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  • 1.
    Ahl, Rebecka
    Örebro universitet, Institutionen för medicinska vetenskaper.
    The Association Between Beta-Blockade and Clinical Outcomes in the Context of Surgical and Traumatic Stress2019Doktorsavhandling, sammanläggning (Övrigt vetenskapligt)
    Abstract [en]

    Traumatic injury and major abdominal surgery are areas in general surgery associated with high rates of morbidity and mortality. The overall colorectal cancer surgery mortality rate is around 4%, with that for emergency surgery more than twice as high as for planned. Surgical morbidity varies between 25% and 45%. Around half of trauma patients develop low mood. In one quarter of patients this becomes permanent. Depression is known to impede physical rehabilitation and recovery. The onset of physiological stress, driven by adrenergic hyperactivity following traumatic and surgical injury is hypothesized to contribute to these adverse outcomes. Interest has therefore been sparked into blocking adrenergic receptor activation.

    Papers I and II investigated the role of beta-blocker therapy in preventing post-traumatic depression following severe traumatic brain injury (Paper I) and severe extracranial injury (Paper II). The Karolinska University Hospital Trauma Registry was used to identify patients admitted between 2007 and 2011. In Paper I (n = 545), patients on pre-injury beta-blocker therapy were matched to beta-blocker naïve patients with equivalent injury burden. Results revealed that beta-blocked patients exhibited a 60% reduced risk of needing antidepressant therapy within one year of trauma. In Paper II (n = 596), the lack of beta-blocker use before extracranial trauma was linked to a three-fold increase in the risk of antidepressant initiation.

    Papers III-V explored the role of pre-operative beta-blocker therapy in patients undergoing surgery for colorectal cancer between 2007 and 2016, identified using the nationwide Swedish Colorectal Cancer Registry. Paper III (n = 3,187) identified a 69% reduction in the risk of 30-day mortality in beta-blocked patients. Paper IV (n = 22,337) outlined long-term survival benefits for patients on beta-blocker therapy prior to undergoing elective surgery for colon cancer. Beta-blocked patients showed a risk reduction of 42% for 1-year all-cause mortality and 18% for 5-year cancerspecific mortality. Similarly, patients on beta-blocker therapy who underwent surgery for rectal cancer demonstrated improved survival up to one year after surgery with a risk reduction of 57% and a reduction in anastomotic failure and infectious complications in Paper V (n = 11,966).

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  • 2.
    Ahl, Rebecka
    et al.
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden.
    Barmparas, Galinos
    Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, USA.
    Riddez, Louis
    Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden.
    Ley, Eric J.
    Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, USA.
    Wallin, Göran
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Ljungqvist, Olle
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohseni, Shahin
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden; Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden.
    Does beta-blockade reduce the risk of depression in patients with isolated severe extracranial injuries?2017Ingår i: World Journal of Surgery, ISSN 0364-2313, E-ISSN 1432-2323, Vol. 41, nr 7, s. 1801-1806Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Approximately half of trauma patients develop post-traumatic depression. It is suggested that beta-blockade impairs trauma memory recollection, reducing depressive symptoms. This study investigates the effect of early beta-blockade on depression following severe traumatic injuries in patients without significant brain injury.

    METHODS: Patients were identified by retrospectively reviewing the trauma registry at an urban university hospital between 2007 and 2011. Severe extracranial injuries were defined as extracranial injuries with Abbreviated Injury Scale score ≥3, intracranial Abbreviated Injury Scale score <3 and an Injury Severity Score ≥16. In-hospital deaths and patients prescribed antidepressant therapy ≤1 year prior to admission were excluded. Patients were stratified into groups based on pre-admission beta-blocker status. The primary outcome was post-traumatic depression, defined as receiving antidepressants ≤1 year following trauma.

    RESULTS: Five hundred and ninety-six patients met the inclusion criteria with 11.4% prescribed pre-admission beta-blockade. Patients receiving beta-blockers were significantly older (57 ± 18 vs. 42 ± 17 years, p < 0.001) with lower Glasgow Coma Scale score (12 ± 3 vs. 14 ± 2, p < 0.001). The beta-blocked cohort spent significantly longer in hospital (21 ± 20 vs. 15 ± 17 days, p < 0.01) and intensive care (4 ± 7 vs. 3 ± 5 days, p = 0.01). A forward logistic regression model was applied and predicted lack of beta-blockade to be associated with increased risk of depression (OR 2.7, 95% CI 1.1-7.2, p = 0.04). After adjusting for group differences, patients lacking beta-blockers demonstrated an increased risk of depression (AOR 3.3, 95% CI 1.2-8.6, p = 0.02).

    CONCLUSIONS: Pre-admission beta-blockade is associated with a significantly reduced risk of depression following severe traumatic injury. Further investigation is needed to determine the beneficial effects of beta-blockade in these instances.

  • 3.
    Ahl, Rebecka
    et al.
    Örebro universitet, Institutionen för medicinska vetenskaper. Sweden Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden; Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.
    Forssten, Maximilian Peter
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Pourlotfi, Arvid
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Cao, Yang
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län.
    Bass, Gary Alan
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Traumatology, Surgical Critical Care and Emergency Surgery, Penn Medicine, Penn Presbyterian Medical Center, Philadelphia, PA, USA.
    Matthiessen, Peter
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Colorectal Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohseni, Shahin
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Sweden.
    The Association Between Revised Cardiac Risk Index and Postoperative Mortality Following Elective Colon Cancer Surgery: A Retrospective Nationwide Cohort Study2021Ingår i: Scandinavian Journal of Surgery, ISSN 1457-4969, E-ISSN 1799-7267, Vol. 111, nr 1, artikel-id 14574969211037588Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    INTRODUCTION: Despite improvements in the perioperative care during the last decades for oncologic colon resection, there is still a substantial risk for postoperative complications and mortality. Opportunities exist for improvement in preoperative risk stratification in this patient population. We hypothesize that the Revised Cardiac Risk Index, a user-friendly tool, could better identify patients with high postoperative mortality risks.

    METHODS: A retrospective analysis of operated patients between the years 2007 and 2017 was undertaken, using the prospectively recorded Swedish Colorectal Cancer Registry, which has a 99.5% national coverage for all cases of colon cancer. Patients were cross-referenced with the Swedish National Board of Health and Welfare dataset, a government registry of mortality and comorbidity data. Revised Cardiac Risk Index (RCRI) scores were calculated for each patient and stratified into four groups (RCRI 1, 2, 3, ⩾ 4). A Poisson regression model with robust standard errors of variance was employed to correlate the 90-day postoperative survival with each level of the Revised Cardiac Risk Index.

    RESULTS: A total of 24,198 patients met the study inclusion criteria. 90-day postoperative mortality increased from 2.4% in patients with RCRI 1 to 10.1% in patients with RCRI ⩾ 4 (p < 0.001). Adjusted 90-day postoperative mortality increased linearly with an increasing RCRI, where an RCRI of 2, 3, and ≥ 4 respectively led to a 46%, 80%, and 167% increased risk of mortality compared to RCRI 1 (p < 0.001).

    CONCLUSIONS: A strong association between an increasing Revised Cardiac Risk Index score and increased 90-day postoperative mortality risk was detected. The Revised Cardiac Risk Index may facilitate risk stratification of patients undergoing elective colon cancer surgery.

  • 4.
    Ahl, Rebecka
    et al.
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden.
    Lindgren, Rickard
    Region Örebro län. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Cao, Yang
    Örebro universitet, Institutionen för medicinska vetenskaper. Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
    Riddez, Louis
    Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, Solna, Sweden.
    Mohseni, Shahin
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, Örebro, Sweden; Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden.
    Risk factors for depression following traumatic injury: An epidemiological study from a scandinavian trauma center2017Ingår i: Injury, ISSN 0020-1383, E-ISSN 1879-0267, Vol. 48, nr 5, s. 1082-1087Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    INTRODUCTION: A significant proportion of patients suffer depression following traumatic injuries. Once manifested, major depression is challenging to overcome and its presence risks impairing the potential for physical rehabilitation and functional recovery. Risk stratification for early detection and intervention in these instances is important. This study aims to investigate patient and injury characteristics associated with an increased risk for depression.

    METHODS: All patients with traumatic injuries were recruited from the trauma registry of an urban university hospital between 2007 and 2012. Patient and injury characteristics as well as outcomes were collected for analysis. Patients under the age of eighteen, prescribed antidepressants within one year of admission, in-hospital deaths and deaths within 30days of trauma were excluded. Pre- and post-admission antidepressant data was requested from the national drugs registry. Post-traumatic depression was defined as the prescription of antidepressants within one year of trauma. To isolate independent risk factors for depression a multivariable forward stepwise logistic regression model was deployed.

    RESULTS: A total of 5981 patients met the inclusion criteria of whom 9.2% (n=551) developed post-traumatic depression. The mean age of the cohort was 42 [standard deviation (SD) 18] years and 27.1% (n=1620) were females. The mean injury severity score was 9 (SD 9) with 18.4% (n=1100) of the patients assigned a score of at least 16. Six variables were identified as independent predictors for post-traumatic depression. Factors relating to the patient were female gender and age. Injury-specific variables were penetrating trauma and GCS score of≤8 on admission. Furthermore, intensive care admission and increasing hospital length of stay were predictors of depression.

    CONCLUSION: Several risk factors associated with the development of post-traumatic depression were identified. A better targeted in-hospital screening and patient-centered follow up can be offered taking these risk factors into consideration.

  • 5.
    Ahl, Rebecka
    et al.
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Surgery, Karolinska University Hospital, Stockholm, Sweden; School of Medical Sciences, Örebro University, Örebro, Sweden.
    Matthiessen, P.
    School of Medical Sciences, Örebro University, Örebro, Sweden; Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Fang, X.
    Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
    Cao, Yang
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden; .
    Sjölin, Gabriel
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Surgery.
    Lindgren, R.
    Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Ljungqvist, Olle
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
    Mohseni, Shahin
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Department of Surgery.
    Effect of beta-blocker therapy on early mortality after emergency colonic cancer surgery2019Ingår i: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 106, nr 4, s. 477-483Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Emergency colorectal cancer surgery is associated with significant mortality. Induced adrenergic hyperactivity is thought to be an important contributor. Downregulating the effects of circulating catecholamines may reduce the risk of adverse outcomes. This study assessed whether regular preoperative beta-blockade reduced mortality after emergency colonic cancer surgery.

    METHODS: This cohort study used the prospectively collected Swedish Colorectal Cancer Registry to recruit all adult patients requiring emergency colonic cancer surgery between 2011 and 2016. Patients were subdivided into those receiving regular beta-blocker therapy before surgery and those who were not (control). Demographics and clinical outcomes were compared. Risk factors for 30-day mortality were evaluated using Poisson regression analysis.

    RESULTS: A total of 3187 patients were included, of whom 685 (21·5 per cent) used regular beta-blocker therapy before surgery. The overall 30-day mortality rate was significantly reduced in the beta-blocker group compared with controls: 3·1 (95 per cent c.i. 1·9 to 4·7) versus 8·6 (7·6 to 9·8) per cent respectively (P < 0·001). Beta-blocker therapy was the only modifiable protective factor identified in multivariable analysis of 30-day all-cause mortality (incidence rate ratio 0·31, 95 per cent c.i. 0·20 to 0·47; P < 0·001) and was associated with a significant reduction in death of cardiovascular, respiratory, sepsis and multiple organ failure origin.

    CONCLUSION: Preoperative beta-blocker therapy may be associated with a reduction in 30-day mortality following emergency colonic cancer surgery.

  • 6.
    Ahl, Rebecka
    et al.
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Surgery, Karolinska University Hospital, Stockholm, Sweden.
    Matthiessen, Peter
    School of Medical Sciences, Örebro University, Örebro, Sweden; Division of Colorectal Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Cao, Yang
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län.
    Sjölin, Gabriel
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Ljungqvist, Olle
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Surgery, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden.
    Mohseni, Shahin
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    The Relationship Between Severe Complications, Beta-Blocker Therapy and Long-Term Survival Following Emergency Surgery for Colon Cancer2019Ingår i: World Journal of Surgery, ISSN 0364-2313, E-ISSN 1432-2323, Vol. 43, nr 10, s. 2527-2535Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Emergency surgery for colon cancer carries significant morbidity, and studies show more than doubled mortality when comparing elective to emergency surgery. The relationship between postoperative complications and survival has been outlined. Beta-blocker therapy has been linked to improved postoperative outcomes. This study aims to assess the impact of postoperative complications on long-term survival following emergency surgery for colon cancer and to determine whether beta-blockade can reduce complications.

    STUDY DESIGN: This cohort study utilized the prospective Swedish Colorectal Cancer Registry to identify adults undergoing emergency colon cancer surgery between 2011 and 2016. Prescription data for preoperative beta-blocker therapy were collected from the national drug registry. Cox regression was used to evaluate the effect of beta-blocker exposure and complications on 1-year mortality, and Poisson regression was used to evaluate beta-blocker exposure in patients with major complications.

    RESULTS: A total of 3139 patients were included with a mean age of 73.1 [12.4] of which 671 (21.4%) were prescribed beta-blockers prior to surgery. Major complications occurred in 375 (11.9%) patients. Those suffering major complications showed a threefold increase in 1-year mortality (adjusted HR = 3.29; 95% CI 2.75-3.94; p < 0.001). Beta-blocker use was linked to a 60% risk reduction in 1-year mortality (adjusted HR = 0.40; 95% CI 0.26-0.62; p < 0.001) but did not show a statistically significant association with reductions in major complications (adjusted IRR = 0.77; 95% CI 0.59-1.00; p = 0.055).

    CONCLUSION: The development of major complications after emergency colon cancer surgery is associated with increased mortality during one year after surgery. Beta-blocker therapy may protect against postoperative complications.

  • 7.
    Ahl, Rebecka
    et al.
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Surgery, Karolinska University Hospital, Stockholm, Sweden.
    Matthiessen, Peter
    School of Medical Sciences, Örebro University, Örebro, Sweden; Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Fang, Xin
    Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
    Cao, Yang
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län.
    Sjölin, Gabriel
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Lindgren, Rickard
    Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Ljungqvist, Olle
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
    Mohseni, Shahin
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Department of Surgery.
    β-Blockade in Rectal Cancer Surgery: A Simple Measure of Improving Outcomes2020Ingår i: Annals of Surgery, ISSN 0003-4932, E-ISSN 1528-1140, Vol. 271, nr 1, s. 140-146Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    OBJECTIVE: To ascertain whether regular β-blocker exposure can improve short- and long-term outcomes after rectal cancer surgery.

    BACKGROUND: Surgery for rectal cancer is associated with substantial morbidity and mortality. There is increasing evidence to suggest that there is a survival benefit in patients exposed to β-blockers undergoing non-cardiac surgery. Studies investigating the effects on outcomes in patients subjected to surgery for rectal cancer are lacking.

    METHODS: All adult patients undergoing elective abdominal resection for rectal cancer over a 10-year period were recruited from the prospectively collected Swedish Colorectal Cancer Registry. Patients were subdivided according to preoperative β-blocker exposure status. Outcomes of interest were 30-day complications, 30-day cause-specific mortality, and 1-year all-cause mortality. The association between β-blocker use and outcomes were analyzed using Poisson regression model with robust standard errors for 30-day complications and cause-specific mortality. One-year survival was assessed using Cox proportional hazards regression model.

    RESULTS: A total of 11,966 patients were included in the current study, of whom 3513 (29.36%) were exposed to regular preoperative β-blockers. A significant decrease in 30-day mortality was detected (incidence rate ratio = 0.06, 95% confidence interval: 0.03-0.13, P < 0.001). Deaths of cardiovascular nature, respiratory origin, sepsis, and multiorgan failure were significantly lower in β-blocker users, as were the incidences in postoperative infection and anastomotic failure. The β-blocker positive group had significantly better survival up to 1 year postoperatively with a risk reduction of 57% (hazard ratio = 0.43, 95% confidence interval: 0.37-0.52, P < 0.001).

    CONCLUSIONS: Preoperative β-blocker use is strongly associated with improved survival and morbidity after abdominal resection for rectal cancer.

  • 8.
    Ahl, Rebecka
    et al.
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Surgery, Karolinska University Hospital, Stockholm, Sweden; School of Health and Medical Sciences, Örebro University, Örebro, Sweden; Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.
    Matthiessen, Peter
    School of Health and Medical Sciences, Örebro University, Örebro, Sweden; Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Sjölin, Gabriel
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Cao, Yang
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län.
    Wallin, Göran
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Ljungqvist, Olle
    Örebro universitet, Institutionen för medicinska vetenskaper.
    Mohseni, Shahin
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län.
    Effects of beta-blocker therapy on mortality after elective colon cancer surgery: a Swedish nationwide cohort study2020Ingår i: BMJ Open, E-ISSN 2044-6055, Vol. 10, nr 7, artikel-id e036164Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    OBJECTIVE: Colon cancer surgery remains associated with substantial postoperative morbidity and mortality despite advances in surgical techniques and care. The trauma of surgery triggers adrenergic hyperactivation which drives adverse stress responses. We hypothesised that outcome benefits are gained by reducing the effects of hyperadrenergic activity with beta-blocker therapy in patients undergoing colon cancer surgery. This study aims to test this hypothesis.

    DESIGN: Retrospective cohort study.

    SETTING AND PARTICIPANTS: This is a nationwide study which includes all adult patients undergoing elective colon cancer surgery in Sweden over 10 years. Patient data were collected from the Swedish Colorectal Cancer Registry. The national drugs registry was used to obtain information about beta-blocker use. Patients were subdivided into exposed and unexposed groups. The association between beta-blockade, short-term and long-term mortality was evaluated using Poisson regression, Kaplan-Meier curves and Cox regression.

    PRIMARY AND SECONDARY OUTCOMES: Primary outcome of interest was 1-year all-cause mortality. Secondary outcomes included 90-day all-cause and 5-year cancer-specific mortality.

    RESULTS: The study included 22 337 patients of whom 36.1% were prescribed preoperative beta-blockers. Survival was higher in patients on beta-blockers up to 1 year after surgery despite this group being significantly older and of higher comorbidity. Regression analysis demonstrated significant reductions in 90-day deaths (IRR 0.29, 95% CI 0.24 to 0.35, p<0.001) and a 43% risk reduction in 1-year all-cause mortality (adjusted HR 0.57, 95% CI 0.52 to 0.63, p<0.001) in beta-blocked patients. In addition, cancer-specific mortality up to 5 years after surgery was reduced in beta-blocked patients (adjusted HR 0.80, 95% CI 0.73 to 0.88, p<0.001).

    CONCLUSION: Preoperative beta-blockade is associated with significant reductions in postoperative short-term and long-term mortality following elective colon cancer surgery. Its potential prophylactic effect warrants further interventional studies to determine whether beta-blockade can be used as a way of improving outcomes for this patient group.

  • 9.
    Ahl, Rebecka
    et al.
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Surgery, Karolinska University Hospital, Stockholm, Sweden.
    Matthiessen, Peter
    School of Medical Science, Örebro University, Örebro, sweden; Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Sjölin, Gabriel
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Cao, Yang
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län.
    Wallin, Göran
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Ljungqvist, Olle
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Surgery, Örebro University Hospital, Örebro, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
    Mohseni, Shahin
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Department of Surgery.
    The Effects of Beta-Blocker Therapy on Mortality After Elective Colon Cancer SurgeryManuskript (preprint) (Övrigt vetenskapligt)
  • 10.
    Ahl, Rebecka
    et al.
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden; Division of Surgery, Department of Clinical Science Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.
    Mohammad Ismail, Ahmad
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Borg, Tomas
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Sjölin, Gabriel
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Forssten, Maximilian Peter
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Cao, Yang
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län.
    Wretenberg, Per
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohseni, Shahin
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    A nationwide observational cohort study of the relationship between beta-blockade and survival after hip fracture surgery2022Ingår i: European Journal of Trauma and Emergency Surgery, ISSN 1863-9933, E-ISSN 1863-9941, Vol. 48, nr 2, s. 743-751Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    PURPOSE: Despite advances in the care of hip fractures, this area of surgery is associated with high postoperative mortality. Downregulating circulating catecholamines, released as a response to traumatic injury and surgical trauma, is believed to reduce the risk of death in noncardiac surgical patients. This effect has not been studied in hip fractures. This study aims to assess whether survival benefits are gained by reducing the effects of the hyper-adrenergic state with beta-blocker therapy in patients undergoing emergency hip fracture surgery.

    METHODS: This is a retrospective nationwide observational cohort study. All adults [Formula: see text] 18 years were identified from the prospectively collected national quality register for hip fractures in Sweden during a 10-year period. Pathological fractures were excluded. The cohort was subdivided into beta-blocker users and non-users. Poisson regression with robust standard errors and adjustments for confounders was used to evaluate 30-day mortality.

    RESULTS: 134,915 patients were included of whom 38.9% had ongoing beta-blocker therapy at the time of surgery. Beta-blocker users were significantly older and less fit for surgery. Crude 30-day all-cause mortality was significantly increased in non-users (10.0% versus 3.7%, p < 0.001). Beta-blocker therapy resulted in a 72% relative risk reduction in 30-day all-cause mortality (incidence rate ratio 0.28, 95% CI 0.26-0.29, p < 0.001) and was independently associated with a reduction in deaths of cardiovascular, respiratory, and cerebrovascular origin and deaths due to sepsis or multiorgan failure.

    CONCLUSIONS: Beta-blockers are associated with significant survival benefits when undergoing emergency hip fracture surgery. Outlined results strongly encourage an interventional design to validate the observed relationship.

  • 11.
    Ahl, Rebecka
    et al.
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Surgery, Division of Trauma and Emergency Surgery, Karolinska University Hospital, Stockholm, Sweden.
    Phelan, Herb A
    Univ of Texas Southwestern Medical Center, Parkland Memorial Hospital, Dallas, USA.
    Dogan, Sinan
    Department of Surgery, Division of Trauma and Emergency Surgery, Örebro University Hospital, Örebro, Sweden.
    Cao, Yang
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
    Cook, Allyson C.
    UT-Southwestern Medical Center. Parkland Memorial Hospital, Dallas, USA.
    Mohseni, Shahin
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Department of Surgery, Division of Trauma and Emergency Surgery, Örebro University Hospital, Örebro, Sweden; Department of Surgery, Division of Trauma and Emergency Surgery, Karolinska University Hospital, Stockholm, Sweden.
    Predicting In-Hospital and 1-Year Mortality in Geriatric Trauma Patients Using Geriatric Trauma Outcome Score2017Ingår i: Journal of the American College of Surgeons, ISSN 1072-7515, E-ISSN 1879-1190, Vol. 224, nr 3, s. 264-269Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: The Geriatric Trauma Outcome Score, GTOS (= [age] + [Injury Severity Score (ISS)x2.5] + 22 [if packed red blood cells (PRBC) transfused ≤24hrs of admission]), was developed and validated as a prognostic indicator for in-hospital mortality in elderly trauma patients. However, GTOS neither provides information regarding post-discharge outcomes, nor discriminates between patients dying with and without care restrictions. Isolating the latter, GTOS prediction performance was examined during admission and 1-year post-discharge in a mature European trauma registry.

    Study Design: All trauma admissions ≥65years in a university hospital during 2007-2011 were considered. Data regarding age, ISS, PRBC transfusion ≤24hrs, therapy restrictions, discharge disposition and mortality were collected. In-hospital deaths with therapy restrictions and patients discharged to hospice were excluded. GTOS was the sole predictor in a logistic regression model estimating mortality probabilities. Performance of the model was assessed by misclassification rate, Brier score and area under the curve (AUC).

    Results: The study population was 1080 subjects with a median age of 75 years, mean ISS of 10 and PRBC transfused in 8.2%). In-hospital mortality was 14.9% and 7.7% after exclusions. Misclassification rate fell from 14% to 6.5%, Brier score from 0.09 to 0.05. AUC increased from 0.87 to 0.88. Equivalent values for the original GTOS sample were 9.8%, 0.07, and 0.87. One-year mortality follow-up showed a misclassification rate of 17.6%, and Brier score of 0.13.

    Conclusion: Excluding patients with care restrictions and discharged to hospice improved GTOS performance for in-hospital mortality prediction. GTOS is not adept at predicting 1-year mortality.

  • 12.
    Ahl, Rebecka
    et al.
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Surgery, Division of Trauma and Acute Care Surgery, Karolinska University Hospital, Stockholm, Sweden.
    Riddez, Louis
    Department of Surgery, Division of Trauma and Acute Care Surgery, Karolinska University Hospital, Stockholm, Sweden.
    Mohseni, Shahin
    Department of Surgery, Division of Trauma and Acute Care Surgery, Karolinska University Hospital, Stockholm, Sweden; Department of Surgery, Division of Trauma and Acute Care Surgery, Örebro University Hospital, Örebro, Sweden; Örebro University, Örebro, Sweden.
    Digital rectal examination for initial assessment of the multi-injured patient: Can we depend on it?2016Ingår i: Annals of Medicine and Surgery, E-ISSN 2049-0801, Vol. 9, s. 77-81Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Digital rectal examination (DRE) is part of the assessment of trauma patients as recommended by ATLS (R). The theory behind is to aid early diagnosis of potential lower intestinal, urethral and spinal cord injuries. Previous studies suggest that test characteristics of DRE are far from reliable. This study examines the correlation between DRE findings and diagnosis and whether DRE findings affect subsequent management.

    Materials and methods: Patients with ICD-10 codes for spinal cord, urethral and lower intestinal injuries were identified from the trauma registry at an urban university hospital between 2007 and 2011. A retrospective review of electronic medical records was carried out to analyse DRE findings and subsequent management.

    Results: 253 patients met the inclusion criteria with a mean age of 44 +/- 20 years and mean ISS of 26 +/- 16. 160 patients had detailed DRE documentation with abnormal findings in 48%. Sensitivity rate was 0.47. Correlational analysis between examination findings and diagnosis gave a kappa of 0.12. Subsequent management was not altered in any case due to DRE findings.

    Conclusion: DRE in trauma settings has low sensitivity and does not change subsequent management. Excluding or postponing this examination should therefore be considered. (C) 2016 The Author(s). Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

  • 13.
    Ahl, Rebecka
    et al.
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Surgery, Karolinska University Hospital, Stockholm, Sweden.
    Sarani, Babak
    Department of Surgery, Center for Trauma and Critical Care, George Washington University, Washington, USA.
    Sjölin, Gabriel
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Surgery, Division of Trauma and Emergency Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohseni, Shahin
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Department of Surgery.
    The Association of Intracranial Pressure Monitoring and Mortality: A Propensity Score-Matched Cohort of Isolated Severe Blunt Traumatic Brain Injury2019Ingår i: Journal of Emergencies, Trauma and Shock, ISSN 0974-2700, E-ISSN 0974-519X, Vol. 12, nr 1, s. 18-22Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Intracranial pressure (ICP) monitoring in traumatic brain injury (TBI) is common. Yet, its efficacy varies between studies, and the actual effect on the outcome is debated. This study investigates the association of ICP monitoring and clinical outcome in patients with an isolated severe blunt TBI.

    Patients and Methods: Patients were recruited from the American College of Surgeons-Trauma Quality Improvement Program database during 2014. Inclusion criteria were limited to adult patients (>= 18 years) who had a sustained isolated severe intracranial injury (Abbreviated Injury Scale [AIS] head of >= 3 and Glasgow Coma Scale [GCS] of <= 8) following blunt trauma to the head. Patients with AIS score >0 for any extracranial body area were excluded. Patients' demographics, injury characteristics, interventions, and outcomes were collected for analysis. Patients receiving ICP monitoring were matched in a 1:1 ratio with controls who were not ICP monitored using propensity score matching.

    Results: A total of 3289 patients met inclusion criteria. Of these, 601 (18.3%) were ICP monitored. After propensity score matching, 557 pairs were available for analysis with a mean age of 44 (standard deviation 18) years and 80.2% of them were male. Median GCS on admission was 4[3,7], and a third of patients required neurosurgical intervention. There were no statistical differences in any variables included in the analysis between the ICP-monitored group and their matched counterparts. ICP-monitored patients required significantly longer intensive care unit and hospital length of stay and had an increased mortality risk with odds ratio of 1.6 (95% confidence interval: 1.1-2.5, P = 0.038).

    Conclusion: ICP monitoring is associated with increased in-hospital mortality in patients with an isolated severe TBI. Further investigation into which patients may benefit from this intervention is required.

  • 14.
    Ahl, Rebecka
    et al.
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Surgery, Division of Trauma and Emergency Surgery, Karolinska University Hospital, Stockholm, Sweden.
    Sjölin, Gabriel
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Surgery, Division of Trauma and Emergency Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohseni, Shahin
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Department of Surgery, Division of Trauma and Emergency Surgery, Karolinska University Hospital, Stockholm, Sweden; Department of Surgery, Division of Trauma and Emergency Surgery, Örebro University Hospital, Örebro, Sweden.
    Corrigendum to "Does early beta-blockade in isolated severe traumatic brain injury reduce the risk of post traumatic depression?": [Injury 48 (2017) 101–105]2017Ingår i: Injury, ISSN 0020-1383, E-ISSN 1879-0267, Vol. 48, nr 11, s. 2612-2612Artikel i tidskrift (Refereegranskat)
  • 15.
    Ahl, Rebecka
    et al.
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden.
    Sjölin, Gabriel
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohseni, Shahin
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden; Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Does early beta-blockade in isolated severe traumatic brain injury reduce the risk of post traumatic depression?2017Ingår i: Injury, ISSN 0020-1383, E-ISSN 1879-0267, Vol. 48, nr 1, s. 101-105Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Introduction: Depressive symptoms occur in approximately half of trauma patients, negatively impacting on functional outcome and quality of life following severe head injury. Pontine noradrenaline has been shown to increase upon trauma and associated beta-adrenergic receptor activation appears to consolidate memory formation of traumatic events. Blocking adrenergic activity reduces physiological stress responses during recall of traumatic memories and impairs memory, implying a potential therapeutic role of beta-blockers. This study examines the effect of pre-admission beta-blockade on post-traumatic depression.

    Methods: All adult trauma patients (>= 18 years) with severe, isolated traumatic brain injury (intracranial Abbreviated Injury Scale score (AIS) >= 3 and extracranial AIS <3) were recruited from the trauma registry of an urban university hospital between 2007 and 2011. Exclusion criteria were in-hospital deaths and prescription of antidepressants up to one year prior to admission. Pre- and post-admission beta-blocker and antidepressant therapy data was requested from the national drugs registry. Post-traumatic depression was defined as the prescription of antidepressants within one year of trauma. Patients with and without pre-admission beta-blockers were matched 1: 1 by age, gender, Glasgow Coma Scale, Injury Severity Score and head AIS. Analysis was carried out using McNemar's and Student's t-test for categorical and continuous data, respectively.

    Results: A total of 545 patients met the study criteria. Of these, 15% (n = 80) were prescribed beta-blockers. After propensity matching, 80 matched pairs were analyzed. 33% (n = 26) of non beta-blocked patients developed post-traumatic depression, compared to only 18% (n = 14) in the beta-blocked group (p = 0.04). There were no significant differences in ICU (mean days: 5.8 (SD 10.5) vs. 5.6 (SD 7.2), p = 0.85) or hospital length of stay (mean days: 21 (SD 21) vs. 21 (SD 20), p = 0.94) between cohorts.

    Conclusion: beta-blockade appears to act prophylactically and significantly reduces the risk of posttraumatic depression in patients suffering from isolated severe traumatic brain injuries. Further prospective randomized studies are warranted to validate this finding.

  • 16.
    Ahl, Rebecka
    et al.
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden ; .
    Thelin, Eric Peter
    Department of Clinical Neuroscience, Karolinska Institutet Solna, Stockholm, Sweden.
    Sjölin, Gabriel
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Bellander, Bo Michael
    Department of Clinical Neuroscience, Karolinska Institutet Solna, Stockholm, Sweden.
    Riddez, Louis
    Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden.
    Talving, Peep
    Department of Surgery, Tartu University Hospital, Tartu, Estonia.
    Mohseni, Shahin
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden; Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, Orebro, Sweden.
    β-Blocker after severe traumatic brain injury is associated with better long-term functional outcome: a matched case control study2017Ingår i: European Journal of Trauma and Emergency Surgery, ISSN 1863-9933, E-ISSN 1863-9941, Vol. 43, nr 6, s. 783-789Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    PURPOSE: Severe traumatic brain injury (TBI) is the predominant cause of death and disability following trauma. Several studies have observed improved survival in TBI patients exposed to β-blockers, however, the effect on functional outcome is poorly documented.

    METHODS: Adult patients with severe TBI (head AIS ≥ 3) were identified from a prospectively collected TBI database over a 5-year period. Patients with neurosurgical ICU length of stay <48 h and those dying within 48 h of admission were excluded. Patients exposed to β-blockers ≤ 48 h after admission and who continued with treatment until discharge constituted β-blocked cases and were matched to non β-blocked controls using propensity score matching. The outcome of interest was Glasgow Outcome Scores (GOS), as a measure of functional outcome up to 12 months after injury. GOS ≤ 3 was considered a poor outcome. Bivariate analysis was deployed to determine differences between groups. Odds ratio and 95% CI were used to assess the effect of β-blockers on GOS.

    RESULTS: 362 patients met the inclusion criteria with 21% receiving β-blockers during admission. After propensity matching, 76 matched pairs were available for analysis. There were no statistical differences in any variables included in the analysis. Mean hospital length of stay was shorter in the β-blocked cases (18.0 vs. 26.8 days, p < 0.01). The risk of poor long-term functional outcome was more than doubled in non-β-blocked controls (OR 2.44, 95% CI 1.01-6.03, p = 0.03).

    CONCLUSION: Exposure to β-blockers in patients with severe TBI appears to improve functional outcome. Further prospective randomized trials are warranted.

  • 17.
    Bass, G. A.
    et al.
    Örebro universitet, Institutionen för medicinska vetenskaper. Departments of Surgery, Tallaght University Hospital, Dublin, Ireland; Division of Traumatology, Surgical Critical Care & Emergency Surgery, Penn Medicine, Penn Presbyterian Medical Center, Philadelphia, USA.
    Pourlotfi, Arvid
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Donnelly, Mark
    Department of Surgery, Tallaght University Hospital, Dublin, Ireland.
    McIntyre, Caroline
    Departments of Surgery, Tallaght University Hospital, Dublin, Ireland.
    Ahl, Rebecka
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Trauma ande Emergency Surgery, department of Surgery, Karolinska University Hospital, Stockholm, Sweden; Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden .
    Flod, Sara
    Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Cao, Yang
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län.
    McNamara, Deirdre
    Department of Gastroenterology, Tallaght University Hospital, Dublin, Ireland.
    Sarani, Babak
    Department of Surgery, George Washington University, Washington DC, USA.
    Gillis, Amy E.
    Department of Surgery, Tallaght University Hospital, Dublin, Ireland.
    Mohseni, Shahin
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Bile Duct Clearance and Cholecystectomy for Choledocholithiasis: Definitive Single-Stage Laparoscopic Cholecystectomy with Intra-Operative Endoscopic Retrograde Cholangiopancreatography (ERCP) versus Staged Procedures2021Ingår i: Journal of Trauma and Acute Care Surgery, ISSN 2163-0755, E-ISSN 2163-0763, Vol. 90, nr 2, s. 240-248Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Clinical equipoise exists regarding optimal sequencing in the definitive management of choledocholithiasis. Our current study compares sequential biliary ductal clearance and cholecystectomy at an interval to simultaneous laparoendoscopic management on index admission in a pragmatic retrospective manner.

    METHODS: Records were reviewed for all patients admitted between January 2015-December 2018 to a Swedish and an Irish university hospital. Both hospitals differ in their practice patterns for definitive management of choledocholithiasis. At the Swedish hospital, patients with choledocholithiasis underwent laparoscopic cholecystectomy with intra-operative rendezvous ERCP at index admission (one-stage). In contrast, interval day-case laparoscopic cholecystectomy followed index admission ERCP (two-stage) at the Irish hospital. Clinical characteristics, post-procedural complications, and inpatient duration were compared between cohorts.

    RESULTS: Three hundred and fifty-seven patients underwent treatment for choledocholithiasis during the study period, of whom 222(62.2%) underwent a one-stage procedure in Sweden, while 135(37.8%) underwent treatment in two stages in Ireland. Patients in both cohorts were closely matched in terms of age, sex, and pre-operative serum total bilirubin. Patients in the one-stage group exhibited a greater inflammatory reaction on index admission (peak C-reactive protein = 136±137 vs. 95±102mg/L,p=0.024), had higher incidence of co-morbidities (age-adjusted Charlson Comorbidity Index ≥3:37.8% vs 20.0%,p=0.003), and overall were less fit for surgery (ASA ≥3: 11.7% vs. 3.7%,p < 0.001). Despite this, a significantly-shorter mean time to definitive treatment, i.e., cholecystectomy (3.1±2.5 vs. 40.3±127 days,p=0.017), without excess morbidity, was seen in the one-stage compared to the two-stage cohort. Patients in the one-stage cohort experienced shorter mean post-procedure length of stay(3.0±4.7 vs 5.0±4.6 days,p < 0.001) and total length of hospital stay(6.5±4.6 vs 9.0±7.3 days,p=0.002). The only significant difference in postoperative complications between the cohorts was urinary retention, with a higher incidence in the one-stage cohort (19% vs. 1%, p=0.004).

    CONCLUSION: Where appropriate expertise and logistics exist within developing models of Acute Care Surgery worldwide, consideration should be given to index-admission laparoscopic cholecystectomy with intraoperative ERCP for the treatment of choledocholithiasis. Our data suggest this strategy significantly shortens the time to definitive treatment, decreases total hospital stay without any excess in adverse outcomes.

  • 18.
    Bass, Gary Alan
    et al.
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania, USA.
    Forssten, Maximilian Peter
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Pourlotfi, Arvid
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Ahl, Rebecka
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; 5 Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden.
    Cao, Yang
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län.
    Matthiessen, Peter
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, Örebro, Sweden.
    Mohseni, Shahin
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Cardiac risk stratification in emergency resection for colonic tumours2021Ingår i: BJS Open, E-ISSN 2474-9842, Vol. 5, nr 4, artikel-id zrab057Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Despite advances in perioperative care, the postoperative mortality rate after emergency oncological colonic resection remains high. Risk stratification may allow targeted perioperative optimization and cardiac risk stratification. This study aimed to test the hypothesis that the Revised Cardiac Risk Index (RCRI), a user-friendly tool, could identify patients who would benefit most from perioperative cardiac risk mitigation.

    METHODS: Patients who underwent emergency resection for colonic cancer from 2007 to 2017 and registered in the Swedish Colorectal Cancer Registry (SCRCR) were analysed retrospectively. These patients were cross-referenced by social security number to the Swedish National Board of Health and Welfare data set, a government registry of mortality, and co-morbidity data. RCRI scores were calculated for each patient and correlated with 90-day postoperative mortality risk, using Poisson regression with robust error of variance.

    RESULTS: Some 5703 patients met the study inclusion criteria. A linear increase in crude 90-day postoperative mortality was detected with increasing RCRI score (37.3 versus 11.3 per cent for RCRI 4 or more versus RCRI 1; P < 0.001). The adjusted 90-day all-cause mortality risk was also significantly increased (RCRI 4 or more versus RCRI 1: adjusted incidence rate ratio 2.07, 95 per cent c.i. 1.49 to 2.89; P < 0.001).

    CONCLUSION: This study documented an association between increasing cardiac risk and 90-day postoperative mortality. Those undergoing emergency colorectal surgery for cancer with a raised RCRI score should be considered high-risk patients who would most likely benefit from enhanced postoperative monitoring and critical care expertise.

    Ladda ner fulltext (pdf)
    Cardiac risk stratification in emergency resection for colonic tumours
  • 19.
    Bass, Gary Alan
    et al.
    Örebro universitet, Institutionen för medicinska vetenskaper.
    Forssten, Maximilian Peter
    Örebro universitet, Institutionen för medicinska vetenskaper.
    Ryan, Eanna
    Biloslavo, Alan
    General Surgery Department, Cattinara University Hospital, Trieste, Italy.
    Tolonen, Matti
    Ahl, Rebecka
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län.
    Kurihara, Hayato
    Pourlotfi, Arvid
    Örebro universitet, Institutionen för medicinska vetenskaper.
    Kaplan, Lewis J.
    Division of Trauma, Surgical Critical Care, and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia PA, USA; Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia PA, USA.
    Mohseni, Shahin
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län.
    Techniques for Mesoappendix Transection and Appendix Resection When Performing Acute Appendectomy: Insights from the SnapAppy Group Audit2022Ingår i: Journal of the American College of Surgeons, ISSN 1072-7515, E-ISSN 1879-1190, Vol. 235, nr 5 Suppl. 2, s. S24-S24Artikel i tidskrift (Övrigt vetenskapligt)
    Abstract [en]

    Introduction: Surgically managed appendicitis exhibits great heterogeneity regarding mesoappendix transection, and appendix amputation from its base. It is unclear whether a particular surgical technique provides an outcome benefit or reduces complication.

    Methods: We undertook a pre-specified subgroup analysis of all patients who underwent laparoscopic appendectomy at index admission during the SnapAppy time-bound prospective multi-institutional non-randomized observational cohort study between November 1st 2020 - August 31st 2021 at 71 centers in 14 countries. Poisson regression models were employed for investigating the association between different surgical techniques for mesoappendix as well as stump management and postoperative complication while adjusting for potential confounding.

    Results: A total of 2,252 patients were included in the analyses of the technique used for dividing the mesoappendix, 69% by electrocautery and 31% by energy device. 3,729 patients were included for analyses of the management of the stump. The appendix was amputated using looped ligatures in 37%, staples in 38%, and clips in 25% of cases. After adjusting for confounders, the risk of postoperative complication was reduced by 42% when an energy device was used for handling the mesoappendix [adjusted incidence rate ratio (95% CI): 0.58 (0.41-0.82), p = 0.002]; however, no difference was detected between the techniques used for dividing the appendix at its base.

    Conclusion: Safe mesoappendix transection and appendix resection are accomplished using heterogeneous techniques. Energy devices are associated with a lower rate of overall complication while no differences were observed when comparing the techniques used for dividing the appendix base.

  • 20.
    Cao, Yang
    et al.
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län.
    Bass, G. A.
    Örebro universitet, Institutionen för medicinska vetenskaper. Faculty of Medicine and Health, School of Medical Sciences, Department of Surgery, Örebro University, Örebro, Sweden; Department of Surgery, Tallaght University Hospital, Dublin, Ireland.
    Ahl, Rebecka
    Örebro universitet, Institutionen för medicinska vetenskaper. Faculty of Medicine and Health, School of Medical Sciences, Department of Surgery, Örebro University, Örebro, Sweden; Department of General Surgery, Karolinska University Hospital, Stockholm, Sweden.
    Pourlotfi, Arvid
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of General Surgery, Örebro University Hospital, Örebro, Sweden.
    Geijer, Håkan
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Radiology.
    Montgomery, Scott
    Örebro universitet, Institutionen för medicinska vetenskaper. Clinical Epidemiology Division, Department of Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Epidemiology and Public Health, University College London, London, UK..
    Mohseni, Shahin
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Department of General Surgery, Örebro University Hospital, Örebro, Sweden.
    The statistical importance of P-POSSUM scores for predicting mortality after emergency laparotomy in geriatric patients2020Ingår i: BMC Medical Informatics and Decision Making, E-ISSN 1472-6947, Vol. 20, nr 1, artikel-id 86Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Geriatric patients frequently undergo emergency general surgery and accrue a greater risk of postoperative complications and fatal outcomes than the general population. It is highly relevant to develop the most appropriate care measures and to guide patient-centered decision-making around end-of-life care. Portsmouth - Physiological and Operative Severity Score for the enumeration of Mortality and morbidity (P-POSSUM) has been used to predict mortality in patients undergoing different types of surgery. In the present study, we aimed to evaluate the relative importance of the P-POSSUM score for predicting 90-day mortality in the elderly subjected to emergency laparotomy from statistical aspects.

    METHODS: One hundred and fifty-seven geriatric patients aged ≥65 years undergoing emergency laparotomy between January 1st, 2015 and December 31st, 2016 were included in the study. Mortality and 27 other patient characteristics were retrieved from the computerized records of Örebro University Hospital in Örebro, Sweden. Two supervised classification machine methods (logistic regression and random forest) were used to predict the 90-day mortality risk. Three scalers (Standard scaler, Robust scaler and Min-Max scaler) were used for variable engineering. The performance of the models was evaluated using accuracy, sensitivity, specificity and area under the receiver operating characteristic curve (AUC). Importance of the predictors were evaluated using permutation variable importance and Gini importance.

    RESULTS: The mean age of the included patients was 75.4 years (standard deviation =7.3 years) and the 90-day mortality rate was 29.3%. The most common indication for surgery was bowel obstruction occurring in 92 (58.6%) patients. Types of post-operative complications ranged between 7.0-36.9% with infection being the most common type. Both the logistic regression and random forest models showed satisfactory performance for predicting 90-day mortality risk in geriatric patients after emergency laparotomy, with AUCs of 0.88 and 0.93, respectively. Both models had an accuracy > 0.8 and a specificity ≥0.9. P-POSSUM had the greatest relative importance for predicting 90-day mortality in the logistic regression model and was the fifth important predictor in the random forest model. No notable change was found in sensitivity analysis using different variable engineering methods with P-POSSUM being among the five most accurate variables for mortality prediction.

    CONCLUSION: P-POSSUM is important for predicting 90-day mortality after emergency laparotomy in geriatric patients. The logistic regression model and random forest model may have an accuracy of > 0.8 and an AUC around 0.9 for predicting 90-day mortality. Further validation of the variables' importance and the models' robustness is needed by use of larger dataset.

  • 21.
    Ekestubbe, Lovisa
    et al.
    School of Medical Sciences, Örebro University, Örebro, Sweden.
    Bass, Gary Alan
    Örebro universitet, Institutionen för medicinska vetenskaper.
    Forssten, Maximilian Peter
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Sjölin, Gabriel
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Cao, Yang
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län.
    Matthiessen, Peter
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Colorectal Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Ahl, Rebecka
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden; Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.
    Mohseni, Shahin
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Pharmacological differences between beta-blockers and postoperative mortality following colon cancer surgery2022Ingår i: Scientific Reports, E-ISSN 2045-2322, Vol. 12, nr 1, artikel-id 5279Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    β-blocker therapy has been positively associated with improved survival in patients undergoing oncologic colorectal resection. This study investigates if the type of β-blocker used affects 90-day postoperative mortality following colon cancer surgery. The study was designed as a nationwide retrospective cohort study including all adult (≥ 18 years old) patients with ongoing β-blocker therapy who underwent elective and emergency colon cancer surgery in Sweden between January 1, 2007 and December 31, 2017. Patients were divided into four cohorts: metoprolol, atenolol, bisoprolol, and other beta-blockers. The primary outcome of interest was 90-day postoperative mortality. A Poisson regression model with robust standard errors was used, while adjusting for all clinically relevant variables, to determine the association between different β-blockers and 90-day postoperative mortality. A total of 9254 patients were included in the study. There was no clinically significant difference in crude 90-day postoperative mortality rate [n (%)] when comparing the four beta-blocker cohorts metoprolol, atenolol, bisoprolol and other beta-blockers. [97 (1.8%) vs. 28 (2.0%) vs. 29 (1.7%) vs. 11 (1.2%), p = 0.670]. This remained unchanged when adjusting for relevant covariates in the Poisson regression model. Compared to metoprolol, there was no statistically significant decrease in the risk of 90-day postoperative mortality with atenolol [adj. IRR (95% CI): 1.45 (0.89-2.37), p = 0.132], bisoprolol [adj. IRR (95% CI): 1.45 (0.89-2.37), p = 0.132], or other beta-blockers [adj. IRR (95% CI): 0.92 (0.46-1.85), p = 0.825]. In patients undergoing colon cancer surgery, the risk of 90-day postoperative mortality does not differ between the investigated types of β-adrenergic blocking agents.

  • 22.
    Forssten, Maximilian Peter
    et al.
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohammad Ismail, Ahmad
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Borg, Tomas
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Ahl, Rebecka
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Surgery, Karolinska University Hospital, Stockholm, Sweden.
    Wretenberg, Per
    Örebro universitet, Institutionen för medicinska vetenskaper. School of Medical Sciences, Örebro University, Örebro, Sweden.
    Cao, Yang
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län.
    Peden, Carol J.
    Department of Clinical Anesthesiology, University of Southern California Keck School of Medicine, Los Angeles, California, USA; Department of Anesthesiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
    Mohseni, Shahin
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Postoperative mortality in hip fracture patients stratified by the Revised Cardiac Risk Index: a Swedish nationwide retrospective cohort study2021Ingår i: Trauma surgery & acute care open, E-ISSN 2397-5776, Vol. 6, nr 1, artikel-id e000778Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objectives: The Revised Cardiac Risk Index (RCRI) is a tool that can be used to evaluate the 30-day risk of postoperative myocardial infarction, cardiac arrest and mortality. This study aims to confirm its association with postoperative mortality in patients who underwent hip fracture surgery.

    Methods: All adults who underwent primary emergency hip fracture surgery in Sweden between January 1, 2008 and December 31, 2017 were included in this study. The database was retrieved by cross-referencing the Swedish National Quality Register for hip fractures with the Swedish National Board of Health and Welfare registers. The outcomes of interest were the association between the RCRI score and mortality at 30 days, 90 days and 1 year postoperatively.

    Results: 134 915 cases were included in the current study. There was a statistically significant linear trend in postoperative mortality with increasing RCRI scores at 30 days, 90 days and 1 year. An RCRI score ≥4 was associated with a 3.1 times greater risk of 30-day postoperative mortality (adjusted incidence rate ratio (IRR) 3.13, p<0.001), a 2.5 times greater risk of 90-day postoperative mortality (adjusted IRR 2.54, p<0.001) and a 2.8 times greater risk of 1-year postoperative mortality (adjusted HR 2.81, p<0.001) compared with that observed with an RCRI score of 0.

    Conclusion: An increasing RCRI score is strongly associated with an elevated risk 30-day, 90-day and 1-year postoperative mortality after primary hip fracture surgery. The objective and easily retrievable nature of the variables included in the RCRI calculation makes it an appealing choice for risk stratification in the clinical setting.

    Levels of evidence: Level III.

  • 23.
    Forssten, Maximilian Peter
    et al.
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohammad Ismail, Ahmad
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Sjölin, Gabriel
    Örebro universitet, Institutionen för medicinska vetenskaper.
    Ahl, Rebecka
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Surgery, Karolinska University Hospital, Stockholm, Sweden; Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden.
    Wretenberg, Per
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Snwede.
    Borg, Tomas
    Region Örebro län. Örebro universitet, Institutionen för medicinska vetenskaper. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohseni, Shahin
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    The association between the Revised Cardiac Risk Index and short-term mortality after hip fracture surgery2022Ingår i: European Journal of Trauma and Emergency Surgery, ISSN 1863-9933, E-ISSN 1863-9941, Vol. 48, nr 3, s. 1885-1892Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    PURPOSE: The post-operative mortality after hip fracture surgery is high and has remained largely unchanged during the last decades. The Revised Cardiac Risk Index (RCRI) is a tool used to evaluate the 30-day risk of, among other outcomes, post-operative mortality. The aim of this study is to determine the association between the RCRI score and post-operative mortality in patients undergoing hip fracture surgery.

    METHODS: Data was obtained from the national hip fracture register which was cross-referenced with patients' electronic hospital records. All adults who underwent primary emergency hip fracture surgery in Orebro County, Sweden, between January 1, 2013 and December 31, 2017, were included. Patients were divided into two cohorts: low RCRI (score = 0-1) and high RCRI (score ≥ 2). A Poisson regression model was employed to investigate the association between a high RCRI score and 30- and 90-day post-operative mortality.

    RESULTS: A total of 2443 patients, of whom 446 (18%) had a high RCRI score, were included in the current study. When adjusting for age, sex, comorbidities and type of surgery, the incidence of 30-day mortality increased by 46% in the high RCRI cohort (adj. IRR 1.46, 95% CI, 1.10-1.94, p = 0.010). Similar results were observed for 90-day mortality (adj. IRR 1.50, 95% CI, 1.21-1.84, p < 0.001).

    CONCLUSION: The RCRI is applicable to patients that undergo surgery for traumatic hip fractures. A high RCRI score is associated with an increased incidence of both 30- and 90-day post-operative mortality. Future studies to evaluate these findings are needed.

  • 24.
    Ioannidis, Ioannis
    et al.
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohammad Ismail, Ahmad
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Forssten, Maximilian Peter
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Orthopedic Surgery, Örebro University.
    Ahl, Rebecka
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Trauma and Emergency surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden.
    Cao, Yang
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län.
    Borg, Tomas
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohseni, Shahin
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Surgical management of displaced femoral neck fractures in patients with dementia: a comparison in mortality between hemiarthroplasty and pins/screws2022Ingår i: European Journal of Trauma and Emergency Surgery, ISSN 1863-9933, E-ISSN 1863-9941, Vol. 48, nr 2, s. 1151-1158Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    INTRODUCTION: Dementia is common in patients with hip fractures and is strongly associated with increased postoperative mortality. The choice of surgical intervention for displaced femoral neck fractures (dFNF) in patients with dementia has been a matter of debate. This study aims to investigate how short- and long-term mortality differs between those who have been operated with hemiarthroplasty or pins/screws.

    METHODS: All patients with dementia and dFNF, i.e., Garden III and IV, who underwent primary emergency hip fracture surgery, with either hemiarthroplasty or pins/screws, in Sweden between Jan 1, 2008 and Dec 31, 2017 were eligible for inclusion in the current study. Patients were divided into two groups based on the surgical intervention: hemiarthroplasty and pins/screws. The primary outcome of interest was 30-day postoperative mortality, and the secondary outcome was 1-year postoperative mortality. Poisson and Cox regression analyses were performed both before and after propensity score matching.

    RESULTS: A total of 9394 cases met the inclusion criteria; 84% received hemiarthroplasty and 16% received pins/screws. In the unmatched analysis, the adjusted incidence rate ratio (IRR) for 30-day postoperative mortality was not affected by the chosen surgical method (adj. IRR 0.96, CI 95% 0.83-1.12, p = 0.629). After propensity score matching, similar results were observed with no difference in 30-day postoperative mortality (adj. IRR 0.89, CI 95% 0.74-1.09, p = 0.286). There was a statistically significant decrease in the risk of 1-year postoperative mortality in the hemiarthroplasty group compared to the pins/screws group, both before and after propensity score matching.

    CONCLUSION: This study could not demonstrate any difference in 30-day mortality in patients with dementia and dFNFs when comparing hemiarthroplasty with pins/screws. Patients that received hemiarthroplasties did, however, have a lower risk of 1-year postoperative mortality.

  • 25.
    Ioannidis, Ioannis
    et al.
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohammad Ismail, Ahmad
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Forssten, Maximilian Peter
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Ahl, Rebecka
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Trauma & Emergency Surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden.
    Cao, Yang
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län.
    Borg, Tomas
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Department of Orthopedic Surgery.
    Mohseni, Shahin
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Division of Trauma and Emergency Surgery, Department of Surgery.
    The mortality burden in patients with hip fractures and dementia2022Ingår i: European Journal of Trauma and Emergency Surgery, ISSN 1863-9933, E-ISSN 1863-9941, Vol. 48, nr 4, s. 2919-2952Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    PURPOSE: Dementia is strongly associated with postoperative death in patients subjected to hip fracture surgery. Nevertheless, there is a distinct lack of research investigating the cause of postoperative mortality in patients with dementia. This study aims to investigate the distribution and the risk of cause-specific postoperative mortality in patients with dementia compared to the general hip fracture population.

    METHODS: All adults who underwent emergency hip fracture surgery in Sweden between 1/1/2008 and 31/12/2017 were considered for inclusion. Pathological, conservatively managed fractures, and reoperations were excluded. The database was retrieved by cross-referencing the Swedish National Quality Registry for Hip Fracture patients with the Swedish National Board of Health and Welfare quality registers. A Poisson regression model was used to determine the association between dementia and all-cause as well as cause-specific 30-day postoperative mortality.

    RESULTS: 134,915 cases met the inclusion criteria, of which 20% had dementia at the time of surgery. The adjusted risk of all-cause 30-day postoperative mortality was 67% higher in patients with dementia after hip fracture surgery compared to patients without dementia [adj. IRR (95% CI): 1.67 (1.60-1.75), p < 0.001]. The risk of cause-specific mortality was also higher in patients with dementia, with up to a sevenfold increase in the risk cerebrovascular mortality [adj. IRR (95% CI): 7.43 (4.99-11.07), p < 0.001].

    CONCLUSIONS: Hip fracture patients with dementia have a higher risk of death in the first 30 days postoperatively, with a substantially higher risk of mortality due to cardiovascular, respiratory, and cerebrovascular events, compared to patients without dementia.

  • 26.
    Khalili, Hosseinali
    et al.
    Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran; Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran.
    Ahl, Rebecka
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden.
    Cao, Yang
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
    Paydar, Shahram
    Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran.
    Sjölin, Gabriel
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Trauma and Emergency Surgery, Department of Surgery, Faculty of Health and Medical Sciences, Örebro University, Örebro, Sweden.
    Niakan, Amin
    Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran; Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran.
    Dabiri, Gholamreza
    Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran.
    Mohseni, Shahin
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Early selenium treatment for traumatic brain injury: Does it improve survival and functional outcome?2017Ingår i: Injury, ISSN 0020-1383, E-ISSN 1879-0267, Vol. 48, nr 9, s. 1922-1926Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Traumatic brain injury (TBI) is a major cause of death and debility following trauma. The initial brain tissue insult is worsened by secondary reactive responses including oxidative stress reactions, inflammatory changes and subsequent permanent neurologic deficits. Effective agents to improve functional outcome and survival following TBI are scarce. Selenium is an antioxidant which has shown to reduce oxidative stress. This study examines the effect of intravenous selenium (Selenase (R)) treatment in patients with severe TBI on functional outcome and survival in a prospective study design.

    Methods: Patients sustaining TBI were prospectively identified during a 12-month period at an academic urban trauma center. Study inclusion criteria applied were: age >= 18 years, blunt injury mechanism and admission to neurosurgical intensive care unit (NICU). Early deaths (<= 48 h) and patients suffering extracranial injuries requiring invasive interventions or surgery were excluded. All consecutive admissions during a six-month period were administered intravenous Selenase (R) for a maximum 10-day period and constituted cases. Patient demographics and outcomes up to six-months post-discharge were collected for analysis.

    Results: A total of 307 patients met inclusion criteria of which 125 were administered Selenase (R). Stepwise Poisson regression analysis identified five common predictors of poor functional outcome and in-hospital mortality: GCS <= 8, age <= 55 years, hypotension at admission, high Rotterdam score and invasive neurosurgical intervention. Selenase (R) significantly reduced the risk of unfavourable functional outcomes, defined as GOS-E <= 4, at both discharge (adjusted RR 0.69, 95% CI 0.51-0.92, p = 0.012) and at six months follow-up (adjusted RR 0.61, 95% CI 0.44-0.83, p = 0.002). Following adjustment for significant group differences similar results were seen for functional outcome. Selenase (R) did not improve survival (adjusted RR 1.12, 95% CI 0.62-2.02, p = 0.709).

    Conclusion: Intravenous Selenase (R) treatment demonstrates a significant improvement in functional neurologic outcome. This effect is sustained at six months following discharge. (C) 2017 Elsevier Ltd. All rights reserved.

  • 27.
    Khalili, Hosseinali
    et al.
    Department of Neurosurgery, Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran.
    Ahl, Rebecka
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Surgery, Karolinska University Hospital,Stockholm, Sweden; .
    Paydar, Shahram
    Trauma Research Center, Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran; Department of Surgery, Shiraz University of Medical Sciences, Shiraz, Iran.
    Sjölin, Gabriel
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Surgery.
    Cao, Yang
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län.
    Fard, Hossein Abdolrahimzadeh
    Department of Surgery, Karolinska University Hospital, Stockholm, Sweden; Trauma Research Center, Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran.
    Niakan, Amin
    Department of Neurosurgery, Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran.
    Hanna, Kamil
    Department of Surgery, University of Arizona College of Medicine, Tucson AZ, USA.
    Joseph, Bellal
    Department of Surgery, University of Arizona College of Medicine, Tucson AZ, USA.
    Mohseni, Shahin
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Division of Trauma and Emergency Surgery, Department of Surgery.
    Beta-Blocker Therapy in Severe Traumatic Brain Injury: A Prospective Randomized Controlled Trial2020Ingår i: World Journal of Surgery, ISSN 0364-2313, E-ISSN 1432-2323, Vol. 44, nr 6, s. 1844-1853Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Observational studies have demonstrated improved outcomes in TBI patients receiving in-hospital beta-blockers. The aim of this study is to conduct a randomized controlled trial examining the effect of beta-blockers on outcomes in TBI patients.

    Methods: Adult patients with severe TBI (intracranial AIS >= 3) were included in the study. Hemodynamically stable patients at 24 h after injury were randomized to receive either 20 mg propranolol orally every 12 h up to 10 days or until discharge (BB+) or no propranolol (BB-). Outcomes of interest were in-hospital mortality and Glasgow Outcome Scale-Extended (GOS-E) score on discharge and at 6-month follow-up. Subgroup analysis including only isolated severe TBI (intracranial AIS >= 3 with extracranial AIS <= 2) was carried out. Poisson regression models were used.

    Results: Two hundred nineteen randomized patients of whom 45% received BB were analyzed. There were no significant demographic or clinical differences between BB+ and BB- cohorts. No significant difference in inhospital mortality (adj. IRR 0.6 [95% CI 0.3-1.4], p = 0.2) or long-term functional outcome was measured between the cohorts (p = 0.3). One hundred fifty-four patients suffered isolated severe TBI of whom 44% received BB. The BB? group had significantly lower mortality relative to the BB- group (18.6% vs. 4.4%, p = 0.012). On regression analysis, propranolol had a significant protective effect on in-hospital mortality (adj. IRR 0.32, p = 0.04) and functional outcome at 6-month follow-up (GOS-E >= 5 adj. IRR 1.2, p = 0.02).

    Conclusion: Propranolol decreases in-hospital mortality and improves long-term functional outcome in isolated severe TBI. This randomized trial speaks in favor of routine administration of beta-blocker therapy as part of a standardized neurointensive care protocol.

    Level of evidence: Level II; therapeutic.

    Study type: Therapeutic study.

  • 28.
    Lillo-Felipe, Miriam
    et al.
    Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Ahl Hulme, Rebecka
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden; Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden .
    Forssten, Maximilian Peter
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Bass, Gary Alan
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Traumatology, Surgical Critical Care & Emergency Surgery, University of Pennsylvania, Penn Presbyterian Medical Center, Philadelphia, USA.
    Cao, Yang
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län.
    Matthiessen, Peter
    Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohseni, Shahin
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Center-Level Procedure Volume Does Not Predict Failure-to-Rescue After Severe Complications of Oncologic Colon and Rectal Surgery2021Ingår i: World Journal of Surgery, ISSN 0364-2313, E-ISSN 1432-2323, Vol. 45, nr 12, s. 3695-3706Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: The relationship between hospital surgical volume and outcome after colorectal cancer surgery has thoroughly been studied. However, few studies have assessed hospital surgical volume and failure-to-rescue (FTR) after colon and rectal cancer surgery. The aim of the current study is to evaluate FTR following colorectal cancer surgery between clinics based on procedure volume.

    METHODS: Patients undergoing colorectal cancer surgery in Sweden from January 2015 to January 2020 were recruited through the Swedish Colorectal Cancer Registry. The primary endpoint was FTR, defined as the proportion of patients with 30-day mortality after severe postoperative complications in colorectal cancer surgery. Severe postoperative complications were defined as Clavien-Dindo ≥ 3. FTR incidence rate ratios (IRR) were calculated comparing center volume stratified in low-volume (≤ 200 cases/year) and high-volume centers (> 200 cases/year), as well as with an alternative stratification comparing low-volume (< 50 cases/year), medium-volume (50-150 cases/year) and high-volume centers (> 150 cases/year).

    RESULTS: A total of 23,351 patients were included in this study, of whom 2964 suffered severe postoperative complication(s). Adjusted IRR showed no significant differences between high- and low-volume centers with an IRR of 0.97 (0.75-1.26, p = 0.844) in high-volume centers in the first stratification and an IRR of 2.06 (0.80-5.31, p = 0.134) for high-volume centers and 2.15 (0.83-5.56, p = 0.116) for medium-volume centers in the second stratification.

    CONCLUSION: This nationwide retrospectively analyzed cohort study fails to demonstrate a significant association between hospital surgical volume and FTR after colorectal cancer surgery. Future studies should explore alternative characteristics and their correlation with FTR to identify possible interventions for the improvement of quality of care after colorectal cancer surgery.

  • 29.
    Lillo-Felipe, Miriam
    et al.
    Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Ahl Hulme, Rebecka
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden; Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.
    Sjölin, Gabriel
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Cao, Yang
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län.
    Bass, G. A.
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Traumatology, Surgical Critical Care & Emergency Surgery, Penn Medicine, Penn Presbyterian Medical Center, Philadelphia, PA, USA.
    Matthiessen, Peter
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohseni, Shahin
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Division of Trauma and Emergency Surgery, Department of Surgery.
    Hospital academic status is associated with failure-to-rescue after colorectal cancer surgery2021Ingår i: Surgery, ISSN 0039-6060, E-ISSN 1532-7361, Vol. 170, nr 3, s. 863-869Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Failure-to-rescue is a quality indicator measuring the response to postoperative complications. The current study aims to compare failure-to-rescue in patients suffering severe complications after surgery for colorectal cancer between hospitals based on their university status.

    METHODS: Patients undergoing colorectal cancer surgery from January 2015 to January 2020 in Sweden were included through the Swedish Colorectal Cancer Registry in the current study. Severe postoperative complications were defined as Clavien-Dindo ≥3. Failure-to-rescue incidence rate ratios were calculated comparing university versus nonuniversity hospitals.

    RESULTS: A total of 23,351 patients were included in this study, of whom 2,964 suffered severe postoperative complication(s). University hospitals had lower failure-to-rescue rates with an incidence rate ratios of 0.62 (0.46-0.84, P = .002) compared with nonuniversity hospitals. There were significantly lower failure-to-rescue rates in almost all types of severe postoperative complications at university than nonuniversity hospitals.

    CONCLUSION: University hospitals have a lower risk for failure-to-rescue compared with nonuniversity hospitals. The exact mechanisms behind this finding are unknown and warrant further investigation to identify possible improvements that can be applied to all hospitals.

  • 30.
    Mohammad Ismail, Ahmad
    et al.
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Ahl, Rebecka
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Surgery, Karolinska University Hospital, Stockholm, Sweden.
    Forssten, Maximilian Peter
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Cao, Yang
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län.
    Wretenberg, Per
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Borg, Tomas
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohseni, Shahin
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Beta-Blocker Therapy Is Associated With Increased 1-Year Survival After Hip Fracture Surgery: A Retrospective Cohort Study2021Ingår i: Anesthesia and Analgesia, ISSN 0003-2999, E-ISSN 1526-7598, Vol. 133, nr 5, s. 1225-1234Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: The high mortality rates seen within the first postoperative year after hip fracture surgery have remained relatively unchanged in many countries for the past 15 years. Recent investigations have shown an association between beta-blocker (BB) therapy and a reduction in risk-adjusted mortality within the first 90 days after hip fracture surgery. We hypothesized that preoperative, and continuous postoperative, BB therapy may also be associated with a decrease in mortality within the first year after hip fracture surgery.

    METHODS: In this retrospective cohort study, all adults who underwent primary emergency hip fracture surgery in Sweden, between January 1, 2008 and December 31, 2017, were included. Patients with pathological fractures and conservatively managed hip fractures were excluded. Patients who filled a prescription within the year before and after surgery were defined as having ongoing BB therapy. The primary outcome of interest was postoperative mortality within the first year. To reduce the effects of confounding from covariates due to nonrandomization in the current study, the inverse probability of treatment weighting (IPTW) method was used. Subsequently, Cox proportional hazards models were fitted to the weighted cohorts. These analyses were repeated while excluding patients who died within the first 30 days postoperatively. This reduces the effect of early deaths due to surgical and anesthesiologic complications as well as the higher degree of advanced directives present in the study population compared to the general population, which allowed for the evaluation of the long-term association between BB therapy and mortality in isolation. Results are reported as hazard ratios (HR) with 95% confidence intervals (CI). Statistical significance was defined as a 2-sided P value <.05.

    RESULTS: A total of 134,915 cases were included in the study. After IPTW, BB therapy was associated with a 42% reduction the risk of mortality within the first postoperative year (adjusted HR = 0.58, 95% CI, 0.57-0.60; P < .001). After excluding patients who died within the first 30 days postoperatively, BB therapy was associated with a 27% reduction in the risk of mortality (adjusted HR = 0.73, 95% CI, 0.71-0.75; P < .001).

    CONCLUSIONS: A significant reduction in the risk of mortality in the first year following hip fracture surgery was observed in patients with ongoing BB therapy. Further investigations into this finding are warranted.

  • 31.
    Mohammad Ismail, Ahmad
    et al.
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Ahl, Rebecka
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Surgery, Karolinska University Hospital, Stockholm, Sweden; Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden.
    Forssten, Maximilian Peter
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Cao, Yang
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län.
    Wretenberg, Per
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Borg, Tomas
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohseni, Shahin
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    The interaction between pre-admission β-blocker therapy, the Revised Cardiac Risk Index, and mortality in geriatric hip fracture patients2022Ingår i: Journal of Trauma and Acute Care Surgery, ISSN 2163-0755, E-ISSN 2163-0763, Vol. 92, nr 1, s. 49-56Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: An association between beta-blocker (BB) therapy and a reduced risk of major cardiac events and mortality in patients undergoing surgery for hip fractures has previously been demonstrated. Furthermore, a relationship between an increased Revised Cardiac Risk Index (RCRI) score and a higher risk of postoperative mortality has also been detected. The purpose of the current study was to investigate the interaction between BB therapy and RCRI in relation to 30-day postoperative mortality in geriatric patients after hip fracture surgery.

    METHODS: All patients over 65 years of age who underwent primary emergency hip fracture surgery in Sweden between January 1, 2008 and December 31, 2017, except for pathological fractures, were included in this retrospective cohort study. Patients were divided into cohorts based on their RCRI score (RCRI 1, 2, 3, and ≥ 4) and whether they had ongoing BB therapy at the time of admission. A Poisson regression model with robust standard errors of variance was used, while adjusting for confounders, to evaluate the association between BB therapy, RCRI, and 30-day mortality.

    RESULTS: A total of 126,934 cases met the study inclusion criteria. Beta-blocker therapy was associated with a 65% decrease in the risk of 30-day postoperative mortality in the whole study population [adj. IRR (95% CI): 0.35 (0.32-0.38), p < 0.001]. The use of BB also resulted in a significant reduction in 30-day postoperative mortality within all RCRI cohorts. However, the most pronounced effect of beta-blocker therapy was seen in patients with an RCRI score greater than 0.

    CONCLUSIONS: Beta-blocker therapy is associated with a reduction in 30-day postoperative mortality, irrespective of RCRI score. Furthermore, patients with an elevated cardiac risk appear to have a greater benefit of beta-blocker therapy.

    LEVEL OF EVIDENCE: Level II, Therapeutic / Care Management.

  • 32.
    Mohammad Ismail, Ahmad
    et al.
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Borg, Tomas
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Department of Orthopedic Surgery.
    Sjölin, Gabriel
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Pourlotfi, Arvid
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Holm, Sebastian
    Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Cao, Yang
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län.
    Wretenberg, Per
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Ahl, Rebecka
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden; Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden.
    Mohseni, Shahin
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Division of Trauma and Emergency Surgery, Department of Surgery.
    β-adrenergic blockade is associated with a reduced risk of 90-day mortality after surgery for hip fractures2020Ingår i: Trauma surgery & acute care open, ISSN 2397-5776, Vol. 5, nr 1, artikel-id e000533Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: There is a significant postoperative mortality risk in patients subjected to surgery for hip fractures. Adrenergic hyperactivity induced by trauma and subsequent surgery is thought to be an important contributor. By downregulating the effect of circulating catecholamines the increased risk of postoperative mortality may be reduced. The aim of the current study is to assess the association between regular β-blocker therapy and postoperative mortality.

    Methods: This cohort study used the prospectively collected Swedish National Quality Registry for hip fractures to identify all patients over 40 years of age subjected to surgery for hip fractures between 2013 and 2017 in Örebro County, Sweden. Patients with ongoing β-blocker therapy at the time of surgery were allocated to the β-blocker-positive cohort. The primary outcome of interest was 90-day postoperative mortality. Risk factors for 90-day mortality were evaluated using Poisson regression analysis.

    Results: A total of 2443 patients were included in this cohort of whom 900 (36.8%) had ongoing β-blocker therapy before surgery. The β-blocker positive group was significantly older, less fit for surgery based on their American Society of Anesthesiologists classification and had a higher prevalence of comorbidities. A significant risk reduction in 90-day mortality was detected in patients receiving β-blockers (adjusted incidence rate ratio=0.82, 95% CI 0.68 to 0.98, p=0.03).

    Conclusions: β-blocker therapy is associated with a significant reduction in 90-day postoperative mortality after hip fracture surgery. Further investigation into this finding is warranted.

    Level of evidence: Therapeutic study, level III; prognostic study, level II.

  • 33.
    Mohseni, Shahin
    et al.
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Department of Surgery, Division of Trauma and Emergency Surgery, Örebro University Hospital, Örebro, Sweden.
    Holzmacher, Jeremy
    Center for Trauma and Critical Care, Department of Surgery, George Washington University, Washington DC, United States.
    Sjölin, Gabriel
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Surgery, Division of Trauma and Emergency Surgery, Faculty of Health and Medical Sciences, Örebro University, Örebro, Sweden.
    Ahl, Rebecka
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Surgery, Division of Trauma and Emergency Surgery, Karolinska University Hospital, Stockholm, Sweden.
    Sarani, Babak
    Center for Trauma and Critical Care, Department of Surgery, George Washington University, Washington DC, United States.
    Outcomes after resection versus non-resection management of penetrating grade III and IV pancreatic injury: A trauma quality improvement (TQIP) databank analysis2018Ingår i: Injury, ISSN 0020-1383, E-ISSN 1879-0267, Vol. 49, nr 1, s. 27-32Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: High-grade traumatic pancreatic injuries are associated with significant morbidity and mortality. Non-resection management is associated with fewer complications in pediatric patients. The present study evaluates outcomes following resection versus non-resection management of severe pancreatic injury caused by penetrating trauma.

    METHODS: A retrospective study of the Trauma Quality Improvement Program (TQIP) database was performed from 1/2010 to 12/2014. Patients with AAST Organ Injury Scale pancreatic grade III and IV injuries caused by penetrating trauma were included in the study. Demographics, vital signs on admission, Abbreviated Injury Scale per body region, Injury Severity Score, transfusion and therapeutic modality were obtained. Mortality, length of stay (LOS), pseudocyst, pancreatitis, sepsis, thromboembolism, renal failure, ARDS and unplanned ICU admission or re-operation were stratified according to injury grade and treatment modality. Patients were stratified into those who did/did not undergo pancreatic resection.

    RESULTS: A total of 4,098 patients had a pancreatic injury of which 15.9% (n=653) had a grade III and 6.7% (n=274) a grade IV pancreatic injury. There were no differences in patient demographics or overall injury severity between the resected and non-resected cohorts within each pancreatic injury grade. Forty-two percent of grade III and 38.0% of grade IV injuries underwent pancreatic resection. The total LOS was longer in the resection arm irrespective of pancreatic injury severity. There was no significant difference in morbidity between cohorts. Similarly, mortality was not significantly different between the two management approaches for grade III: 15.1% (95% CI 11.0-19.9) vs. 18.4% (95% CI 14.6-22.6), p=0.32 and grade IV: 24.0% (95% CI: 16.2-33.4) vs. 27.1% (95% CI: 20.5-34.4), p=0.68.

    CONCLUSION: Resection for treatment of grade III and IV pancreatic injury is not associated with a significant decrease in mortality but is associated with an increase in hospital LOS.

  • 34.
    Mohseni, Shahin
    et al.
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Division of Trauma and Emergency Surgery, Department of Surgery.
    Ivarsson, John
    Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Ahl, Rebecka
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Surgery, Karolinska University Hospital, Stockholm, Sweden.
    Dogan, Sinan
    Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Saar, Sten
    Division of Acute Care Surgery, Department of Surgery, North Estonia Medical Center, Tallin, Estonia.
    Reinsoo, Arvo
    Division of Acute Care Surgery, Department of Surgery, North Estonia Medical Center, Tallin, Estonia.
    Sepp, Teesi
    Division of Acute Care Surgery, Department of Surgery, North Estonia Medical Center, Tallin, Estonia.
    Isand, Karl-Gunnar
    Division of Acute Care Surgery, Department of Surgery, North Estonia Medical Center, Tallin, Estonia.
    Garder, Edvard
    Division of Acute Care Surgery, Department of Surgery, North Estonia Medical Center, Tallin, Estonia.
    Kaur, Ilmar
    Division of Acute Care Surgery, Department of Surgery, North Estonia Medical Center, Tallin, Estonia.
    Ruus, Heiti
    Division of Acute Care Surgery, Department of Surgery, North Estonia Medical Center, Tallin, Estonia.
    Talving, Peep
    Division of Acute Care Surgery, Department of Surgery, North Estonia Medical Center, Tallin, Estonia.
    Simultaneous common bile duct clearance and laparoscopic cholecystectomy: experience of a one-stage approach2019Ingår i: European Journal of Trauma and Emergency Surgery, ISSN 1863-9933, E-ISSN 1863-9941, Vol. 45, nr 2, s. 337-342Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Introduction: The timing and optimal method for common bile duct (CBD) clearance and laparoscopic cholecystectomy remains controversial. Several different approaches are available in clinical practice. The current study presents the experience of two European hospitals of simultaneous laparoscopic cholecystectomy (LC) and intra-operative endoscopic retrograde cholangiopacreatography (IO-ERCP) done by surgeons.

    Methods: Retrospective analysis of all consecutive patients subjected to LC+IO-ERCP during their index admission between 4/2014 and 9/2016. Data accrued included patient demographics, laboratory markers, operation time (min) reported as mean (SD) and hospital length of stay (LOS) reported as median (lower quartile, upper quartile).

    Results: During the 29-month study, a total of 201 consecutive LC+IO-ERCPs were performed. The mean age of patients was 55 +/- 19years and 67% were female. The mean intervention time was 105 +/- 44min. The total LOS was 4 (3, 7) days and the post-operative LOS was 2 (1, 3)days. A total of 6 (3%) patients experienced post-interventional pancreatitis and two (1%) patients suffered a Strasberg type A bile leak. All patients were successfully discharged.

    Conclusion: Simultaneous LC+IO-ERCP is associated with few complications. Further studies investigating cost-benefit and patient satisfaction are warranted.

  • 35.
    Pourlotfi, Arvid
    et al.
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Ahl Hulme, Rebecka
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden; Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.
    Forssten, Maximilian Peter
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Sjölin, Gabriel
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Bass, Gary Alan
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Traumatology, Emergency Surgery and Surgical Critical Care, University of Pennsylvania, Philadelphia, PA, USA.
    Cao, Yang
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län.
    Matthiessen, Peter
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohseni, Shahin
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Department of Surgery, Örebro University Hospital, Örebro, Sweden; Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Statin therapy and its association with long-term survival after colon cancer surgery2022Ingår i: Surgery, ISSN 0039-6060, E-ISSN 1532-7361, Vol. 171, nr 4, s. 890-896Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: The current study aims to address the clinical equipoise regarding the association of ongoing statin therapy at time of surgery with long-term postoperative mortality rates after elective, curative, surgical resections of colon cancer by analyzing data from a large validated national register.

    METHODS: All adults with stage I to III colon cancer who underwent elective surgery with curative intent between January 2007 and October 2016 were retrieved from the Swedish Colorectal Cancer Register, a prospectively collected national register. Patients were identified as having ongoing statin therapy if they filled a prescription within 12 months pre- and postoperatively. Study outcomes included 5-year all-cause and cancer-specific postoperative mortality. To reduce the impact of confounding from covariates owing to nonrandomization, the inverse probability of treatment weighting method was used. Subsequently, Cox proportional hazards models were fitted to the weighted cohorts.

    RESULTS: In total, 19,118 patients underwent elective surgery for colon cancer in the specified period, of whom 31% (5,896) had ongoing statin therapy. Despite being older, having a higher preoperative risk, and having more comorbidities, patients with statin therapy had a higher postoperative survival. After inverse probability of treatment weighting, patients with statin therapy displayed a significantly lower mortality risk up to 5 years after surgery for both all-cause (hazard ratio 0.68, 95% confidence interval 0.63-0.74, P < .001) and cancer-specific mortality (hazard ratio 0.76, 95% confidence interval 0.66-0.89, P < .001).

    CONCLUSION: The results of this study indicate that statin therapy is associated with a sustained reduction in all-cause and cancer-specific mortality up to 5 years after elective colon cancer surgery. The findings warrant validation in future prospective clinical trials.

  • 36.
    Pourlotfi, Arvid
    et al.
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Ahl, Rebecka
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Surgery, Karolinska University Hospital, Stockholm, Sweden.
    Bass, Gary Alan
    Örebro universitet, Institutionen för medicinska vetenskaper. Surgical Critical Care & Emergency Surgery, Penn Medicine, Penn Presbyterian Medical Center, Philadelphia, USA.
    Sjölin, Gabriel
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Cao, Yang
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län.
    Matthiessen, Peter
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohseni, Shahin
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Statin Therapy is Associated with Decreased 90-day Postoperative Mortality After Colon Cancer Surgery2022Ingår i: Diseases of the Colon & Rectum, ISSN 0012-3706, E-ISSN 1530-0358, Vol. 65, nr 4, s. 559-565Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: There have been conflicting reports regarding a protective effect of statin therapy after colon cancer surgery.

    OBJECTIVE: This study aimed to evaluate the association between statin therapy and the postoperative mortality following elective colon cancer surgery.

    DESIGN: This population-based cohort study is a retrospective analysis of prospectively collected data from the Swedish Colorectal Cancer Register.

    SETTINGS: Patient inclusion was achieved by inclusion through a nationwide register.

    PATIENTS: All adult patients undergoing elective surgery for colon cancer between the period of January 2007 and September 2016 were included in the study. Patients who had received and collected a prescription for statins pre- and postoperatively were allocated to the statin positive cohort.

    MAIN OUTCOME MEASURES: The primary and secondary outcomes of interest were 90-day all-cause mortality and 90-day cause-specific mortality.

    RESULTS: A total of 22,337 patients underwent elective surgery for colon cancer during the study period, of whom 6,494 (29%) were classified as statin users. Statin users displayed a significant survival benefit despite being older, having a higher comorbidity burden, and less fit for surgery. Multivariate analysis illustrated significant reductions in the incidence risk for 90-day all-cause mortality (Incidence Rate Ratio = 0.12, p < 0.001) as well as 90-day cause-specific deaths due to sepsis, multiorgan failure, or of cardiovascular and respiratory origin.

    LIMITATIONS: The limitations of this study include its observational retrospective design, restricting the ability to perform standardized follow-up of statin therapy. Confounding from other uncontrolled variables cannot be excluded.

    CONCLUSIONS: Statin users had a significant postoperative benefit regarding short-term mortality following elective colon cancer surgery in the current study, however, further research is needed to ascertain if this relationship is causal. See Video Abstract at http://links.lww.com/DCR/B738.

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  • 37.
    Pourlotfi, Arvid
    et al.
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Ahl, Rebecka
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Surgery, Karolinska University Hospital, Stockholm, Sweden.
    Sjölin, Gabriel
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Forssten, Maximilian Peter
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Orthopedics, Örebro University Hospital, Örebro, Sweden.
    Bass, G. A.
    Örebro universitet, Institutionen för medicinska vetenskaper. Surgical Critical Care & Emergency Surgery, Penn Medicine, Penn Presbyterian Medical Center, Philadelphia, USA.
    Cao, Yang
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län.
    Matthiessen, Peter
    Department of Surgery, Örebro University Hospital, Örebro, Sweden; School of Medical Sciences, Örebro University, Örebro, Sweden.
    Mohseni, Shahin
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Statin Therapy and Postoperative Short-Term Mortality after Rectal Cancer Surgery2021Ingår i: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 23, nr 4, s. 875-881Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    AIM: The study aimed to assess the correlation between regular statin therapy and postoperative mortality following resection surgery for rectal cancer.

    METHOD: This retrospective cohort included all adult patients undergoing abdominal rectal cancer surgery in Sweden between January 2007 and September 2016. Data was gathered from the Swedish Colorectal Cancer Registry, a large population-based prospectively collected registry. Statin users were defined as patients with one or more collected prescriptions of a statin within 12 months before the date of surgery. The statin-positive and statin-negative cohorts were matched by propensity scores based on baseline demographics.

    RESULTS: 11,966 patients underwent resection surgery for rectal cancer, of whom 3,019 (25%) were identified as statin users. After applying propensity score matching (1:1), 3,017 pairs were available for comparison. In the matched groups, statin users demonstrated reduced 90-day all-cause mortality (0.7% versus 5.5%, p < 0.001), additionally displaying significantly reduced cause-specific mortality due to cardiovascular and respiratory events, as well as sepsis and multiorgan failure. The significant postoperative survival benefit of statin users was seen despite a higher rate of cardiovascular comorbidity.

    CONCLUSION: Preoperative statin therapy displays a strong association with reduced postoperative mortality following resectional surgery for rectal cancer. The results from the current study warrant further investigation to determine whether a causal relationship exists.

  • 38.
    Pourlotfi, Arvid
    et al.
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Bass, Gary Alan
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Traumatology, Emergency Surgery & Surgical Critical Care, University of Pennsylvania, Philadelphia, PA, USA.
    Ahl Hulme, Rebecka
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden; Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.
    Forssten, Maximilian Peter
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Sjölin, Gabriel
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Cao, Yang
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län.
    Matthiessen, Peter
    Örebro universitet, Institutionen för medicinska vetenskaper. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohseni, Shahin
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Department of Surgery, Örebro University Hospital, Örebro, Sweden; Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Statin Use and Long-Term Mortality after Rectal Cancer Surgery2021Ingår i: Cancers, ISSN 2072-6694, Vol. 13, nr 17, artikel-id 4288Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: The current study aimed to assess the association between regular statin therapy and postoperative long-term all-cause and cancer-specific mortality following curative surgery for rectal cancer. The hypothesis was that statin exposure would be associated with better survival.

    METHODS: Patients with stage I-III rectal cancer undergoing surgical resection with curative intent were extracted from the nationwide, prospectively collected, Swedish Colorectal Cancer Register (SCRCR) for the period from January 2007 and October 2016. Patients were defined as having ongoing statin therapy if they had filled a statin prescription within 12 months before and after surgery. Cox proportional hazards models were employed to investigate the association between statin use and postoperative five-year all-cause and cancer-specific mortality.

    RESULTS: The cohort consisted of 10,743 patients who underwent a surgical resection with curative intent for rectal cancer. Twenty-six percent (n = 2797) were classified as having ongoing statin therapy. Statin users had a considerably decreased risk of all-cause (adjusted hazard ratio (HR) 0.66, 95% confidence interval (CI): 0.60-0.73, p < 0.001) and cancer-specific (adjusted HR 0.60, 95% CI: 0.47-0.75, p < 0.001) mortality up to five years following surgery.

    CONCLUSIONS: Statin use was associated with a lower risk of both all-cause and rectal cancer-specific mortality following curative surgical resections for rectal cancer. The findings should be confirmed in future prospective clinical trials.

  • 39.
    Reda, Souheil
    et al.
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Upper Gastrointestinal Surgery, Department of Surgery, Örebro University Hospital, Örebro, Swede.
    Ahl, Rebecka
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden; Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden.
    Szabo, Eva
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Division of Upper Gastrointestinal Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Stenberg, Erik
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Division of Upper Gastrointestinal Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Forssten, Maximilian Peter
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Sjölin, Gabriel
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Cao, Yang
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län.
    Mohseni, Shahin
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Pre-operative beta-blocker therapy does not affect short-term mortality after esophageal resection for cancer2020Ingår i: BMC Surgery, E-ISSN 1471-2482, Vol. 20, nr 1, artikel-id 333Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: It has been postulated that the hyperadrenergic state caused by surgical trauma is associated with worse outcomes and that β-blockade may improve overall outcome by downregulation of adrenergic activity. Esophageal resection is a surgical procedure with substantial risk for postoperative mortality. There is insufficient data to extrapolate the existing association between preoperative β-blockade and postoperative mortality to esophageal cancer surgery. This study assessed whether preoperative β-blocker therapy affects short-term postoperative mortality for patients undergoing esophageal cancer surgery.

    METHODS: All patients with an esophageal cancer diagnosis that underwent surgical resection with curative intent from 2007 to 2017 were retrospectively identified from the Swedish National Register for Esophagus and Gastric Cancers (NREV). Patients were subdivided into β-blocker exposed and unexposed groups. Propensity score matching was carried out in a 1:1 ratio. The outcome of interest was 90-day postoperative mortality.

    RESULTS: A total of 1466 patients met inclusion criteria, of whom 35% (n = 513) were on regular preoperative β-blocker therapy. Patients on β-blockers were significantly older, more comorbid and less fit for surgery based on their ASA score. After propensity score matching, 513 matched pairs were available for analysis. No difference in 90-day mortality was detected between β-blocker exposed and unexposed patients (6.0% vs. 6.6%, p = 0.798).

    CONCLUSION: Preoperative β-blocker therapy is not associated with better short-term survival in patients subjected to curative esophageal tumor resection.

  • 40.
    Sadi, Lin
    et al.
    Department of Surgery, Capio St Görans Hospital, Stockholm, Sweden.
    Sjölin, Gabriel
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Ahl Hulme, Rebecka
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden.
    Beta-blockade is not associated with improved outcomes in isolated severe extracranial injury: an observational cohort study2021Ingår i: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, E-ISSN 1757-7241, Vol. 29, nr 1, artikel-id 132Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: There is evidence supporting the use of beta-blockade in patients with traumatic brain injury. The reduction in sympathetic drive is thought to underlie the relationship between beta-blockade and increased survival. There is little evidence for similar effects in extracranial injuries. This study aimed to assess the association between beta-blockade and survival in patients suffering isolated severe extracranial injuries.

    METHODS: Patients treated at an academic urban trauma centre during a 5-year period were retrospectively identified. Adults suffering isolated severe extracranial injury [Injury Severity Score (ISS) ≥ 16 with Abbreviated Injury Score of ≤ 2 for any intracranial injury] were included. Patient characteristics and outcomes were collected from the trauma registry and hospital medical records. Patients were subdivided into beta-blocker exposed and unexposed groups. Patients were matched using propensity score matching. Differences were assessed using McNemar's or paired Student's t test. The primary outcome of interest was 90-day mortality and secondary outcome was in-hospital complications.

    RESULTS: 698 patients were included of whom 10.5% were on a beta-blocker. Most patients suffered blunt force trauma (88.5%) with a mean [standard deviation] ISS of 24.6 [10.6]. Unadjusted mortality was higher in patients receiving beta-blockers (34.2% vs. 9.1%, p < 0.001) as were cardiac complications (8.2% vs. 1.4%, p = 0.002). Patients on beta-blockers were significantly older (69.5 [14.1] vs. 43.2 [18.0] years) and of higher comorbidity. After matching, no statistically significant differences were seen in 90-day mortality (34.2% vs. 30.1%, p = 0.690) or in-hospital complications.

    CONCLUSIONS: Beta-blocker therapy does not appear to be associated with improved survival in patients with isolated severe extracranial injuries.

  • 41.
    Trivedi, Dhanisha Jayesh
    et al.
    Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, Örebro, Sweden.
    Bass, Gary Alan
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Penn Presbyterian Medical Center, Philadelphia PA, USA.
    Forssten, Maximilian Peter
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, Örebro, Sweden.
    Scheufler, Kai-Michael
    Division of Neurosurgery, Department of Neurosurgery, Orebro University Hospital, Örebro, Sweden; Medical School, Heinrich-Heine-University, Düsseldorf, Germany.
    Olivecrona, Magnus
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Division of Neurosurgery, Department of Neurosurgery.
    Cao, Yang
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län.
    Ahl Hulme, Rebecka
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Department of Surgery, Karolinska University Hospital, Stockholm, Sweden.
    Mohseni, Shahin
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Division of Trauma and Emergency Surgery, Department of Surgery.
    The significance of direct transportation to a trauma center on survival for severe traumatic brain injury2022Ingår i: European Journal of Trauma and Emergency Surgery, ISSN 1863-9933, E-ISSN 1863-9941, Vol. 48, nr 4, s. 2803-2811Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Introduction: While timely specialized care can contribute to improved outcomes following traumatic brain injury (TBI), this condition remains the most common cause of post-injury death worldwide. The purpose of this study was to investigate the difference in mortality between regional trauma centers in Sweden (which provide neurosurgical services round the clock) and non-trauma centers, hypothesizing that 1-day and 30-day mortality will be lower at regional trauma centers.

    Patients and methods: This retrospective cohort study used data extracted from the Swedish national trauma registry and included adults admitted with severe TBI between January 2014 and December 2018. The cohort was divided into two subgroups based on whether they were treated at a trauma center or non-trauma center. Severe TBI was defined as a head injury with an AIS score of 3 or higher. Poisson regression analyses with both univariate and multivariate models were performed to determine the difference in mortality risk [Incidence Rate Ratio (IRR)] between the subgroups. As a sensitivity analysis, the inverse probability of treatment weighting (IPTW) method was used to adjust for the effects of confounding.

    Results: A total of 3039 patients were included. Patients admitted to a trauma center had a lower crude 30-day mortality rate (21.7 vs. 26.4% days, p = 0.006). After adjusting for confounding variables, patients treated at regional trauma center had a 28% [adj. IRR (95% CI): 0.72 (0.55-0.94), p = 0.015] decreased risk of 1-day mortality and an 18% [adj. IRR (95% CI): 0.82 (0.69-0.98)] reduction in 30-day mortality, compared to patients treated at a non-trauma center. After adjusting for covariates in the Poisson regression analysis performed after IPTW, admission and treatment at a trauma center were associated with a 27% and 17% reduction in 1-day and 30-day mortality, respectively.

    Conclusion: For patients suffering a severe TBI, treatment at a regional trauma center confers a statistically significant 1-day and 30-day survival advantage over treatment at a non-trauma center.

  • 42.
    Young, Nathalie
    et al.
    Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University, Solna, Sweden.
    Ahl Hulme, Rebecka
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University, Solna, Sweden; Division of Trauma and Emergency Surgery, Örebro University Hospital, Örebro, Sweden.
    Forssten, Maximilian Peter
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Trauma and Emergency Surgery, Örebro University Hospital, Örebro, Sweden.
    Kaplan, Lewis Jay
    Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA; Corporal Michael Crescenz Veterans Affairs Medical Center, Philadelphia, USA.
    Walsh, Thomas Noel
    Royal College of Surgeons in Ireland Medical University, Busaiteen, Bahrain.
    Cao, Yang
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Clinical Epidemiology and Biostatistics.
    Mohseni, Shahin
    Örebro universitet, Institutionen för medicinska vetenskaper. Region Örebro län. Division of Trauma and Emergency Surgery.
    Bass, Gary Alan
    Örebro universitet, Institutionen för medicinska vetenskaper. Division of Trauma and Emergency Surgery, Örebro University Hospital, Örebro, Sweden; Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA; Center for Perioperative Outcomes Research and Transformation (CPORT), University of Pennsylvania, Philadelphia, USA; Leonard Davis Institute of Health Economics (LDI), University of Pennsylvania, Philadelphia, USA.
    Graded operative autonomy in emergency appendectomy mirrors case-complexity: surgical training insights from the SnapAppy prospective observational study2023Ingår i: European Journal of Trauma and Emergency Surgery, ISSN 1863-9933, E-ISSN 1863-9941, Vol. 49, nr 1, s. 33-44Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    INTRODUCTION: Surgical skill, a summation of acquired wisdom, deliberate practice and experience, has been linked to improved patient outcomes. Graded mentored exposure to pathologies and operative techniques is a cornerstone of surgical training. Appendectomy is one of the first procedures surgical trainees perform independently. We hypothesize that, given the embedded training ethos in surgery, coupled with the steep learning curve required to achieve trainer-recognition of independent competency, 'real-world' clinical outcomes following appendectomy for the treatment of acute appendicitis are operator agnostic. The principle of graded autonomy matches trainees with clinical conditions that they can manage independently, and increased complexity drives attending input or assumption of the technical aspects of care, and therefore, one cannot detect an impact of operator experience on outcomes.

    MATERIALS AND METHODS: This study is a subgroup analysis of the SnapAppy international time-bound prospective observational cohort study (ClinicalTrials.gov Trial #NCT04365491), including all consecutive patients aged ≥ 15 who underwent appendectomy for appendicitis during a three-month period in 2020-2021. Patient- and surgeon-specific variables, as well as 90-day postoperative outcomes, were collected. Patients were grouped based on operating surgeon experience (trainee only, trainee with direct attending supervision, attending only). Poisson and quantile regression models were used to (adjusted for patient-associated confounders) assess the relationship between surgical experience and postoperative complications or hospital length of stay (hLOS), respectively, adjusted for patient-associated confounders. The primary outcome of interest was any complications within 90 days.

    RESULTS: A total of 4,347 patients from 71 centers in 14 countries were included. Patients operated on by trainees were younger (Median (IQR) 33 [24-46] vs 38 [26-55] years, p < 0.001), had lower ASA classifications (ASA ≥ 3: 6.6% vs 11.6%, p < 0.001) and fewer comorbidities compared to those operated on by attendings. Additionally, trainees operated alone on fewer patients with appendiceal perforation (AAST severity grade ≥ 3: 8.7% vs 15.6%, p < 0.001). Regression analyses revealed no association between operator experience and complications (IRR 1.03 95%CI 0.83-1.28 for trainee vs attending; IRR 1.13 95%CI 0.89-1.42 for supervised trainee vs attending) or hLOS.

    CONCLUSION: The linkage of case complexity with operator experience within the context of graduated autonomy is a central tenet of surgical training. Either subconsciously, or by design, patients operated on by trainees were younger, fitter and with earlier stage disease. At least in part, these explain why clinical outcomes following appendectomy do not differ depending on the experience of the operating surgeon.

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