found between maternal body mass index (BMI), height, pre-existing diabetes mellitus, female fetal gender and fetal growth, whereas maternal smoking had a negative association. In the univariate analyses, primiparity and parity with four or more previous children were significantly associated with reduced fetal growth, but in the multivariable analysis, no association between parity and fetal growth could be detected. Both univariate and multivariable analyses revealed a significant inverse U-shaped association between maternal age and fetal growth. CONCLUSIONS: Third-trimester fetal growth was positively associated with increasing maternal BMI, height and pre-existing diabetes mellitus, and negatively associated with maternal smoking.

Treatment patterns and survival in patients with hepatocellular carcinoma in the Swedish national registry SweLiv.

BACKGROUND: Consistent data on clinical features, treatment modalities and long-term survival in patients with hepatocellular carcinoma (HCC) using nationwide quality registers are lacking. This study aimed to describe treatment patterns and survival outcomes in patients diagnosed with HCC using a national maintained database. METHODS: Characteristics and treatment patterns in patients diagnosed with HCC and registered in the national register of liver and bile duct tumours (SweLiv) between 2009 and 2016 were reviewed. Overall survival (OS) was estimated using Kaplan-Meier analysis and the log rank test to compare subgroups for clinical features, treatment modalities and outcomes according to the year of treatment. RESULTS: A total of 3376 patients with HCC were registered over 8 years, 246 (7·3 per cent) of whom underwent transplantation. Some 501 (14·8 per cent) and 390 patients (11·6 per cent) had resection and ablation as primary treatment. Transarterial chemoembolization and systemic sorafenib treatment were intended in 476 (14·1 per cent) and 426 patients (12·6 per cent) respectively; the remaining 1337 (39·6 per cent) were registered but referred for best supportive care (BSC). The 5-year survival rate was approximately 75 per cent in the transplantation group. Median OS was 4·6 (i.q.r. 2·0 to not reached) years after resection and 3·1 (2·3-6·7) years following ablation. In patients referred for palliative treatment, median survival was 1·4 (0·8-2·9), 0·5 (0·3-1·2) and 0·3 (0·1-1·0) years for the TACE, sorafenib and BSC groups respectively (P < 0·001). Median survival was 0·9 years for the total HCC cohort in 2009-2012, before publication of the Swedish national treatment programme, increasing to 1·4 years in 2013-2016 (P < 0·001). CONCLUSION: The survival outcomes reported were in line with previous results from smaller cohorts. The introduction of national guidelines may have contributed to improved survival among patients with HCC in Sweden.

ANTECEDENTES: Se carece datos consistentes acerca de las características clínicas, modalidades terapéuticas y supervivencia a largo plazo en pacientes con carcinoma hepatocelular (hepatocellular carcinoma, HCC) basados en registros de calidad de ámbito nacional. El objetivo de este estudio fue describir los patrones de tratamiento y los resultados de supervivencia en pacientes diagnosticados de HCC usando una base de datos nacional. MÉTODOS: Se revisaron las características de los pacientes y los patrones de tratamiento en pacientes con un diagnóstico de HCC incluidos en el registro nacional de tumores de hígado y vías biliares (SweLiv) entre 2009 y 2016. La supervivencia global (overall sirvival, OS) se analizó mediante el método de Kaplan-Meier y test de log-rank para la comparación de subgrupos según las características clínicas de los pacientes, las modalidades de tratamiento y los resultados en función del año de tratamiento. RESULTADOS: Durante un periodo de 7 años, se incluyeron en el registro un total de 3.076 pacientes con HCC, 246 de los cuales recibieron un trasplante (7,2%). Se practicó resección y ablación como tratamiento primerio en 501 (14,8%) y 390 (11,6%) pacientes, respectivamente. La quimioembolización (TACE) y el tratamiento sistémico con sorafenib se efectuó en 476 (14,1%) y 426 (12,6%) pacientes, respectivamente; los 1.337 pacientes restantes (40,0%) fueron incluidos en la base de datos pero se derivaron para recibir el mejor tratamiento de soporte. La tasa de supervivencia a los 5 años fue del 75% en el grupo trasplantado. La mediana de OS fue de 4,6 años (rango intercuartílico, interquartile range, IQR 2,0-no alcanzado) tras la resección y de 3,1 años (IQR 2,3-6,7) tras la ablación. En los pacientes derivados para tratamiento paliativo, la mediana de supervivencia fue de 1,4 años (IQR 0,8-2,9), 0,5 años (IQR 0,2-1,2) y 0,3 años (IQR 0,1-1,0) para los grupos de TACE, sorafenib y mejor tratamiento de soporte, respectivamente (P < 0,001). La mediana de supervivencia para toda la cohorte de HCC en 2009-2012 fue de 0,9 años antes de la publicación del programa de nacional de tratamiento sueco, aumentando a 1,4 años en 2013-2016 (P <0,001). CONCLUSIÓN: Los resultados de supervivencia referidos eran consistentes con resultados previos obtenidos en cohortes más pequeñas; la introducción de guías nacionales puede haber contribuido a mejorar la supervivencia de los pacientes con HCC en Suecia.

Sonographic fetal weight estimation in prolonged pregnancy: comparative study of two- and three-dimensional methods.

OBJECTIVES: To compare two-dimensional (2D) and three-dimensional (3D) ultrasound techniques, including volumetry of fetal thigh, for fetal weight (FW) estimation in prolonged pregnancy, and to develop a new FW estimation formula. METHODS: This prospective comparative study initially included 176 pregnant women. FW estimation was performed at >or= 287 days of gestation within

Identification of Inequalities in the Selection of Liver Surgery for Colorectal Liver Metastases in Sweden.

BACKGROUND:: Liver resection for colorectal liver metastases offers a 5-year survival rate of 25%-58%. This study aimed to analyze whether patients with colorectal liver metastases undergo resection to an equal extent and whether selection factors play a role in the selection process. MATERIAL AND METHODS:: Data were retrieved from the Swedish Colorectal Cancer Registry (2007-2011) for colorectal cancer and colorectal liver metastases. The patients identified were linked to the Swedish Registry of Liver and Bile surgery and the National Patient Registry to identify whether liver surgery or ablative treatment was performed. Analyses for age, sex, type of primary tumor and treating hospital (university, county, or district), American Society of Anesthesiologists class, and radiology for detection of metastatic disease were performed. RESULTS:: Of 28,355 patients with colorectal cancer, 21.6% (6127/28,355) presented with liver metastases. Of the patients with liver metastases, 18.5% (1134/6127) underwent liver resection or ablation. The cumulative proportion of liver resection/ablation was 4% (1134/28,355) of all colorectal cancer. If "not bowel resected" were excluded, the proportion slightly increased to 4.7% (1134/24,262). Around 15% of the patients with metastases were registered as referrals for liver surgery. In a multivariable analysis patients treated at a university hospital for primary tumor were more frequently surgically treated for liver metastases (p < 0.0001). Patients with liver metastases from rectal cancer (p < 0.0001) and men more often underwent liver resection (p = 0.006). A difference was found between health-care regions for the frequency of liver surgery (p < 0.0001). Patients >70 years and those with American Society of Anesthesiologists class >2 underwent liver resection less frequently. Magnetic resonance imaging of the liver was more often used in diagnostic work-up in men. CONCLUSION:: Patients with colorectal liver metastases are unequally treated in Sweden, as indicated by the low referral rate. The proximity to a hepatobiliary unit seems important to enhance the patient's chances of being offered liver surgery.

Hemorrhage after Major Pancreatic Resection: Incidence, Risk Factors, Management, and Outcome.

BACKGROUND AND AIMS: Hemorrhage is a rare but dreaded complication after pancreatic surgery. The aim of this study was to examine the incidence, risk factors, management, and outcome of postpancreatectomy hemorrhage in a tertiary care center. MATERIALS AND METHODS: A retrospective observational study was conducted on 500 consecutive patients undergoing major pancreatic resections at our institution. Postpancreatectomy hemorrhage was defined according to the International Study Group of Pancreatic Surgery criteria. RESULTS: A total of 68 patients (13.6%) developed postpancreatectomy hemorrhage. Thirty-four patients (6.8%) had a type A, 15 patients (3.0%) had a type B, and the remaining 19 patients (3.8%) had a type C bleed. Postoperative pancreatic fistula Grades B and C and bile leakage were significantly associated with severe postpancreatectomy hemorrhage on multivariable logistic regression. For patients with postpancreatectomy hemorrhage Grade C, the onset of bleeding was in median 13 days after the index operation, ranging from 1 to 85 days. Twelve patients (63.2%) had sentinel bleeds. Surgery lead to definitive hemostatic control in six of eight patients (75.0%). Angiography was able to localize the bleeding source in 8/10 (80.0%) cases. The success rate of angiographic hemostasis was 8/8. (100.0%). The mortality rate among patients with postpancreatectomy hemorrhage Grade C was 2/19 (10.5%), and both fatalities occurred late as a consequence of eroded vessels in association with pancreaticogastrostomy. CONCLUSION: Delayed hemorrhage is a serious complication after major pancreatic surgery.Sentinel bleed is an early warning sign. Postoperative pancreatic fistula and bile leakage are important risk factors for severe postpancreatectomy hemorrhage.

Non-ulcer dyspepsia in the long-term perspective.

OBJECTIVE: To study the natural history of non-ulcer dyspepsia. DESIGN: Retrospective study on consecutive cases of non-ulcer dyspepsia diagnosed in 1980 and 1981. The long-term course was ascertained from medical records and from answers to a questionnaire completed by the patients at 10-year follow-up. SETTING: Out-patients at the endoscopy unit of a county hospital. PATIENTS: The diagnosis was based on typical symptoms of dyspepsia, a normal index endoscopy and a lack of evidence of organic disease related to the symptoms during the subsequent 12-month period. Two hundred and seventy-one patients were entered into the study. Of the 195 who received a questionnaire at 10-year follow-up, 165 (85%) responded. RESULTS: The median age at inclusion was 51 years (25-75 percentiles 38-65 years), and 130 men and 141 women were included in the study. The cumulative death rate after 10 years was 18%, a value no greater than that in the general population: 8% had died of cardiovascular disease, 1.5% of gastrointestinal cancer and 3% of other malignancies. One patient had died of a perforated gastric ulcer. At 10-year follow-up, a further three patients had developed peptic ulcers (expected number 4.2), 64% had experienced dyspeptic symptoms during the preceding 12 months and 41% had been taking analgesics during the previous week. Of the symptoms listed by the patients, 30% were typical of irritable bowel syndrome. CONCLUSION: Non-organic dyspepsia seems to be a chronic disease in most patients. The course is benign and unrelated to peptic ulcer disease.

Is there still an indication for pancreatic duct drainage in chronic pancreatitis?

Pain in chronic pancreatitis is supposed to be multifactorial in origin. Pancreatic duct/tissue hypertension is today proved in patients with chronic pancreatitis and pain. Duct drainage reportedly normalizes pancreatic duct/tissue pressure and reduces pain in 70% of the patients. Also, duct drainage by endoscopy may relieve pain. Surgical duct decompression is parenchyma-preserving and even suggested to prevent further progress of exocrine insufficiency. Recent experience indicates that such operations are pain-relieving not only in patients with dilated ducts but also in those with small duct disease.

Bleeding peptic ulcer - time trends in incidence, treatment and mortality in Sweden.

BACKGROUND: The incidence of peptic ulcer disease was expected to decrease following the introduction of acid inhibitors and Helicobacter pylori eradication. AIM: To analyse possible changes in the incidence of bleeding peptic ulcer, treatment and mortality over time. METHODS: Residents of Malmö hospitalized for bleeding gastric or duodenal ulcer disease during 1987-2004 were identified in hospital databases (n = 1610). The material was divided into 6-year periods to identify changes over time. All patients who had been submitted to emergency surgery (n = 137) were reviewed. RESULTS: The incidence rate for bleeding gastric or duodenal ulcers decreased by one half in males and by one-third in females and emergency operations decreased significantly (9.2%, 7.5% and 5.7% during the three time periods, respectively (P < 0.05). The post-operative mortality tended to decrease (9.7, 2.4 and 3.7%, respectively) and the 30-day mortality rates in the whole material were 1.2%, 3.6% and 3.4% during the different time periods. CONCLUSION: The incidence of bleeding gastric and duodenal ulcer disease has decreased markedly. Operative treatment has been replaced by endoscopic treatment. The bleeding ulcer-related mortality was less than 4% and has not changed over time.

The anti-ulcer drug sucralfate does not affect gastric nicotine levels.

OBJECTIVE: It has been claimed that sucralfate can overcome the negative effects of nicotine in patients with peptic ulcer disease, although the possible mechanism being unknown. This study was performed in order to test whether sucralfate was capable of binding intragastric nicotine, thus making it impossible for the substance to exert effect. METHOD: Nicotine was administered via transdermal patches or as capsules yielding gastric concentrations of 40-2980 ng.ml-1. Gastric juice aspirates (n = 9) were incubated with sucralfate, which was then separated by centrifugation, and the nicotine concentration was compared in incubated and non-incubated samples. RESULTS: A median decrease of 13% (range 0-27%) in nicotine concentration was seen after incubation with sucralfate (P = 0.01). CONCLUSION: The binding of nicotine to the precipitating agent sucralfate is not sufficient effectively to remove nicotine from the gastric juice.

Management of uterine perforations in connection with legal abortions.

The incidence of uterine perforation while performing legal abortions was evaluated in the Stockholm area. Among 84,850 legal abortions performed during 1982-1992 there were 145 cases of uterine perforation, 0.17%. In about half of these cases an immediate exploration of the abdomen was decided upon and in 18 patients there were significant bleeding and/or lacerations to organs situated in the pelvis. No case of intestinal perforation was encountered. It is likely that many of these injuries would have healed just as well unattended. Based on this study, the authors advocate a conservative approach in dealing with uterine perforation in connection with vacuum aspiration for legal abortion.

PIP: In Sweden, where abortion is legal during the first 18 weeks of pregnancy, uterine perforation is the most serious potential complication. An analysis of the 84,850 legal induced abortions performed at the six public hospitals in Stockholm, Sweden, in 1982-92 revealed 145 cases (0.17%) of uterine perforation. 49 (33.8%) of these women had experienced at least one prior induced abortion. In women where uterine size exceeded 12 weeks of pregnancy, there were only four instances (2.8%) of uterine perforation. The perforation was caused by the suction cannula in 69 women (47.0%) and by the Hegar dilator in 30 women (20.6%). Immediate exploration of the abdomen (primarily laparotomy) was performed in 69 (47.6%) of these cases; significant bleeding and/or lacerations to organs situated in the pelvis were identified in 18 (26.1%) of these women. There were no cases of intestinal perforation. The majority of injuries would have healed without laparotomy. Unless peritoneal irritation, increasing pain, and signs of blood loss are present, a conservative approach to uterine perforation is recommended.

Transdermally administered nicotine accumulates in gastric juice.

METHODS: Transdermal nicotine patches (Nicorette 15 mg.16 h-1) were administered to 7 healthy volunteers. Nicotine concentrations in gastric juice were monitored for 8 h via a naso-gastric tube and so was nicotine in saliva and plasma. RESULTS: Nicotine accumulated in gastric juice, the average concentration being 60.6-times higher than in plasma. In saliva, too, the concentration was higher than in plasma, the average ratio being 10.5. These results strongly suggested ion-trapping of nicotine base in the acidic gastric juice and possibly also in the acinar cells, followed by active secretion. It is hypothesised that accumulation in saliva occurs via a similar mechanism. Pretreatment with omeprazole did not increase the pH to a sufficiently high degree to test the hypothesis that the accumulation of nicotine in gastric juice was pH dependent. CONCLUSION: Transdermal administration of nicotine produced a high intragastric concentration. The clinical consequence of this effect of long-term nicotine replacement therapy during smoking cessation is unclear.

A financial analysis of laparoscopic and open cholecystectomy.

Laparoscopic cholecystectomy (LC) is now the method of choice in treatment of symptomatic gallstone disease. Despite its rapidly growing popularity, comparative costs of this new method and open cholecystectomy (OC) remain unclear. The most outstanding feature of laparoscopic cholecystectomy is the period of short recovery. In Sweden the social insurance office documents sick leave period, sickness allowance, as well as diagnosis and therefore provides a reliable basis for an economic analysis. The purpose of this study was to estimate the hospital cost and costs due to sick leave in a series of patients operated on with elective cholecystectomy using the two methods. In each group 50 consecutive patients were studied retrospectively. The total hospital cost was 10% lower in the laparoscopy group--$1,864 as compared to $2,030 per patient in the OC group. Median number of days off work was 14 after LC and 35 days after open surgery, which corresponds to a median sickness allowance of $516 per patient (LC) compared to $1,424 (OC). Laparoscopic cholecystectomy is more cost-effective than open cholecystectomy mainly due to a reduced sick leave period.