Background Delayed treatment of Achilles tendon ruptures is generally due to either misdiagnosis or patient delay. When the treatment is delayed more than 4 weeks, the rupture is defined as “chronic”, and almost always requires more invasive surgery and longer rehabilitation time compared with acute Achilles tendon ruptures. There is insufficient knowledge of patient experiences of sustaining and recovering from a chronic Achilles tendon rupture. Methods To evaluate patients’ experiences of suffering a chronic Achilles tendon rupture, semi-structured group interviews were conducted 4–6 years after surgical treatment using a semi-structured interview guide. The data were analyzed using qualitative content analysis described by Graneheim and Lundman. Results The experiences of ten patients (65 ± 14 years, 7 males and 3 females) were summarized into four main categories: (1) “The injury”, where the patients described immediate functional impairments, following either traumatic or non-traumatic injury mechanisms that were misinterpreted by themselves or the health-care system; (2) “The diagnosis”, where the patients expressed relief in receiving the diagnosis, but also disappointment and/or frustration related to the prior misdiagnosis and delay; (3) “The treatment”, where the patients expressed high expectations, consistent satisfaction with the surgical treatment, and addressed the importance of the physical therapist having the right expertise; and (4) “The outcomes”, where the patients expressed an overall satisfaction with the long-term outcome and no obvious limitations in physical activity, although some fear of re-injury emerged. Conclusions An Achilles tendon rupture can occur during both major and minor trauma and be misinterpreted by both the assessing health-care professional as well as the patient themselves. Surgical treatment and postoperative rehabilitation for chronic Achilles tendon rupture results in overall patient satisfaction in terms of the long-term outcomes. We emphasize the need for increased awareness of the occurrence of Achilles tendon rupture in patients with an atypical patient history.

Introduction: In Sweden, during specialty training, the nurse anesthetist learns how to ensure patient safety in a health-care setting by implementing the surgical checklist measures during perioperative care. To date, there are still considerable shortcomings when it comes to implementing these patient safety measures in Swedish hospitals. Aim: The purpose of this study is to describe the use of the WHO surgical safety checklist (WHOSSC) by surgical teams, with special emphasis on nurse anesthetists to increase patient safety. Materials and Methods: This descriptive questionnaire-based study was performed between September 2018 and March 2019 and included 196 health-care professionals who completed the questionnaire. The survey was carried out among all the health-care professionals at two surgical units at a university hospital during the data collection period. Results: The results reveal that the majority of health-care staff in this study agree with the need to implement the WHOSSC during surgery and the necessity of doing so to ensure patient safety. However, it is not clear whether this checklist needs to be made a matter of routine at the clinics and whether this is possible in emergency situations. Conclusion: The nurse anesthetists, as members of the surgical team, use the list all the time in emergency situations and conclude, like other members of the team, that the list improves patient safety. Clearer procedures are needed during surgery regarding the usage of the checklist in practice, and there should be a designated person in the surgical team responsible for implementing the checklist.

Objectives. The present study aimed to assess changes in the perception of and willingness to participate in organ donation (OD) among immigrants from Bosnia and Herzegovina living in Sweden from the perspective of gender differences. Materials and Methods. A cross-sectional study with 60 participants born in Bosnia and Herzegovina and living in Sweden was performed. Data were collected using a self-administrative questionnaire, providing demographic characteristics, information about opinions, awareness, and knowledge on the donation process and religious approach to the subject, willingness to donate/receive organs, and possession of a donor card. Results. Our results showed significant differences between genders regarding the definition of transplantation (P<0.0001), information about OD (P<0.0001), knowledge (P<0.0001) and importance of OD (P<0.003), religious permitting (P=0.0001), and religious opposing (P=0.0007) to OD. Furthermore, a significant difference was observed regarding the preferred recipient (P=0.0062) and the possession of the donor card (P<0.0001). Regression analysis showed that female gender and higher income were statistically significant in prediction of positive attitudes toward OD (P=0.0027, P=0.0002, respectively). Conclusion. Change of social background and integration into Swedish society undoubtedly led to change in the attitudes toward OD, regardless of the perspective of gender differences. However, women were found to have more positive attitudes toward OD.

Background: Despite the overall success of THA, betwen 5-20% report unsatisfactory results. Several factors may cause this variable outcome. One of them is ethnicity, which because of its potential social impact on living conditions may influence life quality. We investigated whether patients born and operated in their home country Bosnia and Herzegovina, report the same results as do patients living in Sweden, born in Europe outside the Nordic countries.Methods: Data were prospectively collected from 280 patients planned to be operated with a THA in Bosnia and Herzegovina, and 449 immigrants born in Europe but outside the Nordic countries. Logistic and linear regression models including age, sex, diagnosis, type of fixation, surgical incision, marital status, and education level were analyzed. Outcomes were the 5 dimensions in EQ-5D, EQ-VAS, pain, VAS, and satisfaction VAS. Data collected before the operation and 1 year after were studied. Results: Before the operation patients born and living in Bosnia and Herzegovina reported more problems with self-care and usual activities before and after adjustment for confounding. Patients living in Sweden reported higher EQ-VAS and more pain on VAS than did those born in Bosnia and Herzegovina, but the difference in EQ-VAS became statistically insignificant after adjustment for confounding. A higher share of patients living in Bosnia and Herzegovina reported more benefit 1 year after the operation in all dimension except from self-care as reflected in the basic chi-square test and the unadjusted and adjusted regression analyses. After adjustment for confounding this group of patients was also more satisfied, but there was no statistically significant difference in pain VAS and EQ-VAS when compared to the immigrant group living in Sweden. Conclusion: Our findings that immigrant patients operated in Sweden despite a tendency to more symptoms before the operation have less benefit from a THA according to EQ5D 1 year after the operation cause concern. We do not know to what extent this situation can be improved by a more multidimensional caretaking of immigrant patients. Probably other factors not only involving the healthcare system play a role as do probably also methodological problems related to these types of studies.

Background For many patients with end-stage disease, organ transplant often provides the only chance for survival. Organ donation (OD) is affected by legislation, cultural and ethnic background, and knowledge and attitudes play a crucial role in promoting that concept. The present study aimed to assess differences in education level, perception, and willingness towards OD among Bosnian immigrants living in Sweden and respondents living in Bosnia and Herzegovina. Study design We performed a quantitative cross-sectional study using a self-administered questionnaire among 204 participants. Methods The questionnaire provided demographic characteristics, information about opinions, awareness, and knowledge on the donation process and religious approach to the subject, willingness to donate/receive organs, and possession of a donor card. Results All respondents supported OD, regardless of their education level. Only 2% of university-educated individuals from Bosnia and Herzegovina claimed to be donor card owners (p<0.001). Most of the university-educated respondents in Sweden, compared to Bosnia and Herzegovina, agreed that OD is needed and should be promoted (73.8% vs. 46.9%, p=0.007), opposite to the non-university-educated (51.4% vs. 66.0%, p=0.024). University-educated respondents stated that the donor card was informative enough (p=0.014) and considered self-perceived knowledge about OD to be sufficient or excellent (p<0.001). Most respondents were married and employed, practicing Muslims. Most of non-university-educated respondents from both countries believe their religion does not oppose OD (p=0.032). However, university-educated individuals strongly believe that OD does not have to be within the same religious group (p=0.016), while other participants did not have a definitive opinion. Conclusions Public behavior towards OD is affected by the social environment and the educational level. The study highlights the importance of achieving a suitable social climate for donation. Also, it suggests that more efforts are needed to harvest the benefits of the substantial support for OD among the Bosnian population.

Background Despite ACL re-ruptures being common, research on patient experiences after knee trauma has primarily focused on the time after primary ACL reconstruction. Integrating qualitative research and patient experiences can facilitate researchers and clinicians in understanding the burden of an ACL re-rupture. The aim of the study was to explore the experiences of an ACL re-rupture journey in young active females aiming to return to knee-strenuous sports after primary ACL reconstruction. Method A two-stage partially mixed sequential dominant status design was used. Fifteen young (19.1[range 16-23] years old) female who suffered an ACL re-rupture were interviewed. Qualitative content analysis using deductive approach based on Wiese-Bjornstal’s ‘integrated model of psychological response to injury’ was used. Results The results are presented in two timelines 1) from first ACL injury to ACL re-rupture, and 2) from ACL re-rupture to present day, and further stratified according to the domains of the ‘integrated model of psychological response to injury’. Results in the first timeline are summarised into seven categories: Finding hope for the journey; Accepting my ACL injury; I succeeded; What matters now? Who am I?; Where will this end? What is going to happen? In the second timeline, eight categories were identified: Fighting spirit; A helping hand; Working hard; I am a new me; I am destroyed; Loneliness; Painful changes; and, I could have made it to the pro´s. Conclusion Young females who suffered an ACL re-rupture did not express any positive experience following their first ACL injury, however, in contrast, expressed positive experiences and personal growth after going through the ACL re-rupture journey, characterized by a lot of struggling, and ultimately lead to the experience of becoming a new, stronger person.

Introduction: The invasion of blood and lymph vessels with tumor tissue represents a negative prognostic factor of the disease course in patients with non-small cell lung cancer. Aim: The aim of the study was to determine the marker value of a preoperatively determined size of pulmonary squamous cell carcinoma and adenocarcinoma and its impact on lymphovascular invasion (LVI) in resected lung tissue. Materials and Methods: The conducted observational cross-sectional study included 322 patients with a complete resection of confirmed squamous cell lung carcinoma and lung adenocarcinoma. Preoperative size and type of tumor were determined by a preoperative chest computed tomography scan and cytological/histological analysis of obtained samples, while LVI status was determined by pathohistological analysis of resected tumor lung tissue. Receiver operating characteristic (ROC) curve analysis was performed to assess whether tumor size could serve as a reliable marker for LVI. P < 0.05 was considered statically significant. Results: A statistically significant difference in the frequency of tumor size (P = 0.580) along with LVI (P = 0.656) was not established between the patients with squamous cell lung cancer and lung adenocarcinoma. A ratio between the size of lung adenocarcinoma and LVI status (P < 0.001) was determined as statistically significant, while such a difference was not established in squamous cell lung cancer (P = 0.052). The ROC analysis revealed that tumor size >39 mm in patients with lung adenocarcinoma has obtained a sensitivity of 70.8% and a specificity of 60.9% to differentiate patients with a LVI (areas under the curve [AUC] = 0.70; 95% CI 0.60‒0.79; P < 0.001). A tumor size >4.6 cm in patients with squamous cell lung cancer obtained a sensitivity of 56.5% and a specificity of 60.3% to differentiate patients with a LVI (AUC = 0.59; 95% CI 0.50‒0.67; P = 0.043). Conclusion: The preoperative size of lung adenocarcinoma could be an acceptable marker of LVI presence in resected lung tissue, while in the squamous cell lung cancer, a potential biomarker role of the preoperative size of the tumor was inadequate.

Psychological impairments can follow an anterior cruciate ligament (ACL) injury and can impact the rehabilitation process. Our aim was to investigate experiences of sports physical therapists (PTs) in addressing psychological impairments in patients after ACL injury. We conducted four focus group interviews with fourteen sports PTs. The PTs’ experiences of working with psychological impairments after ACL injury were summarized in four main categories: (1) “Calling for a guiding light”, where PTs stated that the most common method of acquiring knowledge on addressing psychological impairments was through discussions with colleagues, and, at the same time, PTs expressed an insufficient knowledge of how to address psychological impairments; (2) “Meeting the burden of psychological impairments” where PTs stated that psychological impairments are greater than physical; (3) “Trying to balance physical and psychological aspects” where patient education and assessments were reported to be important in order to understand psychological impairments during rehabilitation; and (4) “Goal setting: a helpful challenge” where sports PTs expressed a need for specific knowledge of the rehabilitation of psychological impairments following ACL injury. To help provide the current best practice, we encourage researchers to develop psychologically centered interventions for rehabilitation after an ACL injury, and PTs to stay up‐to‐date with the literature published on the subject, including to implement eventual interventions.

Background Total hip arthroplasty is the traditional treatment for osteoarthritis in the hip joint. Hip resurfacing arthroplasty, with metal on metal bearing, is a modern concept initially developed mainly for young active people. The metal-on-metal hip arthroplasty implant, Articular Surface Replacement (ASR), was implanted in approximately 93,000 patients before it was recalled in 2010 due to a high complication rate. This study aimed to evaluate patients’ own experiences living with an implant that they knew had a high complication rate and had been recalled from the market. Methods A total of 14 patients, still living with the implant, of a cohort of 34 patients were available for follow-up. Qualitative semi-structured interviews were conducted with 14 patients where a majority actively sought for metal-on-metal hip resurfacing arthroplasty (HRA), and subsequently underwent HRA with an ASR prosthesis between 11/21/2006 and 09/28/2009. The responses were analyzed using content analysis described by Graneheim and Lundman to compress text and identify categories and subcategories. Results The results showed that most patients had already decided that they wanted a metal-on-metal HRA implant before meeting the surgeon. They expressed that the implant made it possible to live an active life. A majority did not think about the fact that they had a hip implant, because they lacked subjective pain. Most of the patients were positive about the annual exams at the hospital and wanted them to continue. None of them felt that their trust towards the healthcare system had changed after the implant recall. They expressed a belief that they would need new surgery sooner than they first thought. Conclusions Despite all the attention when the ASR prosthesis was recalled, patients with ASR-HRA did not report themselves negatively affected by the recall in this group of patients where a majority had actively sought for an HRA procedure. The healthcare system has an obligation to continue the annual exams, even if the implant provider does not continue reimbursement.

BackgroundOrgan donation is a personal choice and many ethical, legal, medical, organisational and social factors are involved. It is possible to transplant some organs from live donors and others only from deceased donors. Nevertheless, the shortage of organs worldwide is a problem. Gender differences may cause decission and willingnes to organ donation. Methods A total of 60 informants (30 men and 30 women), born in Bosnia and Herzegovina and living in Sweden were available for follow-up. Data was collected by a questionnaire and statisticaly analysed according to the chi-square test, the D’Agostino-Pearson test for checking normality of continuous data distribution and, based on the distribution of results, Student’s t test or the Mann-Whitney test. Statistical significance was defined as p < 0.05.Results The result showed that significant differences between men and women was highest in the question about definition of transplantation (p<0.0001), information about organ donation (p<0.0001), knowledge about OD (p<0.0001), importance about OD (p<0.003), religious permitting to OD (p=0.0001), religious opposite to OD (p=0.0007), donate to a special person or not (p=0.0062), religion as factor to donate (p=0.0007). It was not better in question about having the donor card (p<0.0001). ConclusionsWomen were found to have more positive attitudes toward organ donation than men. Different socioeconomic factors, cultural beliefs, a higher level of religiousness, a higher level of information and knowledge about organ donation, as well as the ownership of donor cards, may result in a better perception of and willingness to participate organ donation. More knowledge of the religious understanding of organ donations and the reduction in prejudice among respondents would make the awareness and desire for organ donation even greater.

Aim To examine whether preoperative tumour size may serve as a biomarker for the occurrence of lymphovascular invasion (LVI) in centrally and peripherally located lung adenocarcinoma. Method The study included 261 patients surgically treated for diagnosed lung adenocarcinoma. A ROC curve was used to determine the biomarker potential of tumour size relative to the occurrence of LVI. Binary logistic regression was used to show changes of tumour size impact on the status of LVI. Result Tumour prevalence according to localization had no statistical significance (p=0.464), while the presence of LVI in central, as well as peripheral positions, was statistically significantly different (p<0.001). The area under the curve of 0.978 highlights the fact that tumour size is an excellent marker of the presence of LVI in centrally located adenocarcinomas of the lung. A similar finding was confirmed in peripherally located lung adenocarcinomas with an area below the curve of 0.943. Binary logistical regression showed that in centrally localized adenocarcinomas of the lung, each additional centimetre of tumour growth represents an increase in the likelihood of LVI+ by 17.14 times. In peripherally located adenocarcinomas of the lung, this increase in likelihood of LVI for each centimetre of growth was 5.46 times. Conclusion With a high degree of sensitivity and specificity, preoperative tumour size may serve as an important biomarker and positive predictor of the presence of LVI in lung adenocarcinoma of any location.

Introduction The literature regarding undisplaced femoral neck fractures (FNF) is sparse. The aim of this prospective feasibility study is to compare the clinical outcome after undisplaced FNF treated with internal fixation (IF) and displaced FNF treated with hip arthroplasty. We hypothesized that hip arthroplasty would give a lower incidence of reoperations. Methods A total of 235 patients were included with a median age of 84 years (range 65–99). A consecutive series of 65 patients with undisplaced FNF were treated with IF, and 170 patients with displaced FNF were treated with either a total hip arthroplasty or a hemiarthroplasty. Follow-up interviews were conducted at 1 year using the Harris Hip Score (HHS), WOMAC, and pain numeric rating scale (PNRS). The minimum follow-up time was 22 months. There was no difference in baseline data between the groups. Results Nineteen (8%) hips required reoperation at least once at a mean of 6 months (range 0–35). The rate of reoperation was higher in the IF group compared to the hip arthroplasty group (13.8% vs. 5.9%, 95% CI 0.9–6.4). The overall 1-year and 2-year mortality was 28% and 40%, respectively, with no difference between the groups. The most common reasons for reoperations in the IF group were non-union and avascular necrosis, and 6 patients were treated with hip or excision arthroplasty. In the arthroplasty group, the most common indications were deep infection and dislocation. We did not find any differences between the groups in terms of HHS, WOMAC, and PNRS. Conclusions In this feasibility study, we found no differences in patient-reported outcomes between the groups although IF required a higher rate of reoperations. Further randomized trials are needed to establish the optimal treatment of undisplaced FNF in the elderly. Trial registration ClinicalTrial.org , NCT03392285. Retrospectively registered on 5 February 2018.

Abstract Purpose: To investigate contemporary results of percutaneous transluminal renal angioplasty (PTRA). Materials and Methods: A multicentre retrospective study analysing all patients treated with PTRA for primary symptomatic renal artery stenosis (RAS) between 2010 and 2013 at four tertiary centres. Procedures during the preceding four years were counted to evaluate for change in PTRA frequency. Results: The number of PTRA procedures decreased by approximately 50% from 2006 to 2013. Patients treated in the post-ASTRAL period (n = 224) had a significant reduction in mean systolic pressure (168 to 146 mmHg, p < 0.01), diastolic pressure (84 to 76 mmHg, p < 0.01), number of anti-hypertensive drugs (3.54 to 3.05, p < 0.01), and anti-hypertensive treatment index (21.75 to 16.92, p < 0.01) compared to before PTRA. These improvements were maintained at one year and at the last clinical evaluation after a mean follow-up of 4.31 years. Renal function increased transiently without sustained improvement, or deterioration, during later follow-up. Thirteen patients (5.8%) eventually required dialysis, nine of these had eGFR <20 ml/min/1.73 m2 before PTRA. There was no difference in outcomes between subgroups differentiated by different indications for PTRA. Conclusion: The frequency of PTRA has decreased, indicating a higher threshold for invasive treatment of RAS in recent years. The reduction in blood pressures, the reduced need for anti-hypertensive medication, and stabilization of renal function over time suggest a clinical benefit for most patients who are now being treated with PTRA.

Introduction: Patients with hip fracture are one of the most demanding groups in the health-care system. One of the most important tasks for nurses is to assess pain and ensure the patients are pain free. Pain assessment in patients with dementia is a well-known challenge for health-care professionals due to the patients’ difficulties in verbalising pain problems. Aim: The aim of this study was to explore the experience of intensive care nurses in assessment of pain in patients with hip fracture and dementia in the postoperative setting. Methods: Data were collected through five focus group discussions using open-ended questions and qualitative content analysis. Twenty-one intensive care nurses (6 men and 15 women) participated in the focus group interviews. Results: Analysis of the data resulted in three main categories: “Communication”, “Visual assessment of pain”, and “Practical issues” including a number of subcategories. Some of the factors which influence assessment of pain in patients with dementia are the lack of information and knowledge about the patients, which causes loss of time and increased stress. The different forms of communication and ways of assessing pain in these patients were other factors mentioned by nurses as hindrances regarding assessment of the pain. Conclusion: In order to improve assessment of pain, more knowledge and information about the patients are needed and better coordination between the pre- and postoperative departments regarding these patients. In this context, different intervention studies on patient’s hip fracture and dementia are needed to increase knowledge and awareness regarding this group of patients.

Aim To describe the experience of healthcare professionals in assessing pain and communication in patients with hip fractures and dementia in an emergency department. Methods Data were collected through focus group interviews using open-ended questions, following an interview guide and qualitative content analysis. Twenty one registered nurses participated in the interviews, five male and 16 female, aged 26 to 55 years. Results The analysis of the interviews resulted in three main categories: "Arrival at the emergency department", "Hip track" and "Handover to the ward", including a number of subcategories. All nurses reported that the assessment of pain and communication with patients with dementia and hip fractures was a complex process. A great deal of stress, fast and brief communication, quick decisions and quick treatments in assessment of pain were only some of the difficulties the nurses emphasized. They also suggested a whole series of improvements for those patients. Conclusion The situation of patients with hip fracture and dementia on the emergency department and healthcare professionals who communicate and assess their pain can be said to be untenable. The care environment in the emergency department is not adapted to patients and can of course depend on several factors. To meet the needs of the future and increased numbers of those patients, some improvements such as more extensive research and more studies on the experiences of both the patients and healthcare professionals are required.