Henrik Holmberg

Background: Medicines complement healthy lifestyles in cardiovascular disease (CVD) prevention, but knowledge is lacking on how behaviours in these domains are related. This study aimed at investigating associations between physical activity and diet, and time to initiation of preventive medicines. Method: A cohort study based on the “Visualization of Asymptomatic Atherosclerotic Disease for Optimal Cardiovascular Prevention” (VIPVIZA)-trial, including 60-year-olds of low/moderate CVD-risk who were treatment-naive to antihypertensives or lipid-lowering medicines six months prior trial-inclusion. Sex-specific Cox proportional hazards models were used to analyse impacts of diet and physical activity, each categorized in three levels (least healthy – moderately healthy – healthiest), on initiation of antihypertensives and lipid-lowering medicines. Results: Of 1891 individuals in the cohort, 1340 (58% women) were antihypertensive-naive and 1783 (57% women) were lipid-lowering naive. Significantly faster initiation of antihypertensives was seen in women with the healthiest diet (HR [95%CI] 2.46 [1.18–5.14], ref. least healthy) whereas higher levels of physical activity were significantly associated with slower initiation of antihypertensives in women (HR [95%CI], moderate; 0.51 [0.30–0.88]), high; 0.48 [0.30–0.77], ref. low). Neither diet nor physical activity levels affected initiation of lipid-lowering medicines in women, and lifestyle factors were not associated with initiation of antihypertensives or lipid-lowering medicines in men. Conclusions: Relationships between lifestyle and medicine initiation varies with health behavior, drug-class, and sex. Regarding diet, initiation of antihypertensives in women may agree with a healthy adherer effect, whereas for physical activity, the association appear inverse. Diet and physical activity levels are less influential for initiation in men, and for lipid-lowering medicines. As findings are uncertain, further studies are needed to clarify relationships between these factors. Trial registration: VIPVIZA-trial registration number: NCT01849575, registration date: 2013-05-08.

Background: Despite the global prevalence of groin hernia repairs, there is still limited understanding regarding the impact of surgical expertise on patient outcomes, particularly since a significant portion of hernia repairs worldwide are performed by junior surgeons. This study aims to evaluate the long-term outcomes of groin hernia repairs carried out by specialist compared to those performed by resident surgeons. Material and Methods: This observational, nationwide, population-based registry study utilized prospectively collected data from the Swedish Hernia Register as well as patient-reported outcome measures (PROM) 1 year after groin hernia surgery. Included patients were aged 15 years or older who underwent groin hernia repair between 2012 and 2018. Surgical expertise was categorized as either specialist or resident surgeon. Primary outcome was dissatisfaction and chronic pain 1 year post-surgery. Secondary outcome was reoperation for recurrence with follow-up until 2024. Results: In total, 62 033 groin hernia repairs were analyzed, with a response rate of 70% for PROM questionnaire. Moreover, 72% of surgeries were performed by specialists and 28% by resident surgeons. Multivariable analysis revealed no significant differences. In the specialist group, 5.7% reported dissatisfaction compared to 4.5% in the resident group (odds ratio [OR] 0.92, 95% confidence interval [CI] 0.84–1.02). Chronic pain was experienced by 15.4% of specialist operated patients and 15.5% of resident operated patients (OR 1.05, 95% CI 0.99–1.12). And 2.6% of patients in the specialist group underwent reoperation for recurrence, compared to 2.3% in the resident group (hazard ratio 0.97, 95% CI 0.86–1.11). Conclusion: Groin hernia repairs represent a significant surgical procedure for resident surgeons in training. The level of surgical expertise was not found to be associated with increased long-term complications, suggesting that resident surgeons do not affect groin hernia patients negatively.

Bleeding and thrombotic events are known complications in myeloproliferative neoplasms (MPNs), but few studies have exclusively focused on patients with myelofibrosis (MF). In this nationwide population-based study, we assessed the frequency of major bleeding, thrombotic events, and all-cause mortality in 1079 patients diagnosed with MF and 5395 matched controls using multiple Swedish health care registers. Major bleeding, arterial, and venous events were seen at a rate of 2.55, 2.59, and 1.06 events per 100 years, respectively, in patients with MF. Compared to controls, the rates of bleedings, arterial events, venous events, and mortality were increased, with hazard ratios of 3.78 (95% confidence interval [CI], 2.98-4.79; P < .001), 1.73 (95% CI, 1.40-2.12; P < .001), 2.75 (95% CI, 1.93-3.90; P < .001), and 3.92 (95% CI, 3.50-4.40; P < .001), respectively. Patients treated with JAK inhibitors (JAKis) had higher rates of major bleeding (5.33), arterial events (4.67), and venous events (1.56) than patients with no ongoing symptom–directed therapy (rates, 2.32, 2.15, and 0.79) or hydroxyurea (rates, 2.05, 2.35, and 1.27, respectively). The use of JAKis or low-molecular-weight heparin, previous arterial or venous events, and older age were identified as independent risk factors for new arterial or venous events. A previous venous event, higher leukocyte count at diagnosis, and ongoing JAKi treatment were associated with an increased risk of major bleeding. This study shows that patients with MF have higher rates of thromboembolic events and major bleeding than described in other MPNs, and thromboembolic complications and major bleeding diverge in the different treatment groups.

Purpose: Annually, more than 24,000 groin hernia repairs are performed in Sweden and Denmark, approximately 12,000 of which are laparoscopic like totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) repairs. TEP is the preferred technique in Sweden, whereas TAPP is preferred in Denmark. This study aimed to assess the risk of reoperation for recurrence following TAPP, TEP, and Lichtenstein techniques. Method: Prospectively collected data from the Danish Hernia Database and the Swedish Hernia Register were utilized for this observational register-based study. Primary groin hernia repairs utilizing TEP, TAPP, or Lichtenstein techniques between 2004 and 2020 were included. The primary outcome was the reoperation rate for recurrence analyzed using both crude reoperation rates and Cox proportional hazard regression analysis. Results: During 17 years, 347,912 primary groin hernia repairs were performed, of which 12% were TEP, 15% TAPP, and 74% Lichtenstein repairs. In males, the risk of reoperation was higher after TEP than after TAPP (HR 1.38, 95% CI 1.27–1.5) and Lichtenstein (HR 1.44, 95% CI 1.36–1.53). In females, Lichtenstein repair had a higher risk than the laparoscopic approaches, with no significant difference between TAPP and TEP. Conclusion: Our study demonstrated low rates of reoperation for recurrence after Lichtenstein, TEP, and TAPP repairs. In men, TEP repair is associated with an increased risk of reoperation for recurrence compared with Lichtenstein and TAPP repair. For females, the laparoscopic approaches were superior to the Lichtenstein repair. These findings emphasize the importance of international comparative studies to optimize hernia management strategies.

Background/Objectives: Emergency groin hernia repairs have consistently presented a higher risk of mortality and morbidity. This study aimed to compare both short- and long-term outcomes associated with emergency groin hernia surgery. Methods: A nationwide, population-based cohort study was conducted using prospective collected data from the Swedish Hernia Register combined with a questionnaire assessing patient-reported chronic pain. All patients who underwent a groin hernia repair between 2012 and 2018 were eligible for inclusion. Primary outcomes included 30-day mortality, chronic pain 1-year post-surgery, 30-day postoperative complication, and bowel resection and reoperation for recurrence for emergency versus elective repairs. Risk factors for these outcomes in emergency repair were investigated. Results: A total of 94,349 repairs were analyzed, with 5401 (5%) emergency repairs. Emergency repairs involved older patients (median age 74 vs. 65), more women (25% vs. 9%), more ASA grade III (38% vs. 12%), more femoral hernias (19% vs. 3%) and smaller defects (24% vs. 17%) compared to elective repairs. Multivariable analysis revealed increased rates and significant risks for 30-day mortality (2.7%, OR 11.61), chronic pain (20.6%, OR 1.30), 30-day postoperative complications (21.9%, OR 2.12) and bowel resection (7.8%, OR 408) compared to elective repairs. No significant difference was observed for reoperation for recurrence. Key risk factors for the outcomes following emergency repairs were higher age, higher ASA grade and femoral hernias. Conclusions: Emergency hernia surgery continues to pose a high risk of mortality and morbidity. Elective repair should be considered in frail patients and those with potential femoral hernias.

Ethiopia has experienced growth in the utilization of family planning services. However, there are reports of relatively low client satisfaction across the country. The objective of this study was to assess client and facility level predictors of satisfaction with family planning services in Ethiopia. A multi-level mixed effects logistic regression analysis was conducted on a national survey obtained from the service provision assessment 2021–22. A total of 2071 clients (level one) and 529 facilities (level two) were included. Overall, 56% of clients were highly satisfied with the family planning service they received. Findings from the random effects of the multilevel analysis show there is a significant difference in client satisfaction between facilities, with an intra-class correlation of 0.56 in the null model. At the client-level, age above 30, auditory privacy, and discussion on side effects are significantly associated with higher client satisfaction. At the facility level, having a waiting area, facilities with a quality unit and/or committee, a DHIS2 reporting system, operating for more than 20 days a month, privately owned facilities and availability of family planning guidelines are associated with higher odds of being satisfied. On the other hand, at the client level, having a primary or higher education, increasing wait time and clients asking their providers questions are associated with lower odds of being satisfied. At the facility level, having a fixed user fee significantly reduces the odds of client satisfaction. Human resource and professional development training and health system strengthening is recommended.

Objectives: To explore changes in beliefs about medicines and self-reported medication non-adherence between 3 and 24 months after stroke and to investigate associations between beliefs about medicines and non-adherence at 24 months after stroke. Design: Longitudinal questionnaire survey. Setting: Patients treated for acute stroke in 25 Swedish hospitals. Participants: Only patients living at home were included. Of the 594 individuals who answered the 3 month questionnaire, 401 were included at 24 months; among the remainder, 34 (5.7%) had died, 149 (25,1%) did not respond or had incomplete information on adherence and 10 (1.7%) were not living at home. Measures: The primary outcome was self-reported medication adherence as measured with the Medication Adherence Report Scale (MARS). The Beliefs about Medicines Questionnaires (BMQ) was used to assess personal beliefs about medicines. Background and clinical data were included from the Swedish national stroke register. Results: According to dichotomised MARS sum scores, more individuals were classified as non-adherent at 24 months after stroke (n=63, 15.7%) than at 3 months after stroke (n=45, 11.2%) (p=0.030). For BMQ, the only difference over time was an increase in the Necessity subscale (p=0.007). At 24 months, in comparison to adherent patients, non-adherent patients scored statistically significant higher on negative beliefs about medicines, such as Concern (OR 1.17, 95% CI: 1.09 to 1.25), Overuse (OR: 1.37, 95% CI: 1.21 to 1.54) and Harm (OR: 1.24, 95% CI: 1.11 to 1.39), and lower on positive beliefs about medicines, namely, Necessity (OR: 0.88, 95% CI: 0.80 to 0.96) and Benefit (OR: 0.85, 95% CI: 0.74 to 0.98). Conclusions: Stroke patients‘ beliefs about medicines were associated with adherence, and over time beliefs remained stable across all domains, except for an increased perception of medications as being necessary. Despite this, more patients became non-adherent over time. To counteract non-adherence, interventions targeted to improve intentional adherence as well as non-intentional adherence should be investigated and implemented.

Objective: This study investigated the effectiveness of supramaximal high-intensity interval training (supramaximal HIT) on muscle capacities and physical function compared to moderate-intensity training (MIT) for older adults. Methods: Sixty-eight older adults (66–79 years, 56% women), not engaged in regular exercise, were randomised to 3 months of twice-weekly supramaximal HIT (20 minutes including 10 × 6-second intervals) or MIT (40 minutes including 3 × 8-minute intervals). Both groups performed the training on stationary bicycles in a group setting. Target intensity was watt-controlled, with standardised cadence and individualised resistance. Outcomes analysed with linear-mixed models included leg power (Nottingham Power Rig), hand grip strength (Jamar dynamometer), static and dynamic balance (One leg stance, 30-second step test), chair stand (30-second chair stand), and anaerobic cycling performance (modified Borg Cycle Strength Test). Results: Baseline values were (supramaximal HIT/MIT, mean ± SD) leg power 198 ± 60/189 ± 53 W, hand grip strength 4.2 ± 1.0/4.3 ± 1.1 N/kg, static balance 64 ± 41/62 ± 41 s, dynamic balance 39 ± 7/38 ± 5 steps, chair stands 22 ± 6/22 ± 6 and anaerobic cycling performance 224 ± 60/217 ± 55 W. At 3-month follow-up, a between-group difference in favour of supramaximal HIT [95% CI] was observed in anaerobic cycling performance of 19[3;35] W. Within-group mean changes for supramaximal HIT/MIT were for leg power 8.4[0.9;15.8]/6.0[−1.3;13.3] W, hand grip strength 0.14[0.00;0.27]/0.13[−0.01;0.26] N/kg, static balance 11[3;20]/10[1;18] s, dynamic balance 1.6[0.3;2.8]/2.3[1.1;3.6] steps, 2.1[1.1;3.1]/1.4[0.4;2.3] chair stands and anaerobic cycling performance 31.3[19.6;43.0]/12.0[0.4;23.5] W. Conclusion: Supramaximal HIT showed superior effect on anaerobic cycling performance when compared to MIT. Additionally, the results indicate that supramaximal HIT is comparably beneficial as MIT in terms of effects on muscle capacity and physical function for older adults.

Background: People with intermediate CVD risk constitute most of the population. Within this group, the proportion of events is lower compared to the high-risk group, but they contribute with the largest absolute number of events. Atherosclerosis is a dynamic process and progression can be slowed or even reversed with medication and lifestyle changes, but adherence to prescribed treatment is crucial. Aim: To investigate the long-term effects of interventions with pictorial risk communication of cardiovascular (CVD) risk on average adherence in a group of statin users. Compare response in adherence over time between men and women after intervention. Methods: Participants on active statin treatment were followed up to 5 years after being randomly assigned to an intervention program aimed at raising CVD risk awareness among participants and their physicians. Merging prescribed medication databases with VIPVIZA study to study adherence over time. A moving average adherence was used to compare groups. Results: Generally, the average adherence to statins among the 512 participants was high. Men had a higher average adherence over time, while women had a sharper increase in adherence in conjuncture with the intervention program. Conclusions: Both men and women were receptive to pictorial information regarding CVD risk, but the intervention effect was more pronounced in women. Sex differences are important when considering risk communication strategies. Periodically repeating the intervention was beneficial for maintaining the intervention effect over time. Trial registration: The VIPVIZA study is registered with ClinicalTrials.gov, May 8, 2013, number NCT01849575.