To Örebro University

Introduction: Cerebral glucose (CGlu) is essential for maintaining neuronal function. Haemorrhagic shock (HS) impaires cerebral substrate delivery. Resuscitative endovascular balloon occlusion of the aorta (REBOA) effectively restores arterial pressure; however, its effects on cerebral glucose dynamics, particularly in the presence of elevated ICP, remain incompletely understood. The aim of this study is to investigate CGlu dynamics during HS and subsequent resuscitation with total REBOA (tREBOA), and to assess the influence of intracranial pressure (ICP) on cerebral metabolic responses.

Methods: 18 pigs were assigned to either a normal ICP group (NICPG) or an elevated ICP group (EICPG) and were subjected to controlled HS followed by resuscitation with tREBOA. CGlu concentrations were measured using cerebral microdialysis throughout baseline, HS, and aortic occlusion (AO). Proximal mean arterial pressure (pMAP) and ICP were continuously monitored. Data were analysed using linear mixed-effects models.

Results: HS was associated with a reduction in CGlu in both groups, indicating early cerebral metabolic stress. Following initiation of tREBOA, CPP increased markedly; however, CGlu concentrations did not immediately normalise, particularly in EICPG. Instead, CGlu availability demonstrated time-dependent changes during prolonged AO. No consistent differences in CGlu concentrations between groups were observed once perfusion pressure was restored.

Discussion: tREBOA restored CPP and supported recovery of CGlu availability, even in the presence of elevated ICP. However, haemodynamic restoration was not accompanied by immediate metabolic normalization, demonstrating a dissociation between perfusion and CGlu regulation. These findings provide important physiological insights into the cerebral effects of tREBOA and support its cautious, time-limited use in complex trauma scenarios.

BACKGROUND: Haemorrhagic shock (HS) is frequently associated with secondary cerebral injury due to compromised cerebral perfusion. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an effective haemorrhage control strategy; however, concerns persist regarding its cerebral effects, particularly in the presence of elevated intracranial pressure (ICP). Cerebral microdialysis (CMD) derived glycerol (CGly) is a recognised marker of cellular membrane stress and injury.

OBJECTIVE: To investigate CGly dynamics during prolonged total REBOA (tREBOA) in HS and to compare cerebral cellular responses between animals with normal and elevated ICP.

METHODS: In this experimental porcine study, eighteen pigs were subjected to controlled HS and resuscitated with tREBOA for 90 min. Animals were allocated to either a normal ICP group (NICPG, n = 9) or an elevated ICP group (EICPG, n = 9). Continuous monitoring of proximal arterial pressure, ICP, and cerebral perfusion pressure was performed. CGly concentrations were measured using CMD throughout the experimental protocol.

RESULTS: tREBOA effectively restored proximal arterial pressure and cerebral perfusion pressure in both groups. CGly concentrations remained relatively stable during the haemorrhage phase and increased progressively during prolonged aortic occlusion. Importantly, CGly responses did not differ significantly between animals with normal and elevated ICP. The observed increases in CGly during prolonged occlusion were consistent with cellular membrane perturbation rather than irreversible neuronal injury.

CONCLUSIONS: In this experimental model of HS, prolonged total REBOA restored macrocirculatory parameters but was associated with time-dependent increases in CGly. Elevated ICP was not associated with exacerbation of cerebral cellular membrane stress during total aortic occlusion under the conditions studied. These findings suggest that intracranial hypertension alone does not worsen cerebral cellular responses during tREBOA, while highlighting the importance of occlusion duration and the need for further studies to optimise cerebral protection during prolonged aortic occlusion.

Introduction: Haemorrhagic shock (HS) is frequently associated with secondary cerebral injury due to compromised cerebral perfusion. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an effective haemorrhage control strategy; however, concerns persist regarding its cerebral effects, particularly in the presence of elevated ICP. Cerebral microdialysis (CMD) derived glycerol (CGly) is a recognised marker of cellular membrane stress and injury.

The objective if this study is to investigate CGly dynamics during prolonged total REBOA (tREBOA) in HS and to compare cerebral cellular responses between animals with normal and elevated ICP.

Methods: 18 pigs were subjected to controlled HS and resuscitated with tREBOA for 90 min. Animals were allocated to either a normal ICP group or an elevated ICP group. Monitoring of proximal arterial pressure (pMAP), ICP. CGly concentrations were measured using CMD.

Results: tREBOA effectively restored pMAP in both groups. CGly concentrations remained relatively stable during the haemorrhage phase and increased progressively during prolonged aortic occlusion. Importantly, CGly responses did not differ significantly between animals with normal and elevated ICP. The observed increases in CGly during prolonged occlusion were consistent with cellular membrane perturbation rather than irreversible neuronalinjury.

Discussion: tREBOA restored macrocirculatory parameters but was associated with time-dependent increases in CGly. Elevated ICP was not associated with exacerbation of cerebral cellular membrane stress during total aortic occlusion. These findings suggest that intracranial hypertension alone does no tworsen cerebral cellular responses during tREBOA, while high-lighting the importance of occlusion duration and the need for further studies to optimise cerebral protection during prolonged aortic occlusion.

Hyperthyroidism, including toxic nodular goiter (TNG), adversely affects bones and is a recognized cause of osteoporosis. However, the extent to which it contributes to fractures remains uncertain, as studies have yielded conflicting results. This study aimed to determine whether TNG is associated with a higher incidence of fractures than controls.

Methods: We followed 621 patients with overt hyperthyroidism due to TNG for a median of 13.8 years and searched for fractures in national registries. For each case with TNG, up to 10 controls without hyperthyroidism from the general population were matched for sex, age, and county of residence. We used Cox regression stratified on the matching sets to compare rates of fragility fractures as well as osteoporosis and corticosteroid treatments between case and control groups. Analyses were performed in all as well as stratified by sex and by age (≤52 and >52 years).

Results: Higher rates of total fragility fracture were observed in women ≤52 years (2.15 (1.11-4.15). In women aged >52 years, patients with TNG had higher hip fracture rates (1.41 (1.08-1.84)). When considering all patients in both the case and control groups, total fragility fracture rates did not differ significantly (HR 1.08; 95% CI 0.89-1.32).

Conclusions: In women >52 years with TNG, hip fracture rates were higher than in the reference population. Furthermore, younger women with TNG had higher rates of all fractures. These data suggest that TNG might be a more prominent risk factor for osteoporotic fractures than previously thought.

Aim: To investigate postoperative inflammatory response as assessed by C-reactive protein (CRP) levels in patients undergoing anterior resection (AR) for rectal cancer by minimally invasive surgery (MIS).

Method: All patients diagnosed with rectal cancer between 2011 and 2021 undergoing AR by MIS without conversion at one university hospital were included. Open surgery was not included. Patient data were obtained from the Swedish Colorectal Cancer registry and from local patient charts, including CRP levels preoperatively and postoperative day (POD) 1-5.

Results: A total of 123 patients were identified with rectal cancer, of which the proportion of laparoscopic surgery (LAP) was 31% (n = 38) and robotic assisted rectal cancer surgery (ROBOT) 69% (n = 85). The proportion of women was 37%, median age 69, median body mass index 26, 25% had ASA class >= 3, 27% had neoadjuvant radiotherapy, 12% had neoadjuvant radiotherapy combined with chemotherapy, and 59% had a planned defunctioning stoma. No complications were noted in 44.7% of LAP and in 51.8% of ROBOT. Complications defined as Clavien-Dindo grade >= IIIb were 10.5% in LAP and 9.4% in ROBOT. Hospital stay was a median 9.5 days in LAP and 10 in ROBOT. The median CRP values in LAP and ROBOT preoperatively were 3 and 4 (P = .845), on POD 1: 100 and 110 (P = .865); POD 2: 218 and 145 (P = .159); POD 3: 181 and 141 (P = .097); POD 4: 128 and 95 (P = .502), and on POD 5: 73 and 71 (P = .785), respectively.

Conclusion: Postoperative inflammatory response as assessed by postoperative CRP values was not statistically different between LAP and ROBOT. CRP levels on POD 2-4 were numerically lower in ROBOT. The clinical relevance of this finding warrants further investigation.

Introduction: Planned repairs of primary ventral hernias are often delayed due to constrained operating theatre capacity, leading to prolonged symptoms and potential risk of incarceration/strangulation. The aim of this study was to evaluate the feasibility, perioperative tolerance, and short-term outcomes of repairing small primary ventral hernias under local anesthesia in the outpatient department (OPD) using suture repair.

Methods: This prospective, single-arm study was conducted at the Hernia Center, Region Örebro Län, Sweden, 2023–2025. Adults with primary ventral hernia <2 cm and BMI ≤30 kg/m2 were eligible. The Outpatient Department Repair (OPD-R) was performed under local anesthesia without the conventional operating theatre resources. Pain (VAS) and anxiety (VAS-A) were assessed intraoperatively and postoperatively, with follow-up at one week, one month, and six months.

Results: Thirty-seven patients underwent OPD-R. Age ranged from 32 to 79 years. Mean hernia defect size was 1.2 cm (range 0.3–1.9). Perioperative pain was low (mean VAS 1.0), immediate postoperative pain was low (mean VAS 0.2), and pain decreased over time with near-zero pain at six months (mean VAS 0.05). Mean perioperative anxiety (VAS-A) was 8.5/100 with variability across patients. All procedures were completed in the outpatient setting and patients were discharged without need for post-operative admission or observation. Patient satisfaction was high (mean 8.6/10), and postoperative pain/discomfort was low (mean 2.3/10; range 1–6).

Discussion: Outpatient department repair of selected small primary ventral hernias under local anesthesia is feasible and well tolerated in this pilot cohort. Larger studies, including comparative designs, are needed to evaluate long-term outcomes and recurrence.

Introduction: REBOA is used as an adjunct in haemorrhagic shock (HS) to restore proximal arterial pressure. Its cerebral metabolic effects particularly in the presence of elevated ICP, remain incompletely characterised. The aim of this study is to describe the changes in cerebral metabolism during total AO during HS in animals with normal and elevated ICP.

Methods: In a controlled porcine model, HS was induced by controlled bleeding to a mean arterial pressure of approximately 40 mmHg. Animals were allocated to a normal ICP group or an experimentally elevated ICP group. Total REBOA (zone 1) was applied for 90 min. Cerebral metabolism was assessed using intracerebral microdialysis with measurements of lactate, pyruvate ,and lactate–pyruvate ratio (LPR). Cerebral haemodynamics and ICP were continuously monitored.

Results: HS was associated with a statistically significant increase in LPR in both groups, indicating cerebral metabolic disturbance. Following aortic occlusion, LPR gradually decreased toward baseline in both groups. Animals with elevated ICP demonstrated a transient delay in metabolic normalisation during the early post-occlusion phase. Statistically significant differences between groups were limited to the first 10 min following occlusion. Overall metabolic trajectories were similar thereafter.

Discussion: REBOA restored cerebral metabolic markers of ischaemia in HS, as reflected by normalisation of LPR, even in the presence of experimentally elevated ICP. These findings indicate acute metabolic recovery and so suggest that the use of REBOA in the setting of elevated ICP is not contra indicated and can be a bridge to further treatment.

Background: Guidelines in healthcare should be evidence-based, satisfy patient needs and improve patient outcome.

Methods: We performed a cost-utility analysis in Graves' disease (GD) and estimated incremental costs after the introduction of a national guideline adding the Graves' Recurrent Events After Therapy (GREAT) score with genetic determinants (GREAT+) to predict recurrence, a thyroid nurse, preoperative calcium/vitamin D treatment and thyroid-stimulating immunoglobulins.

Findings: Antithyroid drugs (ATDs) were less costly, achieved 0.88 quality-adjusted life years (QALYs) over 8 years and dominated over radioactive iodine (RAI) treatment. The relevant incremental cost-effectiveness ratio was ATD versus thyroid surgery (Tx). Tx was more costly than ATD but was also more effective. The incremental cost-effectiveness ratio was equal to 40,488 Euro per QALY gained. In recurrent GD, the QALY weight for surgery after ATD was 0.76 compared with 0.79 when surgery was the initial treatment. If individuals requiring surgery could be identified at start of first treatment, QALYs would be higher (6.32) and the cost lower (13,945 Euro). The net cost increase after the new guideline was 17.6%, which was partially an effect from more time being spent with the thyroid nurse. If the GREAT+ score was also applied, the total increased net cost was 14.8% if 24% of the tested patients changed treatment to Tx.

Interpretation: Tx was more cost-effective than RAI when ablative treatment is advocated. Prediction score for recurrence directing patients to earlier Tx is cost-effective and enables the introduction of a specialist thyroid nurse. Health economic evaluations should accompany future guidelines.

BACKGROUND: This study aimed to compare preperitoneal ventral mesh patch with barbed suture in ventral hernia repair, evaluating recurrence rates and complications, and to assess the safety of preperitoneal patch placement.

METHODS: In this randomized clinical trial, adult patients undergoing ventral hernia repair at Karlskoga Hospital between 2020 and 2023 were randomized 1 : 1 to either a ventral mesh patch repair group or a non-absorbable barbed suture repair group, blinded to patients and outcome assessors. The primary outcome was recurrence detected at clinical examination and CT verification 1 year after surgery. Pain (measured on a visual analogue scale and using the Ventral Hernia Pain Questionnaire), nausea, and surgical site events (including wound infection, haematoma and seroma) were assessed 4 h, 1 week, 1 month, and 4 years after operation.

RESULTS: Of 256 eligible patients, 209 were screened, and 205 were randomized to ventral mesh patch repair (103) or barbed suture repair (102). The hernia recurrence rate at 1 year was lower in the ventral patch repair group (1.9 versus 5.9%), although this was not statistically significant (P = 0.14). The surgical site infection rate at 1 month was significantly lower in the ventral patch group (0.9 versus 6.9%; P = 0.02). At 1 month, the ventral patch repair group had higher 'pain right now' scores on the Ventral Hernia Pain Questionnaire (P = 0.02), although this difference had disappeared by 1 year.

CONCLUSION: Preperitoneal ventral hernia patch repair is a safe and effective technique with a recurrence rate not statistically significant from that after barbed suture repair. Although postoperative pain scores at 1 month were higher after ventral patch repair, this difference had disappeared by 1 year.

Introduction: Aim: To compare preperitoneal ventral mesh patch with barbed suture in ventral hernia repair, evaluating recurrence rates and complications, and to assess the safety and efficacy of standardised preperitoneal patch placement.

Methods: In this randomised controlled trial, 205 adult patients undergoing ventral hernia repair were randomised 1:1 to either a ventral mesh patch repair group (n=103) or a 2.0 non-absorbable barbed suture repair group (n=102), blinded to patients and outcome assessors. Primary outcome was recurrence one year after surgery. Pain, nausea, and surgical site events were assessed on four occasions up to one year.

Results: 205 patients were randomised to ventral mesh patch repair (n=103) or barbed suture repair (n=102). Hernia recurrence at one year was lower in the ventral patch group (1.9% vs. 5.9%), though not statistically significant (p=0.14). Surgical site infection rate at one month was significantly less in the ventral patch group (0.9% vs. 6.9%; p=0.02). At one month, the ventral patch group had higher "Pain right now" scores on the VHPQ (p=0.02), this difference had disappeared by one year.

Discussion: Conclusion: Preperitoneal ventral hernia patch repair is a safe and effective technique that results in a lower recurrence rate (though not statistically significant) than barbed suture. While postoperative pain scores at one month were higher in the patch group, this difference had disappeared by one year.