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  • 1.
    Ah, Rebecka
    et al.
    Department of Surgery, Karolinska University Hospital, Stockholm, Sweden.
    BChir, M. B.
    Department of Surgery, Karolinska University Hospital, Stockholm, Sweden; Faculty of Medicine and Health, School of Health and Medical Sciences, Department of Surgery, Örebro University, Örebro, Sweden.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Geijer, Håkan
    Department of Radiology, Örebro University Hospital, Örebro, Sweden.
    Taha, Kardo
    Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Pourhossein-Sarmeh, Sahar
    Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Talving, Peep
    Division of Acute Care Surgery, Department of Surgery, North Estonia Medical Center, Tallinn, Estonia; Department of Surgery, University of Tartu, Estonia.
    Ljungqvist, Olle
    Örebro University, School of Medical Sciences. Department of Surgery.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Division of Trauma and Emergency Surgery, Department of Surgery.
    Prognostic Value of P-POSSUM and Osteopenia for Predicting Mortality After Emergency Laparotomy in Geriatric Patients2019In: Bulletin of emergency and trauma, ISSN 2322-2522, Vol. 7, no 3, p. 223-231Article in journal (Refereed)
    Abstract [en]

    Objective: To evaluate the Portsmouth-Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM) in comparison with other risk factors for mortality including osteopenia as an indicator for frailty in geriatric patients subjected to emergency laparotomy.

    Methods: All geriatric patients (≥65 years) undergoing emergency laparotomy at a single university hospital between 1/2015 and 12/2016 were included in this cohort study. Demographics and outcomes were retrospectively collected from medical records. Association between prognostic markers and 30-day mortality was assessed using Poisson and backward stepwise regression models. Prognostic value was assessed using receiver operating characteristic (ROC) curves.

    Results: =0.004) while osteopenia was not. P-POSSUM had poor prognostic value for 30-day mortality with an area under the ROC curve (AUC) of 0.59. The prognostic value of P-POSSUM improved significantly when adjusting for patient covariates (AUC=0.83).

    Conclusion: P-POSSUM and osteopenia alone hardly predict 30-day mortality in geriatric patients following emergency laparotomy. P-POSSUM adjusted for other patient covariates improves the prediction.

  • 2.
    Ahl, Rebecka
    et al.
    Örebro University, School of Medical Sciences. 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 University, School of Medical Sciences. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Ljungqvist, Olle
    Örebro University, School of Medical Sciences. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. 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?2017In: World Journal of Surgery, ISSN 0364-2313, E-ISSN 1432-2323, Vol. 41, no 7, p. 1801-1806Article in journal (Refereed)
    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 University, School of Medical Sciences. 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 University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Pourlotfi, Arvid
    Örebro University, School of Medical Sciences. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Bass, Gary Alan
    Örebro University, School of Medical Sciences. Division of Traumatology, Surgical Critical Care and Emergency Surgery, Penn Medicine, Penn Presbyterian Medical Center, Philadelphia, PA, USA.
    Matthiessen, Peter
    Örebro University, School of Medical Sciences. Division of Colorectal Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. 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 Study2021In: Scandinavian Journal of Surgery, ISSN 1457-4969, E-ISSN 1799-7267, Vol. 111, no 1, article id 14574969211037588Article in journal (Refereed)
    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 University, School of Medical Sciences. Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden.
    Lindgren, Rickard
    Örebro University Hospital. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Cao, Yang
    Örebro University, School of Medical Sciences. 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 University, School of Medical Sciences. Örebro University Hospital. 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 center2017In: Injury, ISSN 0020-1383, E-ISSN 1879-0267, Vol. 48, no 5, p. 1082-1087Article in journal (Refereed)
    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 University, School of Medical Sciences. 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 University, School of Medical Sciences. Örebro University Hospital. Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden; .
    Sjölin, Gabriel
    Örebro University, School of Medical Sciences. Department of Surgery.
    Lindgren, R.
    Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Ljungqvist, Olle
    Örebro University, School of Medical Sciences. Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    Effect of beta-blocker therapy on early mortality after emergency colonic cancer surgery2019In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 106, no 4, p. 477-483Article in journal (Refereed)
    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 University, School of Medical Sciences. 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 University, School of Medical Sciences. Örebro University Hospital.
    Sjölin, Gabriel
    Örebro University, School of Medical Sciences. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Ljungqvist, Olle
    Örebro University, School of Medical Sciences. 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 University, School of Medical Sciences. Örebro University Hospital. 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 Cancer2019In: World Journal of Surgery, ISSN 0364-2313, E-ISSN 1432-2323, Vol. 43, no 10, p. 2527-2535Article in journal (Refereed)
    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 University, School of Medical Sciences. 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 University, School of Medical Sciences. Örebro University Hospital.
    Sjölin, Gabriel
    Örebro University, School of Medical Sciences. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Lindgren, Rickard
    Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Ljungqvist, Olle
    Örebro University, School of Medical Sciences. Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    β-Blockade in Rectal Cancer Surgery: A Simple Measure of Improving Outcomes2020In: Annals of Surgery, ISSN 0003-4932, E-ISSN 1528-1140, Vol. 271, no 1, p. 140-146Article in journal (Refereed)
    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 University, School of Medical Sciences. 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 University, School of Medical Sciences. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Wallin, Göran
    Örebro University, School of Medical Sciences. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Ljungqvist, Olle
    Örebro University, School of Medical Sciences.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Effects of beta-blocker therapy on mortality after elective colon cancer surgery: a Swedish nationwide cohort study2020In: BMJ Open, E-ISSN 2044-6055, Vol. 10, no 7, article id e036164Article in journal (Refereed)
    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 University, School of Medical Sciences. 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 University, School of Medical Sciences. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Wallin, Göran
    Örebro University, School of Medical Sciences. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Ljungqvist, Olle
    Örebro University, School of Medical Sciences. Department of Surgery, Örebro University Hospital, Örebro, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    The Effects of Beta-Blocker Therapy on Mortality After Elective Colon Cancer SurgeryManuscript (preprint) (Other academic)
  • 10.
    Ahl, Rebecka
    et al.
    Örebro University, School of Medical Sciences. 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 University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Borg, Tomas
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Sjölin, Gabriel
    Örebro University, School of Medical Sciences. Örebro University Hospital. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Forssten, Maximilian Peter
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. 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 surgery2022In: European Journal of Trauma and Emergency Surgery, ISSN 1863-9933, E-ISSN 1863-9941, Vol. 48, no 2, p. 743-751Article in journal (Refereed)
    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 University, School of Medical Sciences. 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 University, School of Medical Sciences. Örebro University Hospital. 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 University, School of Medical Sciences. Örebro University Hospital. 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 Score2017In: Journal of the American College of Surgeons, ISSN 1072-7515, E-ISSN 1879-1190, Vol. 224, no 3, p. 264-269Article in journal (Refereed)
    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 University, School of Medical Sciences. 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 University, School of Medical Sciences. Department of Surgery, Division of Trauma and Emergency Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery.
    The Association of Intracranial Pressure Monitoring and Mortality: A Propensity Score-Matched Cohort of Isolated Severe Blunt Traumatic Brain Injury2019In: Journal of Emergencies, Trauma and Shock, ISSN 0974-2700, E-ISSN 0974-519X, Vol. 12, no 1, p. 18-22Article in journal (Refereed)
    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.

  • 13.
    Ahl, Rebecka
    et al.
    Örebro University, School of Medical Sciences. Department of Surgery, Division of Trauma and Emergency Surgery, Karolinska University Hospital, Stockholm, Sweden.
    Sjölin, Gabriel
    Örebro University, School of Medical Sciences. Department of Surgery, Division of Trauma and Emergency Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. 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]2017In: Injury, ISSN 0020-1383, E-ISSN 1879-0267, Vol. 48, no 11, p. 2612-2612Article in journal (Refereed)
  • 14.
    Ahl, Rebecka
    et al.
    Örebro University, School of Medical Sciences. Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden.
    Sjölin, Gabriel
    Örebro University, School of Medical Sciences. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. 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?2017In: Injury, ISSN 0020-1383, E-ISSN 1879-0267, Vol. 48, no 1, p. 101-105Article in journal (Refereed)
    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.

  • 15.
    Ahl, Rebecka
    et al.
    Örebro University, School of Medical Sciences. 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 University, School of Medical Sciences. 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 University, School of Medical Sciences. Örebro University Hospital. 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 study2017In: European Journal of Trauma and Emergency Surgery, ISSN 1863-9933, E-ISSN 1863-9941, Vol. 43, no 6, p. 783-789Article in journal (Refereed)
    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.

  • 16.
    Barmparas, Galinos
    et al.
    Cedars-Sinai Medical Center, Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Los Angeles California, USA.
    Harada, Megan Y.
    Cedars-Sinai Medical Center, Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Los Angeles California, USA.
    Ko, Ara
    Cedars-Sinai Medical Center, Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Los Angeles California, USA.
    Dhillon, Navpreet K.
    Cedars-Sinai Medical Center, Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Los Angeles California, USA.
    Smith, Eric J. T.
    Cedars-Sinai Medical Center, Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Los Angeles California, USA.
    Li, Tong
    Cedars-Sinai Medical Center, Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Los Angeles California, USA.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery, Division of Trauma and Emergency Surgery.
    Ley, Eric J.
    Cedars-Sinai Medical Center, Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Los Angeles California, USA.
    The Effect of Early Positive Cultures on Mortality in Ventilated Trauma Patients2018In: Surgical Infections, ISSN 1096-2964, E-ISSN 1557-8674, Vol. 19, no 4, p. 410-416Article in journal (Refereed)
    Abstract [en]

    Background: The purpose was to examine the incidence of positive cultures in a highly susceptible subset of trauma patients admitted to the surgical intensive care unit (SICU) for mechanical ventilation and to examine the impact of their timing on outcomes.

    Patients and Methods: A retrospective review was conducted of blunt trauma patients admitted to the SICU for mechanical ventilation at a level I trauma center over a five-year period. All urine, blood, and sputum cultures were abstracted. Patients with at least one positive culture were compared with those with negative or no cultures. The primary outcome was mortality. A Cox regression model with a time-dependent variable was utilized to calculate the adjusted hazard ratio (AHR).

    Results: The median age of 635 patients meeting inclusion criteria was 46 and 74.2% were male. A total of 298 patients (46.9%) had at least one positive culture, with 28.9% occurring within two days of admission. Patients with positive cultures were more likely to be severely injured with an injury severity score (ISS) 16 (68.5% vs. 45.1%, p<0.001). Overall mortality was 22%. Patients who had their first positive culture within two and three days from admission had a significantly higher AHR for mortality (AHR: 14.46, p<0.001 and AHR: 10.59, p=0.028, respectively) compared to patients with a positive culture at day six or later.

    Conclusions: Early positive cultures are common among trauma patients requiring mechanical ventilation and are associated with higher mortality. Early identification with damage control cultures obtained on admission to aid with early targeted treatment might be justified.

  • 17.
    Bass, G. A.
    et al.
    Örebro University, School of Medical Sciences. Department of Surgery, Tallaght University Hospital, Dublin, Ireland.
    Gillis, A. E.
    Department of Surgery, Tallaght University Hospital, Dublin, Ireland.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    European Society for Trauma and Emergency Surgery (ESTES), Cohort Studies Group
    Self-reported and actual adherence to the Tokyo guidelines in the European snapshot audit of complicated calculous biliary disease2020In: BJS Open, E-ISSN 2474-9842, Vol. 4, no 4, p. 622-629Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Complicated acute biliary calculous disease poses clinical challenges. The European Society of Trauma and Emergency Surgery (ESTES) snapshot audit of complicated biliary calculous disease aims to make novel comparisons between self-reported institutional adherence to the Tokyo guidelines (TG18) and 'real-world' contemporary practice across Europe.

    METHODS: A preplanned analysis of a prospective observational multicentre audit that captured patients undergoing emergency admission for complicated biliary calculous disease (complicated cholecystitis, biliary pancreatitis, or choledocholithiasis with or without cholangitis) between 1 and 31 October 2018 was performed. An anonymized survey was administered to participating sites.

    RESULTS: Following an open call for participation, 25 centres from nine countries enrolled 338 patients. All centres completed the anonymized survey. Fifteen centres (60 per cent) self-reported that a minority of patients were treated surgically on index admission, favouring interval cholecystectomy. This was replicated in the snapshot audit, in which 152 of 338 patients (45·0 per cent) underwent index admission cholecystectomy, 17 (5·0 per cent) had interval cholecystectomy, and the remaining 169 (50·0 per cent) had not undergone surgery by the end of the 60-day follow-up. Centres that employed a dedicated acute care surgery model of care were more likely to perform index admission cholecystectomy compared with a traditional general surgery 'on call' service (57 versus 38 per cent respectively; odds ratio 2·14 (95 per cent c.i. 1·37 to 3·35), P < 0·001). Six centres (24 per cent) self-reported routinely performing blood cultures in acute cholecystitis; patient-level audit data revealed that blood cultures were done in 47 of 154 patients (30·5 per cent). No centre self-reported omitting antibiotics in the management of acute cholecystitis, and 144 of 154 (93·5 per cent) of patients in the snapshot audit received antibiotics during their index admission.

    CONCLUSION: Awareness of TG18 recommendations was high, but self-reported adherence and objective snapshot audit data showed low compliance with TG18 in patients with complicated acute biliary calculous disease.

  • 18.
    Bass, G. A.
    et al.
    Örebro University, School of Medical Sciences. Division of Traumatology, Emergency Surgery & Surgical Critical Care, Penn Presbyterian Medical Center, University of Pennsylvania, Philadelphia, PA, USA; Department of Surgery, Tallaght University Hospital, Dublin, Ireland.
    Gillis, Amy E.
    Department of Surgery, Tallaght University Hospital, Dublin, Ireland.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Patients over 65 years with Acute Complicated Calculous Biliary Disease are Treated Differently: Results and Insights from the ESTES Snapshot Audit2021In: World Journal of Surgery, ISSN 0364-2313, E-ISSN 1432-2323, Vol. 45, no 7, p. 2046-2055Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Accrued comorbidities are perceived to increase operative risk. Surgeons may offer operative treatments less often to their older patients with acute complicated calculous biliary disease (ACCBD). We set out to capture ACCBD incidence in older patients across Europe and the currently used treatment algorithms.

    METHODS: The European Society of Trauma and Emergency Surgery (ESTES) undertook a snapshot audit of patients undergoing emergency hospital admission for ACCBD between October 1 and 31 2018, comparing patients under and ≥ 65 years. Mortality, postoperative complications, time to operative intervention, post-acute disposition, and length of hospital stay (LOS) were compared between groups. Within the ≥ 65 cohort, comorbidity burden, mortality, LOS, and disposition outcomes were further compared between patients undergoing operative and non-operative management.

    RESULTS: The median age of the 338 admitted patients was 67 years; 185 patients (54.7%) of these were the age of 65 or over. Significantly fewer patients ≥ 65 underwent surgical treatment (37.8% vs. 64.7%, p < 0.001). Surgical complications were more frequent in the ≥ 65 cohort than younger patients, and the mean postoperative LOS was significantly longer. Postoperative mortality was seen in 2.2% of patients ≥ 65 (vs. 0.7%, p = 0.253). However, operated elderly patients did not differ from non-operated in terms of comorbidity burden, mortality, LOS, or post-discharge rehabilitation need.

    CONCLUSIONS: Few elderly patients receive surgical treatment for ACCBD. Expectedly, postoperative morbidity, LOS, and the requirement for post-discharge rehabilitation are higher in the elderly than younger patients but do not differ from elderly patients managed non-operatively. With multidisciplinary perioperative optimization, elderly patients may be safely offered optimal treatment.

    TRIAL REGISTRATION: ClinicalTrials.gov (Trial # NCT03610308).

  • 19.
    Bass, G. A.
    et al.
    Örebro University, School of Medical Sciences. 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 University, School of Medical Sciences. 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 University, School of Medical Sciences. 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 University, School of Medical Sciences. Örebro University Hospital.
    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 University, School of Medical Sciences. Örebro University Hospital. 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 Procedures2021In: Journal of Trauma and Acute Care Surgery, ISSN 2163-0755, E-ISSN 2163-0763, Vol. 90, no 2, p. 240-248Article in journal (Refereed)
    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.

  • 20.
    Bass, Gary A
    et al.
    Örebro University, School of Medical Sciences. Division of Trauma, Surgical Critical Care, and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia PA, USA; Division of Trauma and Emergency Surgery, Orebro University Hospital and Faculty of School of Medical Sciences, Örebro University, Örebro, Sweden; Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISC-LDI), University of Pennsylvania, Philadelphia PA, USA; Center for Perioperative Outcomes Research and Transformation (CPORT), University of Pennsylvania, Philadelphia PA, USA.
    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.
    Ryan, Éanna J.
    Division of Trauma and Emergency Surgery, Orebro University Hospital and Faculty of School of Medical Sciences, Örebro University, Örebro, Sweden; Department of Surgery, Tallaght University Hospital, Dublin, Ireland.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Clinical Epidemiology and Biostatistics.
    Lane-Fall, Meghan
    Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISC-LDI), University of Pennsylvania, Philadelphia PA, USA; Center for Perioperative Outcomes Research and Transformation (CPORT), University of Pennsylvania, Philadelphia PA, USA; Department of Anesthesia and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
    Duffy, Caoimhe C.
    Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISC-LDI), University of Pennsylvania, Philadelphia PA, USA; Center for Perioperative Outcomes Research and Transformation (CPORT), University of Pennsylvania, Philadelphia PA, USA; Department of Anesthesia and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
    Vail, Emily A.
    Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISC-LDI), University of Pennsylvania, Philadelphia PA, USA; Center for Perioperative Outcomes Research and Transformation (CPORT), University of Pennsylvania, Philadelphia PA, USA; Department of Anesthesia and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Division of Trauma and Emergency Surgery.
    The snapshot audit methodology: design, implementation and analysis of prospective observational cohort studies in surgery2023In: European Journal of Trauma and Emergency Surgery, ISSN 1863-9933, E-ISSN 1863-9941, Vol. 49, no 1, p. 5-15Article in journal (Refereed)
    Abstract [en]

    Purpose: For some surgical conditionns and scientific questions, the "real world" effectiveness of surgical patient care may be better explored using a multi-institutional time-bound observational cohort assessment approach (termed a "snapshot audit") than by retrospective review of administrative datasets or by prospective randomized control trials. We discuss when this might be the case, and present the key features of developing, deploying, and assessing snapshot audit outcomes data.

    Methods: A narrative review of snapshot audit methodology was generated using the Scale for the Assessment of Narrative Review Articles (SANRA) guideline. Manuscripts were selected from domains including: audit design and deployment, statistical analysis, surgical therapy and technique, surgical outcomes, diagnostic testing, critical care management, concomitant non-surgical disease, implementation science, and guideline compliance.

    Results: Snapshot audits all conform to a similar structure: being time-bound, non-interventional, and multi-institutional. A successful diverse steering committee will leverage expertise that includes clinical care and data science, coupled with librarian services. Pre-published protocols (with specified aims and analyses) greatly helps site recruitment. Mentored trainee involvement at collaborating sites should be encouraged through manuscript contributorship. Current funding principally flows from medical professional organizations.

    Conclusion: The snapshot audit approach to assessing current care provides insights into care delivery, outcomes, and guideline compliance while generating testable hypotheses.

  • 21.
    Bass, Gary Alan
    et al.
    Örebro University, School of Medical Sciences. Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA; Leonard Davis Institute of Health Economics (LDI), University of Pennsylvania, Philadelphia, USA; Center for Peri-Operative Outcomes Research and Transformation (CPORT), University of Pennsylvania, Philadelphia, USA.
    Duffy, Caoimhe C.
    Leonard Davis Institute of Health Economics (LDI), University of Pennsylvania, Philadelphia, USA; Center for Peri-Operative Outcomes Research and Transformation (CPORT), University of Pennsylvania, Philadelphia, USA.
    Kaplan, Lewis J.
    Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA; Department of Anesthesia and Critical Care, University of Pennsylvania, Philadelphia, USA; Corporal Michael Cresenscz Veterans Affairs Medical Center (CMCVAMC), Philadelphia, USA.
    Sarani, Babak
    Center for Trauma and Critical Care, George Washington University School of Medicine & Health Sciences, Washington D.C., USA.
    Martin, Niels D.
    Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA.
    Mohammad Ismail, Ahmad
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital. Clinical Epidemiology and Biostatistics.
    Forssten, Maximilian Peter
    Örebro University, School of Medical Sciences.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Division of Trauma & Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    The revised cardiac risk index is associated with morbidity and mortality independent of injury severity in elderly patients with rib fractures2023In: Injury, ISSN 0020-1383, E-ISSN 1879-0267, Vol. 54, no 1, p. 56-62Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Risk factors for mortality and in-hospital morbidity among geriatric patients with traumatic rib fractures remain unclear. Such patients are often frail and demonstrate a high comorbidity burden. Moreover, outcomes anticipated by current rubrics may reflect the influence of multisystem injury or surgery, and thus not apply to isolated injuries in geriatric patients. We hypothesized that the Revised Cardiac Risk Index (RCRI) may assist in risk-stratifying geriatric patients following rib fracture.

    METHODS: All geriatric patients (age ≥65 years) with a conservatively managed rib fracture owing to an isolated thoracic injury (thorax AIS ≥1), in the 2013-2019 TQIP database were assessed including demographics and outcomes. The association between the RCRI and in-hospital morbidity as well as mortality was analyzed using Poisson regression models while adjusting for potential confounders.

    RESULTS: 96,750 geriatric patients sustained rib fractures. Compared to those with RCRI 0, patients with an RCRI score of 1 had a 16% increased risk of in-hospital mortality [adjusted incidence rate ratio (adj-IRR), 95% confidence interval (CI): 1.16 (1.02-1.32), p=0.020]. An RCRI score of 2 [adj-IRR (95% CI): 1.72 (1.44-2.06), p<0.001] or ≥3 [adj-IRR (95% CI): 3.07 (2.31-4.09), p<0.001] was associated with an even greater mortality risk. Those with an increased RCRI also exhibited a higher incidence of myocardial infarction, cardiac arrest, stroke, and acute respiratory distress syndrome.

    CONCLUSIONS: Geriatric patients with rib fractures and an RCRI ≥1 represent a vulnerable and high-risk group. This index may inform the decision to admit for inpatient care and can also guide patient and family counseling as well as computer-based decision-support.

  • 22.
    Bass, Gary Alan
    et al.
    Örebro University, School of Medical Sciences. Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania, USA.
    Forssten, Maximilian Peter
    Örebro University, School of Medical Sciences. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Pourlotfi, Arvid
    Örebro University, School of Medical Sciences. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Ahl, Rebecka
    Örebro University, School of Medical Sciences. 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 University, School of Medical Sciences. Örebro University Hospital.
    Matthiessen, Peter
    Örebro University, School of Medical Sciences. Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, Örebro, Sweden.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Cardiac risk stratification in emergency resection for colonic tumours2021In: BJS Open, E-ISSN 2474-9842, Vol. 5, no 4, article id zrab057Article in journal (Refereed)
    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.

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    Cardiac risk stratification in emergency resection for colonic tumours
  • 23.
    Bass, Gary Alan
    et al.
    Örebro University, School of Medical Sciences.
    Forssten, Maximilian Peter
    Örebro University, School of Medical Sciences.
    Ryan, Eanna
    Biloslavo, Alan
    General Surgery Department, Cattinara University Hospital, Trieste, Italy.
    Tolonen, Matti
    Ahl, Rebecka
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Kurihara, Hayato
    Pourlotfi, Arvid
    Örebro University, School of Medical Sciences.
    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 University, School of Medical Sciences. Örebro University Hospital.
    Techniques for Mesoappendix Transection and Appendix Resection When Performing Acute Appendectomy: Insights from the SnapAppy Group Audit2022In: Journal of the American College of Surgeons, ISSN 1072-7515, E-ISSN 1879-1190, Vol. 235, no 5 Suppl. 2, p. S24-S24Article in journal (Other academic)
    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.

  • 24.
    Bass, Gary Alan
    et al.
    Örebro University, School of Medical Sciences. Emergency Surgery Committee, European Society for Trauma and Emergency Surgery (ESTES), Pölten, Austria; Department of Surgery, Tallaght University Hospital, Dublin 24, Ireland; Department of Surgery, Örebro University School of Medical Sciences, Örebro, Sweden; Department of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, USA.
    Gillis, Amy
    Department of Surgery, Tallaght University Hospital, Dublin 24, Ireland.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Clinical Epidemiology and Biostatistics.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Emergency Surgery Committee, European Society for Trauma and Emergency Surgery (ESTES), Pölten, Austria; Department of Surgery, Örebro University School of Medical Sciences, Örebro, Sweden.
    Patterns of prevalence and contemporary clinical management strategies in complicated acute biliary calculous disease: an ESTES 'snapshot audit' of practice2022In: European Journal of Trauma and Emergency Surgery, ISSN 1863-9933, E-ISSN 1863-9941, Vol. 48, p. 23-25Article in journal (Refereed)
    Abstract [en]

    Background: Acute complications of biliary calculi are common, morbid, and complex to manage. Variability exists in the techniques utilized to treat these conditions at an individual surgeon and unit level.

    Aim: To identify, through an international prospective nonrandomized cohort study, the epidemiology and areas of practice variability in management of acute complicated calculous biliary disease (ACCBD) and to correlate them against reported outcomes.

    Methods: A preplanned analysis of the European Society of Trauma and Emergency Surgery (ESTES) 2018 Complicated Biliary Calculous Disease audit was performed. Patients undergoing emergency hospital admission with ACCBD between 1 October 2018 and 31 October 2018 were included. All eligible patients with acute complicated biliary calculous disease were recorded contemporaneously using a standardized predetermined protocol and a secure online database and followed-up through to 60 days from their admission.

    Endpoints: A two-stage data collection strategy collecting patient demographics, details of operative, endoscopic and radiologic intervention, and outcome metrics. Outcome measures included mortality, surgical morbidity, ICU stay, timing of operative intervention, and length of hospital stay.

    Results: Three hundred thirty-eight patients were included, with a mean age of 65 years and 54% were female. Diagnosis at admission were: cholecystitis (45.6%), biliary pancreatitis (21%), choledocholithiasis with and without cholangitis (13.9% and 18%). Index admission cholecystectomy was performed in just 50% of cases, and 28% had an ERCP performed. Morbidity and mortality were low.

    Conclusion: This first ESTES snapshot audit, a purely descriptive collaborative study, gives rich 'real world' insights into local variability in surgical practice as compared to international guidelines, and how this may impact upon outcomes. These granular data will serve to improve overall patient care as well as being hypothesis generating and inform areas needing future prospective study.

  • 25.
    Bass, Gary Alan
    et al.
    Örebro University, School of Medical Sciences. Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA; Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden; 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.
    Kaplan, Lewis J.
    Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA; Corporal Michael Crescenz Veterans Affairs Medical Center, Philadelphia, USA.
    Forssten, Maximilian Peter
    Örebro University, School of Medical Sciences. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Walsh, Thomas N.
    Royal College of Surgeons in Ireland Medical University, Busaiteen, Bahrain.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Clinical Epidemiology and Biostatistics.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Division of Trauma and Emergency Surgery, Department of Surgery.
    Techniques for mesoappendix transection and appendix resection: insights from the ESTES SnapAppy study2023In: European Journal of Trauma and Emergency Surgery, ISSN 1863-9933, E-ISSN 1863-9941, Vol. 49, no 1, p. 17-32Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: Surgically managed appendicitis exhibits great heterogeneity in techniques for mesoappendix transection and appendix amputation from its base. It is unclear whether a particular surgical technique provides outcome benefit or reduces complications.

    MATERIAL AND METHODS: We undertook a pre-specified subgroup analysis of all patients who underwent laparoscopic appendectomy at index admission during SnapAppy (ClinicalTrials.gov Registration: NCT04365491). We collected routine, anonymized observational data regarding surgical technique, patient demographics and indices of disease severity, without change to clinical care pathway or usual surgeon preference. Outcome measures of interest were the incidence of complications, unplanned reoperation, readmission, admission to the ICU, death, hospital length of stay, and procedure duration. We used Poisson regression models with robust standard errors to calculate incident rate ratios (IRRs) and 95% confidence intervals (CIs).

    RESULTS: Three-thousand seven hundred sixty-eight consecutive adult patients, included from 71 centers in 14 countries, were followed up from date of admission for 90 days. The mesoappendix was divided hemostatically using electrocautery in 1564(69.4%) and an energy device in 688(30.5%). The appendix was amputated by division of its base between looped ligatures in 1379(37.0%), with a stapler in 1421(38.1%) and between clips in 929(24.9%). The technique for securely dividing the appendix at its base in acutely inflamed (AAST Grade 1) appendicitis was equally divided between division between looped ligatures, clips and stapled transection. However, the technique used differed in complicated appendicitis (AAST Grade 2 +) compared with uncomplicated (Grade 1), with a shift toward transection of the appendix base by stapler (58% vs. 38%; p < 0.001). While no statistical difference in outcomes could be detected between different techniques for division of appendix base, decreased risk of any [adjusted IRR (95% CI): 0.58 (0.41-0.82), p = 0.002] and severe [adjusted IRR (95% CI): 0.33 (0.11-0.96), p = 0.045] complications could be detected when using energy devices.

    CONCLUSIONS: Safe mesoappendix transection and appendix resection are accomplished using heterogeneous techniques. Technique selection for both mesoappendix transection and appendix resection correlates with AAST grade. Higher grade led to more ultrasonic tissue transection and stapled appendix resection. Higher AAST appendicitis grade also correlated with infection-related complication occurrence. Despite the overall well-tolerated heterogeneity of approaches to acute appendicitis, increasing disease acuity or complexity appears to encourage homogeneity of intraoperative surgical technique toward advanced adjuncts.

  • 26.
    Bass, Gary Alan
    et al.
    Division of Traumatology, Emergency Surgery and Surgical Critical Care, Perelman School of Medicine, University of Pennsylvania, 51 N. 39th Street, MOB 1, Suite 120, Philadelphia, PA, 19104, USA; Leonard Davis Institute of Health Economics (LDI), University of Pennsylvania, Philadelphia, PA, USA; Center for Perioperative Outcomes Research and Transformation (CPORT), University of Pennsylvania, Philadelphia, PA, USA.
    Kaplan, Lewis Jay
    Division of Traumatology, Emergency Surgery and Surgical Critical Care, Perelman School of Medicine, University of Pennsylvania, 51 N. 39th Street, MOB 1, Suite 120, Philadelphia, PA, 19104, USA; Surgical Critical Care, Corporal Michael J Crescenz VA Medical Center, 3900 Woodland Avenue, Philadelphia, PA, 19104, USA.
    Gaarder, Christine
    Department of Traumatology at Oslo University Hospital Ullevål (OUH U), Olso, Norway.
    Coimbra, Raul
    Riverside University Health System Medical Center, Moreno Valley, CA, USA; Loma Linda University School of Medicine, Loma Linda, CA, USA; Comparative Effectiveness and Clinical Outcomes Research Center - CECORC, Moreno Valley, CA, USA.
    Klingensmith, Nathan John
    Division of Traumatology, Emergency Surgery and Surgical Critical Care, Perelman School of Medicine, University of Pennsylvania, 51 N. 39th Street, MOB 1, Suite 120, Philadelphia, PA, 19104, USA.
    Kurihara, Hayato
    State University of Milan, Milan, Italy; Emergency Surgery Unit, Ospedale Policlinico di Milano, Milan, Italy.
    Zago, Mauro
    General & Emergency Surgery Division, A. Manzoni Hospital, ASST, Lecco, Lombardy, Italy.
    Cioffi, Stefano Piero Bernardo
    Sapienza University, Rome, Italy.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery, Sheikh Shakhbout Medical City (SSMC), Abu Dhabi, United Arab Emirates; Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Sugrue, Michael
    Letterkenny Hospital and Galway University, Letterkenny, Ireland.
    Tolonen, Matti
    Emergency Surgery, Meilahti Tower Hospital, HUS Helsinki University Hospital, Haartmaninkatu 4, PO Box 340, 00029, Helsinki, HUS, Finland.
    Valcarcel, Cristina Rey
    Hospital General Universitario Gregorio Marañón, Madrid (HGGM), Madrid, Spain.
    Tilsed, Jonathan
    Hull Royal Infirmary, Anlaby Road, Hu3 2Jz, Hull, England, UK.
    Hildebrand, Frank
    Department of Orthopaedics Trauma and Reconstructive Surgery, University Hospital RWTH Aachen, Aachen, Germany.
    Marzi, Ingo
    Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Frankfurt, Germany.
    European society for trauma and emergency surgery member-identified research priorities in emergency surgery: a roadmap for future clinical research opportunities2024In: European Journal of Trauma and Emergency Surgery, ISSN 1863-9933, E-ISSN 1863-9941Article, review/survey (Refereed)
    Abstract [en]

    BACKGROUND: European Society for Trauma and Emergency Surgery (ESTES) is the European community of clinicians providing care to the injured and critically ill surgical patient. ESTES has several interlinked missions - (1) the promotion of optimal emergency surgical care through networked advocacy, (2) promulgation of relevant clinical cognitive and technical skills, and (3) the advancement of scientific inquiry that closes knowledge gaps, iteratively improves upon surgical and perioperative practice, and guides decision-making rooted in scientific evidence. Faced with multitudinous opportunities for clinical research, ESTES undertook an exercise to determine member priorities for surgical research in the short-to-medium term; these research priorities were presented to a panel of experts to inform a 'road map' narrative review which anchored these research priorities in the contemporary surgical literature.

    METHODS: Individual ESTES members in active emergency surgery practice were polled as a representative sample of end-users and were asked to rank potential areas of future research according to their personal perceptions of priority. Using the modified eDelphi method, an invited panel of ESTES-associated experts in academic emergency surgery then crafted a narrative review highlighting potential research priorities for the Society.

    RESULTS: Seventy-two responding ESTES members from 23 countries provided feedback to guide the modified eDelphi expert consensus narrative review. Experts then crafted evidence-based mini-reviews highlighting knowledge gaps and areas of interest for future clinical research in emergency surgery: timing of surgery, inter-hospital transfer, diagnostic imaging in emergency surgery, the role of minimally-invasive surgical techniques and Enhanced Recovery After Surgery (ERAS) protocols, patient-reported outcome measures, risk-stratification methods, disparities in access to care, geriatric outcomes, data registry and snapshot audit evaluations, emerging technologies interrogation, and the delivery and benchmarking of emergency surgical training.

    CONCLUSIONS: This manuscript presents the priorities for future clinical research in academic emergency surgery as determined by a sample of the membership of ESTES. While the precise basis for prioritization was not evident, it may be anchored in disease prevalence, controversy around aspects of current patient care, or indeed the identification of a knowledge gap. These expert-crafted evidence-based mini-reviews provide useful insights that may guide the direction of future academic emergency surgery research efforts.

  • 27.
    Bass, Gary Alan
    et al.
    Örebro University, School of Medical Sciences. Division of Traumatology, Surgical Critical Care & Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA; Division of Trauma & Emergency Surgery, Örebro University Hospital, Örebro, Sweden; 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.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Division of Trauma & Emergency Surgery.
    Ryan, Éanna J.
    Tallaght University Hospital, Dublin, Ireland.
    Forssten, Maximilian Peter
    Örebro University, School of Medical Sciences. Division of Trauma & Emergency Surgery, Örebro University Hospital, Örebro, Sweden.
    Tolonen, Matti
    Helsinki University Hospital HUS Meilahden Tornisairaala, Helsinki, Finland.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Clinical Epidemiology and Biostatistics.
    Kaplan, Lewis J.
    Division of Traumatology, Surgical Critical Care & Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA; Corporal Michael Crescenz Veterans Affairs Medical Center, Philadelphia, USA.
    Clinical practice selectively follows acute appendicitis guidelines2023In: European Journal of Trauma and Emergency Surgery, ISSN 1863-9933, E-ISSN 1863-9941, Vol. 49, no 1, p. 45-56Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: Acute appendicitis is a common surgical emergency, and the standard approach to diagnosis and management has been codified in several practice guidelines. Adherence to these guidelines provides insight into independent surgical practice patterns and institutional resource constraints as impediments to best practice. We explored data from the recent ESTES SnapAppy observational cohort study to determine guideline compliance in contemporary practice to identify opportunities to close evidence-to-practice gaps.

    METHODS: We undertook a preplanned analysis of the ESTES SnapAppy observational cohort study, identifying, at a patient level, congruence with, or deviation from WSES Jerusalem guidelines for the diagnosis and management of acute appendicitis and the Surviving Sepsis Campaign in our cohort. Compliance was then correlated with the incidence of postoperative complications.

    RESULTS: Four thousand six hundred and thirteen (4613) consecutive adult and adolescent patients with acute appendicitis were followed from date of admission (November 1, 2020, and May 28, 2021) for 90 days. Patient-level compliance with guideline elements allowed patients to be grouped into those with full compliance (all 5 elements: 13%), partial compliance (1-4 elements: 87%) or noncompliance (0 elements: 0.2%). We identified an excess postoperative complication rate in patients who received noncompliant and partially compliant care, compared with those who received fully guideline-compliant care (36% and 16%, versus 7.3%, p < 0.001).

    CONCLUSIONS: The observed diagnostic and treatment practices of the participating institutions displayed variability in compliance with key recommendations from existing guidelines. In general, practice was congruent with recommendations for preoperative antibiotic surgical site infection prophylaxis administration, time to surgery, and operative approach. However, there remains opportunities for improvement in the choice of diagnostic imaging modality, postoperative antibiotic stewardship to timely discontinue prophylactic antibiotics, and the implementation of ambulatory treatment pathways for uncomplicated appendicitis in the healthy young adult.

  • 28.
    Bass, Gary Alan
    et al.
    Örebro University, School of Medical Sciences. Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, USA.
    Stephen, Christopher
    Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, USA.
    Forssten, Maximilian Peter
    Örebro University, School of Medical Sciences. Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, USA.
    Bailey, Joanelle A.
    Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, USA.
    Mohseni, Shahin
    Department of Surgery, Division of Trauma and Emergency Surgery, Örebro University Hospital, Örebro, Sweden.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Chreiman, Kristen
    Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, USA.
    Duffy, Caoimhe
    Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, USA.
    Seamon, Mark J.
    Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, USA.
    Cannon, Jeremy W.
    Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, USA.
    Martin, Niels Douglas
    Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, USA.
    Admission Triage With Pain, Inspiratory Effort, Cough Score can Predict Critical Care Utilization and Length of Stay in Isolated Chest Wall Injury2022In: Journal of Surgical Research, ISSN 0022-4804, E-ISSN 1095-8673, Vol. 277, p. 310-318Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: Damage to the thoracic cage is common in the injured patient, both when the injuries are confined to this single cavity and as part of the overall injury burden of a polytraumatized patient. In a subset of these patients, the severity of injury to the intrathoracic viscera is either underappreciated at admission or blossom over the following 48-72 h. The ability to promptly identify these patients and abrogate complications therefore requires triage of such at-risk patients to close monitoring in a critical care environment. At our institution, this triage hinges on the Pain, Inspiratory effort, Cough (PIC) score, which generates a composite unitless score from a nomogram which aggregates several variables-patient-reported Pain visual analog scale, Incentive spirometry effort, and the perceived adequacy of Cough. We thus sought to audit PIC's discriminant power in predicting intensive care unit (ICU) need.

    METHODS: This retrospective cohort study was performed at an urban, academic, level 1 trauma center. All isolated chest wall injuries (excluded any Abbreviated Injury Score >2 in head or abdomen) from January 2020 to June 2021 were identified in the local trauma registry. The electronic medical record was queried for standard demographics, admission PIC score, postadmission destination, ICU and hospital length of stay (LOS), and any unplanned admissions to the ICU. Chi-squared tests were used to determine differences between PIC score outcomes and the recursive partitioning method correlated admission PIC score to ICU LOS.

    RESULTS: Two hundred and thirty six isolated chest wall injury patients were identified, of whom 194 were included in the final analysis. The median age was 60 (interquartile range [IQR] 50-74) years, 63.1% were male, and the median (IQR) number of rib fractures was 3.0 (2.0-5.0). A cutoff PIC score of 7 or lower was associated with ICU admission (odds ratio [OR] 95% CI: 8.19 [3.39-22.55], P < 0.001 with a PPV = 41.4%, NPV = 91%), and with ICU admission for greater than 48 h [OR (95% CI): 26.86 (5.5-43.96), P < 0.001, with a PPV = 25.9%, NPV = 98.7%] but not anatomic injury severity score, hospital LOS or ICU, or the requirement for mechanical ventilation. The association between PIC score 7 or below and the presence of bilateral fractures, flail chest, or sternal fracture did not meet statistical significance. The accurate cut point of the PIC score to predict ICU admission over 48 h in our retrospective cohort was calculated as PIC ≤ 7 for P = 0.013 and PIC ≤ 6 for P = 0.001.

    CONCLUSIONS: Patients with isolated chest wall injuries require effective reproducible triage for ICU-level care. The PIC score appears to be a moderate discriminator of critical care need, per se, as judged by our recorded complication rate requiring critical care intervention. This vigilance may pay dividends in early detection and abrogation of respiratory failure emergencies. Furthermore, PIC score delineation for ICU need appears to be appropriate at 7 or less; this threshold can be used during admission triage to guide care.

  • 29.
    Bukur, M.
    et al.
    Division of Trauma and Surgical Critical Care, Department of Surgery, Cedars Sinai Medical Center, Los Angeles CA, United States; Department of Surgery, Cedars Sinai Medical Center, Los Angeles CA, United States.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Department of Acute Care Surgery, Los Angeles County, Los Angeles CA, United States; University of Southern California Medical Center, Los Angeles CA, United States.
    Ley, E.
    Division of Trauma and Surgical Critical Care, Department of Surgery, Cedars Sinai Medical Center, Los Angeles CA, United States.
    Salim, A.
    Division of Trauma and Surgical Critical Care, Department of Surgery, Cedars Sinai Medical Center, Los Angeles CA, United States.
    Margulies, D.
    Division of Trauma and Surgical Critical Care, Department of Surgery, Cedars Sinai Medical Center, Los Angeles CA, United States.
    Talving, P.
    Department of Acute Care Surgery, Los Angeles County, Los Angeles CA, United States; University of Southern California Medical Center, Los Angeles CA, United States.
    Demetriades, D.
    Department of Acute Care Surgery, Los Angeles County, Los Angeles CA, United States; University of Southern California Medical Center, Los Angeles CA, United States.
    Inaba, K.
    Department of Acute Care Surgery, Los Angeles County, Los Angeles CA, United States; University of Southern California Medical Center, Los Angeles CA, United States.
    Efficacy of beta-blockade after isolated blunt head injury: Does race matter? (vol 72, pg 1013, 2012)2012In: Journal of Trauma and Acute Care Surgery, ISSN 2163-0755, E-ISSN 2163-0763, Vol. 72, no 6, p. 1725-1725Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Several retrospective clinical studies and recent prospective animal models demonstrate improved outcomes with beta-blocker administration after isolated blunt head injury. However, no investigations to date have examined the influence of race on the potential therapeutic effectiveness of these medications. Our hypothesis was that mortality benefits associated with beta-blocker exposure after isolated blunt head injury varies based on ethnicity.

    METHODS: The trauma registry and the surgical intensive care unit (ICU) databases of an academic Level I trauma center were used to identify all patients sustaining blunt head injury requiring ICU admission from July 1998 to December 2009. Patients sustaining major associated extracranial injuries (Abbreviated Injury Scale [AIS] score ≥3 in any body region) were excluded. Patient demographics, injury profile, Injury Severity Score, and beta-blocker exposure were abstracted. The primary outcome evaluated was in-hospital mortality stratified by ethnicity.

    RESULTS: During the 11-year study period, 3,750 patients were admitted to the Los Angeles County + University of Southern California Medical Center trauma ICU because of blunt trauma. Of these, 65% (n = 2,446) had an “isolated” head injury. When stratified by race, most patients were Hispanics (60%), followed by Whites (21%), Asians (11%), and African Americans (8%). After adjusting for confounding variables with multivariate regression, only those of Asian and Hispanic descent demonstrated significantly improved outcomes associated with beta-blocker administration.

    CONCLUSIONS: Our results indicate that beta-blockade after traumatic brain injury may not benefit all races equally. Further prospective research is necessary to assess this discrepancy in treatment benefit and explore other possible therapeutic interventions.

    LEVEL OF EVIDENCE: III, therapeutic study; II, prognostic study.

  • 30.
    Cao, Yang
    et al.
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Bass, G. A.
    Örebro University, School of Medical Sciences. 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 University, School of Medical Sciences. 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 University, School of Medical Sciences. Department of General Surgery, Örebro University Hospital, Örebro, Sweden.
    Geijer, Håkan
    Örebro University, School of Medical Sciences. Department of Radiology.
    Montgomery, Scott
    Örebro University, School of Medical Sciences. Clinical Epidemiology Division, Department of Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Epidemiology and Public Health, University College London, London, UK..
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of General Surgery, Örebro University Hospital, Örebro, Sweden.
    The statistical importance of P-POSSUM scores for predicting mortality after emergency laparotomy in geriatric patients2020In: BMC Medical Informatics and Decision Making, E-ISSN 1472-6947, Vol. 20, no 1, article id 86Article in journal (Refereed)
    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.

  • 31.
    Cao, Yang
    et al.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Unit of Integrative Epidemiology, Institute of Environmental Medicine, Karolinska Institute, Stockholm, Sweden.
    Forssten, Maximilian Peter
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohammad Ismail, Ahmad
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Borg, Tomas
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Ioannidis, Ioannis
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Montgomery, Scott
    Örebro University, School of Medical Sciences. Clinical Epidemiology Division, Department of Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Epidemiology and Public Health, University College London, London, UK.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Predictive Values of Preoperative Characteristics for 30-Day Mortality in Traumatic Hip Fracture Patients2021In: Journal of Personalized Medicine, E-ISSN 2075-4426, Vol. 11, no 5, article id 353Article in journal (Refereed)
    Abstract [en]

    Hip fracture patients have a high risk of mortality after surgery, with 30-day postoperative rates as high as 10%. This study aimed to explore the predictive ability of preoperative characteristics in traumatic hip fracture patients as they relate to 30-day postoperative mortality using readily available variables in clinical practice. All adult patients who underwent primary emergency hip fracture surgery in Sweden between 2008 and 2017 were included in the analysis. Associations between the possible predictors and 30-day mortality was performed using a multivariate logistic regression (LR) model; the bidirectional stepwise method was used for variable selection. An LR model and convolutional neural network (CNN) were then fitted for prediction. The relative importance of individual predictors was evaluated using the permutation importance and Gini importance. A total of 134,915 traumatic hip fracture patients were included in the study. The CNN and LR models displayed an acceptable predictive ability for predicting 30-day postoperative mortality using a test dataset, displaying an area under the ROC curve (AUC) of as high as 0.76. The variables with the highest importance in prediction were age, sex, hypertension, dementia, American Society of Anesthesiologists (ASA) classification, and the Revised Cardiac Risk Index (RCRI). Both the CNN and LR models achieved an acceptable performance in identifying patients at risk of mortality 30 days after hip fracture surgery. The most important variables for prediction, based on the variables used in the current study are age, hypertension, dementia, sex, ASA classification, and RCRI.

  • 32.
    Cao, Yang
    et al.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Clinical Epidemiology and Biostatistics, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden; Unit of Integrative Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, 171 77 Stockholm, Sweden.
    Forssten, Maximilian Peter
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Sarani, Babak
    Center of Trauma and Critical Care, George Washington University, Washington, DC 20037, USA.
    Montgomery, Scott
    Örebro University, School of Medical Sciences. Clinical Epidemiology and Biostatistics, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden; Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, 171 77 Stockholm, Sweden; Department of Epidemiology and Public Health, University College London, London WC1E 7HB, UK.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Division of Trauma, Critical Care & Acute Care Surgery, Department of Surgery, Sheikh Shakhbout Medical City, Mayo Clinic, Abu Dhabi P.O. Box 11001, United Arab Emirates.
    Development and Validation of an XGBoost-Algorithm-Powered Survival Model for Predicting In-Hospital Mortality Based on 545,388 Isolated Severe Traumatic Brain Injury Patients from the TQIP Database2023In: Journal of Personalized Medicine, E-ISSN 2075-4426, Vol. 13, no 9, article id 1401Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Traumatic brain injury (TBI) represents a significant global health issue; the traditional tools such as the Glasgow Coma Scale (GCS) and Abbreviated Injury Scale (AIS) which have been used for injury severity grading, struggle to capture outcomes after TBI.

    AIM AND METHODS: This paper aims to implement extreme gradient boosting (XGBoost), a powerful machine learning algorithm that combines the predictions of multiple weak models to create a strong predictive model with high accuracy and efficiency, in order to develop and validate a predictive model for in-hospital mortality in patients with isolated severe traumatic brain injury and to identify the most influential predictors. In total, 545,388 patients from the 2013-2021 American College of Surgeons Trauma Quality Improvement Program (TQIP) database were included in the current study, with 80% of the patients used for model training and 20% of the patients for the final model test. The primary outcome of the study was in-hospital mortality. Predictors were patients' demographics, admission status, as well as comorbidities, and clinical characteristics. Penalized Cox regression models were used to investigate the associations between the survival outcomes and the predictors and select the best predictors. An extreme gradient boosting (XGBoost)-powered Cox regression model was then used to predict the survival outcome. The performance of the models was evaluated using the Harrell's concordance index (C-index). The time-dependent area under the receiver operating characteristic curve (AUC) was used to evaluate the dynamic cumulative performance of the models. The importance of the predictors in the final prediction model was evaluated using the Shapley additive explanations (SHAP) value.

    RESULTS: On average, the final XGBoost-powered Cox regression model performed at an acceptable level for patients with a length of stay up to 250 days (mean time-dependent AUC = 0.713) in the test dataset. However, for patients with a length of stay between 20 and 213 days, the performance of the model was relatively poor (time-dependent AUC < 0.7). When limited to patients with a length of stay ≤20 days, which accounts for 95.4% of all the patients, the model achieved an excellent performance (mean time-dependent AUC = 0.813). When further limited to patients with a length of stay ≤5 days, which accounts for two-thirds of all the patients, the model achieved an outstanding performance (mean time-dependent AUC = 0.917).

    CONCLUSION: The XGBoost-powered Cox regression model can achieve an outstanding predictive ability for in-hospital mortality during the first 5 days, primarily based on the severity of the injury, the GCS on admission, and the patient's age. These variables continue to demonstrate an excellent predictive ability up to 20 days after admission, a period of care that accounts for over 95% of severe TBI patients. Past 20 days of care, other factors appear to be the primary drivers of in-hospital mortality, indicating a potential window of opportunity for improving outcomes.

  • 33.
    Ekestubbe, Lovisa
    et al.
    School of Medical Sciences, Örebro University, Örebro, Sweden.
    Bass, Gary Alan
    Örebro University, School of Medical Sciences.
    Forssten, Maximilian Peter
    Örebro University, School of Medical Sciences. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Sjölin, Gabriel
    Örebro University, School of Medical Sciences. Örebro University Hospital. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Matthiessen, Peter
    Örebro University, School of Medical Sciences. Division of Colorectal Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Ahl, Rebecka
    Örebro University, School of Medical Sciences. 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 University, School of Medical Sciences. Örebro University Hospital. 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 surgery2022In: Scientific Reports, E-ISSN 2045-2322, Vol. 12, no 1, article id 5279Article in journal (Refereed)
    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.

  • 34.
    Falk, Wiebke
    et al.
    Örebro University, School of Medical Sciences. Department of Anesthesiology and Intensive Care, Örebro University Hospital, Sweden.
    Gupta, Anil
    Department of Physiology and Pharmacology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden.
    Forssten, Maximilian Peter
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Hjelmqvist, Hans
    Örebro University, School of Medical Sciences. Department of Anesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden .
    Bass, Gary Alan
    Örebro University, School of Medical Sciences. Division of Traumatology, Surgical Critical Care & Emergency Surgery, Penn Medicine, Penn Presbyterian Medical Center, Philadelphia, USA.
    Matthiessen, Peter
    Örebro University, School of Medical Sciences. Department of Surgery, Örebro University Hospital, Örebro, Sweden .
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden .
    Epidural analgesia and mortality after colorectal cancer surgery: A retrospective cohort study2021In: Annals of Medicine and Surgery, E-ISSN 2049-0801, Vol. 66, article id 102414Article in journal (Refereed)
    Abstract [en]

    Background: Epidural analgesia (EA) has been the standard of care after major abdominal surgery for many years. This study aimed to correlate EA with postoperative complications, short- and long-term mortality in patients with and without EA after open surgery (OS) and minimally invasive surgery (MIS) for colorectal cancer.

    Methods: Patient, clinical and outcome data were obtained from the Swedish Colorectal Cancer Registry and the Swedish Perioperative Registry. All adult patients diagnosed with colorectal cancer without metastases who underwent elective curative MIS or OS for colorectal cancer between January 2016 and December 2018 and who had data recorded in both registries, were included in the study. Data were analyzed for OS and MIS procedures separately. A Poisson regression model was used to investigate the association between EA and the outcomes of interest.

    Results: Five thousand seven hundred sixty-two patients were included in the study, 2712 in the MIS and 3050 patients in the OS group. After adjusting for patient specific and clinically relevant variables in the regression model, no statistically significant difference in risk for complications; 30-day, 90-day, and up to 3-year mortality following either MIS or OS could be detected between the EA+ and EA-cohorts.

    Conclusions: In this large study cohort, EA as part of the comprehensive care provided was not associated with a reduction in postoperative complications risk or improved 30-day, 90-day, or 3-year survival after MIS or OS for colorectal cancer.

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    Epidural analgesia and mortality after colorectal cancer surgery: A retrospective cohort study
  • 35.
    Falk, Wiebke
    et al.
    Örebro University, School of Medical Sciences. Department of Anaesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden.
    Gupta, Anil
    Department of Physiology and Pharmacology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden.
    Forssten, Maximilian Peter
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Hjelmqvist, Hans
    Örebro University, School of Medical Sciences. Department of Anaesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden.
    Bass, Gary Allan
    Örebro University, School of Medical Sciences. Division of Traumatology, Surgical Critical Care & Emergency Surgery, Penn Medicine, Penn Presbyterian Medical Center, Philadelphia, USA.
    Matthiessen, Peter
    Örebro University, School of Medical Sciences. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Epidural Analgesia and Mortality after Colorectal Cancer Surgery: A Retrospective Cohort StudyManuscript (preprint) (Other academic)
  • 36.
    Forssten, Maximilian P.
    et al.
    Örebro University, School of Medical Sciences.
    Sarani, Babak
    Mohammad Ismail, Ahmad
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Ioannidis, Ioannis
    Örebro University, School of Medical Sciences.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Hildebrand, Frank
    Ribeiro, Marcelo A., Jr.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Adverse Outcomes after Pelvic Fracture in Geriatric Patients: The Critical Role of Frailty2023In: Journal of the American College of Surgeons, ISSN 1072-7515, E-ISSN 1879-1190, Vol. 237, no 5, p. S557-S557Article in journal (Other academic)
    Abstract [en]

    Introduction: Pelvic fractures among the elderly are associated with an increased risk of adverse outcomes. Frailty, a condition of depleted physical reserves which increases with age, is likely a contributing factor for such unfavorable events. We endeavored to describe the association between frailty, measured using the Ortho-pedic Frailty Score (OFS), and adverse outcomes in geriatric pelvic fracture patients.

    Methods: All geriatric (≥65yrs) patients registered in the 2013 to 2019 TQIP database with an isolated pelvic fracture following blunt trauma were considered for inclusion. An isolated pelvic fracture was defined as any fracture in the ilium, ischium, pubis, sacrum, coccyx, or acetabulum with an AIS ≤1 in all other regions except for abdominal and lower extremity. Patients were categorized as non-frail (OFS 0), pre-frail (OFS 1), or frail (OFS ≥2). Poisson regression models were employed to determine the association between the OFS and adverse outcomes adjusting for confounders including angiographical and surgical interventions.

    Results: A total of 66,404 patients met inclusion criteria, of whom 52% were classified as non-frail, 32% as pre-frail, and 16% as frail. Compared to non-frail patients, frail patients exhibited 88% increased risk of in-hospital mortality [adjusted IRR (95% CI): 1.88 (1.54-2.30), p<0.001], a 25% increased risk of composite complications [adjusted IRR (95% CI): 1.25 (1.10-1.42), p<0.001], a 56% increased risk of failure to rescue [adjusted IRR (95% CI): 1.56 (1.14-2.14), p=0.006].

    Conclusion: Frail geriatric patients suffering a pelvic fracture have disproportionately increased risk for complications, mortality, and failure-to-rescue. Additional measures are required to mitigate adverse events in this vulnerable population.

  • 37.
    Forssten, Maximilian Peter
    et al.
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Bass, Gary Alan
    Örebro University, School of Medical Sciences. Division of Traumatology, Emergency Surgery and Surgical Critical Care, University of Pennsylvania, Philadelphia, USA.
    Mohammad Ismail, Ahmad
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Predicting 1-Year Mortality after Hip Fracture Surgery: An Evaluation of Multiple Machine Learning Approaches2021In: Journal of Personalized Medicine, E-ISSN 2075-4426, Vol. 11, no 8, article id 727Article in journal (Refereed)
    Abstract [en]

    Postoperative death within 1 year following hip fracture surgery is reported to be up to 27%. In the current study, we benchmarked the predictive precision and accuracy of the algorithms support vector machine (SVM), naïve Bayes classifier (NB), and random forest classifier (RF) against logistic regression (LR) in predicting 1-year postoperative mortality in hip fracture patients as well as assessed the relative importance of the variables included in the LR model. All adult patients who underwent primary emergency hip fracture surgery in Sweden, between 1 January 2008 and 31 December 2017 were included in the study. Patients with pathological fractures and non-operatively managed hip fractures, as well as those who died within 30 days after surgery, were excluded from the analysis. A LR model with an elastic net regularization were fitted and compared to NB, SVM, and RF. The relative importance of the variables in the LR model was then evaluated using the permutation importance. The LR model including all the variables demonstrated an acceptable predictive ability on both the training and test datasets for predicting one-year postoperative mortality (Area under the curve (AUC) = 0.74 and 0.74 respectively). NB, SVM, and RF tended to over-predict the mortality, particularly NB and SVM algorithms. In contrast, LR only over-predicted mortality when the predicted probability of mortality was larger than 0.7. The LR algorithm outperformed the other three algorithms in predicting 1-year postoperative mortality in hip fracture patients. The most important predictors of 1-year mortality were the presence of a metastatic carcinoma, American Society of Anesthesiologists(ASA) classification, sex, Charlson Comorbidity Index (CCI) ≤ 4, age, dementia, congestive heart failure, hypertension, surgery using pins/screws, and chronic kidney disease.

  • 38.
    Forssten, Maximilian Peter
    et al.
    Örebro University, School of Medical Sciences. Division of Trauma and Emergency Surgery, Örebro University Hospital, Örebro, Sweden.
    Bass, Gary Alan
    Örebro University, School of Medical Sciences. Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, PA, USA.
    Scheufler, Kai-Michael
    Department of Neurosurgery, Örebro University Hospital, Örebro, Sweden; Medical School, Heinrich-Heine University Dusseldorf, Düsseldorf, Germany.
    Mohammad Ismail, Ahmad
    Örebro University, School of Medical Sciences. Division of Trauma and Emergency Surgery, Örebro University Hospital, Örebro, Sweden.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Martin, Niels Douglas
    Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, PA, USA.
    Sarani, Babak
    Division of Trauma and Acute Care Surgery, George Washington University School of Medicine & Health Sciences, Washington, DC, USA.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Division of Trauma and Emergency Surgery, Orebro University Hospital, Örebro, Sweden.
    Mortality risk stratification in isolated severe traumatic brain injury using the revised cardiac risk index2022In: European Journal of Trauma and Emergency Surgery, ISSN 1863-9933, E-ISSN 1863-9941, Vol. 48, no 6, p. 4481-4488Article in journal (Refereed)
    Abstract [en]

    PURPOSE: Traumatic brain injury (TBI) continues to be a significant cause of mortality and morbidity worldwide. As cardiovascular events are among the most common extracranial causes of death after a severe TBI, the Revised Cardiac Risk Index (RCRI) could potentially aid in the risk stratification of this patient population. This investigation aimed to determine the association between the RCRI and in-hospital deaths among isolated severe TBI patients.

    METHODS: All adult patients registered in the TQIP database between 2013 and 2017 who suffered an isolated severe TBI, defined as a head AIS ≥ 3 with an AIS ≤ 1 in all other body regions, were included. Patients were excluded if they had a head AIS of 6. The association between different RCRI scores (0, 1, 2, 3, ≥ 4) and in-hospital mortality was analyzed using a Poisson regression model with robust standard errors while adjusting for potential confounders, with RCRI 0 as the reference.

    RESULTS: 259,399 patients met the study's inclusion criteria. RCRI 2 was associated with a 6% increase in mortality risk [adjusted IRR (95% CI) 1.06 (1.01-1.12), p = 0.027], RCRI 3 was associated with a 17% increased risk of mortality [adjusted IRR (95% CI) 1.17 (1.05-1.31), p = 0.004], and RCRI ≥ 4 was associated with a 46% increased risk of in-hospital mortality [adjusted IRR(95% CI) 1.46 (1.11-1.90), p = 0.006], compared to RCRI 0.

    CONCLUSION: An elevated RCRI ≥ 2 is significantly associated with an increased risk of in-hospital mortality among patients with an isolated severe traumatic brain injury. The simplicity and bedside applicability of the index makes it an attractive choice for risk stratification in this patient population.

  • 39.
    Forssten, Maximilian Peter
    et al.
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital. Clinical Epidemiology and Biostatistics.
    Mohammad Ismail, Ahmad
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Orthopedic Surgery.
    Ioannidis, Ioannis
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Tennakoon, Lakshika
    Department of Surgery, Section of Trauma and Acute Care Surgery, Stanford University School of Medicine, Stanford, CA, USA.
    Spain, David A.
    Department of Surgery, Section of Trauma and Acute Care Surgery, Stanford University School of Medicine, Stanford, CA, USA.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Sheik Shakhbout Medical City - Mayo Clinic, Abu Dhabi, United Arab Emirates.
    Validation of the orthopedic frailty score for measuring frailty in hip fracture patients: a cohort study based on the United States National inpatient sample2023In: European Journal of Trauma and Emergency Surgery, ISSN 1863-9933, E-ISSN 1863-9941, Vol. 49, no 5, p. 2155-2163Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The Orthopedic Frailty Score (OFS) has been proposed as a tool for measuring frailty in order to predict short-term postoperative mortality in hip fracture patients. This study aims to validate the OFS using a large national patient register to determine its relationship with adverse outcomes as well as length of stay and cost of hospital stay.

    METHODS: All adult patients (18 years or older) registered in the 2019 National Inpatient Sample Database who underwent emergency hip fracture surgery following a traumatic fall were eligible for inclusion. The association between the OFS and mortality, complications, and failure-to-rescue (FTR) was determined using Poisson regression models adjusted for potential confounders. The relationship between the OFS and length of stay and cost of hospital stay was instead determined using a quantile regression model.

    RESULTS: An estimated 227,850 cases met the study inclusion criteria. There was a stepwise increase in the rate of complications, mortality, and FTR for each additional point on the OFS. After adjusting for potential confounding, OFS 4 was associated with an almost ten-fold increase in the risk of in-hospital mortality [adjusted IRR (95% CI): 10.6 (4.02-27.7), p < 0.001], a 38% increased risk of complications [adjusted IRR (95% CI): 1.38 (1.03-1.85), p = 0.032], and an almost 11-fold increase in the risk of FTR [adjusted IRR (95% CI): 11.6 (4.36-30.9), p < 0.001], compared to OFS 0. Patients with OFS 4 also required a day and a half additional care [change in median length of stay (95% CI): 1.52 (0.97-2.08), p < 0.001] as well as cost approximately $5,200 more to manage [change in median cost of stay (95% CI): 5166 (1921-8411), p = 0.002], compared to those with OFS 0.

    CONCLUSION: Patients with an elevated OFS display a substantially increased risk of mortality, complications, and failure-to-rescue as well as a prolonged and more costly hospital stay.

  • 40.
    Forssten, Maximilian Peter
    et al.
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Trivedi, Dhanisha Jayesh
    School of Medical Sciences, Örebro University, Örebro, Sweden; Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden .
    Ekestubbe, Lovisa
    School of Medical Sciences, Örebro University, Örebro, Sweden.
    Borg, Tomas
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Bass, Gary Alan
    Örebro University, School of Medical Sciences. Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.
    Mohammad Ismail, Ahmad
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Developing and validating a scoring system for measuring frailty in patients with hip fracture: a novel model for predicting short-term postoperative mortality2022In: Trauma surgery & acute care open, E-ISSN 2397-5776, Vol. 7, no 1, article id e000962Article in journal (Refereed)
    Abstract [en]

    Objectives: Frailty is common among patients with hip fracture and may, in part, contribute to the increased risk of mortality and morbidity after hip fracture surgery. This study aimed to develop a novel frailty score for patients with traumatic hip fracture that could be used to predict postoperative mortality as well as facilitate further research into the role of frailty in patients with hip fracture.

    Methods: The Orthopedic Hip Frailty Score (OFS) was developed using a national dataset, retrieved from the Swedish National Quality Registry for Hip Fractures, that contained all adult patients who underwent surgery for a traumatic hip fracture in Sweden between January 1, 2008 and December 31, 2017. Candidate variables were selected from the Nottingham Hip Fracture Score, Sernbo Score, Charlson Comorbidity Index, 5-factor modified Frailty Index, as well as the Revised Cardiac Risk Index and ranked based on their permutation importance, with the top 5 variables being selected for the score. The OFS was then validated on a local dataset that only included patients from Orebro County, Sweden.

    Results: The national dataset consisted of 126,065 patients. 2365 patients were present in the local dataset. The most important variables for predicting 30-day mortality were congestive heart failure, institutionalization, non-independent functional status, an age ≥85, and a history of malignancy. In the local dataset, the OFS achieved an area under the receiver-operating characteristic curve (95% CI) of 0.77 (0.74 to 0.80) and 0.76 (0.74 to 0.78) when predicting 30-day and 90-day postoperative mortality, respectively.

    Conclusions: The OFS is a significant predictor of short-term postoperative mortality in patients with hip fracture that outperforms, or performs on par with, all other investigated indices.

    Level of evidence: Level III, Prognostic and Epidemiological.

  • 41.
    Forssten, Maximilian Peter
    et al.
    Örebro University, School of Medical Sciences. Department of Orthopedics Surgery, Örebro University Hospital, Örebro, Sweden.
    Ioannidis, Ioannis
    Örebro University, School of Medical Sciences. Department of Orthopedics Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohammad Ismail, Ahmad
    Örebro University, School of Medical Sciences. Department of Orthopedics Surgery, Örebro University Hospital, Örebro, Sweden.
    Bass, Gary Alan
    Örebro University, School of Medical Sciences. Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Penn Presbyterian Medical Center, Philadelphia, PA, USA.
    Borg, Tomas
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Orthopedics Surgery, Örebro University Hospital, Örebro, Sweden.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    Dementia is a surrogate for frailty in hip fracture mortality prediction2022In: European Journal of Trauma and Emergency Surgery, ISSN 1863-9933, E-ISSN 1863-9941, Vol. 48, no 5, p. 4157-4167Article in journal (Refereed)
    Abstract [en]

    PURPOSE: Among hip fracture patients both dementia and frailty are particularly prevalent. The aim of the current study was to determine if dementia functions as a surrogate for frailty, or if it confers additional information as a comorbidity when predicting postoperative mortality after a hip fracture.

    METHODS: All adult patients who suffered a traumatic hip fracture in Sweden between January 1, 2008 and December 31, 2017 were considered for inclusion. Pathological fractures, non-operatively treated fractures, reoperations, and patients missing data were excluded. Logistic regression (LR) models were fitted, one including and one excluding measurements of frailty, with postoperative mortality as the response variable. The primary outcome of interest was 30-day postoperative mortality. The relative importance for all variables was determined using the permutation importance. New LR models were constructed using the top ten most important variables. The area under the receiver-operating characteristic curve (AUC) was used to compare the predictive ability of these models.

    RESULTS: 121,305 patients were included in the study. Initially, dementia was among the top ten most important variables for predicting 30-day mortality. When measurements of frailty were included, dementia was replaced in relative importance by the ability to walk alone outdoors and institutionalization. There was no significant difference in the predictive ability of the models fitted using the top ten most important variables when comparing those that included [AUC for 30-day mortality (95% CI): 0.82 (0.81-0.82)] and excluded [AUC for 30-day mortality (95% CI): 0.81 (0.80-0.81)] measurements of frailty.

    CONCLUSION: Dementia functions as a surrogate for frailty when predicting mortality up to one year after hip fracture surgery. The presence of dementia in a patient without frailty does not appreciably contribute to the prediction of postoperative mortality.

  • 42.
    Forssten, Maximilian Peter
    et al.
    Örebro University, School of Medical Sciences. Division of Trauma and Emergency Surgery, Örebro University Hospital, Örebro University, Örebro, Sweden.
    Kaplan, Lewis J.
    Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA; Corporal Michael Crescenz Veterans Affairs Medical Center, Philadelphia, USA.
    Tolonen, Matti
    Helsinki University Hospital HUS Meilahden Tornisairaala, Helsinki, Finland.
    Martinez-Casas, Isidro
    Servicio de Cirugía General, Unidad de Cirugía de Urgencias, Hospital Universitario Virgen del Rocío, Seville, Spain.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital. Clinical Epidemiology and Biostatistics.
    Walsh, Thomas N.
    Royal College of Surgeons in Ireland Medical University, Busaiteen, Bahrain.
    Bass, Gary Alan
    Örebro University, School of Medical Sciences. Division of Trauma and Emergency Surgery, Örebro University Hospital, Örebro, Sweden; Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the 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.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Division of Trauma and Emergency Surgery, Örebro University Hospital, Örebro, Sweden.
    Surgical management of acute appendicitis during the European COVID-19 second wave: safe and effective2023In: European Journal of Trauma and Emergency Surgery, ISSN 1863-9933, E-ISSN 1863-9941, Vol. 49, no 1, p. 57-67Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: The COVID-19 (SARS-CoV-2) pandemic drove acute care surgeons to pivot from long established practice patterns. Early safety concerns regarding increased postoperative complication risk in those with active COVID infection promoted antibiotic-driven non-operative therapy for select conditions ahead of an evidence-base. Our study assesses whether active or recent SARS-CoV-2 positivity increases hospital length of stay (LOS) or postoperative complications following appendectomy.

    METHODS: Data were derived from the prospective multi-institutional observational SnapAppy cohort study. This preplanned data analysis assessed consecutive patients aged ≥ 15 years who underwent appendectomy for appendicitis (November 2020-May 2021). Patients were categorized based on SARS-CoV-2 seropositivity: no infection, active infection, and prior infection. Appendectomy method, LOS, and complications were abstracted. The association between SARS-CoV-2 seropositivity and complications was determined using Poisson regression, while the association with LOS was calculated using a quantile regression model.

    RESULTS: Appendectomy for acute appendicitis was performed in 4047 patients during the second and third European COVID waves. The majority were SARS-CoV-2 uninfected (3861, 95.4%), while 70 (1.7%) were acutely SARS-CoV-2 positive, and 116 (2.8%) reported prior SARS-CoV-2 infection. After confounder adjustment, there was no statistically significant association between SARS-CoV-2 seropositivity and LOS, any complication, or severe complications.

    CONCLUSION: During sequential SARS-CoV-2 infection waves, neither active nor prior SARS-CoV-2 infection was associated with prolonged hospital LOS or postoperative complication. Despite early concerns regarding postoperative safety and outcome during active SARS-CoV-2 infection, no such association was noted for those with appendicitis who underwent operative management.

  • 43.
    Forssten, Maximilian Peter
    et al.
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohammad Ismail, Ahmad
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Borg, Tomas
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Ahl, Rebecka
    Örebro University, School of Medical Sciences. Department of Surgery, Karolinska University Hospital, Stockholm, Sweden.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. School of Medical Sciences, Örebro University, Örebro, Sweden.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    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 University, School of Medical Sciences. Örebro University Hospital. 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 study2021In: Trauma surgery & acute care open, E-ISSN 2397-5776, Vol. 6, no 1, article id e000778Article in journal (Refereed)
    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.

  • 44.
    Forssten, Maximilian Peter
    et al.
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohammad Ismail, Ahmad
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Borg, Tomas
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Bass, Gary Alan
    Örebro University, School of Medical Sciences. Division of Traumatology, Emergency Surgery and Surgical Critical Care, University of Pennsylvania, Philadelphia, USA.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    The consequences of out-of-hours hip fracture surgery: insights from a retrospective nationwide study2022In: European Journal of Trauma and Emergency Surgery, ISSN 1863-9933, E-ISSN 1863-9941, Vol. 48, no 2, p. 709-719Article in journal (Refereed)
    Abstract [en]

    PURPOSE: The study aimed to investigate the association between out-of-hours surgery and postoperative mortality in hip fracture patients. Furthermore, internal fixation and arthroplasty were compared to determine if a difference could be observed in patients operated with these techniques at different times during the day.

    METHODS: All patients above 18 of age years in Sweden who underwent hip fracture surgery between 2008 and 2017 were eligible for inclusion. Pathological fractures, non-operatively managed fractures, or cases whose time of surgery was missing were excluded. The cohort was subdivided into on-hour (08:00-17:00) and out-of-hours surgery (17:00-08:00). Poisson regression with adjustments for confounders was used to evaluate the association between out-of-hours surgery and both 30-day and 90-day postoperative mortality.

    RESULTS: Out-of-hours surgery was associated with a 5% increase in the risk of both 30-day [adj. IRR (95% CI) 1.05 (1.00-1.10), p = 0.040] and 90-day [adj. IRR (95% CI) 1.05 (1.01-1.09), p = 0.005] mortality after hip fracture surgery compared to on-hour surgery. There was no statistically significant association between out-of-hours surgery and postoperative mortality among patients who received an internal fixation. Arthroplasties performed out-of-hours were associated with a 13% increase in 30-day postoperative mortality [adj. IRR (95% CI) 1.13 (1.04-1.23), p = 0.005] and an 8% increase in 90-day postoperative mortality [adj. IRR (95% CI) 1.08 (1.01-1.15), p = 0.022] compared to on-hour surgery.

    CONCLUSION: Out-of-hours surgical intervention is associated with an increase in both 30- and 90-day postoperative mortality among hip fracture patients who received an arthroplasty, but not among patients who underwent internal fixation.

  • 45.
    Forssten, Maximilian Peter
    et al.
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohammad Ismail, Ahmad
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Orthopedic Surgery.
    Ioannidis, Ioannis
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Borg, Tomas
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Orthopedic Surgery.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Ribeiro Jr, Marcelo A. F.
    Pontifical Catholic University of São Paulo, São Paulo, Brazil; Trauma, Burns, Critical Care and Acute Care Surgery, Department of Surgery, Sheikh Shakhbout Medical City-Mayo Clinic, Abu Dhabi, United Arab Emirates.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Division of Trauma and Emergency Surgery, Department of Surgery.
    The mortality burden of frailty in hip fracture patients: a nationwide retrospective study of cause-specific mortality2023In: European Journal of Trauma and Emergency Surgery, ISSN 1863-9933, E-ISSN 1863-9941, Vol. 49, no 3, p. 1467-1475Article in journal (Refereed)
    Abstract [en]

    Purpose: Frailty is a condition characterized by a reduced ability to adapt to external stressors because of a reduced physiologic reserve, which contributes to the high risk of postoperative mortality in hip fracture patients. This study aims to investigate how frailty is associated with the specific causes of mortality in hip fracture patients.

    Methods: All adult patients in Sweden who suffered a traumatic hip fracture and underwent surgery between 2008 and 2017 were eligible for inclusion. The Orthopedic Hip Frailty Score (OFS) was used to classify patients as non-frail (OFS 0), pre-frail (OFS 1), and frail (OFS & GE; 2). The association between the degree of frailty and both all-cause and cause-specific mortality was determined using Poisson regression models with robust standard errors and presented using incidence rate ratios (IRRs) with corresponding 95% confidence intervals (CIs), adjusted for potential sources of confounding.

    Results: After applying the inclusion and exclusion criteria, 127,305 patients remained for further analysis. 23.9% of patients were non-frail, 27.7% were pre-frail, and 48.3% were frail. Frail patients exhibited a 4 times as high risk of all-cause mortality 30 days [adj. IRR (95% CI): 3.80 (3.36-4.30), p < 0.001] and 90 days postoperatively [adj. IRR (95% CI): 3.88 (3.56-4.23), p < 0.001] as non-frail patients. Of the primary causes of 30-day mortality, frailty was associated with a tripling in the risk of cardiovascular [adj. IRR (95% CI): 3.24 (2.64-3.99), p < 0.001] and respiratory mortality [adj. IRR (95% CI): 2.60 (1.96-3.45), p < 0.001] as well as a five-fold increase in the risk of multiorgan failure [adj. IRR (95% CI): 4.99 (3.95-6.32), p < 0.001].

    Conclusion: Frailty is associated with a significantly increased risk of all-cause and cause-specific mortality at 30 and 90 days postoperatively. Across both timepoints, cardiovascular and respiratory events along with multiorgan failure were the most prevalent causes of mortality.

  • 46.
    Forssten, Maximilian Peter
    et al.
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohammad Ismail, Ahmad
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Ioannidis, Ioannis
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Borg, Tomas
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital. Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden.
    Ribeiro, Marcelo A. F.
    Pontifical Catholic University of São Paulo, São Paulo, Brazil; Trauma, Burns, Critical Care and Acute Care Surgery, Department of Surgery, Sheikh Shakhbout Medical City, Mayo Clinic, Abu Dhabi, United Arab Emirates.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden.
    A nationwide analysis on the interaction between frailty and beta-blocker therapy in hip fracture patients2023In: European Journal of Trauma and Emergency Surgery, ISSN 1863-9933, E-ISSN 1863-9941, Vol. 49, no 3, p. 1485-1497Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: Hip fracture patients, who are often frail, continue to be a challenge for healthcare systems with a high postoperative mortality rate. While beta-blocker therapy (BBt) has shown a strong association with reduced postoperative mortality, its effect in frail patients has yet to be determined. This study's aim is to investigate how frailty, measured using the Orthopedic Hip Frailty Score (OFS), modifies the effect of preadmission beta-blocker therapy on mortality in hip fracture patients.

    METHODS: This retrospective register-based study included all adult patients in Sweden who suffered a traumatic hip fracture and subsequently underwent surgery between 2008 and 2017. Treatment effect was evaluated using the absolute risk reduction (ARR) in 30-day postoperative mortality when comparing patients with (BBt+) and without (BBt-) ongoing BBt. Inverse probability of treatment weighting (IPTW) was used to reduce potential confounding when examining the treatment effect. Patients were stratified based on their OFS (0, 1, 2, 3, 4 and 5) and the treatment effect was also assessed within each stratum.

    RESULTS: A total of 127,305 patients were included, of whom 39% had BBt. When IPTW was performed, there were no residual differences in observed baseline characteristics between the BBt+ and BBt- groups, across all strata. This analysis found that there was a stepwise increase in the ARRs for each additional point on the OFS. Non-frail BBt+ patients (OFS 0) exhibited an ARR of 2.2% [95% confidence interval (CI) 2.0-2.4%, p < 0.001], while the most frail BBt+ patients (OFS 5) had an ARR of 24% [95% CI 18-30%, p < 0.001], compared to BBt- patients within the same stratum.

    CONCLUSION: Beta-blocker therapy is associated with a reduced risk of 30-day postoperative mortality in frail hip fracture patients, with a greater effect being observed with higher Orthopedic Hip Frailty Scores.

  • 47.
    Forssten, Maximilian Peter
    et al.
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohammad Ismail, Ahmad
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Sjölin, Gabriel
    Örebro University, School of Medical Sciences.
    Ahl, Rebecka
    Örebro University, School of Medical Sciences. Department of Surgery, Karolinska University Hospital, Stockholm, Sweden; Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden.
    Wretenberg, Per
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Snwede.
    Borg, Tomas
    Örebro University Hospital. Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. 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 surgery2022In: European Journal of Trauma and Emergency Surgery, ISSN 1863-9933, E-ISSN 1863-9941, Vol. 48, no 3, p. 1885-1892Article in journal (Refereed)
    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.

  • 48.
    Forssten, Maximilian Peter
    et al.
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Sarani, Babak
    Center of Trauma and Critical Care, George Washington University, Washington, DC, USA.
    Mohammad Ismail, Ahmad
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Orthopedic Surgery.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital. Clinical Epidemiology and Biostatistics.
    Ribeiro, Marcelo A. F.
    Khalifa University and Gulf Medical University, Abu Dhabi, United Arab Emirates.
    Hildebrand, Frank
    Department of Orthopedics, Trauma and Reconstructive Surgery, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Sheikh Shakhbout Medical City, Mayo Clinic, Abu Dhabi, United Arab Emirates.
    Adverse outcomes following pelvic fracture: the critical role of frailty2023In: European Journal of Trauma and Emergency Surgery, ISSN 1863-9933, E-ISSN 1863-9941, Vol. 49, no 6, p. 2623-2631Article in journal (Refereed)
    Abstract [en]

    PURPOSE: Pelvic fractures among older adults are associated with an increased risk of adverse outcomes, with frailty likely being a contributing factor. The current study endeavors to describe the association between frailty, measured using the Orthopedic Frailty Score (OFS), and adverse outcomes in geriatric pelvic fracture patients.

    METHODS: All geriatric (65 years or older) patients registered in the 2013-2019 Trauma Quality Improvement Program database with an isolated pelvic fracture following blunt trauma were considered for inclusion. An isolated pelvic fracture was defined as any fracture in the pelvis with a lower extremity AIS ≥ 2, any abdomen AIS, and an AIS ≤ 1 in all other regions. Poisson regression models were employed to determine the association between the OFS and adverse outcomes.

    RESULTS: A total of 66,404 patients were included for further analysis. 52% (N = 34,292) were classified as non-frail (OFS 0), 32% (N = 21,467) were pre-frail (OFS 1), and 16% (N = 10,645) were classified as frail (OFS ≥ 2). Compared to non-frail patients, frail patients exhibited a 88% increased risk of in-hospital mortality [adjusted IRR (95% CI): 1.88 (1.54-2.30), p < 0.001], a 25% increased risk of complications [adjusted IRR (95% CI): 1.25 (1.10-1.42), p < 0.001], a 56% increased risk of failure-to-rescue [adjusted IRR (95% CI): 1.56 (1.14-2.14), p = 0.006], and a 10% increased risk of ICU admission [adjusted IRR (95% CI): 1.10 (1.02-1.18), p = 0.014].

    CONCLUSION: Frail pelvic fracture patients suffer from a disproportionately increased risk of mortality, complications, failure-to-rescue, and ICU admission. Additional measures are required to mitigate adverse events in this vulnerable patient population.

  • 49.
    Forssten, Maximilian Peter
    et al.
    Örebro University, School of Medical Sciences.
    Sarani, Babak
    Mohammad Ismail, Ahmad
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Ioannidis, Ioannis
    Örebro University, School of Medical Sciences.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Hildebrand, Frank
    Ribeiro, Marcelo A., Jr.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Adverse Outcomes after Pelvic Fracture in Geriatric Patients: The Critical Role of Frailty2023In: Journal of the American College of Surgeons, ISSN 1072-7515, E-ISSN 1879-1190, Vol. 237, no 5, p. S557-S557Article in journal (Other academic)
    Abstract [en]

    Introduction: Pelvic fractures among the elderly are associated with an increased risk of adverse outcomes. Frailty, a condition of depleted physical reserves which increases with age, is likely a contributing factor for such unfavorable events. We endeavored to describe the association between frailty, measured using the Ortho-pedic Frailty Score (OFS), and adverse outcomes in geriatric pelvic fracture patients.

    Methods: All geriatric (≥65yrs) patients registered in the 2013 to 2019 TQIP database with an isolated pelvic fracture following blunt trauma were considered for inclusion. An isolated pelvic fracture was defined as any fracture in the ilium, ischium, pubis, sacrum, coccyx, or acetabulum with an AIS ≤1 in all other regions except for abdominal and lower extremity. Patients were categorized as non-frail (OFS 0), pre-frail (OFS 1), or frail (OFS ≥2). Poisson regression models were employed to determine the association between the OFS and adverse outcomes adjusting for confounders including angiographical and surgical interventions.

    Results: A total of 66,404 patients met inclusion criteria, of whom 52% were classified as non-frail, 32% as pre-frail, and 16% as frail. Compared to non-frail patients, frail patients exhibited 88% increased risk of in-hospital mortality [adjusted IRR (95% CI): 1.88 (1.54-2.30), p<0.001], a 25% increased risk of composite complications [adjusted IRR (95% CI): 1.25 (1.10-1.42), p<0.001], a 56% increased risk of failure to rescue [adjusted IRR (95% CI): 1.56 (1.14-2.14), p=0.006].

    Conclusion: Frail geriatric patients suffering a pelvic fracture have disproportionately increased risk for complications, mortality, and failure-to-rescue. Additional measures are required to mitigate adverse events in this vulnerable population.

  • 50.
    Forssten, Sebastian Peter
    et al.
    Division of Surgery, CLINTEC, Karolinska Institute, Stockholm, Sweden; Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Ahl Hulme, Rebecka
    Division of Surgery, CLINTEC, Karolinska Institute, Stockholm, Sweden; Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden.
    Forssten, Maximilian Peter
    Örebro University, School of Medical Sciences. Department of Orthopedic Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Ribeiro, Marcelo A. F.
    Pontifical Catholic University of São Paulo, São Paulo, Brazil; Khalifa University and Gulf Medical University, Abu Dhabi, United Arab Emirates; Department of Surgery, Sheikh Shakhbout Medical City, Mayo Clinic, Abu Dhabi, United Arab Emirates.
    Sarani, Babak
    Division of Trauma and Acute Care Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC, United States.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery, Sheikh Shakhbout Medical City, Mayo Clinic, Abu Dhabi, United Arab Emirates.
    Predictors of outcomes in geriatric patients with moderate traumatic brain injury after ground level falls2023In: Frontiers in Medicine, E-ISSN 2296-858X, Vol. 10, article id 1290201Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: The elderly population constitutes one of the fastest-growing demographic groups globally. Within this population, mild to moderate traumatic brain injuries (TBI) resulting from ground level falls (GLFs) are prevalent and pose significant challenges. Between 50 and 80% of TBIs in older individuals are due to GLFs. These incidents result in more severe outcomes and extended recovery periods for the elderly, even when controlling for injury severity. Given the increasing incidence of such injuries it becomes essential to identify the key factors that predict complications and in-hospital mortality. Therefore, the aim of this study was to pinpoint the top predictors of complications and in-hospital mortality in geriatric patients who have experienced a moderate TBI following a GLF.

    METHODS: Data were obtained from the American College of Surgeons' Trauma Quality Improvement Program database. A moderate TBI was defined as a head AIS ≤ 3 with a Glasgow Coma Scale (GCS) 9-13, and an AIS ≤ 2 in all other body regions. Potential predictors of complications and in-hospital mortality were included in a logistic regression model and ranked using the permutation importance method.

    RESULTS: A total of 7,489 patients with a moderate TBI were included in the final analyses. 6.5% suffered a complication and 6.2% died prior to discharge. The top five predictors of complications were the need for neurosurgical intervention, the Revised Cardiac Risk Index, coagulopathy, the spine abbreviated injury severity scale (AIS), and the injury severity score. The top five predictors of mortality were head AIS, age, GCS on admission, the need for neurosurgical intervention, and chronic obstructive pulmonary disease.

    CONCLUSION: When predicting both complications and in-hospital mortality in geriatric patients who have suffered a moderate traumatic brain injury after a ground level fall, the most important factors to consider are the need for neurosurgical intervention, cardiac risk, and measures of injury severity. This may allow for better identification of at-risk patients, and at the same time resulting in a more equitable allocation of resources.

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