Search

Open in new tab Download slide OBJECTIVES The aim of this study was to evaluate the association between statin use after surgical aortic valve replacement for aortic stenosis and long-term risk for major adverse cardiovascular events (MACEs) in a large population-based, nationwide cohort. METHODS All patients who underwent isolated surgical aortic valve replacement due to aortic stenosis in Sweden 2006–2020 and survived 6 months after discharge were included. Individual patient data from 5 nationwide registries were merged. Primary outcome is MACE (defined as all-cause mortality, myocardial infarction or stroke). Multivariable Cox regression model adjusted for age, sex, comorbidities, valve type, operation year and secondary prevention medications is used to evaluate the association between time-updated dispense of statins and long-term outcome in the entire study population and in subgroups based on age, sex and comorbidities. RESULTS A total of 11 894 patients were included. Statins were dispensed to 49.8% (5918/11894) of patients at baseline, and 51.0% (874/1713) after 10 years. At baseline, 3.6% of patients were dispensed low dose, 69.4% medium dose and 27.0% high-dose statins. After adjustments, ongoing statin treatment was associated with a reduced risk for MACE [adjusted hazard ratio 0.77 (95% confidence interval 0.71–0.83). P  < 0.001], mainly driven by a reduction in all-cause mortality [adjusted hazard ratio, 0.70 (0.64–0.76)], P  < 0.001. The results were consistent in all subgroups. CONCLUSIONS The results suggest that statin therapy might be beneficial for patients undergoing surgical aortic valve replacement for aortic stenosis. Randomized controlled trials are warranted to establish causality between statin treatment and improved outcome. [ABSTRACT FROM AUTHOR]

Background The Swedish Breast Reconstruction Outcome Study (SweBRO) initiative is a nationwide study with the primary aim of assessing long-term outcomes after mastectomy with and without breast reconstruction (BR). The current part (SweBRO 2) is designed to evaluate health-related quality of life (HRQoL), with the hypothesis that BR has a positive impact on patient-reported HRQoL in the long-term. Methods Women who underwent mastectomy in Sweden in 2000, 2005, or 2010 and were alive at the time of the survey were identified through the National Breast Cancer Registry. Eligible participants received formal invitation letters to take part in a survey evaluating their HRQoL at 5 , 10, or 15 years post-mastectomy. The EORTC QLQ-C30, EORTC QLQ-BR23, and EQ-5D-3L questionnaires were employed. Results Of 2904 respondents (50% of 5853 invited), 895 (31%) had received BR. Among them, 516 (58%) were reconstructed with implants and 281 (31%) with autologous tissue. Women with BR scored significantly better in the EORCT QLQ-C30 physical functioning domain (mean 90 versus 81 points), fatigue (mean 21 versus 25), and dyspnoea (mean 16 versus 22) compared to non-reconstructed women. The EORTC QLQ-BR23 revealed that women with BR experienced favourable sexual functioning compared with non-reconstructed women (mean 26 versus 14). The EQ-5D-3L visual analogue scale score was similar between groups. Conclusion The current study underscores the benefits of BR for long-term well-being, for example, in terms of physical and sexual functioning. These underline the importance of informing women undergoing mastectomy about BR alternatives and its potential benefits in enhancing long-term well-being. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES Current clinical guidelines have no specific recommendations regarding medical therapy after surgical aortic valve replacement in patients with aortic regurgitation (AR). We studied the association between medical therapy with renin–angiotensin system (RAS) inhibitors, statins and β-blockers and long-term major adverse cardiovascular events. METHODS All patients undergoing valve replacement due to AR between 2006 and 2017 in Sweden and alive 6 months after discharge were included. Time-dependent multivariable Cox regression models adjusted for age, sex, patient characteristics, comorbidities, other medications and year of surgical aortic valve replacement were used. Primary outcome was a composite of all-cause mortality, myocardial infarction and stroke. Subgroup analyses based on age, sex, heart failure, low ejection fraction, hyperlipidaemia and hypertension were performed. RESULTS A total of 2204 patients were included [median follow-up 5.0 years (range 0.0–11.5)]. At baseline, 68% of the patients were dispensed RAS inhibitors, 80% β-blockers and 35% statins. Dispense of RAS inhibitors and β-blockers declined over time, especially during the first year after baseline, while dispense of statins remained stable. Treatment with RAS inhibitors or statins was associated with a reduced risk of the primary outcome [adjusted hazard ratio (aHR) 0.71, 95% confidence interval (CI) 0.57–0.87 and aHR 0.78, 95% CI 0.62–0.99, respectively]. The results were consistent in subgroups based on age, sex and comorbidities. β-Blocker treatment was associated with an increased risk for the primary outcome (aHR 1.35, 95% CI 1.07–1.70). CONCLUSIONS The results indicate a potential beneficial association of RAS inhibitors and statins as part of a secondary preventive treatment regime after aortic valve replacement in patients with AR. The role of β-blockers needs to be further investigated. [ABSTRACT FROM AUTHOR]

Knowledge about preoperative expectations and how they affect satisfaction with breast reconstruction are key in improving care. A prerequisite for such studies are methodologically sound ways to define and measure expectations. The aims of this study were to translate and culturally adapt BREAST-Q Expectations for Sweden, and to perform a psychometric evaluation of the questionnaire. A cross-sectional study was performed. BREAST-Q expectations was translated according to current guidelines and sent to all patients on the waiting list for a breast reconstruction in our department. Internal consistency was assessed by Cronbach's α. Inter-item correlations were calculated, and convergent validity was evaluated using a subjective comparator. Bland–Altman plots were drawn to evaluate test–retest reliability. Floor and ceiling effects were calculated. The questionnaire was sent to 198 patients, of which 129 responded (65%). Internal consistency was acceptable for all domains (Cronbach's α 0.71–0.85) and all except one inter-item correlations were within the predefined intervals. Bland–Altman plots indicated that the agreement is variable. Ceiling effects were high for most domains. The results of the study support that the Swedish version of BREAST-Q expectations has a good content and face validity and internal consistency. Convergent validity and known-group validation cannot be adequately examined for expectations. Further studies are needed regarding test–retest reliability. High ceiling effects indicate that the instrument cannot discriminate between patients with high expectations and very high expectations. More studies are needed on how we can evaluate if expectations are realistic or not. ClinicalTrials.gov Identifier NCT04714463, 19 January 2021 Patient and public contribution: All the data were generated directly from patients. [ABSTRACT FROM AUTHOR]

Immediate breast reconstruction (IBR) is an integral part of modern breast cancer treatment. Our aim was to investigate patient experience with implant loss after IBR by using interpretative phenomenological analysis (IPA). We conducted semi-structured interviews with eight informants. We analyzed data according to the IPA flexible seven-stage process and four main themes were developed: immediate breast reconstruction as the indisputable choice, a difficult experience, an altered body: redefining normality, and trying to cope. The experience of implant loss appears to affect women for many years and might overshadow some of the benefits of IBR. [ABSTRACT FROM AUTHOR]

Background: There is no consensus for when publicly funded breast reduction is indicated and recommendations in guidelines vary greatly, indicating a lack of evidence and unequal access. The primary aim of this review was to examine risks and benefits of breast reduction to treat breast hypertrophy. Secondary aims were to examine how the studies defined breast hypertrophy and indications for a breast reduction.Methods: A systematic literature search was conducted in PubMed, MEDLINE All, Embase, the Cochrane Library, and PsycInfo. The included articles were critically appraised, and certainty of evidence was assessed using the GRADE approach. Meta-analyses were performed when possible.Results: Fifteen articles were included; eight reporting findings from four randomised controlled trials, three non-randomised controlled studies, three case series, and one qualitative study. Most studies had serious study limitations and problems with directness. Few of the studies defined breast hypertrophy. The studies showed significantly improved health-related quality of life and sexuality-related outcomes in patients who had undergone breast reduction compared with controls, as well as reduced depressive symptoms, levels of anxiety and pain. Most effect sizes exceeded the reported minimal important difference for the scale. Certainty of evidence for the outcomes above is low (GRADE ⊕ ⊕). Although four studies reported significantly improved physical function, the effect is uncertain (very low certainty of evidence, GRADE ⊕). None of the included studies reported data regarding work ability or sick leave. Three case series reported a 30-day mortality of zero. Reported major complications after breast reduction ranged from 2.4 to 14% and minor complications from 2.4 to 69%.Conclusion: There is a lack of high-quality studies evaluating the results of breast reduction. A breast reduction may have positive psychological and physical effects for women, but it is unclear which women benefit the most and which women should be offered a breast reduction in the public healthcare system. Several priorities for further research have been identified.Pre-registration: The study is based on a Health Technology Assessment report, pre-registered and then published on the website of The Regional HTA Centre of Region Västra Götaland, Sweden. [ABSTRACT FROM AUTHOR]

Download slide Download slide OBJECTIVES Our goal was to compare short- and midterm outcomes after coronary artery bypass grafting (CABG) using 2 different revascularization strategies. METHODS A total of 6895 patients were included who had CABG in Sweden from 2009 to 2015 using the left internal mammary artery to the left anterior descending artery and either a single sequential saphenous vein graft connecting the left and right coronary territories to the aorta (snake graft, n  = 2122) or separate vein grafts to both territories (n  = 4773). Data were obtained from the Swedish Web System for Enhancement of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART) and the Swedish Patient Registry. The groups were compared using adjusted logistic regression for short-term (30-day) and Cox regression and flexible parametric survival models for midterm outcomes. Primary outcome was a composite of all-cause mortality, myocardial infarction (MI), reangiography and new revascularization. The median follow-up time was 35 months. RESULTS At 30 days, the incidences of the composite end point [odds ratio (OR) 1.31, 95% confidence interval (CI) 1.03–1.68; P  = 0.03] and reangiography (OR 1.51, 95% CI 1.07–2.14; P  = 0.02) were higher in the snake group. There was also a trend towards higher mortality (OR 1.47, 95% CI 0.97–2.22; P  = 0.07). The event rates during the complete follow-up period were 6.5 (5.9–7.2) and 5.7 (5.3–6.1) per 100 person-years for the snake group and the separate vein group, respectively. At the midterm follow-up, no significant difference between the groups could be shown for the composite end point [hazard ratio (HR) 1.08, 95% CI 0.95–1.22; P  = 0.24], mortality (HR 0.95, 95% CI 0.79–1.14; P  = 0.56), MI (HR 1.11, 95% CI 0.88–1.41; P  = 0.39) or new revascularization (HR 1.19, 95% CI 0.94–1.50; P  = 0.15), whereas reangiography remained more common in the snake group (HR 1.25, 95% CI 1.05–1.48; P  = 0.01). CONCLUSIONS Snake grafts were associated with a higher rate of early postoperative complications, possibly reflecting a more demanding surgical technique, whereas midterm outcomes were comparable. Based on these data, one strategy cannot be recommended over the other. [ABSTRACT FROM AUTHOR]

Adoption of Chinese children with cleft lip and palate (CLP) has become increasingly more common in Sweden. The aim of this study was to examine parents' experience when adopting a child with CLP. Since 2008, 34 adopted children with CLP have been treated in our department. A questionnaire was sent to 33 of the families and 30 of them answered (91%). The parents had queued from 1 month to 8 years before they were offered a child. Eighteen families reported that they received information on CLP from the adoption agency and 87% contacted the department of plastic surgery for additional information. In 15 cases (45%) previously unknown medical conditions or birth defects other than CLP were discovered in Sweden. Most parents (67%) had been informed before the adoption that their child could be a carrier of resistant bacteria, but not all had received enough information to grasp what it implies to be a carrier. The great majority of the families did not feel that the early hospitalisation for the first operation had a negative impact on the attachment between them and their adopted child. They thought that the aesthetic and functional results of the operations were 'better than expected'. Seventeen families stated that people react to the cleft and four of them think that the reactions are a problem. Presumptive adoptive parents should be informed that the child might have unsuspected medical conditions, resistant bacteria, what carriage implies, and that needed treatment and long-term results are not predictable. [ABSTRACT FROM AUTHOR]

It has been possible to detect cleft lip (CL), with or without cleft palate (CLP), using ultrasound (US) since the beginning of the 1980s. The aim of this study was to assess the accuracy of prenatal diagnosis of cleft lip with or without cleft palate, and isolated cleft palate (ICP), in our catchment area. Screening protocols in the different US clinics in southern Sweden were also compared, as regards evaluation of the fetal face and prenatal diagnosis of CLP. Forty-four (31%) of the patients were diagnosed by prenatal US and 97/144 (67%) were diagnosed at birth. The detection rate was 44/102 (43%) if the ICP are excluded. The specificity was 100%. Among the prenatally diagnosed clefts, 25/44 (57%) were diagnosed before the gestational age of 20 weeks. In 19/44 (43%) of the cases the US diagnosis of cleft was accurate in the light of the postnatal outcome. All US departments in our catchment area follow the Swedish guidelines and offer one routine US examination during the second trimester between 18 and 20 weeks of pregnancy. In addition, many of the clinics offer an additional US examination during the third trimester. Our detection rate is similar to previous findings. The detection rates and the accuracy of the prenatal diagnosis can be improved. To achieve this, an increased focus on detecting clefts, standardising scanning plans, and rescans in case of incomplete facial views, are essential. [ABSTRACT FROM AUTHOR]

Renin-angiotensin system (RAS) inhibitors are recommended postoperatively to coronary artery bypass grafting (CABG) patients with reduced left ventricular function, diabetes, hypertension or previous myocardial infarction, but not to remaining patients. The aim of the study was to assess the long-term utilization of RAS inhibitors after CABG in patients with and without indication for treatment, and its association with outcome. All patients (n = 28,782) not meeting exclusion criterion in Sweden who underwent isolated first time CABG from 2006 to 2015 were included using nationwide registries. The association between treatment and outcome was assessed using adjusted Cox regression models with time-updated data on medications. The primary outcome was major adverse cardiovascular events (MACE), defined as all-cause mortality, stroke and/or myocardial infarction. At baseline 26,284 (91.3%) of the patients had at least one indication for RAS inhibition while 2498 (8.7%) had not. RAS inhibitors were dispensed to 77.0% and 29.7% of patients with and without indication respectively. Dispense declined over time. RAS inhibition was associated with a reduction in MACE in the whole study population (adjusted hazard ratio (aHR) 0.88, 95% confidence interval (95% CI) 0.83–0.93, p < 0.0001), and in patients with (aHR 0.87 95% CI: 0.82–0.93, p < 0.0001) and without indication (aHR 0.75, 95% CI: 0.58–0.98, p = 0.034). RAS inhibition is underutilized after CABG. The use of RAS inhibitors was associated with a reduction in MACE, both in patients with and without indication for treatment. The results suggest that RAS inhibition is beneficial for all CABG patients. Randomized controlled trials are necessary to confirm this hypothesis. • RAS inhibitors are inadequately dispensed after CABG. • Treatment with RAS inhibitors were associated with improved outcomes. • Patients without indication for RAS inhibitors had improved outcomes with treatment. [ABSTRACT FROM AUTHOR]

Background and Aims: The long-term outcomes of percutaneous coronary intervention (PCI) vs. coronary artery bypass grafting (CABG) in patients with non-ST-segment elevation myocardial infarction (NSTEMI) and multivessel disease remain debated., Methods: The Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies registry was used to analyse 57 097 revascularized patients with NSTEMI with multivessel disease in Sweden from January 2005 to June 2022. The primary endpoint was all-cause mortality, encompassing both in-hospital and long-term mortality; the secondary endpoints included myocardial infarction (MI), stroke, new revascularization, and heart failure. Multilevel logistic regression with follow-up time as a log-transformed offset variable and double-robust adjustment with the instrumental variable method were applied to control for known and unknown confounders., Results: Percutaneous coronary intervention was the primary therapy in 42 190 (73.9%) patients, while 14 907 (26.1%) received CABG. Percutaneous coronary intervention patients were generally older with more prior cardiovascular events, whereas CABG patients had higher incidences of diabetes, hypertension, left main and three-vessel disease, and reduced ejection fraction. Over a median follow-up of 7.1 years, PCI was associated with higher risks of death [adjusted odds ratio (aOR) 1.67; 95% confidence interval (CI) 1.54-1.81] and MI (aOR 1.51; 95% CI 1.41-1.62) but there was no significant difference in stroke. Repeat revascularization was three times more likely to PCI (aOR 3.01; 95% CI 2.57-3.51), while heart failure risk was 15% higher (aOR 1.15; 95% CI 1.07-1.25). Coronary artery bypass grafting provided longer survival within 15 years, especially in patients under 70 years of age, with left main disease or left ventricular dysfunction, though this benefit diminished over shorter time horizons., Conclusions: Coronary artery bypass grafting is associated with lower risks of mortality, MI, repeat revascularization, and heart failure in patients with NSTEMI, particularly in high-risk subgroups. However, its survival benefit lessens with shorter life expectancy., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Breast cancer can lead to changes in appearance and subsequent concerns about body image. This study aimed to translate the body investment instrument, Appearance Schemas Inventory-Revised (ASI-R), to Swedish, and perform a validation in women who underwent mastectomy and were awaiting breast reconstruction. The instrument was translated, and its psychometric properties were investigated according to current guidelines. Three hundred and ninety-seven women were eligible for the study, and 215 (54%) participants responded. An exploratory factor analysis (EFA) revealed that a three-factor structure was the most adequate solution. Three new subscales were suggested: body image investment cognition; breast and body image investment emotions; breast reflecting dysfunctional cognitive and emotional patterns of appearance investment and body image investment behaviors; breast reflecting positive ways of investing in body image. Consistent with previous findings, control over appearance is a central theme in women with breast cancer undergoing mastectomy and reconstruction. The obtained factor structure was considered similar to the original structure and three-factor solutions obtained from an American cohort of patients with breast cancer. The ASI-R has shown good psychometric properties in Swedish women undergoing mastectomy and reconstruction. Further studies on convergent validity and confirmatory factor analysis are required.

Objectives: Previous reports suggest that betablockers appear non-beneficial after surgical aortic valve replacement (SAVR). This study aims to clarify the associations between betablockers and long-term outcome after SAVR., Methods: All patients with isolated SAVR due to aortic stenosis in Sweden between 2006 and 2020, alive at 6 months after surgery, were included. Patients were identified in the SWEDEHEART registry, and records were merged with data from 3 other mandatory national registries. Association between dispensed betablockers and major adverse cardiovascular events (MACE) (all-cause mortality, myocardial infarction and stroke) was analyzed using Cox proportional hazards models, with time-updated data on medication and adjusted for age, sex and comorbidities at baseline., Results: In total, 11 849 patients were included [median follow-up 5.4 years (range 0-13.5)]. Betablockers were prescribed to 79.7% of patients at baseline, decreasing to 62.2% after 5 years. Continuing treatment was associated with higher risk of MACE [adjusted hazard ratio 1.14 (95% confidence interval, CI 1.05-1.23)]. The association was consistent over subgroups based on age, sex and comorbidities except atrial fibrillation [hazard ratio (HR) 1.05 (95% CI 0.93-1.19)]. A sensitivity analysis including time-updated data on comorbidites attenuated the difference between the groups [HR 1.04 (95% CI 0.95-1.14, P = 0.33)]., Conclusions: Treatment with betablockers did not appear to be associated with inferior long-term outcome after SAVR, when adjusting for new concomitant diseases. Thus, it is likely that it is the underlying cardiac diseases that are associated with MACE rather than betablocker treatment., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Background: Breast reconstruction after mastectomy helps women with breast cancer feel better about their bodies and lives. There is debate about the best time and type of reconstruction (immediate versus delayed, and using own tissue versus implants). Long-term studies are rare., Aim: This study looked at long-term results of different breast reconstruction methods and timings in Swedish women who had mastectomies in 2000, 2005 or 2010. It focused on how satisfied the women were with their surgeries and their quality of life., Method: The study included 5853 women from the Swedish National Breast Cancer Registry who had mastectomies in 2000, 2005 or 2010. Of these, 2904 women answered the survey, and 895 had breast reconstruction. Satisfaction and quality of life were measured using two surveys: EORTC QLQ-BRECON23 and BREAST-Q., Results: Of the women who answered the survey, 895 (31%) had breast reconstruction. Of these, 176 (20%) had immediate reconstruction, and 719 (80%) had delayed reconstruction; 58% had implant-based reconstructions, 31% had reconstructions using their own tissue, 2% had both types and 9% did not report the type of reconstruction. There were no major differences in satisfaction between immediate and delayed reconstruction. Women who used their own tissue were more satisfied with their results and breast appearance than those with implants., Conclusion: Autologous reconstruction leads to better satisfaction and outcomes than implants. The timing of reconstruction (immediate versus delayed) was less of an influence on quality of life., (© The Author(s) 2024. Published by Oxford University Press on behalf of BJS Foundation Ltd.)

Introduction: Although breast reconstruction is an integral part of breast cancer treatment, there is little high-quality evidence to indicate which method is the most effective. Randomised controlled trials (RCTs) are generally thought to provide the most solid scientific evidence, but there are significant barriers to conducting RCTs in breast reconstruction, making both recruitment and achieving unbiased and generalisable results a challenge. The objective of this study is to compare implant-based and autologous breast reconstruction in non-irradiated patients. Moreover, the study aims to improve the evidence for trial decision-making in breast reconstruction., Methods and Analysis: The study design partially randomised patient preference trial might be a way to overcome the aforementioned challenges. In the present study, patients who consent to randomisation will be randomised to implant-based and autologous breast reconstruction, whereas patients with strong preferences will be able to choose the method. The study is designed as a superiority trial based on the patient-reported questionnaire BREAST-Q and 124 participants will be randomised. In the preference cohort, patients will be included until 62 participants have selected the least popular alternative. Follow-up will be 60 months. Embedded qualitative studies and within-trial economic evaluation will be performed. The primary outcome is patient-reported breast-specific quality of life/satisfaction, and the secondary outcomes are complications, factors affecting satisfaction and cost-effectiveness., Ethics and Dissemination: The study has been approved by the Swedish Ethical Review Authority (2023-04754-01). Results will be published in peer-reviewed scientific journals and presented at peer-reviewed scientific meetings., Trial Registration Number: NCT06195865., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Breast hypertrophy may cause significant suffering, such as back- and breast pain, painful shoulder groves, and eczemas. Furthermore, women with breast hypertrophy may have lower quality of life than women without breast hypertrophy. Although 50% of the women undergoing breast reduction in the US have body mass index (BMI) >30 kg/m 2 , the current standard of normality is based on studies focusing on women <40 years of age and BMIs <25 kg/m 2 . This study aimed to present reference values for breast measurements for women with obesity and to investigate the relationship between BMI loss and each breast measurement., Materials and Methods: One hundred and six women underwent laparoscopic Roux-en-Y gastric bypass in Gothenburg, Sweden. The participants' breast anthropometrics were measured before and after bariatric surgery and their perception of the skin on their breasts was measured using the Sahlgrenska Excess Skin Questionnaire., Results: Breast volume, sternal notch to nipple (SNN) distance, and ptosis increased significantly with increasing BMI. For instance, women with BMIs between 30-34.9 kg/m 2 have a mean breast volume of approximately 770 ml, those with BMIs of 40-44.9 kg/m 2 have approximately 1150 ml, and those with BMIs above 50 kg/m 2 have approximately 1400 ml. Furthermore, the percent change in the respective breast measurements relative to percent BMI change can be predicted, for instance, with a 20% reduction in BMI, the breast volume, SNN-distance, and ptosis decrease by 25%, 4%, and 20% respectively., Conclusions: This article presents the first standard of normality for breast anthropometrics in women with obesity and a model for predicting the change in breast anthropometrics relative to BMI., Clinical Trial Registration: This is a longitudinal observation study, registered https://fou.nu/is/gsb/ansokan/49651, No: VGFOUGSB-49651. Trial registry name: "Överskottshud efter överviktskirurgi - dess utveckling samt behov och effekt av plastikkirurgi" ("Excess skin after bariatric surgery - its development and the need and effect of plastic surgery")., (Copyright © 2024 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

A large number of children with cleft lip and palate (CLP) were adopted to Sweden in the last decade, mainly from China. Most of the children arrived with unoperated palates and at later ages than earlier years. This article aims to present an overview of ethical challenges within the practice of international adoption of children with CLP from the perspective of plastic surgery in a welfare health care system. An overview of CLP treatment is presented, followed by a normative discussion and ethical analysis using the 4 principles of Beauchamp and Childress: non-maleficence, beneficence, autonomy, and justice. The following themes and subthemes were analyzed: the search for normality and the potential challenge of being adopted and having CLP-treatment autonomy of the child and future preferences, adoptive parents' expectations of plastic surgery, the journey of the adoptee and the adoptive parents; and general issues-reconstructive possibilities and consequences of CLP in the country of origin, information to the adoptive parents, health care needs, and reconstructive possibilities for children with CLP in the receiving country. Clinical implications are discussed, and suggestions for future research are provided., Competing Interests: The authors report no conflicts of interest. The authors report no conflicts of interest., (Copyright © 2024 by Mutaz B. Habal, MD.)

Background: Normative data for interpreting the BREAST-Q reconstruction module are currently limited to four populations. The primary aim of this study was to create Swedish normative values for the BREAST-Q reconstruction domains. The secondary aim was to describe what aspects of the breasts and potential donor sites that women of the general population are generally satisfied or dissatisfied with., Methods: The BREAST-Q reconstruction module was sent to a random sample of 400 women currently living in Region Västra Götaland. Descriptive data are presented., Results: One hundred and forty-six women answered the questionnaire (36.5%). The mean age of the cohort was 53 years, and the mean body mass index (BMI) was 25 kg/m2. Mean total scores ranged from 50 to 90. The mean score for satisfaction with breast was 57 on a 0-100 scale. Women with high BMI values seem to be less satisfied with their breasts and physical and sexual well-being. The participants were most satisfied with their breasts when clothed. Overall, the reported physical well-being related to potential donor sites was high., Conclusions: Normative data for BREAST-Q constitute a reference point, which allows us to put another perspective on changes in scores rather than just comparing scores before and after surgery. Scores were somewhat different than scores in previously published normative populations, which indicates that there might be cultural differences in breast satisfaction.

Background: Knowledge about the prevalence of women with breast implants is paramount in calculations of risks and in estimations of effects on screening and breast cancer treatment. Most of the estimations of prevalence made to date are rough and often based on sales data. The main aim of this study was to  calculate the prevalence of breast implants in Swedish women. The secondary aim was to investigate if it is feasible to establish the occurrence of breast implants with the help of the public mammography screening programme, in a country with a publicly funded welfare-type healthcare system and with a clear documentation of screening., Methods: Information on implants was prospectively collected from all screening attendants from 1st of February 2022 to 1st of August 2022 based on a question from the radiographer to the woman and later verified on the mammogram., Results: During the study period 4,639 women were screened, of which 182 had implants (3.9%). The  frequency varies between 1.6 and 6.4% in different age groups., Conclusion: The prevalence of breast implants in Swedish women is estimated to be around 4%. The population-based mammography screening programme in countries with a publicly funded welfare-type healthcare system and a clear documentation of mammography screening attendance, seems to be a feasible way to establish the prevalence of breast implants in the population. The large number of women with breast implants warrants further studies regarding the best diagnostic and treatment alternatives for this group. Pre-registration: ClinicalTrials.Gov identifier NCT05222100.

Background: Norm values for patient reported outcomes, that is knowledge about how the general population of women rate their breast-related satisfaction and quality of life, are necessary to interpret the meaning of scores. The aims of this study were to create Swedish normative values for the BREAST-Q reduction/mastopexy module and to describe what healthy women are most satisfied/dissatisfied with regarding their breasts., Methods: A random sample of 400 women aged 18-80, currently living in Region Västra Götaland, were sent BREAST-Q reduction/mastopexy. Descriptive data are presented., Results: One hundred and forty-six women answered the questionnaire (36.5%). Mean total scores ranged from 48 to 78. No clear changes in scores could be seen with age and women with a high BMI seem to be less satisfied with their breasts. The participants were most satisfied with the appearance of the breasts when dressed, the appearance in the mirror dressed, the shape of the breasts with bra, and symmetry of size and most dissatisfied with appearance in the mirror naked and the shape of the breasts without a bra. Thirty to forty-five per cent of healthy women never or almost never feel sexually attractive. Among physical symptoms often described in breast hypertrophy, the most common among healthy women were lack of energy, pain in the neck, arms and shoulders, headache and difficulty performing intense physical activity., Conclusion: The norms for BREAST-Q reduction/mastopexy add another piece to the puzzle to what constitutes normal breast satisfaction and how surgical outcomes can be evaluated., Level of Evidence Iv: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors   www.springer.com/00266 ., (© 2022. The Author(s).)

Importance: Guidelines recommend dual antiplatelet therapy after coronary artery bypass grafting (CABG) for patients with acute coronary syndrome (ACS). However, the evidence for these recommendations is weak., Objective: To compare midterm outcomes after CABG in patients with ACS treated postoperatively with acetylsalicylic acid (ASA) and ticagrelor or with ASA monotherapy., Design, Setting, and Participants: This cohort study used merged data from several national registries of Swedish patients who were diagnosed with ACS and subsequently underwent CABG. All included patients underwent isolated CABG in Sweden between 2012 and 2017 with an ACS diagnosis less than 6 weeks before the procedure, survived 14 days after discharge from hospital, and were treated postoperatively with ASA plus ticagrelor or ASA monotherapy. A multivariable Cox regression model was used for the main analysis, and propensity score-matched models were performed as sensitivity analysis. Data were analyzed between May and September 2020., Exposures: Postoperative antiplatelet treatment, defined as filled prescriptions, with either ASA and ticagrelor or ASA only., Main Outcomes and Measures: Major adverse cardiovascular events (MACE), defined as all-cause mortality, myocardial infarction, and stroke, and major bleeding, at 12 months and at the end of follow-up., Results: A total of 6558 patients (5281 [80.5%] men; mean [SD] age at surgery, 67.6 [9.3] years) were included; 1813 (27.6%) were treated with ASA plus ticagrelor and 4745 (72.4%) were treated with ASA monotherapy. Crude MACE rate was 3.0 per 100 person years (95% CI, 2.5-3.6 per 100 person years) in the ASA plus ticagrelor group and 3.8 per 100 person years (95% CI, 3.5-4.1 per 100 person years) in the ASA group. After adjustment, there was no significant difference in MACE risk between ASA plus ticagrelor vs ASA only, neither during the first 12 months (adjusted hazard ratio [aHR], 0.84; 95% CI, 0.58-1.21; P = .34) or during total follow-up (aHR, 0.89; 95% CI, 0.71-1.11; P = .29). The use of ASA plus ticagrelor was associated with a significantly increased risk for major bleeding during the first 12 months (aHR, 1.90; 95% CI, 1.16-3.13; P = .011). Sensitivity analyses confirmed the results., Conclusions and Relevance: In patients with ACS who survived 2 weeks after CABG, no significant difference in the risk of death or ischemic events could be demonstrated between ASA plus ticagrelor and patients treated with ASA only, while the risk for major bleeding was higher in patients treated with ASA plus ticagrelor. Sufficiently powered prospective randomized trials comparing different antiplatelet therapy strategies after CABG are warranted.

Aims: To compare coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for treatment of patients with heart failure due to ischaemic heart disease., Methods and Results: We analysed all-cause mortality following CABG or PCI in patients with heart failure with reduced ejection fraction and multivessel disease (coronary artery stenosis >50% in ≥2 vessels or left main) who underwent coronary angiography between 2000 and 2018 in Sweden. We used a propensity score-adjusted logistic and Cox proportional-hazards regressions and instrumental variable model to adjust for known and unknown confounders. Multilevel modelling was used to adjust for the clustering of observations in a hierarchical database. In total, 2509 patients (82.9% men) were included; 35.8% had diabetes and 34.7% had a previous myocardial infarction. The mean age was 68.1 ± 9.4 years (47.8% were >70 years old), and 64.9% had three-vessel or left main disease. Primary designated therapy was PCI in 56.2% and CABG in 43.8%. Median follow-up time was 3.9 years (range 1 day to 10 years). There were 1010 deaths. Risk of death was lower after CABG than after PCI [odds ratio (OR) 0.62; 95% confidence interval (CI) 0.41-0.96; P = 0.031]. The risk of death increased linearly with quintiles of hospitals in which PCI was the preferred method for revascularization (OR 1.27, 95% CI 1.17-1.38, Ptrend < 0.001)., Conclusion: In patients with ischaemic heart failure, long-term survival was greater after CABG than after PCI., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: The main aim of post-mastectomy breast reconstruction is to improve the patient's quality of life, which makes high-quality and validated patient-reported outcome measurements essential. None of the established instruments include evaluation of donor-site morbidity, such as impact on upper extremity and back function, when a latissimus dorsi (LD) muscle is used; and BREAST-Q LD questionnaire was therefore recently developed for this purpose. The aim of this study was to translate into Swedish and culturally adapt the BREAST-Q LD questionnaire's two subscales, appearance and function, and perform a psychometric evaluation of the subscales in a Swedish population of patients., Methods: This was a cross-sectional study. The questionnaire was translated according to established guidelines. The questionnaires were sent to all patients operated using an LD flap between 2007 and 2017. Internal consistency was assessed using Cronbach's α. Inter-item correlations and corrected item-total correlations were calculated using the Pearson's correlation coefficient. Convergent validity was evaluated by comparing the BREAST-Q LD questionnaire to the Western Ontario Osteoarthritis of the Shoulder Index, using the Spearman correlation coefficient. Test-retest reliability was tested with intraclass correlation coefficients (ICCs), and the coefficient of variation and Bland-Altman plots were drawn. Floor and ceiling effects were calculated. Known-group validation was tested by comparing scores from the patients and from normal controls using the Mann-Whitney U-test and by calculating eta squared effect size., Results: The questionnaires were sent to 176 eligible patients and 125 responded (71%). The patients had been operated a mean of 6.6 years ago, and most (92%) had previous radiation. Internal consistency was satisfactory for both subscales. The correlation coefficients between questions were r > 0.30 for all items of both scales. The corrected item-total correlation coefficient ranged from 0.62 to 0.90. As hypothesised, the function scale was correlated with the WOOS "Physical symptoms" subscale. Reliability was adequate according to the ICCs. The ceiling effect threshold for the appearance scale was reached and that for the back scale was almost reached. There were significant differences between patients and controls, in the hypothesised direction., Conclusions: The results of this study support a good internal consistency, convergent validity, test-retest reliability and known-group validation for the Swedish BREAST-Q LD questionnaire. However, it may be difficult to discriminate between patients with very mild and those with no symptoms using the appearance scale., Trial Registration: ClinicalTrials.Gov identifier NCT04526561.

Introduction: We examined the long-term risk of dementia after coronary artery bypass grafting (CABG) in relation to age and sex., Methods: All CABG patients in Sweden 1992-2015 (n = 111,335), and matched controls (n = 222,396) were included in a population-based study. Adjusted hazard ratios (aHR) for all-cause dementia, vascular dementia, and Alzheimer's disease were calculated., Results: There was no difference in the risk for all-cause dementia between CABG patients and control subjects (aHR 0.98 [95% confidence interval 0.95 to 1.02]). CABG patients <65 years and 65 to 74 years had higher risk (aHR 1.29 [1.17-1.42] and 1.08 [1.02-1.13], respectively), and patients ≥75 years had lower risk (aHR 0.76 [0.71-0.81]). The highest risk was observed in women <65 years (aHR 1.64 [1.31-2.05])., Discussion: Overall, the long-term risk for all-cause dementia does not differ between CABG patients and the general population. Younger patients have a higher risk, while older patients have a lower risk, compared to controls., (© 2020 The Authors. Alzheimer's & Dementia published by Wiley Periodicals, Inc. on behalf of Alzheimer's Association.)

Aims: To evaluate the long-term use of secondary prevention medications [statins, β-blockers, renin-angiotensin-aldosterone system (RAAS) inhibitors, and platelet inhibitors] after coronary artery bypass grafting (CABG) and the association between medication use and mortality., Methods and Results: All patients who underwent isolated CABG in Sweden from 2006 to 2015 and survived at least 6 months after discharge were included (n = 28 812). Individual patient data from SWEDEHEART and other mandatory nationwide registries were merged. Multivariable Cox regression models using time-updated data on dispensed prescriptions were used to assess associations between medication use and long-term mortality. Statins were dispensed to 93.9% of the patients 6 months after discharge and to 77.3% 8 years later. Corresponding figures for β-blockers were 91.0% and 76.4%, for RAAS inhibitors 72.9% and 65.9%, and for platelet inhibitors 93.0% and 79.8%. All medications were dispensed less often to patients ≥75 years. Treatment with statins [hazard ratio (HR) 0.56, 95% confidence interval (95% CI) 0.52-0.60], RAAS inhibitors (HR 0.78, 95% CI 0.73-0.84), and platelet inhibitors (HR 0.74, 95% CI 0.69-0.81) were individually associated with lower mortality risk after adjustment for age, gender, comorbidities, and use of other secondary preventive drugs (all P < 0.001). There was no association between β-blockers and mortality risk (HR 0.97, 95% CI 0.90-1.06; P = 0.54)., Conclusion: The use of secondary prevention medications after CABG was high early after surgery but decreased significantly over time. The results of this observational study, with inherent risk of selection bias, suggest that treatment with statins, RAAS inhibitors, and platelet inhibitors is essential after CABG whereas the routine use of β-blockers may be questioned., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background Low income and short education have been found to be independently associated with inferior survival after coronary artery bypass grafting (CABG), whereas the use of secondary prevention medications is associated with improved survival. We investigated whether underusage of secondary prevention medications contributes to the inferior long-term survival in CABG patients with a low income and short education. Methods and Results Patients who underwent CABG in Sweden between 2006 to 2015 and survived at least 6 months after discharge (n=28 448) were included in a population-based cohort study. Individual patient data from 5 national registries, including the SWEDEHEART (Swedish Web System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies) registry, covering dispensing of secondary prevention medications (statins, platelet inhibitors, β-blockers, and RAAS inhibitors), socioeconomic factors, patient characteristics, comorbidity, and long-term mortaity were merged. All-cause mortality risk was estimated using multivariable Cox regression models adjusted for patient characteristics, baseline comorbidities, time-updated secondary prevention medications, and socioeconomic status. Long-term mortality was higher in patients with a low income and short education. Statins and platelet inhibitors were dispensed less often to patients with a low income, both at baseline and after 8 years. The decline in dispensing over time was steeper for low-income patients. Short education was not associated with reduced dispensing of any secondary prevention medication. Use of statins (adjusted hazard ratio=0.57 [95% CI, 0.53-0.61]), RAAS inhibitors (adjusted hazard ratio=0.78 [0.73-0.84]), and platelet inhibitors (adjusted hazard ratio=0.74 [0.68-0.80]) were associated with reduced long-term mortality irrespective of socioeconomic status. Conclusions Secondary prevention medications are dispensed less often after CABG to patients with low income. Underusage of secondary prevention medications after CABG is associated with increased mortality risk independently of income and extent of education.

In Sweden, evidence-based national guidelines for the indication for reduction mammaplasty in the public health-care system have been developed by a group of experts. They were defined as breast volume≥800 ml at normal weight. Furthermore, a volume asymmetry of 25% or at least 200 ml or an extreme ptosis may be an indication in some cases. The aim of the present paper was to describe an easy-to-use computer-based tool that has been developed to assure that patients with mammary hyperplasia are evaluated and offered care in a standardized fashion and that the adherence to the guidelines is monitored. Included variables were based on a model for priority grouping originally presented by Strömbeck and Malm in 1986 and comprise body mass index (BMI), BMI-corrected breast volume, ptosis, asymmetry, and general breast-related factors preoperatively and 1 year postoperatively and complications postoperatively. Between June 2007 and January 2013, 377 patients were evaluated. Of which, 275 qualified for operation. With the help of the computer-based tool, compliance to the indications for operation can be easily followed, and hence the intended patients offered a reduction mammaplasty in the public health-care system., (Copyright © 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

The aim of palate repair is to restore normal eating and drinking function and normal speech development and still maintain undisturbed facial growth. The repair should be performed with a low frequency of complications. A number of factors are thought to contribute to the formation of fistulas after palatoplasty; they include patient factors and treatment issues. The aim of this study was to review all patients operated on with palatoplasties according to Sommerlad in our clinic, examine the fistula frequency and analyse risk factors for the development of fistulas after palate repair. During the study period, 175 patients were operated on with palatoplasties according to Sommerlad by the senior cleft surgeon. The group included 150 native patients and 25 adopted children. In the native population, seven patients developed fistulas and the fistula frequency was thus 5%. In the non-native group four patients developed fistulas, which gave a fistula frequency of 16%. In conclusion, the fistula frequency after Sommerlad repair of cleft palate is low in our material and few patients need fistula repair. The liberal usage of Langenbeck flaps might give a lower fistula rate. The most common place for fistulas is the junction of the soft and hard palate. No clear difference could be seen between different types of clefts. Syndromes and associated malformation seem to play a small role in the formation of fistulas. The fistula frequency in the non-native population is higher. A number of factors are different in the non-native population., (Copyright © 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Objective: To assess the prevalence, indications and appropriateness of antiplatelet therapy in patients operated for acute aortic dissection and its associations with bleeding complications and mortality., Design: A retrospective single-centre study comparing patients with and without ongoing antiplatelet therapy., Setting: University Hospital in Western Sweden., Patients: 133 consecutive patients operated during 2007-2011., Interventions: All patients were operated for acute aortic dissection type A., Main Outcome Measures: Indication and appropriateness of antiplatelet therapy; perioperative bleeding complications, transfusions and mortality., Results: 43 of 133 patients (32%) had ongoing platelet inhibition at the time of surgery, 19 (14%) with acetylsalicylic acid (ASA) alone and 24 (18%) with ASA and clopidogrel. Unspecific chest pain and ST depression were the most common indications (42% and 23%, respectively). 2.3% had ST elevation and 12% had elevated biomarkers for myocardial injury. Only 29% of the patients with dual antiplatelet therapy had appropriate treatment according to current guidelines. Patients with ongoing platelet inhibition had significantly larger intraoperative (1800 (IQR 950-4250) vs 800 ml (500-2500), p=0.010) and postoperative bleeding volumes (800 (420-1605) vs 500 ml (390-1070), p=0.037). 30-day mortality in patients on dual antiplatelet therapy was 30.4% compared with 13.0% in patients with no or single antiplatelet therapy (p=0.038)., Conclusions: The indication for immediate antiplatelet therapy in patients later operated for acute aortic dissection was weak or absent in the majority of cases. Patients with ongoing platelet inhibition had more bleeding complications. Dual antiplatelet therapy was associated with increased early mortality.

Previously, glucose concentration has been presumed to be similar in seroma, lymph, and plasma. However, there are few studies actually measuring glucose concentration in seroma. The aim of this pilot study was to determine if the glucose concentration in seroma is similar to that in plasma, as it has previously been presumed. Biochemical analysis of seroma was performed on 11 patients that had undergone plastic surgery. Fluid was taken from the drains between postoperative day 3 and 6. The median glucose concentration was 3.09 millimolar (mM) (range 2.25-3.89 mM). Glucose concentration in seroma does not seem to be similar to that of plasma and lymph that has previously been presumed. The result of this pilot study warrants further investigation to determine the span of normal glucose concentration, its development over time, its relation to plasma glucose concentration, and how it is affected by infection.

Body composition measurements are used to evaluate surgical treatment, such as bariatric surgery in overweight patients. Nowadays, there are many different methods to measure body composition available. However, none of them has been validated for use in patients after operation. The aim of the present study was to compare the amount of surgically removed fat with two different methods, bioelectrical impedance analysis (BIA) and total body potassium (TBK). Amount of removed fat during liposuction was measured 1, 2, 3, 4, 14 days, and 1 year postoperatively in 27 obese patients after liposuction. The results were compared with actual removed fat during the operation. The median fat mass removed was 4020 grams (range 1954-9655). Postoperatively there was a varying reduction in fat mass, as measured with BIA and with TBK. There was a clear difference between the range of amounts removed measured with BIA and the range of amount removed measured with TBK. This study indicates that BIA, but not TBK, is an appropriate method to measure fat mass in obese subjects in a surgical setting. BIA seems to underestimate the amount of fat removed, whereas TBK seems to overestimate it.

In recent years adoption of children with cleft lip, with or without cleft palate (CLP), and other birth defects has become more common. The aim of the present study was to describe the characteristics and initial care and treatment of adopted children with CLP. A total of 25 children were referred to our department between 2008 and 2010, 7 (28%) of whom had bilateral CLP and 16 (64%) had unilateral CLP. Two children had atypical clefts. Twenty of the patients (80%) had been operated on with a lip plasty in China before adoption. Most patients (n = 14) was seen by the cleft team within two months of arrival, and 13 were operated on within a month of the first visit at our department. In total, 22 primary palatoplasties, 6 lip plasties, and 1 lip adhesion were done. There were 5 fistulas (14%) three months after the palatoplasty. On arrival, 11 (44%) of the children were carriers of methicillin-resistant Staphylococcus aureus (MRSA). Adoption of children with CLP creates new challenges for the cleft teams, as we no longer have control over the overall treatment plan as regards preoperative and surgical treatment and timing of the operations. The patients are also often carriers of resistant bacteria, which create nursing challenges. In cases where the child is older than a year and has not been operated on, we advocate that the palatoplasty, or combined lip plasty and palatoplasty, is always given priority so that speech development is not compromised.