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Ioannidis I, Forssten MP, Mohammad Ismail A, Cao Y, Tennakoon L, Spain DA, Mohseni S. The relationship and predictive value of dementia and frailty for mortality in patients with surgically managed hip fractures. Eur J Trauma Emerg Surg 2024; 50:339-345. [PMID: 37656179 PMCID: PMC11035458 DOI: 10.1007/s00068-023-02356-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 08/21/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Both dementia and frailty have been associated with worse outcomes in patients with hip fractures. However, the interrelation and predictive value of these two entities has yet to be clarified. The current study aimed to investigate the predictive relationship between dementia, frailty, and in-hospital mortality after hip fracture surgery. METHODS All patients registered in the 2019 National Inpatient Sample Database who were 50 years or older and underwent emergency hip fracture surgery following a traumatic fall were eligible for inclusion. Logistic regression (LR) models were constructed with in-hospital mortality as the response variables. One model was constructed including markers of frailty and one model was constructed excluding markers of frailty [Orthopedic Frailty Score (OFS) and weight loss]. The feature importance of all variables was determined using the permutation importance method. New LR models were then fitted 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 An estimated total of 216,395 patients were included. Dementia was the 7th most important variable for predicting in-hospital mortality. When the OFS and weight loss were included, they replaced dementia in importance. There was no significant difference in the predictive ability of the models when comparing the model that included markers of frailty [AUC for in-hospital mortality (95% CI) 0.79 (0.77-0.81)] with the model that excluded markers of frailty [AUC for in-hospital mortality (95% CI) 0.79 (0.77-0.80)]. CONCLUSION Dementia functions as a surrogate for frailty when predicting in-hospital mortality in hip fracture patients. This finding highlights the importance of early frailty screening for improvement of care pathways and discussions with patients and their families in regard to expected outcomes.
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Affiliation(s)
- Ioannis Ioannidis
- 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
| | - 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
| | - Lakshika Tennakoon
- Department of Surgery, Section of Trauma and Acute Care Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - David A Spain
- Department of Surgery, Section of Trauma and Acute Care Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Shahin Mohseni
- Department of Orthopedic Surgery, Orebro University Hospital, Orebro, Sweden.
- Division of Trauma, Critical Care & Acute Care Surgery, Department of Surgery, Sheik Shakhbot Medical City Mayo Clinic, Abu Dhabi, United Arab Emirates.
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Mohammad Ismail A, Forssten MP, Hildebrand F, Sarani B, Ioannidis I, Cao Y, Ribeiro MAF, Mohseni S. Cardiac risk stratification and adverse outcomes in surgically managed patients with isolated traumatic spine injuries. Eur J Trauma Emerg Surg 2024; 50:523-530. [PMID: 38170276 PMCID: PMC11035445 DOI: 10.1007/s00068-023-02413-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 11/25/2023] [Indexed: 01/05/2024]
Abstract
INTRODUCTION As the incidence of traumatic spine injuries has been steadily increasing, especially in the elderly, the ability to categorize patients based on their underlying risk for the adverse outcomes could be of great value in clinical decision making. This study aimed to investigate the association between the Revised Cardiac Risk Index (RCRI) and adverse outcomes in patients who have undergone surgery for traumatic spine injuries. METHODS All adult patients (18 years or older) in the 2013-2019 TQIP database with isolated spine injuries resulting from blunt force trauma, who underwent spinal surgery, were eligible for inclusion in the study. The association between the RCRI and in-hospital mortality, cardiopulmonary complications, and failure-to-rescue (FTR) was determined using Poisson regression models with robust standard errors to adjust for potential confounding. RESULTS A total of 39,391 patients were included for further analysis. In the regression model, an RCRI ≥ 3 was associated with a threefold risk of in-hospital mortality [adjusted IRR (95% CI): 3.19 (2.30-4.43), p < 0.001] and cardiopulmonary complications [adjusted IRR (95% CI): 3.27 (2.46-4.34), p < 0.001], as well as a fourfold risk of FTR [adjusted IRR (95% CI): 4.27 (2.59-7.02), p < 0.001], compared to RCRI 0. The risk of all adverse outcomes increased stepwise along with each RCRI score. CONCLUSION The RCRI may be a useful tool for identifying patients with traumatic spine injuries who are at an increased risk of in-hospital mortality, cardiopulmonary complications, and failure-to-rescue after surgery.
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Affiliation(s)
- Ahmad Mohammad Ismail
- School of Medical Sciences, Orebro University, 701 82, Orebro, Sweden
- Department of Orthopedic Surgery, Orebro University Hospital, 701 85, Orebro, Sweden
| | - Maximilian Peter Forssten
- School of Medical Sciences, Orebro University, 701 82, Orebro, Sweden
- Department of Orthopedic Surgery, Orebro University Hospital, 701 85, Orebro, Sweden
| | - Frank Hildebrand
- Department of Orthopedics, Trauma and Reconstructive Surgery, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Babak Sarani
- Center of Trauma and Critical Care, George Washington University, Washington, DC, USA
| | - Ioannis Ioannidis
- School of Medical Sciences, Orebro University, 701 82, Orebro, Sweden
- Department of Orthopedic Surgery, Orebro University Hospital, 701 85, Orebro, Sweden
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Faculty of Medicine and Health, Orebro University, 701 82, Orebro, Sweden
| | - Marcelo A F Ribeiro
- Division of Trauma, Critical Care & Acute Care Surgery, Department of Surgery, Sheikh Shakhbout Medical City, Mayo Clinic, Abu Dhabi, United Arab Emirates
- Pontifical Catholic University of São Paulo, São Paulo, Brazil
- Khalifa University and Gulf Medical University, Abu Dhabi, United Arab Emirates
| | - Shahin Mohseni
- School of Medical Sciences, Orebro University, 701 82, Orebro, Sweden.
- Division of Trauma, Critical Care & Acute Care Surgery, Department of Surgery, Sheikh Shakhbout Medical City, Mayo Clinic, Abu Dhabi, United Arab Emirates.
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Forssten MP, Mohammad Ismail A, Ioannidis I, Ribeiro MAF, Cao Y, Sarani B, Mohseni S. Prioritizing patients for hip fracture surgery: the role of frailty and cardiac risk. Front Surg 2024; 11:1367457. [PMID: 38525320 PMCID: PMC10957751 DOI: 10.3389/fsurg.2024.1367457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 02/19/2024] [Indexed: 03/26/2024] Open
Abstract
Introduction The number of patients with hip fractures continues to rise as the average age of the population increases. Optimizing outcomes in this cohort is predicated on timely operative repair. The aim of this study was to determine if patients with hip fractures who are frail or have a higher cardiac risk suffer from an increased risk of in-hospital mortality when surgery is postponed >24 h. Methods All patients registered in the 2013-2021 TQIP dataset who were ≥65 years old and underwent surgical fixation of an isolated hip fracture caused by a ground-level fall were included. Adjustment for confounding was performed using inverse probability weighting (IPW) while stratifying for frailty with the Orthopedic Frailty Score (OFS) and cardiac risk using the Revised Cardiac Risk Index (RCRI). The outcome was presented as the absolute risk difference in in-hospital mortality. Results A total of 254,400 patients were included. After IPW, all confounders were balanced. A delay in surgery was associated with an increased risk of in-hospital mortality across all strata, and, as the degree of frailty and cardiac risk increased, so too did the risk of mortality. In patients with OFS ≥4, delaying surgery >24 h was associated with a 2.33 percentage point increase in the absolute mortality rate (95% CI: 0.57-4.09, p = 0.010), resulting in a number needed to harm (NNH) of 43. Furthermore, the absolute risk of mortality increased by 4.65 percentage points in patients with RCRI ≥4 who had their surgery delayed >24 h (95% CI: 0.90-8.40, p = 0.015), resulting in a NNH of 22. For patients with OFS 0 and RCRI 0, the corresponding NNHs when delaying surgery >24 h were 345 and 333, respectively. Conclusion Delaying surgery beyond 24 h from admission increases the risk of mortality for all geriatric hip fracture patients. The magnitude of the negative impact increases with the patient's level of cardiac risk and frailty. Operative intervention should not be delayed based on frailty or cardiac risk.
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Affiliation(s)
- Maximilian Peter Forssten
- Department of Orthopedic Surgery, Faculty of Medicine and Health, Orebro University, Orebro, Sweden
- School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Ahmad Mohammad Ismail
- Department of Orthopedic Surgery, Faculty of Medicine and Health, Orebro University, Orebro, Sweden
- School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Ioannis Ioannidis
- Department of Orthopedic Surgery, Faculty of Medicine and Health, Orebro University, Orebro, Sweden
- School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Marcelo A. F. Ribeiro
- 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, Abu Dhabi, United Arab Emirates
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Faculty of Medicine and Health, Orebro University, Orebro, Sweden
| | - Babak Sarani
- Division of Trauma and Acute Care Surgery, George Washington University School of Medicine & Health Sciences, Washington, DC, United States
| | - Shahin Mohseni
- School of Medical Sciences, Orebro University, Orebro, Sweden
- Department of Surgery, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Mohammad Ismail A, Forssten MP, Sarani B, Ribeiro MAF, Chang P, Cao Y, Hildebrand F, Mohseni S. Sex disparities in adverse outcomes after surgically managed isolated traumatic spinal injury. Eur J Trauma Emerg Surg 2024; 50:149-155. [PMID: 37191713 PMCID: PMC10923959 DOI: 10.1007/s00068-023-02275-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 05/02/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND Traumatic spinal injury (TSI) encompasses a wide range of injuries affecting the spinal cord, nerve roots, bones, and soft tissues that result in pain, impaired mobility, paralysis, and death. There is some evidence suggesting that women may have different physiological responses to traumatic injury compared to men; therefore, this study aimed to investigate if there are any associations between sex and adverse outcomes following surgically managed isolated TSI. METHODS Using the 2013-2019 TQIP database, all adult patients with isolated TSI, defined as a spine AIS ≥ 2 with an AIS ≤ 1 in all other body regions, resulting from blunt force trauma requiring spinal surgery, were eligible for inclusion in the study. The association between the sex and in-hospital mortality as well as cardiopulmonary and venothromboembolic complications was determined by calculating the risk ratio (RR) after adjusting for potential confounding using inverse probability weighting. RESULTS A total of 43,756 patients were included. After adjusting for potential confounders, female sex was associated with a 37% lower risk of in-hospital mortality [adjusted RR (95% CI): 0.63 (0.57-0.69), p < 0.001], a 27% lower risk of myocardial infarction [adjusted RR (95% CI): 0.73 (0.56-0.95), p = 0.021], a 37% lower risk of cardiac arrest [adjusted RR (95% CI): 0.63 (0.55-0.72), p < 0.001], a 34% lower risk of deep vein thrombosis [adjusted RR (95% CI): 0.66 (0.59-0.74), p < 0.001], a 45% lower risk of pulmonary embolism [adjusted RR (95% CI): 0.55 (0.46-0.65), p < 0.001], a 36% lower risk of acute respiratory distress syndrome [adjusted RR (95% CI): 0.64 (0.54-0.76), p < 0.001], a 34% lower risk of pneumonia [adjusted RR (95% CI): 0.66 (0.60-0.72), p < 0.001], and a 22% lower risk of surgical site infection [adjusted RR (95% CI): 0.78 (0.62-0.98), p < 0.032], compared to male sex. CONCLUSION Female sex is associated with a significantly decreased risk of in-hospital mortality as well as cardiopulmonary and venothromboembolic complications following surgical management of traumatic spinal injuries. Further studies are needed to elucidate the cause of these differences.
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Affiliation(s)
- 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
| | - Babak Sarani
- Surgery and Emergency Medicine, Center of Trauma and Critical Care, George Washington University, Washington, DC, USA
| | - Marcelo A F Ribeiro
- Surgery, Pontifical Catholic University of São Paulo, São Paulo, Brazil
- Surgery, Khalifa University and Gulf Medical University, Abu Dhabi, United Arab Emirates
- Division of Trauma, Critical Care & Acute Care Surgery, Department of Surgery, Sheikh Shakhbout Medical City, Mayo Clinic, Abu Dhabi, United Arab Emirates
| | - Parker Chang
- Center for Trauma and Critical Care, Department of Surgery, George Washington University, Washington, DC, USA
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, Faculty of Medicine and Health, School of Medical Sciences, Orebro University, 701 82, Orebro, Sweden
| | - Frank Hildebrand
- Department of Orthopedics, Trauma and Reconstructive Surgery, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Shahin Mohseni
- School of Medical Sciences, Orebro University, 702 81, Orebro, Sweden.
- Division of Trauma, Critical Care & Acute Care Surgery, Department of Surgery, Sheikh Shakhbout Medical City, Mayo Clinic, Abu Dhabi, United Arab Emirates.
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Trivedi D, Forssten MP, Cao Y, Ismail AM, Czeiter E, Amrein K, Kobeissy F, Wang KKW, DeSoucy E, Buki A, Mohseni S. Screening Performance of S100 Calcium-Binding Protein B, Glial Fibrillary Acidic Protein, and Ubiquitin C-Terminal Hydrolase L1 for Intracranial Injury Within Six Hours of Injury and Beyond. J Neurotrauma 2024; 41:349-358. [PMID: 38115670 DOI: 10.1089/neu.2023.0322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023] Open
Abstract
The Scandinavian NeuroTrauma Committee (SNC) guidelines recommend S100 calcium-binding protein B (S100B) as a screening tool for early detection of Traumatic brain injury (TBI) in patients presenting with an initial Glasgow Coma Scale (GCS) of 14-15. The objective of the current study was to compare S100B's diagnostic performance within the recommended 6-h window after injury, compared with glial fibrillary acidic protein (GFAP) and UCH-L1. The secondary outcome of interest was the ability of these biomarkers in detecting traumatic intracranial pathology beyond the 6-h mark. The Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) core database (2014-2017) was queried for data pertaining to all TBI patients with an initial GCS of 14-15 who had a blood sample taken within 6 h of injury in which the levels of S100B, GFAP, and UCH-L1 were measured. As a subgroup analysis, data involving patients with blood samples taken within 6-9 h and 9-12 h were analyzed separately for diagnostic ability. The diagnostic ability of these biomarkers for detecting any intracranial injury was evaluated based on the area under the receiver operating characteristic curve (AUC). Each biomarker's sensitivity, specificity, and accuracy were also reported at the cutoff that maximized Youden's index. A total of 531 TBI patients with GCS 14-15 on admission had a blood sample taken within 6 h, of whom 24.9% (n = 132) had radiologically confirmed intracranial injury. The AUCs of GFAP (0.86, 95% confidence interval [CI]: 0.82-0.90) and UCH-L1 (0.81, 95% CI: 0.76-0.85) were statistically significantly higher than that of S100B (0.74, 95% CI: 0.69-0.79) during this time. There was no statistically significant difference in the predictive ability of S100B when sampled within 6 h, 6-9 h, and 9-12 h of injury, as the p values were >0.05 when comparing the AUCs. Overlapping AUC 95% CI suggests no benefit of a combined GFAP and UCH-L1 screening tool over GFAP during the time periods studied [0.87 (0.83-0.90) vs. 0.86 (0.82-0.90) when sampled within 6 h of injury, 0.83 (0.78-0.88) vs. 0.83 (0.78-0.89) within 6 to 9 h and 0.81 (0.73-0.88) vs. 0.79 (0.72-0.87) within 9-12 h]. Targeted analysis of the CENTER-TBI core database, with focus on the patient category for which biomarker testing is recommended by the SNC guidelines, revealed that GFAP and UCH-L1 perform superior to S100B in predicting CT-positive intracranial lesions within 6 h of injury. GFAP continued to exhibit superior predictive ability to S100B during the time periods studied. S100B displayed relatively unaltered screening performance beyond the diagnostic timeline provided by SNC guidelines. These findings suggest the need for a reevaluation of the current SNC TBI guidelines.
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Affiliation(s)
- Dhanisha Trivedi
- Department of Neurosurgery, Orebro University Hospital, Orebro, Sweden
- School of Medical Sciences , Orebro University Hospital, Orebro, Sweden
| | | | - Yang Cao
- Clinical Epidemiology and Biostatistics, Orebro University Hospital, Orebro, Sweden
| | | | - Endre Czeiter
- Department of Neurosurgery, University of Pecs, Pecs, Hungary
- Neurotrauma Research Group, Szentágothai Research Center, University of Pecs, Pecs, Hungary
- ELKH-PTE Clinical Neuroscience MR Research Group, University of Pecs, Pecs, Hungary
| | - Krisztina Amrein
- Department of Neurosurgery, University of Pecs, Pecs, Hungary
- Neurotrauma Research Group, Szentágothai Research Center, University of Pecs, Pecs, Hungary
- ELKH-PTE Clinical Neuroscience MR Research Group, University of Pecs, Pecs, Hungary
| | - Firas Kobeissy
- Center for Neurotrauma, Multiomics, and Biomarkers, Department of Neurobiology, Neuroscience Institute, Morehouse School of Medicine, Atlanta, Georgia, USA
| | - Kevin K W Wang
- Center for Neurotrauma, Multiomics, and Biomarkers, Department of Neurobiology, Neuroscience Institute, Morehouse School of Medicine, Atlanta, Georgia, USA
| | - Erik DeSoucy
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Sheikh Shakhbout Medical City-Mayo Clinic, Abu Dhabi, United Arab Emirates
| | - Andras Buki
- Department of Neurosurgery, Orebro University Hospital, Orebro, Sweden
- School of Medical Sciences , Orebro University Hospital, Orebro, Sweden
| | - Shahin Mohseni
- School of Medical Sciences , Orebro University Hospital, Orebro, Sweden
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Rauh JL, Neff LP, Forssten MP, Ribeiro MAF, Sarani B, Mohseni S. Contemporary Management and Outcomes of Blunt Traumatic AAST-OIS Grade III and IV Pancreatic Injuries in Children: A TQIP analysis. J Trauma Acute Care Surg 2024:01586154-990000000-00630. [PMID: 38282245 DOI: 10.1097/ta.0000000000004270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
BACKGROUND The Trauma Quality Improvement Program (TQIP) database has delineated management strategies and outcomes for adults with AAST-OIS grade III-IV pancreatic injuries and suggests that non-operative management (NOM) is a viable option for these injuries. However, management strategies vary for children following significant pancreatic injuries and outcomes for these intermediate/high grade injuries have not been sufficiently studied. Our aim is to describe the management and outcomes for grade III-IV pancreatic injuries utilizing TQIP. We hypothesize that pediatric patients with intermediate/high grade injuries can be safely managed with NOM. METHODS All pediatric patients (<18 years old) registered in TQIP between 2013-2021 who suffered a grade III or IV pancreatic injury due to blunt trauma were included in the current study. Patient demographics, clinical characteristics, complications, and in-hospital mortality were compared between the different treatment strategies for pancreatic injury: NOM versus drainage and/or pancreatic resection. RESULTS 580 patients meeting criteria were identified. A total of 416 pediatric patients suffered a grade III pancreatic injury; 79% (N = 332) were NOM, 7% (N = 27) received a drain, and 14% (N = 57) underwent a pancreatic resection. A further 164 patients suffered a grade IV pancreatic injury; 77% (N = 126) were NOM, 11% (N = 18) received a drain, and 12% (N = 20) underwent a pancreatic resection. No differences in overall injury severity or demographical data were observed between the treatment groups. No difference in in-hospital mortality was detected between the different management strategies. Patients who received a drain had a longer hospital length of stay (LOS). CONCLUSION The majority of children with AAST-OIS grade III-IV pancreatic injuries are managed nonoperatively. NOM is a reasonable strategy for these injuries and results in equivalent in-hospital adverse outcome profiles as pancreatic drainage or resection with a shorter hospital LOS. LEVEL OF EVIDENCE Level III.
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Forssten SP, Ahl Hulme R, Forssten MP, Ribeiro MAF, Sarani B, Mohseni S. Predictors of outcomes in geriatric patients with moderate traumatic brain injury after ground level falls. Front Med (Lausanne) 2023; 10:1290201. [PMID: 38152301 PMCID: PMC10751787 DOI: 10.3389/fmed.2023.1290201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 11/02/2023] [Indexed: 12/29/2023] Open
Abstract
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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Affiliation(s)
- Sebastian Peter Forssten
- Division of Surgery, CLINTEC, Karolinska Institute, Stockholm, Sweden
- Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden
| | - Rebecka Ahl Hulme
- Division of Surgery, CLINTEC, Karolinska Institute, Stockholm, Sweden
- Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Maximilian Peter Forssten
- Department of Orthopedic Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Marcelo A. F. Ribeiro
- 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
| | - Babak Sarani
- Division of Trauma and Acute Care Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Shahin Mohseni
- School of Medical Sciences, Örebro University, Örebro, Sweden
- Department of Surgery, Sheikh Shakhbout Medical City, Mayo Clinic, Abu Dhabi, United Arab Emirates
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9
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Forssten MP, Sarani B, Mohammad Ismail A, Cao Y, Ribeiro MAF, Hildebrand F, Mohseni S. Adverse outcomes following pelvic fracture: the critical role of frailty. Eur J Trauma Emerg Surg 2023; 49:2623-2631. [PMID: 37644193 PMCID: PMC10728265 DOI: 10.1007/s00068-023-02355-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 08/21/2023] [Indexed: 08/31/2023]
Abstract
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.
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Affiliation(s)
- Maximilian Peter Forssten
- School of Medical Sciences, Orebro University, 701 82, Orebro, Sweden
- Department of Orthopedic Surgery, Orebro University Hospital, 701 85, Orebro, Sweden
| | - Babak Sarani
- Center of Trauma and Critical Care, George Washington University, Washington, DC, USA
| | - Ahmad Mohammad Ismail
- School of Medical Sciences, Orebro University, 701 82, Orebro, Sweden
- Department of Orthopedic Surgery, Orebro University Hospital, 701 85, Orebro, Sweden
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Faculty of Medicine and Health, Orebro University, 701 82, Orebro, Sweden
| | - Marcelo A F Ribeiro
- Khalifa University and Gulf Medical University, Abu Dhabi, United Arab Emirates
| | - Frank Hildebrand
- Department of Orthopedics, Trauma and Reconstructive Surgery, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Shahin Mohseni
- School of Medical Sciences, Orebro University, 701 82, Orebro, Sweden.
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Sheikh Shakhbout Medical City, Mayo Clinic, Abu Dhabi, United Arab Emirates.
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10
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Zwemer C, Kartiko S, Forssten MP, Zebley JA, Hughes JD, Sarani B, Mohseni S. Firearms-related injury and sex: a comparative National Trauma Database (NTDB) Study. Trauma Surg Acute Care Open 2023; 8:e001181. [PMID: 38156275 PMCID: PMC10753733 DOI: 10.1136/tsaco-2023-001181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 10/22/2023] [Indexed: 12/30/2023] Open
Abstract
Background Existing study findings on firearms-related injury patterns are largely skewed towards males, who comprise the majority of this injury population. Given the paucity of existing data for females with these injuries, we aimed to elucidate the demographics, injury patterns, and outcomes of firearms-related injury in females compared with males in the USA. Materials and methods A 7-year (2013-2019) retrospective review of the National Trauma Database was conducted to identify all adult patients who suffered firearms-related injuries. Patients who were males were matched (1:1, caliper 0.2) to patients who were females by demographics, comorbidities, injury patterns and severity, and payment method, to compare differences in mortality and several other post-injury outcomes. Results There were 196 696 patients admitted after firearms-related injury during the study period. Of these patients, 23 379 (11.9%) were females, 23 378 of whom were successfully matched to a male counterpart. After matching, females had a lower rate of in-hospital mortality (18.6% vs. 20.0%, p<0.001), deep vein thrombosis (1.2% vs. 1.5%, p=0.014), and had a lower incidence of drug or alcohol withdrawal syndrome (0.2% vs. 0.5%, p<0.001) compared with males. Conclusion Female victims of firearms-related injuries experience lower rates of mortality and complications compared with males. Further studies are needed to elucidate the cause of these differences. Level of evidence Level III.
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Affiliation(s)
- Catherine Zwemer
- Department of Surgery, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Susan Kartiko
- Department of Surgery, The George Washington University Hospital, Washington, District of Columbia, USA
| | - Maximilian Peter Forssten
- Örebro University School of Medical Sciences, Orebro, Sweden
- Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden
| | - James A Zebley
- Department of Surgery, The George Washington University Hospital, Washington, District of Columbia, USA
| | - Joy Dowden Hughes
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Sheikh Shakhbout Medical City, Abu Dhabi, UAE
| | - Babak Sarani
- Center for Trauma and Critical Care, The George Washington University Hospital, Washington, District of Columbia, USA
| | - Shahin Mohseni
- Örebro University School of Medical Sciences, Orebro, Sweden
- Division of Trauma and Emergency Surgery, Department of Surgery, Sheikh Shakhbout Medical City, Abu Dhabi, UAE
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11
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Zebley JA, Estroff JM, Forssten MP, Bass GA, Cao Y, Quintana MT, Sarani B, Mohseni S. Racial Disparities in Administration of Venous Thromboembolism Prophylaxis After Severe Traumatic Injuries. Am Surg 2023; 89:4696-4706. [PMID: 36151753 DOI: 10.1177/00031348221129519] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Race is associated with differences in quality of care process measures and incidence of venous thromboembolism (VTE) in trauma patients. We aimed to investigate if racial disparities exist in the administration of VTE prophylaxis in trauma patients. METHODS We queried the Trauma Quality Improvement Project database from 2017 to 2019. Patients ages ≥16 years old with ISS ≥15 were included. Patients with no signs of life on arrival, any AIS ≥6, hospital length of stay <1 day, anticoagulant use before admission, or without recorded race were excluded. Patients were grouped by race: white, black, Asian, American Indian, and Native Hawaiian or Pacific Islander. The association between VTE prophylaxis administration and race was determined using a Poisson regression model with robust standard errors to adjust for confounders. RESULTS A total of 285,341 patients were included. Black patients had the highest rates of VTE prophylaxis exposure (73.8%), shortest time to administration (1.6 days), and highest use of low molecular weight heparin (56%). Black patients also had the highest incidence of deep vein thrombosis (2.8%) and pulmonary embolism (1.4%). Black patients were 4% more likely to receive VTE prophylaxis than white patients [adj. IRR (95% CI): 1.04 (1.03-1.05), P < .001]. American Indians were 8% less likely to receive VTE prophylaxis [adj. IRR (95% CI): .92 (.88-.97), P < .001] than white patients. No differences between white and Asian or Native Hawaiian or Pacific Islander patients existed. DISCUSSION While black patients had the highest incidence of DVT and PE, they had higher administration rates and earlier initiation of VTE prophylaxis. Further work can elucidate modifiable causes of these differences.
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Affiliation(s)
- James A Zebley
- Center for Trauma and Critical Care, Department of Surgery, George Washington University, Washington, DC, USA
| | - Jordan M Estroff
- Center for Trauma and Critical Care, Department of Surgery, George Washington University, Washington, DC, USA
| | - Maximilian Peter Forssten
- School of Medical Sciences, Orebro University, Orebro, Sweden
- Division of Trauma & Emergency Surgery, Department of Surgery, Orebro University Hospital, Orebro, Sweden
| | - Gary Alan Bass
- School of Medical Sciences, Orebro University, Orebro, Sweden
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Megan T Quintana
- Center for Trauma and Critical Care, Department of Surgery, George Washington University, Washington, DC, USA
| | - Babak Sarani
- Center for Trauma and Critical Care, Department of Surgery, George Washington University, Washington, DC, USA
| | - Shahin Mohseni
- School of Medical Sciences, Orebro University, Orebro, Sweden
- Division of Trauma & Emergency Surgery, Department of Surgery, Orebro University Hospital, Orebro, Sweden
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12
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Forssten MP, Cao Y, Mohammad Ismail A, Ioannidis I, Tennakoon L, Spain DA, Mohseni S. Validation of the orthopedic frailty score for measuring frailty in hip fracture patients: a cohort study based on the United States National inpatient sample. Eur J Trauma Emerg Surg 2023; 49:2155-2163. [PMID: 37349513 PMCID: PMC10520138 DOI: 10.1007/s00068-023-02308-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 06/06/2023] [Indexed: 06/24/2023]
Abstract
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.
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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
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Faculty of Medicine and Health, Orebro University, 701 82 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
| | - Lakshika Tennakoon
- Department of Surgery, Section of Trauma and Acute Care Surgery, Stanford University School of Medicine, Stanford, CA USA
| | - David A. Spain
- Department of Surgery, Section of Trauma and Acute Care Surgery, Stanford University School of Medicine, Stanford, CA USA
| | - Shahin Mohseni
- School of Medical Sciences, Orebro University, 702 81 Orebro, Sweden
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, Sheik Shakhbout Medical City – Mayo Clinic, Abu Dhabi, United Arab Emirates
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13
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Zebley JA, Wanersdorfer K, Chang P, Schwartz R, Forssten MP, Cao Y, Mohseni S, Sarani B, Kartiko S. Early Tracheostomy in Older Trauma Patient Is Associated With Comparable Outcomes to Younger Cohort. J Surg Res 2023; 290:178-187. [PMID: 37269801 DOI: 10.1016/j.jss.2023.03.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 03/22/2023] [Accepted: 03/26/2023] [Indexed: 06/05/2023]
Abstract
INTRODUCTION Early tracheostomy (ET) is associated with a lower incidence of pneumonia (PNA) and mechanical ventilation duration (MVD) in hospitalized patients with trauma. The purpose of this study is to determine if ET also benefits older adults compared to the younger cohort. METHODS Adult hospitalized trauma patients who received a tracheostomy as registered in The American College of Surgeons Trauma Quality Improvement Program from 2013 to 2019 were analyzed. Patients with tracheostomy prior to admission were excluded. Patients were stratified into 2 cohorts consisting of those aged ≥65 and those aged <65. These cohorts were analyzed separately to compare the outcomes of ET (<5 d; ET) versus late tracheostomy (LT) (≥5 d; LT). The primary outcome was MVD. Secondary outcomes were in-hospital mortality, hospital length of stay (HLOS), and PNA. Univariate and multivariate analyses were performed with significance defined as P value < 0.05. RESULTS In patients aged <65, ET was performed within a median of 2.3 d (interquartile range, 0.47-3.8) after intubation and a median of 9.9 d (interquartile range, 7.5-13) in the LT group. The ET group's Injury Severity Score was significantly lower with fewer comorbidities. There were no differences in injury severity or comorbidities when comparing the groups. ET was associated with lower MVD (d), PNA, and HLOS on univariate and multivariate analyses in both age cohorts, although the degree of benefit was higher in the less than 65 y cohort [ET versus LT MVD: 5.08 (4.78-5.37), P < 0.001; PNA: 1.45 (1.36-1.54), P < 0.001; HLOS: 5.48 (4.93-6.04), P < 0.001]. Mortality did not differ based on time to tracheostomy. CONCLUSIONS ET is associated with lower MVD, PNA, and HLOS in hospitalized patients with trauma regardless of age. Age should not factor into timing for tracheostomy placement.
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Affiliation(s)
- James A Zebley
- Department of Surgery, Center for Trauma and Critical Care, George Washington University, Washington, District of Columbia
| | - Karen Wanersdorfer
- Department of Surgery, Center for Trauma and Critical Care, George Washington University, Washington, District of Columbia
| | - Parker Chang
- Department of Surgery, Center for Trauma and Critical Care, George Washington University, Washington, District of Columbia
| | - Rachel Schwartz
- Department of Surgery, Center for Trauma and Critical Care, George Washington University, Washington, District of Columbia
| | - Maximilian Peter Forssten
- School of Medical Sciences, Orebro University, Orebro, Sweden; Division of Trauma & Emergency Surgery, Department of Surgery, Orebro University Hospital, Orebro, Sweden
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Shahin Mohseni
- School of Medical Sciences, Orebro University, Orebro, Sweden; Division of Trauma & Emergency Surgery, Department of Surgery, Orebro University Hospital, Orebro, Sweden
| | - Babak Sarani
- Department of Surgery, Center for Trauma and Critical Care, George Washington University, Washington, District of Columbia
| | - Susan Kartiko
- Department of Surgery, Center for Trauma and Critical Care, George Washington University, Washington, District of Columbia.
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14
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Cao Y, Forssten MP, Sarani B, Montgomery S, Mohseni S. 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 Database. J Pers Med 2023; 13:1401. [PMID: 37763168 PMCID: PMC10533165 DOI: 10.3390/jpm13091401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 09/04/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023] Open
Abstract
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.
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Affiliation(s)
- Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, 701 82 Orebro, Sweden;
- Unit of Integrative Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Maximilian Peter Forssten
- Department of Orthopedic Surgery, Örebro University Hospital, 701 85 Orebro, Sweden;
- School of Medical Sciences, Örebro University, 701 82 Orebro, Sweden;
| | - Babak Sarani
- Center of Trauma and Critical Care, George Washington University, Washington, DC 20037, USA;
| | - Scott Montgomery
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, 701 82 Orebro, 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
| | - Shahin Mohseni
- School of Medical Sciences, Örebro University, 701 82 Orebro, Sweden;
- 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
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Zwemer CH, Mohseni S, Forssten MP, Malyavko A, Zebley JA, Qaddumi WN, Cornejo M, Sarani B, Kartiko S. The relationship of ADHD and trauma mortality: An NTDB analysis. Trauma 2023. [DOI: 10.1177/14604086231163660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
Abstract
Objective Nearly 7% of the adult US population has symptomatic Attention Deficit Hyperactivity Disorder (ADHD), which is associated with an increased risk for traumatic injury. There is limited data on the outcome of hospitalized trauma patients with ADHD. This study aimed to use a large nationwide database to investigate the relationship between a diagnosis of ADHD and clinical outcomes in hospitalized patients after major trauma. Methods All patients 18 years or older in the National Trauma Database were retrospectively reviewed. Propensity score analysis was used to match patients with and without the diagnosis of ADHD at a 1:1 ratio based on age, sex, race, highest AIS in each region, comorbidities, and the presence of advanced directives limiting care. Outcomes of patients with ADHD admitted to the trauma service between the years 2015 and 2017 were compared to those without ADHD. The primary outcome of interest was in-hospital mortality, while the secondary outcomes included complications and hospital length of stay. Results There were 9399 patients included in the study with a diagnosis of ADHD. These patients were overall more likely to be younger, male, and Caucasian, compared to their matched counterparts without ADHD. ADHD was associated with a significantly lower in-hospital mortality than patients without ADHD. There was no difference in the ICU admission rate, ICU LOS, ventilator use, or complication rates between patients with and without ADHD. Conclusion A diagnosis of ADHD has a complex association with clinical outcomes after trauma. The current large national analysis found that patients with a diagnosis of ADHD had significantly lower overall in-hospital mortality.
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Affiliation(s)
- Catherine H Zwemer
- Center for Trauma and Critical Care, Department of Surgery, The George Washington University, Washington, DC, USA
| | - Shahin Mohseni
- School of Medical Sciences, Orebro University, Orebro, Sweden
- Division of Trauma & Emergency Surgery, Department of Surgery, Orebro University Hospital, Orebro, Sweden
| | - Maximilian Peter Forssten
- School of Medical Sciences, Orebro University, Orebro, Sweden
- Division of Trauma & Emergency Surgery, Department of Surgery, Orebro University Hospital, Orebro, Sweden
| | - Alisa Malyavko
- Center for Trauma and Critical Care, Department of Surgery, The George Washington University, Washington, DC, USA
| | - James A Zebley
- Center for Trauma and Critical Care, Department of Surgery, The George Washington University, Washington, DC, USA
| | - Waleed N Qaddumi
- Center for Trauma and Critical Care, Department of Surgery, The George Washington University, Washington, DC, USA
| | - Miglia Cornejo
- Department of Psychiatry, Division of Child/Adolescent and Family Psychiatry, The George Washington University, Washington DC, USA
| | - Babak Sarani
- Center for Trauma and Critical Care, Department of Surgery, The George Washington University, Washington, DC, USA
| | - Susan Kartiko
- Center for Trauma and Critical Care, Department of Surgery, The George Washington University, Washington, DC, USA
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Bass GA, Mohseni S, Ryan ÉJ, Forssten MP, Tolonen M, Cao Y, Kaplan LJ. Clinical practice selectively follows acute appendicitis guidelines. Eur J Trauma Emerg Surg 2023; 49:45-56. [PMID: 36719428 PMCID: PMC9888346 DOI: 10.1007/s00068-022-02208-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 12/20/2022] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Gary Alan Bass
- Division of Traumatology, Surgical Critical Care & Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA.
- Division of Trauma & Emergency Surgery, Orebro University Hospital and School of Medical Sciences, Orebro University, 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.
| | - Shahin Mohseni
- Division of Trauma & Emergency Surgery, Orebro University Hospital and School of Medical Sciences, Orebro University, Örebro, Sweden.
| | | | - Maximilian Peter Forssten
- Division of Trauma & Emergency Surgery, Orebro University Hospital and School of Medical Sciences, Orebro University, Örebro, Sweden
| | - Matti Tolonen
- Helsinki University Hospital HUS Meilahden Tornisairaala, Helsinki, Finland
| | - Yang Cao
- Department of Clinical Epidemiology and Biostatistics, School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Lewis J Kaplan
- 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
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Forssten MP, Kaplan LJ, Tolonen M, Martinez-Casas I, Cao Y, Walsh TN, Bass GA, Mohseni S. Surgical management of acute appendicitis during the European COVID-19 second wave: safe and effective. Eur J Trauma Emerg Surg 2023; 49:57-67. [PMID: 36658305 PMCID: PMC9851576 DOI: 10.1007/s00068-022-02149-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 10/14/2022] [Indexed: 01/21/2023]
Abstract
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.
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Affiliation(s)
- Maximilian Peter Forssten
- Division of Trauma and Emergency Surgery, Orebro University Hospital and School of Medical Sciences, Orebro University, Örebro, Sweden
| | - Lewis J Kaplan
- 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
| | - Matti Tolonen
- Helsinki University Hospital HUS Meilahden Tornisairaala, Helsinki, Finland
| | - Isidro Martinez-Casas
- Servicio de Cirugía General, Unidad de Cirugía de Urgencias, Hospital Universitario Virgen del Rocío, Seville, Spain
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Orebro University, Örebro, Sweden
| | - Thomas N Walsh
- Royal College of Surgeons in Ireland Medical University, Busaiteen, Bahrain
| | - Gary Alan Bass
- Division of Trauma and Emergency Surgery, Orebro University Hospital and School of Medical Sciences, Orebro University, 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
| | - Shahin Mohseni
- Division of Trauma and Emergency Surgery, Orebro University Hospital and School of Medical Sciences, Orebro University, Örebro, Sweden.
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18
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Bass GA, Duffy CC, Kaplan LJ, Sarani B, Martin ND, Ismail AM, Cao Y, Forssten MP, Mohseni S. The revised cardiac risk index is associated with morbidity and mortality independent of injury severity in elderly patients with rib fractures. Injury 2023; 54:56-62. [PMID: 36402584 DOI: 10.1016/j.injury.2022.11.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 10/23/2022] [Accepted: 11/10/2022] [Indexed: 11/14/2022]
Abstract
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.
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Affiliation(s)
- Gary Alan Bass
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA; School of Medical Sciences, Orebro University, Orebro, Sweden; 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
| | - Caoimhe C Duffy
- 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
| | - Lewis J Kaplan
- 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
| | - Babak Sarani
- Center for Trauma and Critical Care, George Washington University School of Medicine & Health Sciences, Washington D.C., USA
| | - Niels D Martin
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | | | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Orebro University, Orebro, Sweden
| | | | - Shahin Mohseni
- School of Medical Sciences, Orebro University, Orebro, Sweden; Division of Trauma & Emergency Surgery, Department of Surgery, Orebro University Hospital, Orebro, Sweden.
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19
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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: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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20
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Mohseni S, Bass GA, Forssten MP, Casas IM, Martin M, Davis KA, Haut ER, Sugrue M, Kurihara H, Sarani B, Cao Y, Coimbra R. Common bile duct stones management: A network meta-analysis. J Trauma Acute Care Surg 2022; 93:e155-e165. [PMID: 35939370 DOI: 10.1097/ta.0000000000003755] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Timely management is critical for treating symptomatic common bile duct (CBD) stones; however, a single optimal management strategy has yet to be defined in the acute care setting. Consequently, this systematic review and network meta-analysis, comparing one-stage (CBD exploration or intraoperative endoscopic retrograde cholangiopancreatography [ERCP] with simultaneous cholecystectomy) and two-stage (precholecystectomy or postcholecystectomy ERCP) procedures, was undertaken with the main outcomes of interest being postprocedural complications and hospital length of stay (LOS). METHODS PubMed, SCOPUS, MEDLINE, Embase, and Cochrane Central Register of Controlled Trials were methodically queried for articles from 2010 to 2021. The search terms were a combination of medical subject headings terms and the subsequent terms: gallstone; common bile duct (stone); choledocholithiasis; cholecystitis; endoscopic retrograde cholangiography/ERCP; common bile duct exploration; intraoperative, preoperative, perioperative, and postoperative endoscopic retrograde cholangiography; stone extraction; and one-stage and two-stage procedure. Studies that compared two procedures or more were included, whereas studies not recording complications (bile leak, hemorrhage, pancreatitis, perforation, intra-abdominal infections, and other infections) or LOS were excluded. A network meta-analysis was conducted to compare the four different approaches for managing CBD stones. RESULTS A total of 16 studies (8,644 participants) addressing the LOS and 41 studies (19,756 participants) addressing postprocedural complications were included in the analysis. The one-stage approaches were associated with a decrease in LOS compared with the two-stage approaches. Common bile duct exploration demonstrated a lower overall risk of complications compared with preoperative ERCP, but there were no differences in the overall risk of complications in the remaining comparisons. However, differences in specific postprocedural complications were detected between the four different approaches managing CBD stones. CONCLUSION This network meta-analysis suggests that both laparoscopic CBD exploration and intraoperative ERCP have equally good outcomes and provide a preferable single-anesthesia patient pathway with a shorter overall length of hospital stay compared with the two-stage approaches. LEVEL OF EVIDENCE Systematic Review/Meta Analysis; Level III.
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Affiliation(s)
- Shahin Mohseni
- From the Division of Trauma and Emergency Surgery, Department of Surgery (S.M., M.P.F.), Orebro University Hospital; School of Medical Sciences, Orebro University (S.M., G.A.B., M.P.F.), Orebro, Sweden; Division of Traumatology, Surgical Critical Care and Emergency Surgery (G.A.B.), Penn Presbyterian Medical Center, University of Pennsylvania, Philadelphia, Pennsylvania; Servicio de Cirugía General y Digestiva, Unidad de Cirugía de Urgencias y Trauma (I.M.C.), Hospital Universitario Virgen del Rocio, Sevilla, Andalucia, Spain; Division of Acute Care Surgery (M.M.), Los Angeles County + USC Medical Center, Uniformed Services University Health Sciences, Los Angeles, California; Division of General Surgery, Trauma, and Surgical Critical Care, Department of Surgery (K.A.D.), Yale School of Medicine, New Haven, Connecticut; Division of Acute Care Surgery, Department of Surgery (E.R.H.), Department of Anesthesiology and Critical Care Medicine (E.R.H.), and Department of Emergency Medicine (E.R.H.), The Johns Hopkins University School of Medicine; Department of Health Policy and Management (E.R.H.), The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Letterkenny Hospital (M.S.), Galway University, Galway, Ireland; UOSD Chirurgia d'Urgenza (H.K.), Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Center of Trauma and Critical Care (B.S.), George Washington University, Washington, DC; Clinical Epidemiology and Biostatistics (Y.C.), School of Medical Sciences, Orebro University, Orebro, Sweden; Department of Surgery, Riverside University Health System Medical Center (R.C.); Department of Surgery, Loma Linda University School of Medicine (R.C.), Loma Linda; and Department of Surgery, Comparative Effectiveness and Clinical Outcomes Research Center (R.C.), California
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21
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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22
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Forssten MP, Cao Y, Trivedi DJ, Ekestubbe L, Borg T, Bass GA, Mohammad Ismail A, Mohseni S. Developing and validating a scoring system for measuring frailty in patients with hip fracture: a novel model for predicting short-term postoperative mortality. Trauma Surg Acute Care Open 2022; 7:e000962. [PMID: 36117728 PMCID: PMC9472206 DOI: 10.1136/tsaco-2022-000962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 08/19/2022] [Indexed: 11/06/2022] Open
Abstract
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.
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Affiliation(s)
- Maximilian Peter Forssten
- School of Medical Sciences, Orebro University, Orebro, Sweden.,Department of Orthopedic Surgery, Orebro University Hospital, Orebro, Sweden
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Orebro University, Orebro, Sweden
| | - 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
| | | | - Tomas Borg
- School of Medical Sciences, Orebro University, Orebro, Sweden.,Department of Orthopedic Surgery, Orebro University Hospital, Orebro, Sweden
| | - Gary Alan Bass
- School of Medical Sciences, Orebro University, Orebro, Sweden.,Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Ahmad Mohammad Ismail
- School of Medical Sciences, Orebro University, Orebro, Sweden.,Department of Orthopedic Surgery, Orebro University Hospital, Orebro, Sweden
| | - 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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23
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Bass GA, Stephen C, Forssten MP, Bailey JA, Mohseni S, Cao Y, Chreiman K, Duffy C, Seamon MJ, Cannon JW, Martin ND. Admission Triage With Pain, Inspiratory Effort, Cough Score can Predict Critical Care Utilization and Length of Stay in Isolated Chest Wall Injury. J Surg Res 2022; 277:310-318. [DOI: 10.1016/j.jss.2022.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/04/2022] [Accepted: 04/01/2022] [Indexed: 02/02/2023]
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Trivedi DJ, Bass GA, Forssten MP, Scheufler KM, Olivecrona M, Cao Y, Ahl Hulme R, Mohseni S. The significance of direct transportation to a trauma center on survival for severe traumatic brain injury. Eur J Trauma Emerg Surg 2022; 48:2803-2811. [PMID: 35226114 PMCID: PMC9360055 DOI: 10.1007/s00068-022-01885-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 01/17/2022] [Indexed: 11/05/2022]
Abstract
INTRODUCTION While timely specialized care can contribute to improved outcomes following traumatic brain injury (TBI), this condition remains the most common cause of post-injury death worldwide. The purpose of this study was to investigate the difference in mortality between regional trauma centers in Sweden (which provide neurosurgical services round the clock) and non-trauma centers, hypothesizing that 1-day and 30-day mortality will be lower at regional trauma centers. PATIENTS AND METHODS This retrospective cohort study used data extracted from the Swedish national trauma registry and included adults admitted with severe TBI between January 2014 and December 2018. The cohort was divided into two subgroups based on whether they were treated at a trauma center or non-trauma center. Severe TBI was defined as a head injury with an AIS score of 3 or higher. Poisson regression analyses with both univariate and multivariate models were performed to determine the difference in mortality risk [Incidence Rate Ratio (IRR)] between the subgroups. As a sensitivity analysis, the inverse probability of treatment weighting (IPTW) method was used to adjust for the effects of confounding. RESULTS A total of 3039 patients were included. Patients admitted to a trauma center had a lower crude 30-day mortality rate (21.7 vs. 26.4% days, p = 0.006). After adjusting for confounding variables, patients treated at regional trauma center had a 28% [adj. IRR (95% CI): 0.72 (0.55-0.94), p = 0.015] decreased risk of 1-day mortality and an 18% [adj. IRR (95% CI): 0.82 (0.69-0.98)] reduction in 30-day mortality, compared to patients treated at a non-trauma center. After adjusting for covariates in the Poisson regression analysis performed after IPTW, admission and treatment at a trauma center were associated with a 27% and 17% reduction in 1-day and 30-day mortality, respectively. CONCLUSION For patients suffering a severe TBI, treatment at a regional trauma center confers a statistically significant 1-day and 30-day survival advantage over treatment at a non-trauma center.
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Affiliation(s)
- Dhanisha Jayesh Trivedi
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, 701 85, 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, Penn Presbyterian Medical Center, Philadelphia, PA, 19104, USA
| | - Maximilian Peter Forssten
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, 701 85, Örebro, Sweden
- School of Medical Sciences, Orebro University, 702 81, Örebro, Sweden
| | - Kai-Michael Scheufler
- Division of Neurosurgery, Department of Neurosurgery, Orebro University Hospital, Örebro, Sweden
- Medical School, Heinrich-Heine-University, Düsseldorf, Germany
| | - Magnus Olivecrona
- School of Medical Sciences, Orebro University, 702 81, Örebro, Sweden
- Division of Neurosurgery, Department of Neurosurgery, Orebro University Hospital, Örebro, Sweden
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Orebro University, 701 82, Örebro, Sweden
| | - Rebecka Ahl Hulme
- School of Medical Sciences, Orebro University, 702 81, Örebro, Sweden
- Department of Surgery, Karolinska University Hospital, 171 76, Stockholm, Sweden
| | - Shahin Mohseni
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, 701 85, Örebro, Sweden.
- School of Medical Sciences, Orebro University, 702 81, Örebro, Sweden.
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25
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Mohammad Ismail A, Ahl R, Forssten MP, Cao Y, Wretenberg P, Borg T, Mohseni S. The interaction between pre-admission β-blocker therapy, the Revised Cardiac Risk Index, and mortality in geriatric hip fracture patients. J Trauma Acute Care Surg 2022; 92:49-56. [PMID: 34252058 PMCID: PMC8677608 DOI: 10.1097/ta.0000000000003358] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/23/2021] [Accepted: 07/04/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND An association between β-blocker (BB) therapy and a reduced risk of major cardiac events and mortality in patients undergoing surgery for hip fractures has previously been demonstrated. Furthermore, a relationship between an increased Revised Cardiac Risk Index (RCRI) score and a higher risk of postoperative mortality has also been detected. The purpose of the current study was to investigate the interaction between BB therapy and RCRI in relation to 30-day postoperative mortality in geriatric patients after hip fracture surgery. METHODS All patients older than 65 years who underwent primary emergency hip fracture surgery in Sweden between January 1, 2008, and December 31, 2017, except for pathological fractures, were included in this retrospective cohort study. Patients were divided into cohorts based on their RCRI score (RCRI 1, 2, 3, and ≥4) and whether they had ongoing BB therapy at the time of admission. A Poisson regression model with robust standard errors of variance was used, while adjusting for confounders, to evaluate the association between BB therapy, RCRI, and 30-day mortality. RESULTS A total of 126,934 cases met the study inclusion criteria. β-Blocker therapy was associated with a 65% decrease in the risk of 30-day postoperative mortality in the whole study population (adjusted incidence rate ratio [95% confidence interval], 0.35 [0.32-0.38]; p < 0.001). The use of BB also resulted in a significant reduction in 30-day postoperative mortality within all RCRI cohorts. However, the most pronounced effect of BB therapy was seen in patients with an RCRI score greater than 0. CONCLUSION β-Blocker therapy is associated with a reduction in 30-day postoperative mortality, irrespective of RCRI score. Furthermore, patients with an elevated cardiac risk appear to have a greater benefit of BB therapy. LEVEL OF EVIDENCE Therapeutic/care management, level II.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Hulme RA, Forssten MP, Pourlotfi A, Cao Y, Bass GA, Matthiessen P, Mohseni S. The Association Between Revised Cardiac Risk Index and Postoperative Mortality Following Elective Colon Cancer Surgery: A Retrospective Nationwide Cohort Study. Scand J Surg 2021; 111:14574969211037588. [PMID: 34605315 DOI: 10.1177/14574969211037588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Rebecka Ahl Hulme
- School of Medical Sciences, Örebro University, Örebro, 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
| | - Maximilian Peter Forssten
- Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Arvid Pourlotfi
- Department of Surgery, Örebro University Hospital, Örebro, Sweden School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Gary Alan Bass
- School of Medical Sciences, Örebro University, Örebro, Sweden Division of Traumatology, Surgical Critical Care and Emergency Surgery, Penn Medicine, Penn Presbyterian Medical Center, Philadelphia, PA, USA
| | - Peter Matthiessen
- School of Medical Sciences, Örebro University, Örebro, Sweden Division of Colorectal Surgery, Department of Surgery, Örebro University Hospital, Örebro, Sweden
| | - Shahin Mohseni
- Division of Trauma and Emergency Surgery, Department of Surgery, Örebro University Hospital, 701 85 Örebro, Sweden
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Pourlotfi A, Bass GA, Ahl Hulme R, Forssten MP, Sjolin G, Cao Y, Matthiessen P, Mohseni S. Statin Use and Long-Term Mortality after Rectal Cancer Surgery. Cancers (Basel) 2021; 13:4288. [PMID: 34503098 PMCID: PMC8428352 DOI: 10.3390/cancers13174288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 08/03/2021] [Accepted: 08/20/2021] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND The current study aimed to assess the association between regular statin therapy and postoperative long-term all-cause and cancer-specific mortality following curative surgery for rectal cancer. The hypothesis was that statin exposure would be associated with better survival. METHODS Patients with stage I-III rectal cancer undergoing surgical resection with curative intent were extracted from the nationwide, prospectively collected, Swedish Colorectal Cancer Register (SCRCR) for the period from January 2007 and October 2016. Patients were defined as having ongoing statin therapy if they had filled a statin prescription within 12 months before and after surgery. Cox proportional hazards models were employed to investigate the association between statin use and postoperative five-year all-cause and cancer-specific mortality. RESULTS The cohort consisted of 10,743 patients who underwent a surgical resection with curative intent for rectal cancer. Twenty-six percent (n = 2797) were classified as having ongoing statin therapy. Statin users had a considerably decreased risk of all-cause (adjusted hazard ratio (HR) 0.66, 95% confidence interval (CI): 0.60-0.73, p < 0.001) and cancer-specific (adjusted HR 0.60, 95% CI: 0.47-0.75, p < 0.001) mortality up to five years following surgery. CONCLUSIONS Statin use was associated with a lower risk of both all-cause and rectal cancer-specific mortality following curative surgical resections for rectal cancer. The findings should be confirmed in future prospective clinical trials.
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Affiliation(s)
- Arvid Pourlotfi
- Department of Surgery, Orebro University Hospital, 701 85 Orebro, Sweden; (M.P.F.); (G.S.); (P.M.)
- School of Medical Sciences, Orebro University, 702 81 Orebro, Sweden; (G.A.B.); (R.A.H.)
| | - Gary Alan Bass
- School of Medical Sciences, Orebro University, 702 81 Orebro, Sweden; (G.A.B.); (R.A.H.)
- Division of Traumatology, Emergency Surgery & Surgical Critical Care, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Rebecka Ahl Hulme
- School of Medical Sciences, Orebro University, 702 81 Orebro, Sweden; (G.A.B.); (R.A.H.)
- Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, 171 76 Stockholm, Sweden
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, 141 52 Stockholm, Sweden
| | - Maximilian Peter Forssten
- Department of Surgery, Orebro University Hospital, 701 85 Orebro, Sweden; (M.P.F.); (G.S.); (P.M.)
- School of Medical Sciences, Orebro University, 702 81 Orebro, Sweden; (G.A.B.); (R.A.H.)
| | - Gabriel Sjolin
- Department of Surgery, Orebro University Hospital, 701 85 Orebro, Sweden; (M.P.F.); (G.S.); (P.M.)
- School of Medical Sciences, Orebro University, 702 81 Orebro, Sweden; (G.A.B.); (R.A.H.)
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Orebro University, 701 82 Orebro, Sweden;
| | - Peter Matthiessen
- Department of Surgery, Orebro University Hospital, 701 85 Orebro, Sweden; (M.P.F.); (G.S.); (P.M.)
- School of Medical Sciences, Orebro University, 702 81 Orebro, Sweden; (G.A.B.); (R.A.H.)
| | - Shahin Mohseni
- Department of Surgery, Orebro University Hospital, 701 85 Orebro, Sweden; (M.P.F.); (G.S.); (P.M.)
- School of Medical Sciences, Orebro University, 702 81 Orebro, Sweden; (G.A.B.); (R.A.H.)
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, 701 85 Orebro, Sweden
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Forssten MP, Mohammad Ismail A, Borg T, Ahl R, Wretenberg P, Cao Y, Peden CJ, Mohseni S. Postoperative mortality in hip fracture patients stratified by the Revised Cardiac Risk Index: a Swedish nationwide retrospective cohort study. Trauma Surg Acute Care Open 2021; 6:e000778. [PMID: 34395919 PMCID: PMC8314694 DOI: 10.1136/tsaco-2021-000778] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 07/06/2021] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
- 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
| | - Tomas Borg
- Department of Orthopedic Surgery, Orebro University Hospital, Orebro, Sweden.,School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Rebecka Ahl
- School of Medical Sciences, Orebro University, Orebro, Sweden.,Department of Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Per Wretenberg
- 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, Orebro University, Orebro, Sweden
| | - 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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Mohammad Ismail A, Ahl R, Forssten MP, Cao Y, Wretenberg P, Borg T, Mohseni S. Beta-Blocker Therapy Is Associated With Increased 1-Year Survival After Hip Fracture Surgery: A Retrospective Cohort Study. Anesth Analg 2021; 133:1225-1234. [PMID: 34260428 PMCID: PMC8505142 DOI: 10.1213/ane.0000000000005659] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The high mortality rates seen within the first postoperative year after hip fracture surgery have remained relatively unchanged in many countries for the past 15 years. Recent investigations have shown an association between beta-blocker (BB) therapy and a reduction in risk-adjusted mortality within the first 90 days after hip fracture surgery. We hypothesized that preoperative, and continuous postoperative, BB therapy may also be associated with a decrease in mortality within the first year after hip fracture surgery.
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Affiliation(s)
- Ahmad Mohammad Ismail
- From the Department of Orthopedic Surgery, Orebro University Hospital, Orebro, Sweden.,School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Rebecka Ahl
- School of Medical Sciences, Orebro University, Orebro, Sweden.,Department of Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Maximilian Peter Forssten
- From the 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, Orebro University, Orebro, Sweden
| | - Per Wretenberg
- From the Department of Orthopedic Surgery, Orebro University Hospital, Orebro, Sweden.,School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Tomas Borg
- From the Department of Orthopedic Surgery, Orebro University Hospital, Orebro, Sweden.,School of Medical Sciences, Orebro University, Orebro, Sweden
| | - 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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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Falk W, Gupta A, Forssten MP, Hjelmqvist H, Bass GA, Matthiessen P, Mohseni S. Epidural analgesia and mortality after colorectal cancer surgery: A retrospective cohort study. Ann Med Surg (Lond) 2021; 66:102414. [PMID: 34113442 PMCID: PMC8170121 DOI: 10.1016/j.amsu.2021.102414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 05/16/2021] [Accepted: 05/16/2021] [Indexed: 12/01/2022] Open
Abstract
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. No reduction in postoperative complications with epidural analgesia. No reduction in short-term mortality with epidural analgesia after colorectal surgery. No reduction in long-term mortality with epidural analgesia in colorectal cancer.
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Affiliation(s)
- Wiebke Falk
- Department of Anesthesiology and Intensive Care, Orebro University Hospital, 701 85, Orebro, Sweden.,School of Medical Sciences, Orebro University, 702 81, Orebro, Sweden
| | - Anil Gupta
- Department of Physiology and Pharmacology, Karolinska Institutet and Karolinska University Hospital, 171 77, Stockholm, Sweden
| | - Maximilian Peter Forssten
- School of Medical Sciences, Orebro University, 702 81, Orebro, Sweden.,Department of Orthopedic Surgery, Orebro University Hospital, 701 85, Orebro, Sweden
| | - Hans Hjelmqvist
- School of Medical Sciences, Orebro University, 702 81, Orebro, Sweden.,Department of Anesthesiology and Intensive Care, Orebro University Hospital, 701 85, Orebro, Sweden
| | - Gary Alan Bass
- School of Medical Sciences, Orebro University, 702 81, Orebro, Sweden.,Division of Traumatology, Surgical Critical Care & Emergency Surgery, Penn Medicine, Penn Presbyterian Medical Center, Philadelphia, USA
| | - Peter Matthiessen
- School of Medical Sciences, Orebro University, 702 81, Orebro, Sweden.,Department of Surgery, Orebro University Hospital, 701 85, 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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Cao Y, Forssten MP, Mohammad Ismail A, Borg T, Ioannidis I, Montgomery S, Mohseni S. Predictive Values of Preoperative Characteristics for 30-Day Mortality in Traumatic Hip Fracture Patients. J Pers Med 2021; 11:353. [PMID: 33924993 PMCID: PMC8146802 DOI: 10.3390/jpm11050353] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 03/21/2021] [Accepted: 04/23/2021] [Indexed: 12/23/2022] Open
Abstract
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.
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Affiliation(s)
- Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, 70182 Örebro, Sweden;
- Unit of Integrative Epidemiology, Institute of Environmental Medicine, Karolinska Institute, 17177 Stockholm, Sweden
| | - Maximilian Peter Forssten
- Department of Orthopedic Surgery, Orebro University Hospital, 70185 Orebro, Sweden; (M.P.F.); (A.M.I.); (T.B.); (I.I.)
- School of Medical Sciences, Orebro University, 70182 Orebro, Sweden;
| | - Ahmad Mohammad Ismail
- Department of Orthopedic Surgery, Orebro University Hospital, 70185 Orebro, Sweden; (M.P.F.); (A.M.I.); (T.B.); (I.I.)
- School of Medical Sciences, Orebro University, 70182 Orebro, Sweden;
| | - Tomas Borg
- Department of Orthopedic Surgery, Orebro University Hospital, 70185 Orebro, Sweden; (M.P.F.); (A.M.I.); (T.B.); (I.I.)
- School of Medical Sciences, Orebro University, 70182 Orebro, Sweden;
| | - Ioannis Ioannidis
- Department of Orthopedic Surgery, Orebro University Hospital, 70185 Orebro, Sweden; (M.P.F.); (A.M.I.); (T.B.); (I.I.)
- School of Medical Sciences, Orebro University, 70182 Orebro, Sweden;
| | - Scott Montgomery
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, 70182 Örebro, Sweden;
- Clinical Epidemiology Division, Department of Medicine, Karolinska Institutet, 17177 Stockholm, Sweden
- Department of Epidemiology and Public Health, University College London, London WC1E 6BT, UK
| | - Shahin Mohseni
- School of Medical Sciences, Orebro University, 70182 Orebro, Sweden;
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, 70185 Orebro, Sweden
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Pourlotfi A, Ahl R, Sjolin G, Forssten MP, Bass GA, Cao Y, Matthiessen P, Mohseni S. Statin therapy and postoperative short-term mortality after rectal cancer surgery. Colorectal Dis 2021; 23:875-881. [PMID: 33305498 PMCID: PMC8246857 DOI: 10.1111/codi.15481] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 11/26/2020] [Accepted: 12/01/2020] [Indexed: 12/13/2022]
Abstract
AIM This study aimed to assess the correlation between regular statin therapy and postoperative mortality following surgical resection for rectal cancer. METHOD This retrospective cohort study included all adult patients undergoing abdominal rectal cancer surgery in Sweden between January 2007 and September 2016. Data were gathered from the Swedish Colorectal Cancer Registry, a large population-based prospectively collected registry. Statin users were defined as patients with one or more collected prescriptions of a statin within 12 months before the date of surgery. The statin-positive and statin-negative cohorts were matched by propensity scores based on baseline demographics. RESULTS A total of 11 966 patients underwent surgical resection for rectal cancer, of whom 3019 (25%) were identified as statin users. After applying propensity score matching (1:1), 3017 pairs were available for comparison. In the matched groups, statin users demonstrated reduced 90-day all-cause mortality (0.7% vs. 5.5%, p < 0.001) and also showed significantly reduced cause-specific mortality due to cardiovascular and respiratory events, as well as sepsis and multiorgan failure. The significant postoperative survival benefit of statin users was seen despite a higher rate of cardiovascular comorbidity. CONCLUSION Preoperative statin therapy displays a strong association with reduced postoperative mortality following surgical resection for rectal cancer. The results from the current study warrant further investigation to determine whether a causal relationship exists.
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Affiliation(s)
- Arvid Pourlotfi
- Division of Trauma & Emergency Surgery, Department of SurgeryOrebro University HospitalOrebroSweden,School of Medical SciencesOrebro UniversityOrebroSweden
| | - Rebecka Ahl
- School of Medical SciencesOrebro UniversityOrebroSweden,Division of SurgeryDepartment of Clinical Science, Intervention and TechnologyKarolinska InstitutetStockholmSweden
| | - Gabriel Sjolin
- Division of Trauma & Emergency Surgery, Department of SurgeryOrebro University HospitalOrebroSweden,School of Medical SciencesOrebro UniversityOrebroSweden
| | - Maximilian Peter Forssten
- Division of Trauma & Emergency Surgery, Department of SurgeryOrebro University HospitalOrebroSweden,School of Medical SciencesOrebro UniversityOrebroSweden
| | - Gary A. Bass
- School of Medical SciencesOrebro UniversityOrebroSweden,Surgical Critical Care and Emergency SurgeryPenn MedicinePenn Presbyterian Medical CenterPAUSA
| | - Yang Cao
- Clinical Epidemiology and BiostatisticsSchool of Medical SciencesOrebro UniversityOrebroSweden
| | - Peter Matthiessen
- Division of Trauma & Emergency Surgery, Department of SurgeryOrebro University HospitalOrebroSweden,School of Medical SciencesOrebro UniversityOrebroSweden
| | - Shahin Mohseni
- Division of Trauma & Emergency Surgery, Department of SurgeryOrebro University HospitalOrebroSweden,School of Medical SciencesOrebro UniversityOrebroSweden
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Ioannidis I, Mohammad Ismail A, Forssten MP, Ahl R, Cao Y, Borg T, Mohseni S. The mortality burden in patients with hip fractures and dementia. Eur J Trauma Emerg Surg 2021; 48:2919-2925. [PMID: 33638650 PMCID: PMC9360069 DOI: 10.1007/s00068-021-01612-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 02/05/2021] [Indexed: 12/29/2022]
Abstract
Purpose Dementia is strongly associated with postoperative death in patients subjected to hip fracture surgery. Nevertheless, there is a distinct lack of research investigating the cause of postoperative mortality in patients with dementia. This study aims to investigate the distribution and the risk of cause-specific postoperative mortality in patients with dementia compared to the general hip fracture population. Methods All adults who underwent emergency hip fracture surgery in Sweden between 1/1/2008 and 31/12/2017 were considered for inclusion. Pathological, conservatively managed fractures, and reoperations were excluded. The database was retrieved by cross-referencing the Swedish National Quality Registry for Hip Fracture patients with the Swedish National Board of Health and Welfare quality registers. A Poisson regression model was used to determine the association between dementia and all-cause as well as cause-specific 30-day postoperative mortality. Results 134,915 cases met the inclusion criteria, of which 20% had dementia at the time of surgery. The adjusted risk of all-cause 30-day postoperative mortality was 67% higher in patients with dementia after hip fracture surgery compared to patients without dementia [adj. IRR (95% CI): 1.67 (1.60–1.75), p < 0.001]. The risk of cause-specific mortality was also higher in patients with dementia, with up to a sevenfold increase in the risk cerebrovascular mortality [adj. IRR (95% CI): 7.43 (4.99–11.07), p < 0.001]. Conclusions Hip fracture patients with dementia have a higher risk of death in the first 30 days postoperatively, with a substantially higher risk of mortality due to cardiovascular, respiratory, and cerebrovascular events, compared to patients without dementia.
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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
| | - Rebecka Ahl
- School of Medical Sciences, Orebro University, 702 81 Orebro, Sweden
- Division of Trauma & Emergency Surgery, Department of Surgery, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Orebro University, 701 82 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
| | - 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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Ahl R, Mohammad Ismail A, Borg T, Sjölin G, Forssten MP, Cao Y, Wretenberg P, Mohseni S. A nationwide observational cohort study of the relationship between beta-blockade and survival after hip fracture surgery. Eur J Trauma Emerg Surg 2021; 48:743-751. [PMID: 33507317 PMCID: PMC9001555 DOI: 10.1007/s00068-020-01588-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 12/27/2020] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Rebecka Ahl
- 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
- School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Ahmad Mohammad Ismail
- School of Medical Sciences, Orebro University, Orebro, Sweden
- Department of Orthopedic Surgery, Orebro University Hospital, Orebro, Sweden
| | - Tomas Borg
- School of Medical Sciences, Orebro University, Orebro, Sweden
- Department of Orthopedic Surgery, Orebro University Hospital, Orebro, Sweden
| | - Gabriel Sjölin
- School of Medical Sciences, Orebro University, Orebro, Sweden
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, Orebro, Sweden
| | - Maximilian Peter Forssten
- School of Medical Sciences, Orebro University, Orebro, Sweden
- Department of Orthopedic Surgery, Orebro University Hospital, Orebro, Sweden
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Per Wretenberg
- School of Medical Sciences, Orebro University, Orebro, Sweden
- Department of Orthopedic Surgery, Orebro University Hospital, Orebro, Sweden
| | - 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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Reda S, Ahl R, Szabo E, Stenberg E, Forssten MP, Sjolin G, Cao Y, Mohseni S. Pre-operative beta-blocker therapy does not affect short-term mortality after esophageal resection for cancer. BMC Surg 2020; 20:333. [PMID: 33353542 PMCID: PMC7754575 DOI: 10.1186/s12893-020-01017-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 12/15/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND It has been postulated that the hyperadrenergic state caused by surgical trauma is associated with worse outcomes and that β-blockade may improve overall outcome by downregulation of adrenergic activity. Esophageal resection is a surgical procedure with substantial risk for postoperative mortality. There is insufficient data to extrapolate the existing association between preoperative β-blockade and postoperative mortality to esophageal cancer surgery. This study assessed whether preoperative β-blocker therapy affects short-term postoperative mortality for patients undergoing esophageal cancer surgery. METHODS All patients with an esophageal cancer diagnosis that underwent surgical resection with curative intent from 2007 to 2017 were retrospectively identified from the Swedish National Register for Esophagus and Gastric Cancers (NREV). Patients were subdivided into β-blocker exposed and unexposed groups. Propensity score matching was carried out in a 1:1 ratio. The outcome of interest was 90-day postoperative mortality. RESULTS A total of 1466 patients met inclusion criteria, of whom 35% (n = 513) were on regular preoperative β-blocker therapy. Patients on β-blockers were significantly older, more comorbid and less fit for surgery based on their ASA score. After propensity score matching, 513 matched pairs were available for analysis. No difference in 90-day mortality was detected between β-blocker exposed and unexposed patients (6.0% vs. 6.6%, p = 0.798). CONCLUSION Preoperative β-blocker therapy is not associated with better short-term survival in patients subjected to curative esophageal tumor resection.
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Affiliation(s)
- Souheil Reda
- Division of Upper Gastrointestinal Surgery, Department of Surgery, Orebro University Hospital, Orebro, Sweden
- School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Rebecka Ahl
- School of Medical Sciences, Orebro University, Orebro, Sweden
- Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden
- Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Eva Szabo
- Division of Upper Gastrointestinal Surgery, Department of Surgery, Orebro University Hospital, Orebro, Sweden
- School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Erik Stenberg
- Division of Upper Gastrointestinal Surgery, Department of Surgery, Orebro University Hospital, Orebro, Sweden
- School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Maximilian Peter Forssten
- School of Medical Sciences, Orebro University, Orebro, Sweden
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, Orebro, Sweden
| | - Gabriel Sjolin
- School of Medical Sciences, Orebro University, Orebro, Sweden
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, Orebro, Sweden
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Orebro University, Orebro, Sweden
| | - 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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Forssten MP, Mohammad Ismail A, Sjolin G, Ahl R, Wretenberg P, Borg T, Mohseni S. The association between the Revised Cardiac Risk Index and short-term mortality after hip fracture surgery. Eur J Trauma Emerg Surg 2020; 48:1885-1892. [PMID: 32944823 PMCID: PMC9192369 DOI: 10.1007/s00068-020-01488-w] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 09/04/2020] [Indexed: 11/26/2022]
Abstract
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.
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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
| | - Gabriel Sjolin
- School of Medical Sciences, Orebro University, 702 81 Orebro, Sweden
- Department of Surgery, Orebro University Hospital, 702 81 Orebro, Sweden
| | - Rebecka Ahl
- School of Medical Sciences, Orebro University, 702 81 Orebro, Sweden
- Department of Surgery, Karolinska University Hospital, 171 76 Stockholm, Sweden
- Division of Surgery, CLINTEC, Karolinska Institutet, 171 76 Stockholm, 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
| | - 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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Forssten MP, Thelin EP, Nelson DW, Bellander BM. The Role of Glycerol-Containing Drugs in Cerebral Microdialysis: A Retrospective Study on the Effects of Intravenously Administered Glycerol. Neurocrit Care 2020; 30:590-600. [PMID: 30430381 PMCID: PMC6513829 DOI: 10.1007/s12028-018-0643-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cerebral microdialysis (CMD) is a valuable tool for monitoring compounds in the cerebral extracellular fluid (ECF). Glycerol is one such compound which is regarded as a marker of cell membrane decomposition. Notably, in some acutely brain-injured patients, CMD-glycerol levels rise without any other apparent indication of cerebral deterioration. The aim of this study was to investigate whether this could be due to an association between CMD-glycerol levels and the administration of glycerol-containing drugs. METHODS Microdialysis data were retrospectively retrieved from the hospital's intensive care unit patient data management system (PDMS). All patients who were monitored with CMD for ≥ 96 h were included. Administered drug doses were retrieved from the PDMS and converted to exact doses of glycerol. Cross-correlation analyses were performed between the free, metabolized as well as total administered dose of glycerol and the detrended and differenced CMD-glycerol concentration. These analyses were repeated for two sets of subgroups based upon the individual catheter's graphical trend and its location in relation to the lesion. RESULTS There was no significant correlation between the differenced CMD-glycerol levels and drug-administered glycerol. Furthermore, there was no significant correlation between CMD-glycerol and catheter location or graphical trend. However, if the CMD-glycerol levels were detrended, significant but clinically non-relevant correlations were identified (maximum correlation coefficient of 0.1 (0.04-0.15, 95% CI) at a lag of 7 h using the total administered dose of glycerol). CONCLUSIONS Glycerol-containing drugs routinely administered intravenously in the clinical setting appear to have a minimal and clinically insignificant effect on levels of glycerol in the cerebral ECF.
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Affiliation(s)
- Maximilian Peter Forssten
- Department of Clinical Neuroscience, Section for Neurosurgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
| | - Eric Peter Thelin
- Department of Clinical Neuroscience, Section for Neurosurgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - David W Nelson
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Bo-Michael Bellander
- Department of Clinical Neuroscience, Section for Neurosurgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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