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Trauzeddel RF, Rothe LM, Nordine M, Dehé L, Scholtz K, Spies C, Hadzidiakos D, Winterer G, Borchers F, Kruppa J, Treskatsch S. Influence of a chronic beta-blocker therapy on perioperative opioid consumption - a post hoc secondary analysis. BMC Anesthesiol 2024; 24:80. [PMID: 38413849 PMCID: PMC10898005 DOI: 10.1186/s12871-024-02456-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 02/12/2024] [Indexed: 02/29/2024] Open
Abstract
BACKGROUND Beta-blocker (BB) therapy plays a central role in the treatment of cardiovascular diseases. An increasing number of patients with cardiovascular diseases undergoe noncardiac surgery, where opioids are an integral part of the anesthesiological management. There is evidence to suggest that short-term intravenous BB therapy may influence perioperative opioid requirements due to an assumed cross-talk between G-protein coupled beta-adrenergic and opioid receptors. Whether chronic BB therapy could also have an influence on perioperative opioid requirements is unclear. METHODS A post hoc analysis of prospectively collected data from a multicenter observational (BioCog) study was performed. Inclusion criteria consisted of elderly patients (≥ 65 years) undergoing elective noncardiac surgery as well as total intravenous general anesthesia without the use of regional anesthesia and duration of anesthesia ≥ 60 min. Two groups were defined: patients with and without BB in their regular preopreative medication. The administered opioids were converted to their respective morphine equivalent doses. Multiple regression analysis was performed using the morphine-index to identify independent predictors. RESULTS A total of 747 patients were included in the BioCog study in the study center Berlin. 106 patients fulfilled the inclusion criteria. Of these, 37 were on chronic BB. The latter were preoperatively significantly more likely to have arterial hypertension (94.6%), chronic renal failure (27%) and hyperlipoproteinemia (51.4%) compared to patients without BB. Both groups did not differ in terms of cumulative perioperative morphine equivalent dose (230.9 (BB group) vs. 214.8 mg (Non-BB group)). Predictive factors for increased morphine-index were older age, male sex, longer duration of anesthesia and surgery of the trunk. In a model with logarithmised morphine index, only gender (female) and duration of anesthesia remained predictive factors. CONCLUSIONS Chronic BB therapy was not associated with a reduced perioperative opioid consumption. TRIAL REGISTRATION This study was registered at ClinicalTrials.gov ( NCT02265263 ) on the 15.10.2014 with the principal investigator being Univ.-Prof. Dr. med. Claudia Spies.
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Affiliation(s)
- Ralf F Trauzeddel
- Department of Anesthesiology and Intensive Care Medicine, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Hindenburgdamm 30, Berlin, 12203, Germany
| | - Luisa M Rothe
- IS Global Campus Cliníc Rosselló, Barcelona Institute for Global Health, 132, 7è, Barcelona, 08036, Spain
| | - Michael Nordine
- Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt, Germany
| | - Lukas Dehé
- Department of Anesthesiology and Intensive Care Medicine, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Hindenburgdamm 30, Berlin, 12203, Germany
| | - Kathrin Scholtz
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Claudia Spies
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Daniel Hadzidiakos
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Georg Winterer
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Friedrich Borchers
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Augustenburger Platz 1, Berlin, 13353, Germany
| | - Jochen Kruppa
- Hochschule Osnabrück, University of Applied Sciences, Osnabrück, Germany
| | - Sascha Treskatsch
- Department of Anesthesiology and Intensive Care Medicine, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität and Humboldt Universität zu Berlin, Hindenburgdamm 30, Berlin, 12203, Germany.
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Mohseni S, Forssten MP, Mohammad Ismail A, Cao Y, Hildebrand F, Sarani B, Ribeiro MAF. Investigating the link between frailty and outcomes in geriatric patients with isolated rib fractures. Trauma Surg Acute Care Open 2024; 9:e001206. [PMID: 38347893 PMCID: PMC10860062 DOI: 10.1136/tsaco-2023-001206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024] Open
Abstract
Background Studies have shown an increased risk of morbidity in elderly patients suffering rib fractures from blunt trauma. The association between frailty and rib fractures on adverse outcomes is still ill-defined. In the current investigation, we sought to delineate the association between frailty, measured using the Orthopedic Frailty Score (OFS), and outcomes in geriatric patients with isolated rib fractures. Methods All geriatric (aged 65 years or older) patients registered in the 2013-2019 Trauma Quality Improvement database with a conservatively managed isolated rib fracture were considered for inclusion. An isolated rib fracture was defined as the presence of ≥1 rib fracture, a thorax Abbreviated Injury Scale (AIS) between 1 and 5, an AIS ≤1 in all other regions, as well as the absence of pneumothorax, hemothorax, or pulmonary contusion. Based on patients' OFS, patients were classified as non-frail (OFS 0), pre-frail (OFS 1), or frail (OFS ≥2). The prevalence ratio (PR) of composite complications, in-hospital mortality, failure-to-rescue (FTR), and intensive care unit (ICU) admission between the OFS groups was determined using Poisson regression models to adjust for potential confounding. Results A total of 65 375 patients met the study's inclusion criteria of whom 60% were non-frail, 29% were pre-frail, and 11% were frail. There was a stepwise increased risk of complications, in-hospital mortality, and FTR from non-frail to pre-frail and frail. Compared with non-frail patients, frail patients exhibited a 87% increased risk of in-hospital mortality [adjusted PR (95% CI): 1.87 (1.52-2.31), p<0.001], a 44% increased risk of complications [adjusted PR (95% CI): 1.44 (1.23-1.67), p<0.001], a doubling in the risk of FTR [adjusted PR (95% CI): 2.08 (1.45-2.98), p<0.001], and a 17% increased risk of ICU admission [adjusted PR (95% CI): 1.17 (1.11-1.23), p<0.001]. Conclusion There is a strong association between frailty, measured using the OFS, and adverse outcomes in geriatric patients managed conservatively for rib fractures.
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Affiliation(s)
- Shahin Mohseni
- Orebro universitet Fakulteten for medicin och halsa, Orebro, Sweden
- Department of Surgery, Sheikh Shakhbout Medical City—Mayo Clinic, Abu Dhabi, UAE
| | - Maximilian Peter Forssten
- Department of Orthopedic Surgery, Orebro University Hospital, Orebro, Sweden
- School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Ahmad Mohammad Ismail
- Department of Orthopedic Surgery, Orebro University Hospital, Orebro, Sweden
- School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Faculty of Medicine and Health, Orebro University, Orebro, Sweden
| | - Frank Hildebrand
- Department of Orthopedics, Trauma and Reconstructive Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Babak Sarani
- George Washington University, Washington, District of Columbia, USA
| | - Marcelo AF Ribeiro
- Department of Surgery, Sheikh Shakhbout Medical City—Mayo Clinic, Abu Dhabi, UAE
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A nationwide analysis on the interaction between frailty and beta-blocker therapy in hip fracture patients. Eur J Trauma Emerg Surg 2023; 49:1485-1497. [PMID: 36633610 DOI: 10.1007/s00068-023-02219-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 12/31/2022] [Indexed: 01/13/2023]
Abstract
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.
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Forssten MP, Mohammad Ismail A, Ioannidis I, Wretenberg P, Borg T, Cao Y, Ribeiro MAF, Mohseni S. The mortality burden of frailty in hip fracture patients: a nationwide retrospective study of cause-specific mortality. Eur J Trauma Emerg Surg 2022; 49:1467-1475. [PMID: 36571633 DOI: 10.1007/s00068-022-02204-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 12/18/2022] [Indexed: 12/27/2022]
Abstract
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 ≥ 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.
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Affiliation(s)
- Maximilian Peter Forssten
- Department of Orthopedic Surgery, Orebro University Hospital, 701 85, Orebro, Sweden.,School of Medical Sciences, Orebro University, 702 81, Orebro, Sweden
| | - Ahmad Mohammad Ismail
- Department of Orthopedic Surgery, Orebro University Hospital, 701 85, Orebro, Sweden.,School of Medical Sciences, Orebro University, 702 81, Orebro, Sweden
| | - Ioannis Ioannidis
- Department of Orthopedic Surgery, Orebro University Hospital, 701 85, Orebro, Sweden.,School of Medical Sciences, Orebro University, 702 81, Orebro, Sweden
| | - Per Wretenberg
- Department of Orthopedic Surgery, Orebro University Hospital, 701 85, Orebro, Sweden.,School of Medical Sciences, Orebro University, 702 81, Orebro, Sweden
| | - Tomas Borg
- Department of Orthopedic Surgery, Orebro University Hospital, 701 85, Orebro, Sweden.,School of Medical Sciences, Orebro University, 702 81, Orebro, Sweden
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Orebro University, 701 82, Orebro, Sweden
| | - Marcelo A F Ribeiro
- 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
| | - Shahin Mohseni
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, 701 85, Orebro, Sweden. .,School of Medical Sciences, Orebro University, 702 81, Orebro, Sweden.
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Mohammad Ismail A, Forssten MP, Bass GA, Trivedi DJ, Ekestubbe L, Ioannidis I, Duffy CC, Peden CJ, Mohseni S. Mode of anesthesia is not associated with outcomes following emergency hip fracture surgery: a population-level cohort study. Trauma Surg Acute Care Open 2022; 7:e000957. [PMID: 36148316 PMCID: PMC9486374 DOI: 10.1136/tsaco-2022-000957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 08/31/2022] [Indexed: 11/05/2022] Open
Abstract
Background Hip fractures often occur in frail patients with several comorbidities. In those undergoing emergency surgery, determining the optimal anesthesia modality may be challenging, with equipoise concerning outcomes following either spinal or general anesthesia. In this study, we investigated the association between mode of anesthesia and postoperative morbidity and mortality with subgroup analyses. Methods This is a retrospective study using all consecutive adult patients who underwent emergency hip fracture surgery in Orebro County, Sweden, between 2013 and 2017. Patients were extracted from the Swedish National Hip Fracture Registry, and their electronic medical records were reviewed. The association between the type of anesthesia and 30-day and 90-day postoperative mortality, as well as in-hospital severe complications (Clavien-Dindo classification ≥3a), was analyzed using Poisson regression models with robust SEs, while the association with 1-year mortality was analyzed using Cox proportional hazards models. All analyses were adjusted for potential confounders. Results A total of 2437 hip fracture cases were included in the study, of whom 60% received spinal anesthesia. There was no statistically significant difference in the risk of 30-day postoperative mortality (adjusted incident rate ratio (IRR) (95% CI): 0.99 (0.72 to 1.36), p=0.952), 90-day postoperative mortality (adjusted IRR (95% CI): 0.88 (0.70 to 1.11), p=0.281), 1-year postoperative mortality (adjusted HR (95% CI): 0.98 (0.83 to 1.15), p=0.773), or in-hospital severe complications (adjusted IRR (95% CI): 1.24 (0.85 to 1.82), p=0.273), when comparing general and spinal anesthesia. Conclusions Mode of anesthesia during emergency hip fracture surgery was not associated with an increased risk of postoperative mortality or in-hospital severe complications in the study population or any of the investigated subgroups. Level of evidence: Therapeutic/Care Management, level III
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Affiliation(s)
- Ahmad Mohammad Ismail
- Department of Orthopedic Surgery, Orebro University Hospital, Orebro, Sweden.,School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Maximilian Peter Forssten
- Department of Orthopedic Surgery, Orebro University Hospital, Orebro, Sweden.,School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Gary Alan Bass
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Dhanisha Jayesh Trivedi
- School of Medical Sciences, Orebro University, Orebro, Sweden.,Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, Orebro, Sweden
| | - Lovisa Ekestubbe
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, Orebro, Sweden
| | - Ioannis Ioannidis
- Department of Orthopedic Surgery, Orebro University Hospital, Orebro, Sweden.,School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Caoimhe C Duffy
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Carol J Peden
- 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
| | - Shahin Mohseni
- School of Medical Sciences, Orebro University, Orebro, Sweden.,Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, Orebro, Sweden
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Kobbe P, Pishnamaz M, Hildebrand F. Focus on geriatric proximal femur fractures: factors that influence the outcome. Eur J Trauma Emerg Surg 2022; 48:699-700. [PMID: 35403890 PMCID: PMC9001556 DOI: 10.1007/s00068-022-01954-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 03/11/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Philipp Kobbe
- Department of Orthopaedics, Trauma and Reconstructive Surgery, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Miguel Pishnamaz
- Department of Orthopaedics, Trauma and Reconstructive Surgery, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Frank Hildebrand
- Department of Orthopaedics, Trauma and Reconstructive Surgery, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany.
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Dementia is a surrogate for frailty in hip fracture mortality prediction. Eur J Trauma Emerg Surg 2022; 48:4157-4167. [PMID: 35355091 PMCID: PMC9532301 DOI: 10.1007/s00068-022-01960-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 03/13/2022] [Indexed: 12/12/2022]
Abstract
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. Supplementary Information The online version contains supplementary material available at 10.1007/s00068-022-01960-9.
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Forssten MP, Bass GA, Scheufler KM, Mohammad Ismail A, Cao Y, Martin ND, Sarani B, Mohseni S. Mortality risk stratification in isolated severe traumatic brain injury using the revised cardiac risk index. Eur J Trauma Emerg Surg 2021; 48:4481-4488. [PMID: 34839374 DOI: 10.1007/s00068-021-01841-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 11/10/2021] [Indexed: 12/01/2022]
Abstract
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.
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Affiliation(s)
- Maximilian Peter Forssten
- School of Medical Sciences, Orebro University, 702 81, Örebro, Sweden.,Division of Trauma and Emergency Surgery, Orebro University Hospital, 70185, Örebro, Sweden
| | - Gary Alan Bass
- School of Medical Sciences, Orebro University, 702 81, Örebro, Sweden.,Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Kai-Michael Scheufler
- Department of Neurosurgery, Orebro University Hospital, 70185, Örebro, Sweden.,Medical School, Heinrich-Heine University Dusseldorf, Düsseldorf, Germany
| | - Ahmad Mohammad Ismail
- School of Medical Sciences, Orebro University, 702 81, Örebro, Sweden.,Division of Trauma and Emergency Surgery, Orebro University Hospital, 70185, Örebro, Sweden
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Orebro University, Örebro, Sweden
| | - Niels Douglas Martin
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Babak Sarani
- Division of Trauma and Acute Care Surgery, George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Shahin Mohseni
- School of Medical Sciences, Orebro University, 702 81, Örebro, Sweden. .,Division of Trauma and Emergency Surgery, Orebro University Hospital, 70185, Örebro, Sweden.
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Wang Z, Chen X, Wu Y, Jiang W, Yang L, Wang H, Liu S, Liu Y. Admission Resting Heart Rate as an Independent Predictor of All-Cause Mortality in Elderly Patients with Hip Fracture. Int J Gen Med 2021; 14:7699-7706. [PMID: 34764683 PMCID: PMC8575447 DOI: 10.2147/ijgm.s333971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 10/27/2021] [Indexed: 11/26/2022] Open
Abstract
Purpose To investigate the relationship between admission resting heart rate (RHR) and all-cause mortality in elderly patients with hip fracture. Methods A retrospective cohort study with 837 patients based on the established hip fracture database was conducted. Admission RHR was measured via electrocardiogram, and patients were grouped by the median RHR value (beats per minute, bpm). The main outcomes were 1-year and total all-cause mortality. Cox proportional hazard models and restricted cubic spline were used to assess the relationship between RHR and mortality. Sensitivity analyses were further performed to determine whether the results were stable. Results The mean and median RHR were 82.3 and 80.0 bpm, respectively. After a median follow-up of 31.8 months, the 1-year and total all-cause mortality were 17.6% and 31.2%. Multivariable Cox analyses showed that high RHR was an independent risk factor for 1-year mortality (HR = 1.51; 95% CI: 1.08–2.13; p = 0.016), and total mortality (HR = 1.44; 95% CI: 1.12–1.85; p = 0.005). For each 10 bpm increase in RHR, the risk of 1-year death increased by 23.0% (HR = 1.23; 95% CI: 1.09–1.39; p = 0.001), and total death increased by 21.0% (HR = 1.21; 95% CI: 1.09–1.34; p < 0.001). A typical J-shaped curve was observed in the restricted cubic spline for the association between RHR and 1-year mortality, with the lowest mortality risk at 70 bpm. Sensitivity analyses yielded similar findings. Conclusion An increase in RHR was independently associated with all-cause mortality, and may be a useful prognostic predictor for elderly patients with hip fracture.
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Affiliation(s)
- Zhicong Wang
- Orthopaedic Center of Deyang City, Department of Orthopedics, Deyang People's Hospital, Deyang, Sichuan, People's Republic of China
| | - Xi Chen
- Orthopaedic Center of Deyang City, Department of Orthopedics, Deyang People's Hospital, Deyang, Sichuan, People's Republic of China
| | - Yuxuan Wu
- Orthopaedic Center of Deyang City, Department of Orthopedics, Deyang People's Hospital, Deyang, Sichuan, People's Republic of China
| | - Wei Jiang
- Orthopaedic Center of Deyang City, Department of Orthopedics, Deyang People's Hospital, Deyang, Sichuan, People's Republic of China
| | - Ling Yang
- Orthopaedic Center of Deyang City, Department of Orthopedics, Deyang People's Hospital, Deyang, Sichuan, People's Republic of China
| | - Hong Wang
- Orthopaedic Center of Deyang City, Department of Orthopedics, Deyang People's Hospital, Deyang, Sichuan, People's Republic of China
| | - Shuping Liu
- Orthopaedic Center of Deyang City, Department of Orthopedics, Deyang People's Hospital, Deyang, Sichuan, People's Republic of China
| | - Yuehong Liu
- Orthopaedic Center of Deyang City, Department of Orthopedics, Deyang People's Hospital, Deyang, Sichuan, People's Republic of China
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Forssten MP, Mohammad Ismail A, Borg T, Cao Y, Wretenberg P, Bass GA, Mohseni S. The consequences of out-of-hours hip fracture surgery: insights from a retrospective nationwide study. Eur J Trauma Emerg Surg 2021; 48:709-719. [PMID: 34622327 PMCID: PMC9001198 DOI: 10.1007/s00068-021-01804-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 09/28/2021] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- Maximilian Peter Forssten
- Department of Orthopedic Surgery, Orebro University Hospital, 701 85 Orebro, Sweden
- School of Medical Sciences, Orebro University, 702 81 Orebro, Sweden
| | - Ahmad Mohammad Ismail
- Department of Orthopedic Surgery, Orebro University Hospital, 701 85 Orebro, Sweden
- School of Medical Sciences, Orebro University, 702 81 Orebro, Sweden
| | - Tomas Borg
- Department of Orthopedic Surgery, Orebro University Hospital, 701 85 Orebro, Sweden
- School of Medical Sciences, Orebro University, 702 81 Orebro, Sweden
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Orebro University, 701 82 Orebro, Sweden
| | - Per Wretenberg
- Department of Orthopedic Surgery, Orebro University Hospital, 701 85 Orebro, Sweden
- School of Medical Sciences, Orebro University, 702 81 Orebro, Sweden
| | - Gary Alan Bass
- School of Medical Sciences, Orebro University, 702 81 Orebro, Sweden
- Division of Traumatology, Emergency Surgery and Surgical Critical Care, University of Pennsylvania, Philadelphia, USA
| | - Shahin Mohseni
- School of Medical Sciences, Orebro University, 702 81 Orebro, Sweden
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, 701 85 Orebro, Sweden
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Predicting 1-Year Mortality after Hip Fracture Surgery: An Evaluation of Multiple Machine Learning Approaches. J Pers Med 2021; 11:jpm11080727. [PMID: 34442370 PMCID: PMC8401745 DOI: 10.3390/jpm11080727] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 07/24/2021] [Accepted: 07/24/2021] [Indexed: 12/15/2022] Open
Abstract
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.
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Ioannidis I, Mohammad Ismail A, Forssten MP, Cao Y, Bass GA, Borg T, Mohseni S. β-Adrenergic blockade in patients with dementia and hip fracture is associated with decreased postoperative mortality. Eur J Trauma Emerg Surg 2021; 48:1463-1469. [PMID: 34129093 PMCID: PMC9001220 DOI: 10.1007/s00068-021-01723-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 06/05/2021] [Indexed: 11/27/2022]
Abstract
Purpose Dementia, present in 20% of hip fracture patients, is associated with an almost threefold increase in postoperative mortality risk. These patients have a substantially higher incidence of cardiovascular, respiratory, and cerebrovascular mortality after hip fracture surgery compared to patients without dementia. This study aimed to investigate the association between beta-blocker therapy and postoperative mortality in patients with dementia undergoing hip fracture surgery. Methods This nationwide study included all patients in Sweden with the diagnosis of dementia who underwent emergency surgery for a hip fracture between January 2008 and December 2017. Cases where the hip fracture was pathological or conservatively managed were not included. Poisson regression analysis with robust standard errors was performed while controlling for confounders to determine the relationship between beta-blocker therapy and all-cause, as well as cause-specific, postoperative mortality. Results A total of 26,549 patients met the study inclusion criteria, of whom 8258 (31%) had ongoing beta-blocker therapy at time of admission. After adjusting for clinically relevant variables, the incidence of postoperative mortality in patients receiving beta-blocker therapy was decreased by 50% at 30 days [adj. IRR (95% CI) 0.50 (0.45–0.54), p < 0.001] and 34% at 90 days [adj. IRR (95% CI) 0.66 (0.62–0.70), p < 0.001]. Cause-specific mortality analysis demonstrated a significant reduction in the incidence of postoperative cardiovascular, respiratory, and cerebrovascular death within 30 and 90 days postoperatively. Conclusion Beta-blocker therapy is associated with decreased postoperative mortality in hip fracture patients with dementia up to 90 days after surgery. This finding warrants further investigation. Supplementary Information The online version contains supplementary material available at 10.1007/s00068-021-01723-y.
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Affiliation(s)
- Ioannis Ioannidis
- Department of Orthopedic Surgery, Orebro University Hospital, 701 85 Orebro, Sweden
- School of Medical Sciences, Orebro University, 702 81 Orebro, Sweden
| | - Ahmad Mohammad Ismail
- Department of Orthopedic Surgery, Orebro University Hospital, 701 85 Orebro, Sweden
- School of Medical Sciences, Orebro University, 702 81 Orebro, Sweden
| | - Maximilian Peter Forssten
- Department of Orthopedic Surgery, Orebro University Hospital, 701 85 Orebro, Sweden
- School of Medical Sciences, Orebro University, 702 81 Orebro, Sweden
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Orebro University, 701 82 Orebro, Sweden
| | - Gary Alan Bass
- School of Medical Sciences, Orebro University, 702 81 Orebro, Sweden
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, USA
| | - Tomas Borg
- Department of Orthopedic Surgery, Orebro University Hospital, 701 85 Orebro, Sweden
- School of Medical Sciences, Orebro University, 702 81 Orebro, Sweden
| | - Shahin Mohseni
- School of Medical Sciences, Orebro University, 702 81 Orebro, Sweden
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, 701 85 Orebro, Sweden
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Mitigating the stress response to improve outcomes for older patients undergoing emergency surgery with the addition of beta-adrenergic blockade. Eur J Trauma Emerg Surg 2021; 48:799-810. [PMID: 33847766 PMCID: PMC9001541 DOI: 10.1007/s00068-021-01647-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 03/11/2021] [Indexed: 12/14/2022]
Abstract
As population age, healthcare systems and providers are likely to experience a substantial increase in the proportion of elderly patients requiring emergency surgery. Emergency surgery, compared with planned surgery, is strongly associated with increased risks of adverse postoperative outcomes due to the short time available for diagnosis, optimization, and intervention in patients presenting with physiological derangement. These patient populations, who are often frail and burdened with a variety of co-morbidities, have lower reserves to deal with the stress of the acute condition and the required emergency surgical intervention. In this review article, we discuss topical areas where mitigation of the physiological stress posed by the acute condition and asociated surgical intervention may be feasible. We consider the impact of the adrenergic response and use of beta blockers for these high-risk patients and discuss common risk factors such as frailty and delirium. A proactive multidisciplinary approach to peri-operative care aimed at mitigation of the stress response and proactive management of common conditions in the older emergency surgical patient could yield more favorable outcomes.
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