Micael Appelblad

Purpose: The interval between breast cancer diagnosis and surgery is psychologically demanding, and meeting the Swedish standardised care pathway target has remained challenging. We examined whether diagnosis-to-surgery lead time is associated with patient-reported psychological outcomes. Methods: We conducted a longitudinal cohort study using Swedish National Quality Register for Breast Cancer data (2020–2024). The cohort comprised 2,906 women with primary invasive breast cancer undergoing surgery, with patient-reported outcome measure (PROM) data at baseline ( n = 2,906), 6 months ( n = 2,638), and 12 months ( n = 2,678). Lead time from biopsy to surgery was modelled continuously (per 1 SD ≈ 19 days). The primary outcome was worry about future health (EORTC QLQ-BR23 item 43); secondary outcomes were general worry, tension, depressed mood, and overall quality of life. Associations were estimated using mixed-effects cumulative link models adjusted for clinical and tumour factors, pandemic era, patient, and healthcare region. Results: Median lead time was 32 days (IQR 23–42). Longer lead time was associated with greater worry about future health (adjusted OR 1.15 per SD, 95% CI 1.04–1.27), while associations with the secondary outcomes were smaller and not statistically significant. At baseline, high future-health worry was more common with lead times > 35 vs. ≤ 35 days (42.2% vs. 35.1%). Conclusion: Longer diagnosis-to-surgery lead time was associated with greater future-health worry, with smaller, non-significant associations for general distress and quality of life. The findings highlight the preoperative waiting period as a potential context for improved communication about expected timelines and reasons for delay.

Background: In aortic arch surgery, bilateral selective antegrade cerebral perfusion (bSACP) maintains cerebral blood flow during circulatory arrest. bSACP is often delivered using a single pump with a Y-connector, dividing the flow. Current practice has veered towards perfusion of the left common carotid artery by cannula and the right subclavian artery by a vascular graft. Flow distribution may therefore depend on left-sided cannula resistance, particularly in patients with limited collateral circulation. We investigated how cannula design influences perfusion pressure and flow distribution during bSACP. Methods: Four clinically available carotid perfusion cannulas were characterized using bench measurements (40–200 mL/min) and computational fluid dynamics (CFD). The resulting resistance models were integrated into patient-specific CFD models of the cerebral circulation in three patients with varying collateral capacity. Both flow- and pressure-targeted perfusion strategies were simulated. Results: Bench testing demonstrated a 3-4-fold difference in flow resistance between the lowest- and highest-resistance cannulas, which was accurately reproduced in CFD simulations. Importantly, resistance did not correlate with nominal French size. In the patient-specific CFD models, increasing left side cannula resistance roughly doubled the pressure laterality (7–9 to 14–23 mmHg) and halved the left side inflow (135–160 to 70–100 mL/min) for the cannulas tested. Effects were most pronounced in patients with limited collateral circulation. Sensitivity analyses confirmed robustness across physiological and geometric perturbations. Conclusions: Cannula resistance does not correlate with nominal French size. Cannula design may influence cerebral perfusion pressure and flow distribution during bSACP and may warrant increased attention.

Selective antegrade cerebral perfusion (SACP) maintains cerebral perfusion during aortic arch surgery and is mainly achieved by cannulating unilaterally (uSACP) or bilaterally (bSACP). The choice of applying uSACP or bSACP is often made according to institutional practice, whereas neurological complications may be reduced if the approaches instead were applied according to the patient’s individual cerebral collateral circulation. However, no method for predicting intraoperative cerebral collateral capacity is currently available. This study evaluates a computational method for predicting the cerebral perfusion pressure (CPP) in patients undergoing aortic arch surgery with SACP. Twenty-two patients underwent elective aortic arch surgery with bSACP, including a five-minute intervention of right-sided uSACP. Patients preoperatively underwent computed tomography angiography and 4D flow magnetic resonance imaging to assess patient-specific arterial anatomy and blood flows. Computational fluid dynamics modelling estimated the vascular resistance of the vascular beds distal of the segmented arterial anatomy. Based on these resistances, a subsequent model predicted CPP during uSACP and bSACP given intraoperatively measured input. There was no difference between predicted and measured left side CPP for uSACP (-3.0 ± 11.2 mmHg, p=0.25; r=0.75, p<0.001) or bSACP (-0.4 ± 5.7 mmHg, p=0.78; r=0.94, p<0.001). There was good group level agreement (90% CI, uSACP: [-7.5, 1.4]; bSACP: [-2.6, 1.9]) whereas limits of agreement showed substantial spread (uSACP: [-24.9, 18.9], bSACP: [-11.5, 10.8]). The new method predicted CPP on group level, while improved individual prediction accuracy may be achievable through refined arterial segmentation and more accurate estimation of intraoperative vascular resistances.

Background: Operating-room productivity is commonly pursued through throughput metrics, yet frontline staff point to organizational and interpersonal conditions that make a working pace sustainable. How everyday practices relate to staff motivation, and thereby to dependable workflow, remains underexplored. Research question: (1) What organizational and interpersonal conditions support or thwart a sustainable work pace among perioperative nursing staff? (2) How can these conditions be understood through Self-Determination Theory (SDT)? Methods: We used a sequential explanatory mixed-methods design at two operating room units in a Swedish university hospital. In Phase 1 the Safety Attitudes Questionnaire–Operating Room version was administered (October 2022; n = 47) to profile contextual contrasts between units. In Phase 2, semi-structured interviews (December 2022–March 2025; n = 24) were analyzed with inductive qualitative content analysis, after which SDT was used to interpret the resulting categories. Qualitative reporting followed the COREQ. Results: Survey responses differed between units in safety climate (32% vs. 68%; P = .02), stress recognition (57% vs. 21%; P = .02) and perceptions of management (18% vs. 63%; P = .002). Interviews yielded four cross-cutting conditions: predictable workflow and usable tools; psychologically safe teamwork; participatory planning with visible follow-through; and learning structures for mastery, with workload as a boundary condition. The same families of practice appeared at both units but were described with differing emphasis. Interpreted through SDT, these conditions supported autonomy, competence and relatedness when present and thwarted them when absent; need-thwarting patterns (late list changes, parallel documentation, sharp communication, tokenistic consultation) co-occurred with workarounds and conditional intentions to stay. Conclusion: Among perioperative nursing staff, a sustainable pace was described less as working slowly than as predictable routines, professional judgement over timing, stable teamwork, and protected standards of care under pressure. Modest, auditable routines that jointly support autonomy, competence and relatedness offer transferable, hypothesis-generating design principles for dependable operating-room productivity, rather than a ranking of units.

Modelling of hemodynamics in the circle of Willis (CoW) depends on vascular segmentation, which may vary based on imaging modality. Computed tomography angiography (CTA) is commonly used in clinic but involves radiation and injection of contrast agents, whereas magnetic resonance angiography (MRA) offers a non-invasive alternative. This study aims to compare CoW morphology and modelled cerebral perfusion pressure of CTA and MRA segmentations, validating if MRA can replace CTA in modelling workflows. CTA and time-of-flight MRA (TOF-MRA) of the CoW was performed in 19 patients undergoing elective aortic arch surgery (67±7 years, 8 women). The CoW was semi-automatically segmented based on signal intensity thresholding. A TOF-MRA threshold was optimized against the CTA segmentation, using the CTA as reference standard. Computational fluid dynamics (CFD) modelling with boundary conditions based on subject-specific flow rates from 4D flow MRI simulated cerebral perfusion pressure in the segmented geometries. A baseline simulation and a unilateral brain inflow simulation, i.e., occlusion of a carotid, were carried out. Linear mixed models indicated there was no effect of choice of modality on either average arterial lumen area (CTA − TOF-MRA: -0.2±1.3 mm ² ; p=0.762) or baseline pressure drops (0.2±1.9 mmHg; p=0.257). In the unilateral inflow simulation, we found no difference in pressure laterality (-6.6±18.4 mmHg; p=0.185) or collateral flow rate (10±46 ml/min; p=0.421). TOF-MRA geometries can with signal intensity thresholding be matched to produce similar morphology and modelled cerebral perfusion pressure to CTA geometries. The modelled pressure drops over the collateral arteries were sensitive to the segmentation regardless of modality.

Background: Healthcare systems face challenges in optimizing resources while maintaining high-quality care. Breast cancer surgery represents a substantial share of elective surgery and provides an opportunity to evaluate different organizational models. This study presents a health economic analysis comparing two models for breast cancer surgery at the same hospital. Methods: A bottom-up micro-costing approach was employed to evaluate potential cost-savings of breast cancer surgeries performed at a general surgical department (GS) versus a cardiothoracic surgery department (CT). We analyzed 543 consecutive patients undergoing elective breast cancer surgery between January 2014 and September 2016. Resource use was identified through direct observation, hospital administrative systems, and operating room logs. Personnel, disposables, medications, and facility costs were quantified based on observed resource use within the study dataset; no external benchmarking was performed. Results: CT was less expensive, with an average saving of 3,547 Swedish krona (SEK) per operation (95% CI: -674 to 7,510 SEK). Bootstrap analysis with 1,000 iterations showed CT was less costly in 96.2% of samples. Procedures were shorter at CT (170.8 vs. 221.3 min), enabling more operations per day (3.2 vs. 2.4). In our deterministic simulation, removing CT capacity increased waiting times by 15%, from 39 to 45.1 days, conditional on steady inflow and constant OR availability. Annual savings at the observed annual volume (~ 192 patients) were 681,104 SEK and could reach ~ 1.77 million SEK if volumes increased to 500 patients/year. Conclusions: The CT organizational model was more likely to be less costly while maintaining shorter waiting times. These findings suggest that CT capacity may be prioritized, particularly at higher patient volumes, to support both economic efficiency and patient access.

Introduction: The study objective was to investigate whether a Ringer’s acetate based priming solution with addition of Mannitol and sodium concentrate increases the risk of cardiac surgery associated kidney injury (CSA-AKI). Methods: This is a double blind, prospective randomized controlled trial from a single tertiary teaching hospital in Sweden including patients aged ≥65 years ( n = 195) admitted for routine cardiac surgery with cardiopulmonary bypass. Patients in the study group received Ringer’s acetate 1000 mL + 400 mL Mannitol (60 g) + sodium chloride 40 mL (160 mmol) and heparin 2 mL (10 000 IU) 966 mOsmol ( n = 98), while patients in the control group received Ringer’s acetate 1400 mL + heparin 2 mL (10 000 IU), 388 mOsmol ( n = 97) as pump prime. Acute kidney injury was analysed based on the Kidney Disease Improving Outcomes (KDIGO 1-3) definition. Results: The overall incidence of CSA-AKI (KDIGO stage 1) was 2.6% on day 1 in the ICU and 5.6% on day 3, postoperatively. The serum creatinine level did not show any postoperative intergroup differences, when compared to baseline preoperative values. Six patients in the Ringer and five patients in the Mannitol group developed CSA-AKI (KDIGO 1-3), all with glomerular filtration rates 2. These patients showed significantly higher plasma osmolality levels compared to preoperative values. Hyperosmolality together with patient age and the duration of the surgery were independent risk factors for postoperative acute kidney injury (KDIGO 1-3). Conclusions: The use of a hyperosmolar prime solution did not increase the incidence of postoperative CSA-AKI in this study, while high plasma osmolality alone increased the associated risk by 30%. The data suggests further examination of plasma hyperosmolality as a relative risk factor of CSA-AKI.

Background: Cerebral blood flow (CBF) is believed to be relatively constant within an upper and lower blood pressure limit. Different methods are available to monitor CBF autoregulation during surgery. This study aims to critically analyze the application of the cerebral oxygenation index (COx), one of the commonly used techniques, using a reference to data from a series of clinical registrations. Method: CBF was monitored using near-infrared spectroscopy, while cerebral blood pressure was estimated by recordings obtained from either the radial or femoral artery in 10 patients undergoing cardiopulmonary bypass. The association between CBF and blood pressure was calculated as a moving continuous correlation coefficient. A COx index > 0.4 was regarded as a sign of abnormal cerebral autoregulation (CA). Recordings were examined to discuss reliability measures and clinical feasibility of the measurements, followed by interpretation of individual results, identification of possible pitfalls, and suggestions of alternative methods. Results and Conclusion: Monitoring of CA during cardiopulmonary bypass is intriguing and complex. A series of challenges and limitations should be considered before introducing this method into clinical practice.

Objective: Postoperative delirium (POD) is common after cardiac surgery. We have previously identified plasma sodium concentration and the volume of infused fluids during surgery as possible risk factors. Both are linked to the selection and composition of the pump prime used for cardiopulmonary bypass (CPB). Present study aims to examine whether hyperosmolality increases the risk for POD. Design: Patients ≥65 years (n = 195) scheduled for cardiac surgery were prospectively enrolled into this double blinded randomised clinical trial. Study group received a pump prime containing mannitol and ringer-acetate (966 mOsmol) (n = 98) vs. ringer-acetate (388 mOsmol) (n = 97) in the control group. Postoperative delirium was defined according to DSM-5 criteria based on a test-battery pre- and postoperatively (days 1–3). Plasma osmolality was measured on five occasions and coordinated with the POD assessments. The primary outcome was the POD incidence related to hyperosmolality as the secondary outcome. Results: The incidence of POD was 36% in the study group and 34% in the control group, without intergroup difference (p=.59). The plasma osmolality was significantly higher in the study group, both on days 1 and 3 and after CPB (p<.001). Post hoc analysis indicated that high osmolality levels increased the risk for delirium on day 1 by 9% (odds ratio (OR) 1.09, 95% CI 1.03–1.15) and by 10% on day 3 (OR 1.10, 95% CI 1.04–1.16). Conclusions: Use of a prime solution with high osmolality did not increase the incidence of POD. However, the influence of hyperosmolality as a risk factor for POD warrants further investigation.