Adverse Surgical Outcomes Linked to Co-occurring Smoking and Risky Alcohol Use Among General Surgery Patients

Effect of tobacco use on Zenker's diverticulotomy outcomes

OBJECTIVE

To compare clinical outcomes in patients with and without history of tobacco use who underwent Zenker's diverticulotomy (ZD).

STUDY DESIGN

Single institution retrospective review.

SETTING

Tertiary care academic hospital.

METHODS

A retrospective review of patients who underwent ZD via an open stapler, rigid endoscopic CO2 laser, stapler or harmonic scalpel, and flexible endoscopic technique from January 2006 to December 2020 was performed. Data were abstracted for patient demographics, diverticular features, and rates of adverse events and symptomatic recurrence.

RESULTS

Out of 424 patients, 146 (34.4 %) had a history of tobacco use: 126 (29.7 %) were former smokers, and 20 (4.7 %) were active smokers. In univariable cross-sectional analyses, the likelihood of postoperative bleeding, perforation, emergency department visits, unplanned readmission, or recurrence did not demonstrate an association with tobacco use history even after adjustment for age, sex, and surgical approach. Similarly, in Cox Proportional Hazards regression, tobacco use was not associated with an increased risk of recurrence, even after correcting for age, sex, and type of surgery. The median time to recurrence observed in our cohort was 11.5 years amongst non-smokers, 8.7 years amongst former smokers, and 1.2 years amongst active smokers (p = 0.94).

CONCLUSIONS

There were no significant differences in post-operative adverse events or frequency of recurrence of ZD between active, former, and non-smokers. Although underpowered and not statistically significant, median time to recurrence appears to be shorter in smokers when compared with former and non-smokers following surgery.

Transforming the Future of Surgeon-Scientists

OBJECTIVE

To create a blueprint for surgical department leaders, academic institutions, and funding agencies to optimally support surgeon-scientists.

BACKGROUND

Scientific contributions by surgeons have been transformative across many medical disciplines. Surgeon-scientists provide a distinct approach and mindset toward key scientific questions. However, lack of institutional support, pressure for increased clinical productivity, and growing administrative burden are major challenges for the surgeon-scientist, as is the time-consuming nature of surgical training and practice.

METHODS

An American Surgical Association Research Sustainability Task Force was created to outline a blueprint for sustainable science in surgery. Leaders from top NIH-sponsored departments of surgery engaged in video and in-person meetings between January and April 2023. A strength, weakness, opportunities, threats analysis was performed, and workgroups focused on the roles of surgeons, the department and institutions, and funding agencies.

RESULTS

Taskforce recommendations: (1) SURGEONS: Growth mindset : identifying research focus, long-term planning, patience/tenacity, team science, collaborations with disparate experts; Skill set : align skills and research, fill critical skill gaps, develop team leadership skills; DEPARTMENT OF SURGERY (DOS): (2) MENTORSHIP: Chair : mentor-mentee matching/regular meetings/accountability, review of junior faculty progress, mentorship training requirement, recognition of mentorship (eg, relative value unit equivalent, awards; Mentor: dedicated time, relevant scientific expertise, extramural funding, experience and/or trained as mentor, trusted advisor; Mentee : enthusiastic/eager, proactive, open to feedback, clear about goals; (3) FINANCIAL SUSTAINABILITY: diversification of research portfolio, identification of matching funding sources, departmental resource awards (eg, T-/P-grants), leveraging of institutional resources, negotiation of formalized/formulaic funds flow investment from academic medical center toward science, philanthropy; (4) STRUCTURAL/STRATEGIC SUPPORT: Structural: grants administrative support, biostats/bioinformatics support, clinical trial and research support, regulatory support, shared departmental laboratory space/equipment; Strategic: hiring diverse surgeon-scientist/scientists faculty across DOS, strategic faculty retention/ recruitment, philanthropy, career development support, progress tracking, grant writing support, DOS-wide research meetings, regular DOS strategic research planning; (5) COMMUNITY AND CULTURE: Community: right mix of faculty, connection surgeon with broad scientific community; Culture: building research infrastructure, financial support for research, projecting importance of research (awards, grand rounds, shoutouts); (6) THE ROLE OF INSTITUTIONS: Foundation: research space co-location, flexible start-up packages, courses/mock study section, awards, diverse institutional mentorship teams; Nurture: institutional infrastructure, funding (eg, endowed chairs), promotion friendly toward surgeon-scientists, surgeon-scientists in institutional leadership positions; Expectations: RVU target relief, salary gap funding, competitive starting salaries, longitudinal salary strategy; (7) THE ROLE OF FUNDING AGENCIES: change surgeon research training paradigm, offer alternate awards to K-awards, increasing salary cap to reflect market reality, time extension for surgeon early-stage investigator status, surgeon representation on study section, focused award strategies for professional societies/foundations.

CONCLUSIONS

Authentic recommitment from surgeon leaders with intentional and ambitious actions from institutions, corporations, funders, and society is essential in order to reap the essential benefits of surgeon-scientists toward advancements of science.

Automated-detection of risky alcohol use prior to surgery using natural language processing

BACKGROUND

Preoperative risky alcohol use is one of the most common surgical risk factors. Accurate and early identification of risky alcohol use could enhance surgical safety. Artificial Intelligence-based approaches, such as natural language processing (NLP), provide an innovative method to identify alcohol-related risks from patients' electronic health records (EHR) before surgery.

METHODS

Clinical notes (n = 53,629) from pre-operative patients in a tertiary care facility were analyzed for evidence of risky alcohol use and alcohol use disorder. One hundred of these records were reviewed by experts and labeled for comparison. A rule-based NLP model was built, and we assessed the clinical notes for the entire population. Additionally, we assessed each record for the presence or absence of alcohol-related International Classification of Diseases (ICD) diagnosis codes as an additional comparator.

RESULTS

NLP correctly identified 87% of the human-labeled patients classified with risky alcohol use. In contrast, diagnosis codes alone correctly identified only 29% of these patients. In terms of specificity, NLP correctly identified 84% of the non-risky cohort, while diagnosis codes correctly identified 90% of this cohort. In the analysis of the full dataset, the NLP-based approach identified three times more patients with risky alcohol use than ICD codes.

CONCLUSIONS

NLP, an artificial intelligence-based approach, efficiently and accurately identifies alcohol-related risk in patients' EHRs. This approach could supplement other alcohol screening tools to identify patients in need of intervention, treatment, and/or postoperative withdrawal prophylaxis. Alcohol-related ICD diagnosis had limited utility relative to NLP, which extracts richer information within clinical notes to classify patients.

Physical Activity, Alcohol, and Cigarette Use in Urological Cancer Patients over Time since Diagnosis

Urological cancers represent a substantial global public health concern, exerting far-reaching effects on both individuals and their families. There is an urgent need to comprehensively understand the transformations in patients' lifestyles and behaviors, given their critical role in the treatment process and overall well-being. This study, involving 128 urological cancer patients, aims to investigate changes in physical activity levels, problematic drinking behaviors assessed through the Alcohol Use Disorders Identification Test (AUDIT), and smoking habits assessed using the Fagerström Test for Nicotine Dependence (FTND) over four distinct time intervals over the subsequent three years from the time of diagnosis and among individuals diagnosed more than three years ago. The results reveal a significant decrease in physical activity levels between study intervals (p < 0.0001), declining from 69% to 45% between the first and second post-diagnosis assessments. Furthermore, the highest levels of problematic substance use, indicated by mean scores, were noted in the first year following diagnosis (AUDIT: 4.20, p = 0.01; FTND: 4.83, p = 0.08). Given the significant impact of physical activity on the prospects of recovery, it is imperative to delve more deeply into the factors contributing to this decline and devise targeted interventions for its improvement. In the context of substance use, it is essential to ascertain whether the initially high levels are a result of coping with the cancer diagnosis or represent a turning point at which patients modify their behaviors and cease their addiction. A more thorough understanding of this phenomenon would enhance the effectiveness of precisely focused interventions.

Surgical Residents´ Results Seem to be Non-Inferior Comparing to More Experienced Surgeons in Femoral Neck Fracture Osteosynthesis

Purpose of the Study

Femoral neck fracture osteosynthesis is usually performed by using dynamic hip screw (DHS) or multiple parallel cannulated screws (MCS). In orthopedic surgery training, certain hip fractures are one of the most common operations performed by residents. It has been questioned, whether residents can provide as safe treatment and patient outcomes as those of more experienced surgeons. The aim of this study was to evaluate the effect of surgical experience on risk of complications by comparing the surgical performance and clinical outcomes in femoral neck osteosyntheses between surgical residents and orthopaedic surgeons.

Methods

All patients with femoral neck fracture admitted to Helsinki and Uusimaa Hospital District (HUS) Hyvinkää Hospital from 2011 to 2016 were collected as research material. 88 hip fractures (87 patients) treated with DHS or MCS osteosyntheses were included in this study. The patients were divided into 2 groups, based on the surgeon's experience: an orthopedic surgeon group (n = 68) and a surgical resident group (n = 20). All data from complications, reoperations, and the duration of operations were collected.

Results

There was no significant difference in characteristics of operated patients between orthopaedics and residents group. There was no significant difference in complications or re-operations between groups (p = 0.4, p = 0.2). Surgical residents had statistically longer surgical time (mean 76 min, 95% CI 62.92 min, mean 46 min, 95% Cl 42.51 min; p-value < 0.001). Still surgical time was not a risk factor for complication (p-value 0.5).

Conclusion

Our results show that surgical residents´ outcomes in femoral neck fracture osteosynthesis seem to be as favorable as those of orthopedic surgeons; the operations just last slightly longer.