| 1. |
- Ah, Rebecka, et al.
(author)
-
Prognostic Value of P-POSSUM and Osteopenia for Predicting Mortality After Emergency Laparotomy in Geriatric Patients
- 2019
-
In: Bulletin of emergency and trauma. - : Shiraz University of Medical Sciences. - 2322-2522 .- 2322-3960. ; 7:3, s. 223-231
-
Journal article (peer-reviewed)abstract
- Objective: To evaluate the Portsmouth-Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM) in comparison with other risk factors for mortality including osteopenia as an indicator for frailty in geriatric patients subjected to emergency laparotomy.Methods: All geriatric patients (≥65 years) undergoing emergency laparotomy at a single university hospital between 1/2015 and 12/2016 were included in this cohort study. Demographics and outcomes were retrospectively collected from medical records. Association between prognostic markers and 30-day mortality was assessed using Poisson and backward stepwise regression models. Prognostic value was assessed using receiver operating characteristic (ROC) curves.Results: =0.004) while osteopenia was not. P-POSSUM had poor prognostic value for 30-day mortality with an area under the ROC curve (AUC) of 0.59. The prognostic value of P-POSSUM improved significantly when adjusting for patient covariates (AUC=0.83).Conclusion: P-POSSUM and osteopenia alone hardly predict 30-day mortality in geriatric patients following emergency laparotomy. P-POSSUM adjusted for other patient covariates improves the prediction.
|
|
| 2. |
- Ahl, Rebecka, 1987-, et al.
(author)
-
β-Blocker after severe traumatic brain injury is associated with better long-term functional outcome : a matched case control study
- 2017
-
In: European Journal of Trauma and Emergency Surgery. - : Springer Berlin/Heidelberg. - 1863-9933 .- 1863-9941. ; 43:6, s. 783-789
-
Journal article (peer-reviewed)abstract
- PURPOSE: Severe traumatic brain injury (TBI) is the predominant cause of death and disability following trauma. Several studies have observed improved survival in TBI patients exposed to β-blockers, however, the effect on functional outcome is poorly documented.METHODS: Adult patients with severe TBI (head AIS ≥ 3) were identified from a prospectively collected TBI database over a 5-year period. Patients with neurosurgical ICU length of stay <48 h and those dying within 48 h of admission were excluded. Patients exposed to β-blockers ≤ 48 h after admission and who continued with treatment until discharge constituted β-blocked cases and were matched to non β-blocked controls using propensity score matching. The outcome of interest was Glasgow Outcome Scores (GOS), as a measure of functional outcome up to 12 months after injury. GOS ≤ 3 was considered a poor outcome. Bivariate analysis was deployed to determine differences between groups. Odds ratio and 95% CI were used to assess the effect of β-blockers on GOS.RESULTS: 362 patients met the inclusion criteria with 21% receiving β-blockers during admission. After propensity matching, 76 matched pairs were available for analysis. There were no statistical differences in any variables included in the analysis. Mean hospital length of stay was shorter in the β-blocked cases (18.0 vs. 26.8 days, p < 0.01). The risk of poor long-term functional outcome was more than doubled in non-β-blocked controls (OR 2.44, 95% CI 1.01-6.03, p = 0.03).CONCLUSION: Exposure to β-blockers in patients with severe TBI appears to improve functional outcome. Further prospective randomized trials are warranted.
|
|
| 3. |
- Bass, Gary Alan, 1979-, et al.
(author)
-
Techniques for mesoappendix transection and appendix resection: insights from the ESTES SnapAppy study
- 2023
-
In: European Journal of Trauma and Emergency Surgery. - : Springer Science and Business Media LLC. - 1863-9933 .- 1615-3146 .- 1863-9941. ; 49, s. 17-32
-
Journal article (peer-reviewed)abstract
- Introduction: Surgically managed appendicitis exhibits great heterogeneity in techniques for mesoappendix transection and appendix amputation from its base. It is unclear whether a particular surgical technique provides outcome benefit or reduces complications. Material and methods: We undertook a pre-specified subgroup analysis of all patients who underwent laparoscopic appendectomy at index admission during SnapAppy (ClinicalTrials.gov Registration: NCT04365491). We collected routine, anonymized observational data regarding surgical technique, patient demographics and indices of disease severity, without change to clinical care pathway or usual surgeon preference. Outcome measures of interest were the incidence of complications, unplanned reoperation, readmission, admission to the ICU, death, hospital length of stay, and procedure duration. We used Poisson regression models with robust standard errors to calculate incident rate ratios (IRRs) and 95% confidence intervals (CIs). Results: Three-thousand seven hundred sixty-eight consecutive adult patients, included from 71 centers in 14 countries, were followed up from date of admission for 90days. The mesoappendix was divided hemostatically using electrocautery in 1564(69.4%) and an energy device in 688(30.5%). The appendix was amputated by division of its base between looped ligatures in 1379(37.0%), with a stapler in 1421(38.1%) and between clips in 929(24.9%). The technique for securely dividing the appendix at its base in acutely inflamed (AAST Grade 1) appendicitis was equally divided between division between looped ligatures, clips and stapled transection. However, the technique used differed in complicated appendicitis (AAST Grade 2 +) compared with uncomplicated (Grade 1), with a shift toward transection of the appendix base by stapler (58% vs. 38%; p < 0.001). While no statistical difference in outcomes could be detected between different techniques for division of appendix base, decreased risk of any [adjusted IRR (95% CI): 0.58 (0.41–0.82), p = 0.002] and severe [adjusted IRR (95% CI): 0.33 (0.11–0.96), p = 0.045] complications could be detected when using energy devices. Conclusions: Safe mesoappendix transection and appendix resection are accomplished using heterogeneous techniques. Technique selection for both mesoappendix transection and appendix resection correlates with AAST grade. Higher grade led to more ultrasonic tissue transection and stapled appendix resection. Higher AAST appendicitis grade also correlated with infection-related complication occurrence. Despite the overall well-tolerated heterogeneity of approaches to acute appendicitis, increasing disease acuity or complexity appears to encourage homogeneity of intraoperative surgical technique toward advanced adjuncts.
|
|
| 4. |
- Forssten, Maximilian Peter, 1996-, et al.
(author)
-
Surgical management of acute appendicitis during the European COVID-19 second wave: safe and effective
- 2023
-
In: European Journal of Trauma and Emergency Surgery. - : Springer Science and Business Media LLC. - 1863-9933 .- 1615-3146 .- 1863-9941. ; 49, s. 57-67
-
Journal article (peer-reviewed)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 ≥ 15years 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.
|
|
| 5. |
- Mohseni, Shahin, 1978-, et al.
(author)
-
Preinjury β-blockade is protective in isolated severe traumatic brain injury
- 2014
-
In: Journal of Trauma and Acute Care Surgery. - Philadelphia, USA : Lippincott Williams & Wilkins. - 2163-0755 .- 2163-0763. ; 76:3, s. 804-808
-
Journal article (peer-reviewed)abstract
- Background: The purpose of this study was to investigate the effect of preinjury β-blockade in patients experiencing isolated severe traumatic brain injury (TBI). We hypothesized that β-blockade before TBI is associated with improved survival.Methods: The trauma registry of an urban academic trauma center was queried to identify patients with an isolated severe TBI between January 2007 and December 2011. Isolated severe TBI was defined as an intracranial injury with an Abbreviated Injury Scale (AIS) score of 3 or greater excluding all extracranial injuries AIS score of 3 or greater. Patient demographics, clinical characteristics on admission, injury profile, Injury Severity Score (ISS), AIS score, in-hospital morbidity, and β-blocker exposure were abstracted for analysis. The primary outcome evaluated was in-hospital mortality stratified by preinjury β-blockade exposure.Results: Overall, a total of 662 patients met the study criteria. Of these, 25% (n = 159) were exposed to β-blockade before their traumatic insult. When comparing the demographics and injury characteristics between the groups, the sole difference was age, with the β-blocked group being older (69 [12] years vs. 63 [13] years, p < 0.001). β-blocked patients had a higher rate of infectious complications (30% vs. 19%, p = 0.04), with no difference in cardiac or pulmonary complications between the cohorts. Patients exposed to β-blockade versus no β-blockade experienced 13% and 22% mortality, respectively (p = 0.01). Stepwise logistic regression predicted the absence of β-blockade exposure as a risk factor for mortality (odds ratio, 2.7; 95% confidence interval, 1.5-4.8; p = 0.002). After adjustment for significant differences between the groups, patients not exposed to β-blockade experienced twofold increased risk of mortality (adjusted odds ratio, 2.2; 95% confidence interval, 1.3-3.7; p = 0.004).Conclusion: Preinjury β-blockade improves survival following isolated severe TBI. The role of prophylactic β-blockade and the timing of initiation of such therapy after TBI warrant further investigations.Level of evidence: Therapeutic study, level III; prognostic study, level II.
|
|
| 6. |
- Mohseni, Shahin, 1978-, et al.
(author)
-
Simultaneous common bile duct clearance and laparoscopic cholecystectomy : experience of a one-stage approach
- 2019
-
In: European Journal of Trauma and Emergency Surgery. - : Springer Berlin/Heidelberg. - 1863-9933 .- 1863-9941. ; 45:2, s. 337-342
-
Journal article (peer-reviewed)abstract
- Introduction: The timing and optimal method for common bile duct (CBD) clearance and laparoscopic cholecystectomy remains controversial. Several different approaches are available in clinical practice. The current study presents the experience of two European hospitals of simultaneous laparoscopic cholecystectomy (LC) and intra-operative endoscopic retrograde cholangiopacreatography (IO-ERCP) done by surgeons.Methods: Retrospective analysis of all consecutive patients subjected to LC+IO-ERCP during their index admission between 4/2014 and 9/2016. Data accrued included patient demographics, laboratory markers, operation time (min) reported as mean (SD) and hospital length of stay (LOS) reported as median (lower quartile, upper quartile).Results: During the 29-month study, a total of 201 consecutive LC+IO-ERCPs were performed. The mean age of patients was 55 +/- 19years and 67% were female. The mean intervention time was 105 +/- 44min. The total LOS was 4 (3, 7) days and the post-operative LOS was 2 (1, 3)days. A total of 6 (3%) patients experienced post-interventional pancreatitis and two (1%) patients suffered a Strasberg type A bile leak. All patients were successfully discharged.Conclusion: Simultaneous LC+IO-ERCP is associated with few complications. Further studies investigating cost-benefit and patient satisfaction are warranted.
|
|
| 7. |
- Mohseni, Shahin, 1978-, et al.
(author)
-
The Effect of beta-blockade on Survival After Isolated Severe Traumatic Brain Injury
- 2015
-
In: World Journal of Surgery. - : Springer Science and Business Media LLC. - 0364-2313 .- 1432-2323. ; 39:8, s. 2076-2083
-
Journal article (peer-reviewed)abstract
- Several North American studies have observed survival benefit in patients exposed to beta-blockers following traumatic brain injury (TBI). The purpose of this study was to evaluate the effect of beta-blockade on mortality in a Swedish cohort of isolated severe TBI patients.The trauma registry of an urban academic trauma center was queried to identify patients with an isolated severe TBI between 1/2007 and 12/2011. Isolated severe TBI was defined as an intracranial injury with an Abbreviated Injury Scale (AIS) a parts per thousand yen3 excluding extra-cranial injuries AIS a parts per thousand yen3. Multivariable logistic regression analysis was used to determine the effect of beta-blocker exposure on mortality. Also, a subgroup analysis was performed to investigate the risk of mortality in patients on pre-admission beta-blocker versus not and the effect of specific type of beta-blocker on the overall outcome.Overall, 874 patients met the study criteria. Of these, 33 % (n = 287) were exposed to beta-blockers during their hospital admission. The exposed patients were older (62 +/- A 16 years vs. 49 +/- A 21 years, p < 0.001), and more severely injured based on their admission GCS, ISS, and head AIS scores (GCS a parts per thousand currency sign8: 32 % vs. 28 %, p = 0.007; ISS a parts per thousand yen16: 71 % vs. 59 %, p = 0.001; head AIS a parts per thousand yen4: 60 % vs. 45 %, p < 0.001). The crude mortality was higher in patients who did not receive beta-blockers (17 % vs. 11 %, p = 0.007) during their admission. After adjustment for significant confounders, the patients not exposed to beta-blockers had a 5-fold increased risk of in-hospital mortality (AOR 5.0, CI 95 % 2.7-8.5, p = 0.001). No difference in survival was noted in regards to the type of beta-blocker used. Subgroup analysis revealed a higher risk of mortality in patients naive to beta-blockers compared to those on pre-admission beta-blocker therapy (AOR 3.0 CI 95 % 1.2-7.1, p = 0.015).Beta-blocker exposure after isolated severe traumatic brain injury is associated with significantly improved survival. We also noted decreased mortality in patients on pre-admission beta-blocker therapy compared to patients naive to such treatment. Further prospective studies are warranted.
|
|
| 8. |
- Reintam Blaser, A., et al.
(author)
-
Incidence, diagnosis, management and outcome of acute mesenteric ischaemia: a prospective, multicentre observational study (AMESI Study)
- 2024
-
In: Critical Care. - : BioMed Central (BMC). - 1364-8535 .- 1466-609X. ; 28:1
-
Journal article (peer-reviewed)abstract
- Background: The aim of this multicentre prospective observational study was to identify the incidence, patient characteristics, diagnostic pathway, management and outcome of acute mesenteric ischaemia (AMI). Methods: All adult patients with clinical suspicion of AMI admitted or transferred to 32 participating hospitals from 06.06.2022 to 05.04.2023 were included. Participants who were subsequently shown not to have AMI or had localized intestinal gangrene due to strangulating bowel obstruction had only baseline and outcome data collected. Results: AMI occurred in 0.038% of adult admissions in participating acute care hospitals worldwide. From a total of 705 included patients, 418 patients had confirmed AMI. In 69% AMI was the primary reason for admission, while in 31% AMI occurred after having been admitted with another diagnosis. Median time from onset of symptoms to hospital admission in patients admitted due to AMI was 24 h (interquartile range 9-48h) and time from admission to diagnosis was 6h (1–12 h). Occlusive arterial AMI was diagnosed in 231 (55.3%), venous in 73 (17.5%), non-occlusive (NOMI) in 55 (13.2%), other type in 11 (2.6%) and the subtype could not be classified in 48 (11.5%) patients. Surgery was the initial management in 242 (58%) patients, of which 59 (24.4%) underwent revascularization. Endovascular revascularization alone was carried out in 54 (13%), conservative treatment in 76 (18%) and palliative care in 46 (11%) patients. From patients with occlusive arterial AMI, revascularization was undertaken in 104 (45%), with 40 (38%) of them in one site admitting selected patients. Overall in-hospital and 90-day mortality of AMI was 49% and 53.3%, respectively, and among subtypes was lowest for venous AMI (13.7% and 16.4%) and highest for NOMI (72.7% and 74.5%). There was a high variability between participating sites for most variables studied. Conclusions: The overall incidence of AMI and AMI subtypes varies worldwide, and case ascertainment is challenging. Pre-hospital delay in presentation was greater than delays after arriving at hospital. Surgery without revascularization was the most common management approach. Nearly half of the patients with AMI died during their index hospitalization. Together, these findings suggest a need for greater awareness of AMI, and better guidance in diagnosis and management. Trial registration: NCT05218863 (registered 19.01.2022).
|
|
| 9. |
|
|
| 10. |
- Talving, Peep
(author)
-
Aspects of hepatoduodenal trauma and fluid therapy in hemorrhagic shock
- 2006
-
Doctoral thesis (other academic/artistic)abstract
- Traumatic injury is the leading cause of death among young adults and children, accounting for 5 million deaths worldwide on an annual basis. In Sweden alone, 2500 individuals succumb to traumatic injuries yearly. Beyond the burden of death, injuries contribute to a large proportion of disability. Hemorrhagic shock and severe abdominal injuries are frequent causes of preventable death after trauma, whereas early recognition and proper treatment of these conditions improve survival considerably. The aim of this thesis is to review some aspects of abdominal injuries and fluid therapy in hemorrhagic shock. Paper I evaluated the population-based incidence and injury severity of the most frequently injured abdominal organ, the liver, in the County of Stockholm comprising 1.75 million inhabitants. Cases of liver injuries were retrieved from the National Board of Forensic Medicine and the Public Health and Medical Services Committee Register (in-patients register). The results show a relatively low incidence of liver injuries in the studied population (2.95/100,000). The hazard of liver injury in the County was calculated to be 0.003% per annum. Grade II and III injuries prevail. Nonoperative management was applied in 54% of patients. Only simple operative measures were employed in the 32% of surgically explored patients. No complex hepatic injuries were operated upon. The nonoperative management of liver injuries is mounting and is currently employed around the world. The objective of paper II was to describe a simplified surgical algorithm for the treatment of low-velocity duodenal gunshot injuries currently in use in a large South African civilian trauma center and to verify its validity by measuring morbidity and mortality. Seventy-five consecutive patients with gunshot injuries to the duodenum were reviewed. Primary repair was performed in 86%, a resection and re-anastomosis in 11% and pancreatoduodenectomy in 3% of patients. The overall morbidity and mortality was 58% and 28%, respectively. Most civilian low-velocity duodenal gunshot injuries are treated with simple primary repair resulting in overall morbidity, mortality, and duodenum-related complication rates comparable to those in reports where more complex surgical procedures are employed. Primary repair is also applicable in the majority of combined pancreatic and duodenal gunshot wounds. Few previous studies have been conducted on prehospital management of hypotensive trauma patients in Stockholm County and therefore a retrospective review of these patients is discussed in paper III. We found that the mean time interval at the scene of injury (19 min) exceeded Prehospital Trauma Life Supports general guidelines (10 min). Most of the hypotensive trauma patients were fluid-resuscitated on the scene of injury regardless of the type, mechanism, or severity of injury. A predefined fluid resuscitation regimen is not employed in hypotensive trauma victims with different types of injuries. The outcome was worsened by male gender, progressive age and an Injury Severity Score >20. In paper IV, we discuss an experimental study on a porcine model of near-lethal liver injury associated with hemorrhagic shock. We hypothesized that early intravenous fluid therapy does not improve short-term survival, the volume of intra-abdominal hemorrhage, and aortic and visceral hemodynamics. We found no differences in these parameters when animals were randomized into early or delayed resuscitation groups, receiving intravenous hypertonic saline dextran either 20 minutes or 40 minutes after trauma. We concluded that rebleeding after severe liver injury occurs infrequently; hepatic hemodynamics and short-term survival were not improved by the early initiation of fluid therapy.
|
|
