American Surgeon最新文献

BackgroundChatbots and large language models, particularly ChatGPT, have led to an increasing number of studies on the potential for chatbots in patient education. In this systematic review, we aimed to provide a pooled assessment of the appropriateness and accuracy of chatbot responses in patient education across various medical disciplines.MethodsThis was a PRISMA-compliant systematic review and meta-analysis. PubMed and Scopus were searched from January-August 2023. Eligible studies that assessed the utility of chatbots in patient education were included. Primary outcomes were the appropriateness and quality of chatbot responses. Secondary outcomes included readability and concordance with published guidelines and Google searches. A random-effect proportional meta-analysis was used for pooling data.ResultsFollowing initial screening, 21 studies were included. The pooled rate of appropriateness of chatbot answers was 89.1% (95%CI: 84.9%-93.3%). ChatGPT was the most assessed chatbot. Responses, while accurate, were found to be at a college reading level as the weighted mean Flesh-Kincaid Grade Level was 13.1 (95%CI: 11.7-14.5) and the weighted mean Flesch Reading Ease Score was 38.6 (95%CI: 29- 48.2). Answers of chatbots to questions relevant to patient education had 78.6%-95% concordance with published guidelines in colorectal surgery and urology. Chatbots had higher patient education scores (87% vs 78%) than Google Search.ConclusionsChatbots provide largely accurate and appropriate answers for patient education. The advanced reading level of chatbot responses might be a limitation to their wide adoption as a source for patient education. However, they outperform traditional search engines and align well with professional guidelines, showcasing their potential in patient education.

Disparities in health care access have long affected both rural and urban communities across the United States. While much of the discourse has focused on rural hospital closures, inner-city hospitals-often safety-net institutions serving vulnerable populations-are increasingly shutting down due to financial instability, systemic underfunding, and policy changes. These closures have profound consequences for access to surgical care, exacerbating existing disparities and straining remaining health care infrastructure. Patients in affected urban areas face longer travel distances, increased wait times, and, in some cases, the inability to receive critical surgical interventions. This paper explores the impact of inner-city hospital closures on surgical care access, examining trends in urban hospital insolvency, disparities in surgical outcomes, and the financial and policy challenges that contribute to these closures. Through case studies of major hospital shutdowns, including Atlanta Medical Center and Hahnemann University Hospital, we highlight the real-world consequences of losing essential surgical services. We further analyze policy solutions such as Medicaid expansion, financial stabilization strategies, and community-driven health care initiatives that may mitigate these effects. Addressing urban hospital closures is imperative to ensuring equitable access to timely surgical care in underserved populations.

BackgroundThe advent of biologic therapy has been used as a surrogate marker for the shift from reactive to preventative management and surveillance for inflammatory bowel disease (IBD). This shift has resulted in earlier detection, earlier medical therapy, and increased bowel preservation in many published series.MethodsA retrospective population-based study was conducted in adult patients (age ≥18) with an IBD diagnosis using SCPMG Clinical & Administrative Database containing diagnostic, prescribing, and billing codes for IBD and IBD-related gastrointestinal surgery. An Interrupted Time Series design with a segmented regression analysis was used to estimate the rate of change in bowel resection and/or strictureplasty before and after the introduction of biologic therapy (1993-1999 and 1999-2009).ResultsBowel resection and/or strictureplasty rate of change was higher between 1993 and 1999, with a rate of -0.26 (P < 0.0001, 95% CI: -0.34 to -0.18), compared to -0.10 between 1999 and 2009. The difference in the rates of change between 2 time periods (0.16) was significant (α = 0.05, P = 0.0003, 95% CI: 0.07 to 0.24).DiscussionA declining trend in bowel resection rates was evident before the introduction of biologic therapy in IBD patients. This finding suggests that the transition from reactive to preventative management and surveillance began well before the biologic era within our health care system.

In 1916 Paul Kaznelson (1892-1959), a 26-year-old medical student at German University in Prague, was the first to describe splenectomy for what would be recognized today as immune thrombocytopenic purpura (ITP). From his physical examination, microscopy of a blood smear, and what was then known about the life cycle of platelets, he concluded that his patient's bleeding diathesis and enlarged spleen were linked: she had no platelets because they were being destroyed by the organ. He convinced the chief of surgery to remove the patient's spleen, a landmark operation that succeeded beyond "the wildest expectations". He stayed on faculty, but his promising academic career was derailed by virulent antisemitism, first in his own university medical school, then his home country. Forced into exile in 1939 he found refuge in the United Kingdom, which allowed him to practice medicine but denied him formal residency. At war's end he found himself unwanted in the West by his Russian heritage and citizenship in an Iron Curtain country. Czechoslovakia's newly installed communist regime barred his repatriation due to the ambiguous circumstances of his wartime residency in England. Today treatment of ITP is directed toward controlling autoimmune reaction against platelet antigens. Splenectomy is done only after nonsurgical options have been exhausted. The operation and its history are a fading coda to the story of a medical prodigy whose career was crushed by prejudice and world events.

The perioperative period poses significant physiological challenges, often leading to complications such as organ injury and systemic inflammation, which impact surgical outcomes. Growth differentiation factor 15 (GDF15), a stress-responsive cytokine within the TGF-β superfamily, has emerged as a promising biomarker and therapeutic target in perioperative medicine. This review synthesizes current evidence on GDF15's multifaceted roles across various surgical contexts. As a predictive biomarker, GDF15 demonstrates superior accuracy in stratifying risks for postoperative complications, particularly in cardiovascular and transplant surgeries, outperforming traditional markers like CRP and BNP. Mechanistically, GDF15 contributes to organ protection by modulating inflammation, mitochondrial function, and tissue repair pathways. In bariatric surgery, GDF15 mediates sustained metabolic benefits, while in sepsis, it reflects mitochondrial stress and immune dysfunction. Despite its potential, challenges such as context-dependent pleiotropy, assay variability, and unresolved mechanistic pathways hinder clinical translation. Future directions include advancing receptor-specific therapies, standardizing assays, and integrating GDF15 into AI-driven predictive models. By decoding its complex biology, GDF15 could revolutionize personalized perioperative care, enhancing surgical resilience and outcomes across diverse clinical scenarios.

BackgroundEmergent paraesophageal hernia repair (emPEHR) may be required due to complications such as incarceration or gastric volvulus. However, data regarding changes in management and outcomes of emPEHR is limited. Our objective was to evaluate national trends in emPEHR over an 8-year period.MethodsThe 2015-2022 ACS-NSQIP databases were queried for cases of emPEHR using Current Procedural Terminology (CPT) codes. Trends in patient demographics, operative characteristics, and 30-day postoperative outcomes were evaluated.ResultsA total of 42 476 cases of PEHR were performed during the study period. Of these, 1583 (3.7%) were emergent. The proportion of emPEHR cases has increased from 2015 to 2022 (3.1% to 5.6%, P < 0.001). Utilization of laparoscopy has increased from 60.3% to 79.1% (P < 0.001). Emergent cases had a higher likelihood of wound (OR 4.0, P < 0.001), pulmonary (OR 4.5, P < 0.001), neurovascular (OR 3.9, P < 0.001), renal (OR 2.5, P < 0.001), and cardiac (OR 2.0, P < 0.001) complications, sepsis (OR 6.4, P < 0.001), reoperation (OR 1.9, P < 0.001), readmission (OR 1.5, P < 0.001), and mortality (OR 4.5, P < 0.001) compared to elective cases. However, between, there was a decrease in renal complications (6.9% to 1.7%, P = 0.004) and bleeding requiring transfusions (6.9% to 3.7%, P < 0.001) following emPEHR.DiscussionThere has been an increase in rates of emergent PEHR since 2015. Emergent cases have poorer outcomes compared to elective cases, with only a minimal decrease in certain postoperative complications over time. This data highlights the importance of elective repair for PEHs and the need to proactively identify patients who will benefit from elective repair or specialist referral.

BackgroundTraumatic rib fractures can lead to respiratory complications necessitating unplanned intubation, but predictors have been inadequately delineated. We used interpretable machine learning to predict unplanned intubations in rib fracture patients while identifying predictors.MethodsTQIP 2017-2022 was queried for adult patients admitted to the hospital following a rib fracture injury. An XGBoost model was developed to predict unplanned intubation using variables that can be known on admission. A 70/10/20 train/validation/test split was used. SHapley Additive exPlanations (SHAP) were used for interpretation. SHAP allows individualized interpretation of predictors for each patient.ResultsThe cohort had 905 615 patients; 2.3% had unplanned intubations. Model metrics at the F1 maximizing threshold (0.78) included AUROC = 0.83, F1 score = 0.17, accuracy = 0.94, precision = 0.12, recall = 0.29, specificity = 0.95, and Brier score = 0.17. The most influential variables, as determined by mean absolute SHAP values, were admission location (0.62), Injury Severity Score (0.40), age (0.37), absence of comorbidities (0.18), pulse rate (0.14), pneumothorax (0.13), oxygen saturation (0.15), chronic obstructive pulmonary disease (0.11), respiratory rate (0.10), and sex (0.10). ICU admission was the location most influential in predicting an unplanned intubation. SHAP dependency plots determined the directional relationship between variables' values and SHAP values.DiscussionPatients above the F1 maximizing threshold had a 7.4-fold increase in unplanned intubations compared to those below. Nearly 30% of all unplanned intubations were captured at this threshold. Our model's identification of these high-risk patients and influential factors not previously considered in the literature could guide closer monitoring and early interventions.

Stop the Bleed™, the education program created by the American College of Surgeons to address life-threatening bleeding, came from concepts of combat casualty care in tactical settings in the US military. Tourniquet control of exsanguinating extremity injuries dates from its first recorded use in the French military in the 17th century and its general issue to ships of the Royal Navy during the Napoleonic Wars. Wound packing and pressure dressings, specifically in junctional sites and head and neck, also date from the 16th century, illustrating the priority of hemorrhage control throughout the history of military medicine.

Inattentional Blindness (IB) is a cognitive phenomenon where individuals fail to notice both obvious and unexpected stimuli while focused on other tasks. It can have significant implications for performance, especially in healthcare. This study investigated the prevalence and nature of IB among surgical and internal medicine (IM) residents. Results indicated that IM residents more frequently identified a relevant stimulus, a lung nodule (81.3%) compared to surgical residents (57.1%), though the difference was not statistically significant. However, surgical residents more often noted an irrelevant stimulus, a gorilla, compared to IM residents (85.7% vs 50.0%, P < 0.02). The study documents the existence of IB among residents with differences in detection between specialties. The findings suggest the potential importance of teaching residents to recognize and address perceptual flaws in clinical work. Future research should explore strategies to mitigate IB, optimizing clinical performance and patient safety.

Background: During colorectal cancer (CRC) surveillance, tumor markers, such as carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9), play important roles in the diagnosis, prediction, and monitoring of tumors. Herein, we devised a novel combined index comprising the CA19-9-to-CEA ratio and investigated its prognostic value in patients with stage I-III CRC after resection. Methods: This retrospective study included 306 patients who underwent radical resection between 2011 and 2020. CA19-9 and CEA levels were evaluated preoperatively. The CA19-9-to-CEA ratio cutoff value was determined via receiver-operating characteristic analysis using the survival status at the 5-year follow-up evaluation. Multivariate Cox proportional hazard models were used to assess disease-free survival (DFS) and overall survival (OS). Results: According to the multivariate analysis, T3 or T4 tumor (P = 0.041; hazard ratio [HR], 2.54), pathological stage III (P = 0.001; HR, 3.07), serum CEA level ≥5.0 ng/mL (P = 0.018; HR, 2.11), and high CA19-9-to-CEA ratio (P = 0.015; HR, 2.89) were independently associated with DFS. Age 65≥ years (P = 0.03; HR, 2.86), pathological stage III (P = 0.001; HR, 2.00), high neutrophil-to-lymphocyte ratio (P = 0.003; HR, 2.27), and high CA19-9-to-CEA ratio (P = 0.009; HR, 3.16) were independent prognostic factors for OS. Patients with high CA19-9-to-CEA ratios had significantly worse DFS (P < 0.001) and OS (P < 0.001). Discussion: A high CA19-9-to-CEA ratio can be used for detailed risk prediction in patients with CRC.