Management of groin hernia repair in Sweden: A register-based comparative analysis of public and private healthcare providers.

BACKGROUND: Swedish healthcare is in a period of transition with an expanding private sector. This study compares quality of outcome after groin hernia repair performed in a public or private healthcare setting. METHODS: A cohort study based on data from the Swedish National Hernia Register combined with Patient-Reported Outcome Measures (PROMs) 1 year after groin hernia repair. Between September 2012 and December 2018, a questionnaire was sent to all patients registered in the hernia register 1 year after surgery. Endpoints were reoperation for recurrence, chronic pain, and patient satisfaction. RESULTS: From a total of 87,650 patients with unilateral groin hernia repair, 61,337 PROM answers (70%) were received from 71 public and 28 private healthcare providers. More females, acute and recurrent cases, and patients with high American Society of Anesthesiology (ASA) scores were operated under the national healthcare system. The private sector had more experience surgeons with higher annual volume per surgeon, shorter time on waiting lists, and shorter operation times. No difference was seen in patient satisfaction. Groin hernia repair performed in a private clinic was associated with less postoperative chronic pain (OR 0.85, 95% CI 0.8-0.91) but a higher recurrence rate (HR 1.41; 95% CI 1.26-1.59) in a multivariable logistic regression analysis. CONCLUSION: Despite private clinics having a higher proportion of experienced surgeons and fewer complex cases, the recurrence rate was higher, whereas the risk for chronic postoperative pain was higher among patients treated in the public sector.

Thromboembolic events, major bleeding and mortality in essential thrombocythaemia and polycythaemia vera-A matched nationwide population-based study.

Thromboembolic events and bleeding are known complications in essential thrombocythaemia (ET) and polycythaemia vera (PV). Using multiple Swedish health care registers, we assessed the rate of arterial and venous events, major bleeding, all-cause stroke and all-cause mortality in ET and PV compared to matched controls. For each patient with ET (n = 3141) and PV (n = 2604), five matched controls were randomly selected. In total, 327 and 405 arterial or venous events were seen in the group of ET and PV patients respectively. Compared to corresponding controls, the rate of venous thromboembolism, major bleeding and all-cause mortality per 100 treatment years was significantly increased among both ET (0.63, 0.79 and 3.70) and PV patients (0.94, 1.20 and 4.80). The PV patients also displayed a significantly higher rate of arterial events and all-cause stroke compared to controls. When dividing the cohort into age groups, we found a significantly higher rate of arterial and venous events in all age groups of PV patients, and the rate of all-cause mortality was significantly higher in both ET and PV patients in all ages above the age of 50. This study confirms that PV and ET are diseases truly marked by thromboembolic complications and bleeding.

Effects of Controlled Supramaximal High-Intensity Interval Training on Cardiorespiratory Fitness and Global Cognitive Function in Older Adults: The Umeå HIT Study-A Randomized Controlled Trial.

BACKGROUND: This study examined the effects of regulated and controlled supramaximal high-intensity interval training (HIT) adapted for older adults, compared to moderate-intensity training (MIT), on cardiorespiratory fitness; cognitive, cardiovascular, and muscular function; and quality of life. METHODS: Sixty-eight nonexercising older adults (66-79 years, 44% males) were randomized to 3 months of twice-weekly HIT (20-minute session including 10 × 6-second intervals) or MIT (40-minute session including 3 × 8-minute intervals) on stationary bicycles in an ordinary gym setting. Individualized target intensity was watt controlled with a standardized pedaling cadence and individual adjustment of the resistance load. Primary outcomes were cardiorespiratory fitness (V̇o2peak) and global cognitive function (unit-weighted composite). RESULTS: V̇o2peak increased significantly (mean 1.38 mL/kg/min, 95% CI [0.77, 1.98]), with no between-group difference (mean difference 0.05 [-1.17, 1.25]). Global cognition did not improve (0.02 [-0.05, 0.09]), nor differed between groups (0.11 [-0.03, 0.24]). Significant between-group differences in change were observed for working memory (0.32 [0.01, 0.64]), and maximal isometric knee extensor muscle strength (0.07 N·m/kg [0.003, 0.137]), both in favor of HIT. Irrespective of the group, there was a negative change in episodic memory (-0.15 [-0.28, -0.02]), a positive change in visuospatial ability (0.26 [0.08, 0.44]), and a decrease in systolic (-2.09 mmHg [-3.54, -0.64]) and diastolic (-1.27 mmHg [-2.31, -0.25]) blood pressure. CONCLUSIONS: In nonexercising older adults, 3 months of watt-controlled supramaximal HIT improved cardiorespiratory fitness and cardiovascular function to a similar extent as MIT, despite half the training time. In favor of HIT, there was an improvement in muscular function and a potential domain-specific effect on working memory. CLINICAL TRIAL REGISTRATION: NCT03765385.

Erythrocytosis, thrombocytosis, and rate of recurrent thromboembolic event-A population based cohort study.

INTRODUCTION: The management to reduce risk of thromboembolic complications in polycythemia vera and essential thrombocythemia are well established, but for other conditions with elevated hemoglobin, hematocrit, or platelets there are no consensus regarding treatment and follow up. AIMS: To assess frequency of elevated blood values in patients with thromboembolic event, how many of these should be investigated further regarding myeloproliferative neoplasm and if the risk of recurrent event is depending on underlying condition. METHODS: Retrospective cohort study of 3931 adult patients in the county of Norrbotten, Sweden, with thromboembolism during 2017 and 2018. RESULTS: Of the 3931 patients, 1195 had either elevated Hb, HCT, or platelets fulfilling the 2016 revised WHO criteria for PV and ET, and out of these 411 should be evaluated regarding underlying myeloproliferative neoplasms. Unexplained thrombocytosis and secondary erythrocytosis were associated with the highest rate of recurrent event as well as the most inferior restricted mean survival time. CONCLUSION: Elevated blood values are common in patients with thromboembolic event and the high risk of recurrent event and inferior restricted mean survival time in patients with unexplained thrombocytosis and secondary erythrocytosis implicates the importance of finding and managing the underlying condition.

Collaboration between the Danish and Swedish hernia registers - a study protocol.

INTRODUCTION: The most common laparo-endoscopic groin hernia repair techniques are TEP (total extraperitoneal) and TAPP (transabdominal preperitoneal) repair. Despite geographic proximity, Swedish surgeons distinctively favour TEP, whereas Danish surgeons prefer TAPP. The aim of this study is to analyse the risk of reoperation for recurrence after TAPP, TEP and Lichtenstein repair using data from two nationwide registers. We also aim to discuss advantages of international collaboration between nationwide registers. METHODS: All groin hernia operations registered as TEP, TAPP or Lichtenstein repair in the Swedish Hernia Register and the Danish Hernia Database between January 2004 and December 2020 will be included. Cumulative hazard rate of reoperation for recurrence will be estimated using Cox-regression analyses adjusted for age and anatomy. CONCLUSION: Approximately 400,000 operations are estimated to have been registered prospectively in the inclusion period in the registers. The merging of two nationwide registers was made possible owing to close cooperation between the register steering committees and by obtaining the necessary approvals. This unique collaboration between nationwide registers will make it possible to compare the risk of reoperation for recurrence after TAPP, TEP and Lichtenstein repair on an international level. In future, similar collaboration may be established to explore other outcomes such as complication rates and chronic pain. FUNDING: This study protocol is financed by grants generated from Sahlgrenska University Hospital (ALF grant ALFGBG-733561, an agreement concerning research and education of doctors) and the Swedish Society of Medicine (SLS-784551). TRIAL REGISTRATION: not relevant.

Chronic Pain After Groin Hernia Surgery in Women: A Patient-reported Outcome Study Based on Data From the Swedish Hernia Register.

OBJECTIVE: The aim of this study was to evaluate chronic pain 1 year after surgery, and risk factors for chronic pain after groin hernia repair in women. BACKGROUND: Groin hernia surgery in women is less frequently studied than in men. Chronic pain is common after groin hernia surgery and remains an important area with room for improvement. Previous studies are small or inconclusive. Guidelines recommend timely repair of all female groin hernias. METHODS: From the Swedish Hernia Register 4021 female and 37,542 male patients operated between September 1, 2012 and August 30, 2017 responded to a patient-reported outcome questionnaire (response rate 70.0%) 1 year after primary groin hernia surgery. Multivariable analysis was performed to compare chronic postoperative pain in women with men as a control group, and to evaluate risk factors for chronic pain in women. RESULTS: Among women operated for groin hernia, 18% suffered chronic postoperative pain. The risk for chronic pain was significantly higher for women [odds ratio 1.3 (95% confidence interval 1.16-1.46). Three risk factors for chronic pain in women were found: high body mass index, high American Society of Anesthesiologists classification, and femoral hernia. No differences in chronic pain in women were seen when comparing surgical methods or emergency versus elective surgery. CONCLUSIONS: Almost one-fifth of women suffered of chronic pain affecting daily activity after groin hernia repair. Chronic pain was more common for women than men. In view of the high-rate chronic postoperative pain, further research on management strategies in female groin hernia is warranted.

Prophylactic anticoagulants to prevent venous thromboembolism in patients with nephrotic syndrome-A retrospective observational study.

BACKGROUND: Nephrotic syndrome (NS) is associated with increased risk of venous thromboembolism (VTE). Guidelines suggest prophylactic anticoagulants to patients with high risk of thrombosis and low risk of bleeding, but the evidence behind this is poor. This study aims to investigate the effectiveness and risks of prophylactic anticoagulants (PAC) and investigate risk factors for VTE and bleeding in NS. METHODS: A retrospective medical records study including adults with NS, biopsy proven glomerular disease in the county of Västernorrland, Sweden. Outcomes were VTE, bleeding and death. Patients divided into PAC- and no PAC group were compared using Fisher's exact test. Patient time was divided into serum/plasma(S/P)-albumin intervals (<20g/L and ≥20g/L) and VTE- and bleeding rates were calculated. RESULTS: In 95 included NS patients (PAC = 40, no PAC = 55), 7 VTE (7.4%) and 17 bleedings (18%) were found. Outcomes didn't differ significantly between the PAC and no PAC group. Time with S/P-albumin <20g/L conferred higher rates/100 years of VTE (IRR 21.7 (95%CI 4.5-116.5)) and bleeding (IRR 5.0 (1.4-14.7)), compared to time with S/P-albumin>20g/L. CONCLUSION: Duration of severe hypoalbuminemia (S/P-albumin <20g/L) in NS is a risk factor for both VTE and bleeding. There is a need for randomized controlled studies regarding the benefit of PAC in NS as well as risk factors of thrombosis and bleeding in NS.

Chronic pain and risk for reoperation for recurrence after inguinal hernia repair using self-gripping mesh.

BACKGROUND: Improved recurrence rates after groin hernia surgery have led to chronic pain becoming the most troublesome postoperative complication. Self-gripping mesh was developed to decrease the risk for development of chronic pain. The aim of this nationwide cohort study was to compare recurrence rate and chronic pain 1 year after an open, anterior mesh repair of inguinal hernias with either a self-gripping mesh or other lightweight mesh. METHOD: All operations registered as open anterior mesh repair (Lichtenstein) in the Swedish Hernia Registry between September 2012 and October 2016 were selected. At 1 year after repair, patients were sent a pain questionnaire assessing chronic pain. We compared the prevalence of chronic pain and reoperation for recurrence using lightweight, sutured mesh or self-gripping mesh. RESULTS: We analyzed the 1,803 repairs using self-gripping mesh and 16,567 repairs using lightweight mesh. We found no difference in the prevalence of chronic pain 1 year after the hernia repair between self-gripping mesh and sutured lightweight mesh (OR 0.92, CI 95% 0.80-1.06, P = .257). There was no increase in reoperation for recurrence when using self-gripping mesh (HR 0.71, CI 95% 0.45-1.14, P = .156). Mean operation time was considerably less when using self-gripping mesh (43 vs 70 minutes; P > .001). CONCLUSION: The use of self-gripping mesh does not decrease the incidence of chronic pain and reoperation for recurrence compared with lightweight, sutured mesh for open anterior mesh repair of inguinal hernias. Furthermore, the use of self-gripping mesh is associated with a clinically important, lesser operation time.

Groin hernia repair in women - A nationwide register study.

INTRODUCTION: The aim of this study was to investigate reoperation for recurrence in men and women with respect to method of repair, hernia anatomy and year of operation. METHOD: Since 1992, groin hernia repairs performed in Sweden are prospectively registered in the Swedish Hernia Register, (SHR). Reoperations are noted, regardless of where the reoperation is performed. Risk of reoperation for recurrence is calculated for men and women with respect of method of repair, hernia anatomy and year of operation. RESULTS: Out of 221 108 eligible operations registered between 1992-2013, 17 545 (8%) were performed on women. The risk of being operated for recurrence after laparoscopic surgery was lowered in women, RR 0,4(95%CI 0.3-0.7) and increased in men, RR 2.3(95% CI 2.0-2.7), compared to the Lichtenstein technique. DISCUSSION: The reoperation for recurrence rate differed significantly between men and women. As regards the technique used for primary repair, laparoscopic groin hernia repair lowered the risk of reoperation for recurrence in women whereas it doubled the risk in men.

Low complication rate and an increasing incidence of surgical repair of primary indirect sliding inguinal hernia.

PURPOSE: The purpose of the present study was to explore the risk for complications and reoperations following open repairs for sliding groin hernias. METHOD: All primary indirect inguinal hernia repairs registered in the Swedish Hernia Register 1998-2011 were identified. Repeated and bilateral procedures were excluded. The epidemiology, the incidence of per- and postoperative complications, and the reoperation rate due to recurrences were analyzed. RESULTS: 100 240 non-repeated unilateral repairs were registered with sliding hernias in 13 132 (13.1 %) (male 14 %, female 5 %) procedures. The methods of repair for sliding and non-sliding hernias were Lichtenstein and other open anterior mesh repairs (N = 10865, 82.7 % and N = 60790, 69.8 %), endoscopic techniques (N = 136, 1.0 % and N = 4352, 5.0 %), and other techniques (N = 2131, 16.2 % and N = 21966, 25.2 %). In multivariate analyses with adjustment for gender, acute/planned surgery, reducibility, method of repair and age, sliding hernias were associated with a low but slightly increased risk for perioperative complications (hazard ratio 1.30, 95 % confidence interval 1.04-1.62, p = 0.023) and postoperative hematoma (hazard ratio 1.13, confidence interval 1.02-1.26, p = 0.019). There was no increased risk of reoperation due to recurrences. CONCLUSION: Compared to older reports, the incidence of repairs due to primary indirect sliding inguinal hernias has increased over time and it is not just a male disease. The overall results are good with low and comparable complication rates, and no increased risk of reoperations due to recurrences.