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CORK Bibliography: Surgery

58 citations. January 2010 to present

Prepared: March 2012

Angarita FA; Acuna SA; Torregrosa L; Tawil M; Escallon J; Ruiz A. Perioperative variables associated with surgical site infection in breast cancer surgery. Journal of Hospital Infection 79(4): 328-332, 2011. (49 refs.)

Despite the fact that breast operations are usually categorized as clean procedures, higher surgical site infection (SSI) rates are reported. This study aimed to determine the perioperative variables related to SSI in breast cancer patients. Medical records of breast cancer patients undergoing surgery between January 2005 and August 2007 at a university based hospital were reviewed. Preoperative, intraoperative, and postoperative clinical data from 199 patients were extracted and analysed. Overall, the SSI rate was 19.1% (38 cases). SSI was associated with a high body mass index (P = 0.001), history of diabetes mellitus (P < 0.0001), smoking (P < 0.0001), or active skin disorders (P < 0.0001). Other SSI-related variables included a tumour at an advanced clinical stage (P = 0.003) and neoadjuvant therapy (P = 0.003). Breast-conserving operations were less frequently associated with SSI than were radical procedures (mastectomy alone and mastectomy followed by immediate reconstruction) (P = 0.0001).

Aveyard P; Dautzenberg B. Temporary abstinence from smoking prior to surgery reduces harm to smokers. International Journal of Clinical Practice 64(3): 285-288, 2010. (17 refs.)

Balch CM; Bechamps G. Substance abuse among surgeons: The perils of losing your credentials. (editorial). Archives of Surgery 146(11): 1291-1292, 2011. (2 refs.)

Bozbas SS; Yilmaz EB; Dogrul I; Ergur FO; Savas N; Eyuboglu F et al. Preoperative pulmonary evaluation of liver transplant candidates: Results from 341 adult patients. Annals of Transplantation 16(3): 88-96, 2011. (22 refs.)

Background: Pulmonary disorders are among the commonly encountered and prognostically important problems in patients with chronic liver disease. To define the prevalence and types of respiratory disorders in patients with advanced liver disease evaluated for liver transplant (LT) candidacy, and to determine factors affecting postoperative outcome. Material/Methods: The records of 341 adult patients evaluated for LT candidacy were retrospectively examined. Demographic, clinical and laboratory data including chest X-ray, spirometry and echocardiography results were collected. Postoperative pulmonary complications and mortality rates were determined. Results: With a mean age of 45.1 years, 73 (21.4%) patients presented with respiratory symptoms or signs. The most common radiographic abnormality on chest X-ray was right diaphragm elevation (53.2%). Hypoxemia was detected in 38.1% of the patients. Pulmonary hypertension was detected in 100 of 327 (30.6%) patients on Doppler echocardiography. There were 141 patients who underwent surgery. Postoperative pulmonary complications developed in 60 patients, with pneumonia being the most prevalent complication (n=28). Smoking, emphysema, abnormal spirometry, pulmonary hypertension, hypoxia and orthodeoxia were found to be factors associated with increased postoperative pulmonary complications (P < 0.05 for all). Mortality rate was 24.1% (n=34) and found to be significantly higher in patients who developed a postoperative complication than in those who did not (38.7% vs. 13.8%, respectively; p=0.001). Conclusions: The authors' findings indicate that pulmonary disorders impact prognosis and are common in patients evaluated for LT candidacy. Postoperative pulmonary complication is one of the major factors affecting mortality. Therefore, in order to increase the success of the transplant operation, a thorough preoperative pulmonary evaluation is of paramount importance.

Brattwall M; Stomberg MW; Rawal N; Segerdahl M; Houltz E; Jakobsson J. Postoperative impact of regular tobacco use, smoking or snuffing, a prospective multi-center study. Acta Anaesthesiologica Scandinavica 54(3): 321-327, 2010. (18 refs.)

Background: The aim was to study the effects of different tobacco administration routes on pain and post-operative nausea and vomiting (PONV), following three common day surgical procedures: cosmetic breast augmentation (CBA), inguinal hernia repair (IHR) and arthroscopic procedures (AS). We have prospectively investigated the effects of regular tobacco use in ambulatory surgery. Methods: The 355 allocated patients were followed during recovery and the first day at home. Results: Thirty-two percent of the patients used tobacco regularly, 33% of CBA, 27% of IHR and 34% of AS. Pain was well controlled in the post-anesthesia care unit at rest; during ambulation, 37% of all patients reported VAS > 3. Tobacco use had no impact on early post-operative pain. Post-operative nausea was experienced by 30% of patients during recovery while in hospital. On day 1, 14% experienced nausea. We found a significant reduction of PONV among tobacco users (smoking and/or snuffing). Smoking or snuffing reduced the risk of PONV by nearly 50% in both genders on the day of surgery and at the first day at home. The reduction of PONV was equal, regardless of tobacco administration routes. Conclusion: We found that regular use of tobacco, both by smoking and snuffing, had a significant effect on PONV during the early post-operative period. Non-tobacco users undergoing breast surgery were found to have the highest risk for PONV. We could not see any influence of nicotine use on post-operative pain. Thus, it seems of value to identify regular tobacco use, not only smoking, as a part of the pre-operative risk assessment.

Burra P; Senzolo M; Adam R; Delvart V; Karam V. Liver transplantation for alcoholic liver disease in Europe: A study from the ELTR (European Liver Transplant Registry). American Journal of Transplantation 10(1): 138-148, 2010. (25 refs.)

Alcohol-related liver disease (ALD) is one of the most common indications for liver transplantation (LT). Long-term outcome after LT for ALD versus other etiologies is still under debate. The aim of this study was to compare outcome after LT of patients with ALD, viral (VIR), and cryptogenic cirrhosis. Donor, graft and recipient ELTR variables were analysed in transplants for alcoholic and nonalcoholic cirrhosis (1988-2005) and were correlated with patient survival. Causes of death and/or graft failure were compared between groups. Nine thousand eight hundred eighty ALD, 10 943 VIR, 1478 ALD + VIR and 2410 cryptogenic (CRYP) liver transplants were evaluated. One, 3, 5 and 10 years graft survival rates after LT in ALD patients were 84%, 78%, 73%, 58%, significantly higher than in VIR and CRYP (p = 0.04, p = 0.05). By multivariate analysis, ALD + VIR (RR 1.14) and viral alone (RR 1.06) were significant risk factors for mortality. De novo tumors, cardiovascular and social causes were causes of death/graft failure in higher percentage in ALD groups versus other etiologies. LT for ALD cirrhosis has a favorable outcome, however, hepatitis C virus co-infection seems to eliminate this advantage. Screening for de novo tumors and prevention of cardiovascular complications are essential to provide better long-term results.

Carbonneau M; Jensen LA; Bain VG; Kelly K; Meeberg G; Tandon P. Alcohol use while on the liver transplant waiting list: A single-center experience. Liver Transplantation 16(1): 91-97, 2010. (23 refs.)

Alcoholic liver disease (ALD) is a leading indication for liver transplantation. Our center has randomly checked blood alcohol levels (BALs) in ALD patients on the waiting list since 2004. We aimed to identify the incidence and predictors of inactivation on the transplant list due to alcohol use and to determine the utility of BAL-screening in this process. We conducted a retrospective review of patients with ALD listed for liver transplantation with at least 3 months of postlisting follow-up. Alcohol use while on the transplant list was defined as a positive BAL, an admission of alcohol use, or refusal to perform screening within 12 hours of request. Cox proportional hazards regression was used to estimate risk ratios (RRs). Of 134 patients meeting eligibility criteria, 78% were male, and mean age was 52 years. Alcohol use was documented in 23 patients (17%). Of these, 12 refused to have a random screen, 8 had detectable serum ethanol levels, and 3 had self-reported alcohol use. On multivariable analysis, a higher number of random BAL-checks [RR = 0.63(0.52, 0.76), P = 0.001] and a longer duration of prelisting abstinence [RR = 0.88(0.83, 0.94), P = 0.001] independently reduced the risk of alcohol use by patients while on the waiting list. None of the patients with > 24 months of prelisting abstinence had a positive screen. In conclusion, this study supports random BAL-screening before transplantation and reinforces the importance of abstinence duration as a predictor of relapse. For patients with < 24 months of prelisting abstinence, our center will increase the frequency of random BAL screening and increase the rehabilitation requirements to include an intensive 3-week rehabilitation program. We hope that these measures will reduce the rate of relapse to alcohol use post-transplantation.

Carlfjord S; Kristenson M; Lindberg M. Experiences of working with the tobacco issue in the context of health promoting hospitals and health services: A qualitative study. International Journal of Environmental Research and Public Health 8(2): 498-513, 2011. (27 refs.)

The worldwide Health Promoting Hospital and Health Services (HPH) network was initiated by the World Health Organizations in the late 1980s. The goal of the network is to change the focus of health services from curing patients to also embrace disease prevention and health promotion. In Sweden the network started in 1996, and involves mainly hospitals and primary care. The network members collaborate in task forces, one of which is working on the tobacco issue. There is limited evidence on the value of working within an HPH organization. The aim of this study was to investigate the experiences of members of the Swedish HPH network tobacco task force. Focus group interviews with task force members were analyzed using implementation theory. Three themes, overall experiences of working with tobacco issues, experiences of working with. free from tobacco in connection with surgery, and experiences of work in the HPH tobacco task force, emerged from the interviews. The results show that working with the tobacco issue in the context of health-promoting hospitals and health services met with difficulties involving the following important factors: evidence, context, facilitation and adopter characteristics. Leadership, one contextual factor, at national and local level, seems to be crucial if the work is going to succeed. The tobacco task force of the HPH network is an important facilitator supporting the task.

Cataldo JK; Dubey S; Prochaska JJ. Smoking cessation: An integral part of lung cancer treatment. (review). Oncology 78(5-6): 289-301, 2010 , 2010. (92 refs.)

Lung cancer is the leading cause of cancer death in the US. About 50% of lung cancer patients are current smokers at the time of diagnosis and up to 83% continue to smoke after diagnosis. A recent study suggests that people who continue to smoke after a diagnosis of early-stage lung cancer almost double their risk of dying. Despite a growing body of evidence that continued smoking by patients after a lung cancer diagnosis is linked with less effective treatment and a poorer prognosis, the belief prevails that treating tobacco dependence is useless. With improved cancer treatments and survival rates, smoking cessation among lung cancer patients has become increasingly important. There is a pressing need to clarify the role of smoking cessation in the care of lung cancer patients. Objective: This paper will report on the benefits of smoking cessation for lung cancer patients and the elements of smoking cessation treatment, with consideration of tailoring to the needs of lung cancer patients. Results: Given the significant benefits of smoking cessation and that tobacco dependence remains a challenge for many lung cancer patients, cancer care providers need to offer full support and intensive treatment with a smoking cessation program that is tailored to lung cancer patients' specific needs. Conclusion: A tobacco dependence treatment plan for lung cancer patients is provided.

Cherkassky L. A fair trial? Assessment of liver transplant candidates with psychiatric illnesses. Journal of Medical Ethics 37(12): 739-742, 2011. (18 refs.)

Allocating scarce organs to transplant candidates is only one stage in the long process of organ transplantation. Before being listed, all candidates must undergo a rigorous assessment by a multidisciplinary transplant team. The Department of Health and NHS Blood and Transplant (NHSBT) are responsible for the development of detailed strategies to ensure a fair and objective assessment experience for all transplant candidates. Difficulties arise when particularly vulnerable candidates, such as candidates with psychiatric illnesses, are assessed. NHSBT has already developed unique assessment guidelines for alcoholic and substance-abusing liver transplant candidates to allow for a more comprehensive evaluation, but candidates with psychiatric illnesses are still assessed against general criteria. Should these candidates be assessed against their own criteria? On what clinical grounds do transplant teams justify excluding such candidates from transplantation? Is redress available for candidates who feel they have been unfairly refused a liver transplant simply because of their psychiatric illness? This essay will critically examine the provisions published by the Department of Health and NHSBT for the assessment of liver transplant candidates with psychiatric illnesses, and will provide a commentary as to whether enough is being done to protect these particularly vulnerable candidates from inconsistent assessment decisions.

Cone JD; Harrington MA; Kelley SS; Prince MD; Payne WG; Smith DJ. Drug abuse in plastic surgery patients: Optimizing detection and minimizing complications. Plastic and Reconstructive Surgery 127(1): 445-455, 2011. (42 refs.)

Drugs of abuse present numerous challenges to plastic surgeons, and detection remains difficult. With rates of drug abuse and misuse on the rise, clinicians must remain especially attentive to drug abusers' verbal and nonverbal cues, and be familiar with treating perioperative complications if they arise. Informed deductions regarding drug abuse can enable a plastic surgeon to identify drug abuse, minimize complications, and optimize patient care.

Czarnetzki C; Schiffer E; Lysakowski C; Haller G; Bertrand D; Tramer MR. Transcutaneous nicotine does not prevent postoperative nausea and vomiting: A randomized controlled trial. British Journal of Clinical Pharmacology 71(3): 383-390, 2011. (19 refs.)

There is empirical evidence that smokers are less likely to suffer from postoperative nausea and vomiting (PONV). center dot Tobacco smoke is known to induce enzymes, for instance, cytochrome P450, and this may partially explain the PONV-protecting effect of smoking. center dot Chronic exposure to nicotine that is contained in the tobacco may lead to a desensitization of central nicotine receptors, and, subsequently, to an increased tolerance to the emetogenic effects of surgery and anaesthesia. WHAT THIS STUDY ADDS: center dot In non-smokers undergoing surgery under general anaesthesia, pre-operatively administered transcutaneous nicotine did not decrease the incidence of PONV within 24 h. center dot Patients receiving nicotine had a tendency to develop PONV symptoms earlier than controls. center dot Exposure to transcutaneous nicotine significantly increased the risk of insomnia during the first postoperative night. AIMS: There is empirical evidence that smokers are less likely to suffer from postoperative nausea and vomiting (PONV). We sought to investigate whether transcutaneus nicotine prevents PONV. METHODS: Non-smokers receiving general anaesthesia for surgery were randomly allocated to Nicotinell (R) Patch 10 cm2 (TTS 10), containing 17.5 mg of nicotine (average delivery rate, 7 mg 24 h-1) or matching placebo patch. Patches were applied 1 h before surgery and were left in situ until 24 h after surgery (or until the first PONV symptoms occurred). RESULTS: We randomized 90 patients (45 nicotine, 45 placebo). In the post-anaesthetic care unit, the incidence of nausea was 22.2% with nicotine and 24.4% with placebo (P = 0.80), and the incidence of vomiting was 20.0% with nicotine and 17.8% with placebo (P = 0.78). Cumulative 24 h incidence of nausea was 42.2% with nicotine and 40.0% with placebo (P = 0.83), and of vomiting was 31.1% with nicotine and 28.9% with placebo (P = 0.81). PONV episodes tended to occur earlier in the nicotine group. Postoperative headache occurred in 17.8% of patients treated with nicotine and in 15.6% with placebo (P = 0.49). More patients receiving nicotine reported a low quality of sleep during the first postoperative night (26.7% vs. 6.8% with placebo; P = 0.01). CONCLUSIONS: Non-smokers receiving a prophylactic nicotine patch had a similar incidence of PONV during the first 24 h and tended to develop PONV symptoms earlier compared with controls. They had a significantly increased risk of insomnia during the first postoperative night.

Daneman N; Lu H; Redelmeier DA. Discharge after discharge: Predicting surgical site infections after patients leave hospital. Journal of Hospital Infection 75(3): 188-194, 2010. (24 refs.)

In this population-based retrospective cohort study, we examined the frequency, severity, and prediction of post-discharge surgical site infections (SSIs). We evaluated all patients admitted for their first elective surgical procedure in Ontario, Canada, between 1 April 2002 and 31 March 2008. Procedure and patient characteristics were derived from linked hospital, emergency room and physician claims databases within Canada's universal healthcare system. The 30 day risk of SSI was derived from the initial hospital admission, outpatient consultations, return emergency room visits and readmissions. The cohort included 622 683 patients, of whom 84 081 (13.5%) were diagnosed with SSI, and more than half (48 725) were diagnosed post-discharge. Post-discharge infections were associated with an increased risk of reoperation (odds ratio: 2.28; 95% confidence interval: 2.11-2.48), return emergency room visit (9.08; 8.89-9.27), and readmission (6.16; 5.98-6.35). The most common risk index predicted incremental increases in the risk of in-hospital SSI, but did not predict increases in the risk of post-discharge infection. Patients with post-discharge infections had baseline characteristics more akin to uninfected patients than patients with in-hospital infections. Predictors of post-discharge infection included shorter procedure duration, shorter length of stay, rural residence, alcoholism, diabetes and obesity. Post-discharge SSIs are frequent, severe, scattered over time and location, and hard to predict using common risk indices. They represent an important hidden burden in our healthcare system.

Danker H; Keszte J; Singer S; Thoma J; Taschner R; Brahler E et al. Alcohol consumption after laryngectomy. Clinical Otolaryngology 36(4): 336-344, 2011. (32 refs.)

Objective: The aim of the study was the analysis of drinking behaviour in laryngectomised patients and its concomitants in quality of life and mental health. Study design: Multi-centered cross-sectional study. Participants and setting: Two hundred and twenty-five laryngectomised patients were asked to participate in the study. One hundred and seventy nine patients (80%) were interviewed after laryngectomy at six different ENT clinics in Germany. Main outcome measures: 'Questionnaire of Health Behaviour' (FEG), 'Short Questionnaire of Alcohol Risk', Hospital Anxiety and Depression Scale (HADS), Hornheider Questionnaire (HFB), Visual Analogue Scales (VAS) and the Quality of Life Questionnaires of the European Organization of Research and Treatment of Cancer (EORTC) (EORTC QLQ-C30, EORTC QLQ-H & N35). Results: Alcohol dependence was found in 7% of the patients. Half of the respondents showed a constant consumption of alcohol with 6% of the patients who wanted to change their consumption. Patients with alcohol dependence indicated in comparison with non-dependent persons increased anxiety (p = 0.03), problems in coping with illness (p = 0.03), increased psychosocial care needs (p = 0.02), fatigue (p = 0.04), shortness of breath (p = 0.04), diarrhoea (p = 0.02) and a worse emotional functioning level (p = 0.03). Alcohol intake was independent of tumour stage (p = 0.48), employment status (p = 0.54), social class (p = 0.82), the time interval since laryngectomy (p = 0.64) and type of voice substitute (p = 0.76). The quality of life and mental state were independent of the amount of alcohol consumed. Conclusions: The results show that alcohol dependence is associated with adverse psychosocial and medical consequences, which require treatment. Socio-demographic and medical parameters do not allow any conclusions to alcoholism risk. Therefore, an individual exploration of the patients' drinking behaviour is needed, which could prepare the ground to specific treatment.

De Gottardi A; Hilleret MN; Gelez P; La Mura V; Guillaud O; Majno P et al. Injection drug use before and after liver transplantation: A retrospective multicenter analysis on incidence and outcome. Clinical Transplantation 24(4): 564-571, 2010 , 2010. (20 refs.)

Background and aims: Injecting drug use (IDU) before and after liver transplantation (LT) is poorly described. The aim of this study was to quantify relapse and survival in this population and to describe the causes of mortality after LT. Methods: Past injection drug users were identified from the LT listing protocols from four centers in Switzerland and France. Data on survival and relapse were collected and used for uni- and multivariate analysis. Results: Between 1988 and 2006, we identified 59 patients with a past history of IDU. The mean age at transplantation was 42.4 yr and the majority of patients were men (84.7%). The indication for LT was for the vast majority viral cirrhosis accounting for 91.5% of cases, while alcoholic cirrhosis was 5.1%. There were 16.9% of patients who had a substitution therapy before and 6.8% who continued after LT. Two patients (3.4%) relapsed into IDU after LT and died at 18 and 41 months. The mean follow-up was 51 months. Overall survival was 84%, 66%, and 61% at 1, 5, and 10 yr after transplantation. Conclusions: Documented IDU was rare in liver transplanted patients. Past IDU was not associated with poorer survival after LT, and relapse after LT occurred in 3.4%.

Dom G; Francque S; Michielsen P. Risk for relapse of alcohol use after liver transplantation for alcoholic liver disease: A review and proposal of a set of risk assessment criteria. (review)18. Acta Gastro-Enterologica Belgica 73(2): 247-251, 2010 , 2010. (18 refs.)

Background : Liver transplantation for end stage alcoholic liver disease is becoming an increasingly frequent procedure. Within this context assessing the risk on relapse in alcohol use is a major issue. However, up to now, there is a clear lack in validated criteria that can be used to assess future relapse risk. Method : Literature review based upon Medline search identifying all new studies that have been published after the latest meta-analysis on this subject (2007-2009). Results : Five new original studies were identified. They provide new evidence for the prospective validity of different criteria; pre-transplant abstinence duration, diagnosis of alcohol dependence versus abuse, level of social support, additional psychiatric co-morbidity. Conclusions: These criteria seem promising as to the prediction of relapse in alcohol after liver transplantation. Based upon these results a new comprehensive assessment scale is proposed.

Epstein RH; Gratch DM; McNulty S; Grunwald Z. Validation of a system to detect scheduled drug diversion by anesthesia care providers. Anesthesia and Analgesia 113(1): 160-164, 2011. (6 refs.)

BACKGROUND: We recently described a method to identify drug diversion in the operating room (OR) from automated drug dispensing carts by anesthesia care providers, based on a retrospective outlier analysis of atypical transactions. Such transactions included those occurring on patients after their exit from the OR and on patients whose drugs were not dispensed at the location where the case was performed. In this report, we demonstrate prospectively the utility of our methodology to detect diversion by unsuspected individuals. METHODS: Each month, all transactions involving scheduled drugs by anesthesia care providers are downloaded from the pharmacy database and matched to case records from the anesthesia information management system. The frequency of atypical transactions is determined for each provider, normalized by the number of days they worked in the OR. For individuals who are > 2 SDs above the mean for the month for any of the screening queries, a manual examination of their drug transaction logs is performed. Anesthesia records for such providers are examined manually to help determine the likelihood that diversion is taking place, and evidence of escalating activity is considered. Actions taken depend on an assessment of the strength of the evidence that diversion has been occurring. RESULTS: Two unsuspected individuals were identified prospectively as diverting drugs. Two individuals identified as abusing drugs recreationally outside the workplace showed no evidence of drug diversion through examination of the screening reports and transaction logs, and their rehabilitation treatment teams concurred that there was a very low probability of diversion. A final individual who demonstrated suspicious activity by the screening process was determined to have been careless in documentation practices, rather than diverting. CONCLUSIONS: The drug diversion screening methodology previously developed is valid for the prospective detection of unsuspected individuals diverting drugs from the OR. The system also provides material useful in the evaluation of possible diversion by anesthesia providers determined to be abusing drugs outside the workplace.

Gjeilo KH; Stenseth R; Klepstad P; Lydersen S; Wahba A. Patterns of smoking behaviour in patients following cardiac surgery. A prospective study. Scandinavian Cardiovascular Journal 44(5): 295-300, 2010 , 2010. (24 refs.)

Objectives. To describe patterns of smoking behaviour in patients undergoing cardiac surgery. Design. A prospective population-based study of patients undergoing cardiac surgery between September 2004 and September 2005. Smoking behaviour and socio-demographic variables were obtained by questionnaires at baseline, six and 12 months after surgery. Results. At baseline 534 patients (median age 69 years, 23% females) were included, 89% responded after six and 12 months. At baseline 14% (n=74) were current smokers, 59% (n=316) were former smokers and 27% (n=143) had never smoked. At six months 8% were current smokers (n=36) while 9% (n=40) were current smokers at 12 months. A total of nine smokers had relapsed at 12 months. Conclusion. About half of the current smokers gave up smoking after cardiac surgery. Changes in smoking behaviour were most likely to occur during the first six months. This supports that smoking cessation interventions should continue after discharge. Cardiac surgery can serve as a teachable moment; an opportunity to encourage patients to give up smoking and prevent relapses among those who stopped smoking before surgery.

Gold MS; Graham NA; Goldberger BA. Second-hand and third-hand drug exposures in the operating room: A factor in anesthesiologists' dependency on fentanyl. Journal of Addictive Diseases 29(3): 280-281, 2010. (8 refs.)

Gombos P; Langer RM; Korbely R; Varga M; Kaposi A; Dinya E et al. Smoking following renal transplantation in Hungary and its possible deleterious effect on renal graft function. Transplantation Proceedings 42(6): 2357-2359, 2010 , 2010. (9 refs.)

Smoking is a known risk factor for kidney damage and also influences graft function following renal transplantation. Because smoking habits following kidney transplantation are not systematically evaluated, we analyzed them in a single center in Hungary. The survey was conducted among 402 randomly selected kidney graft recipients. We assessed smoking-related questions as well as clinical kidney disease and transplantation data. Posttransplantation renal function was analyzed based on serum creatinine values at 1 month and at 3 years after transplantation. In our study 25% (n = 102) of patients continued to smoke after transplantation. Smokers who received grafts displayed a significantly younger age compared with nonsmokers (40.1 +/- 13.4 vs 47.1 +/- 12.7 years; P < .001) independent of underlying kidney disease. Posttransplantation kidney function in smokers did not differ at 1 month after engraftment, but was significantly impaired at 3 years as assessed based on serum creatinine levels: 138.9 +/- 42.4 versus 128.4 +/- 48.5 mu mol/L (P < .05). Decrease of renal function correlated with smoking intensity defined in pack-years (r(2) = 0.102; P < .05). Smoking is common following kidney transplantation in Hungary and might represent a risk factor for kidney damage following renal transplantation. Therefore, effective tobacco-dependence treatment is necessary in this patient population.

Gourgiotis S; Aloizos S; Aravosita P; Mystakelli C; Isaia EC; Gakis C et al. The effects of tobacco smoking on the incidence and risk of intraoperative and postoperative complications in adults. (review). Surgeon: Journal of the Royal Colleges of Surgeons of Edinburgh and Ireland 9(4): 225-232, 2011. (83 refs.)

Introduction: Despite the warnings of health hazards of cigarette smoking, still one third of the population in industrial countries smoke. This review was conducted with the aim of exploring the effects of preoperative tobacco smoking on the risk of intra- and postoperative complications and to identify the value of preoperative smoking cessation. Methods: The databases that were searched included The Cochrane Library Database, Medline, and EMBASE. Articles were also identified through a general internet search using the Google search engine. The incidence or risk of different types of intra- and postoperative complications were used as outcome measures. Results: Tobacco smoking has a negative effect on surgical outcome, as has been found to be a risk factor for the development of complications during and after many types of surgery, even in the absence of chronic lung disease. Furthermore, the long-term health hazards of smoking reduce health-related quality of life and premature death. Conclusion: It is widely documented that stopping smoking before surgery has substantial health benefits in the longer term and should be recommended to every smoker in order for them to gain maximum benefit from their treatment. However, identification of the optimal period of preoperative smoking cessation on postoperative complications cannot be determined.

Haller DL; Acosta MC; Lewis D; Miles DR; Schiano T; Shapiro PA et al. Hair analysis versus conventional methods of drug testing in substance abusers seeking organ transplantation. American Journal of Transplantation 10(5): 1305-1311, 2010. (35 refs.)

As substance abusers need to demonstrate abstinence prior to transplant, valid/reliable drug tests are needed. Patients may deny use, fearing surgery will be delayed. Breath, blood and urine tests have brief detection windows that allow patients to evade detection. Routine laboratory tests do not include all substances of abuse. Hair analysis overcomes these barriers, increasing the likelihood that active users will be identified. This study compared results for alcohol, opioids and cocaine based on 445 self-report, breath, urine and hair samples from 42 patients who had been denied a transplant due to recent substance abuse. Compared to hair toxicology, sensitivity for conventional drug tests was moderate for cocaine and opioids, but poor for alcohol. Of positive hair tests, only half were corroborated through other tests. In contrast, specificity was high across tests and substances, with positive findings from conventional tests confirmed through hair toxicology. Based on a 90-day detection window for hair analysis, two negative tests suggest 6 months of continuous abstinence. Hair testing should be considered as an alternative approach for monitoring substance use in the transplant population, either as a routine procedure or when the veracity of findings from conventional tests is in doubt.

Hantson P; Capron A; Wallemacq P. Toxicokinetics of cocaine and metabolites in a body-packer becoming symptomatic. Journal of Forensic and Legal Medicine 18(8): 385-387, 2011

Life-threatening complications may occur in body-packers and the rupture of a single packet containing cocaine may lead to fatality. We report the case of a 35-year-old body-packer who developed at the airport clinical signs of cocaine toxicity. There was evidence of bowel obstruction. The plasma concentration of cocaine, benzoylecgonine (BZE) and ecgonine methyl ester (EME) was determined 1h after symptoms onset, during surgery and postoperative period. The measured peak value at 1h was 594ng/ml for cocaine, 9423ng/ml for BZE and 3261ng/ml for EME. We confirm the following order BZE>EME>cocaine for peak plasma concentrations. A rebound in plasma levels was found during surgery, together with electrocardiographic changes. A total of 107 packets were eliminated, and the patient survived.

Hartl J; Scherer MN; Loss M; Schnitzbauer A; Farkas S; Baier L et al. Strong predictors for alcohol recidivism after liver transplantation: Non-acceptance of the alcohol problem and abstinence of < 3 months. Scandinavian Journal of Gastroenterology 46(10): 1257-1266, 2011. (29 refs.)

Objective. Alcohol-toxic liver cirrhosis (ALC) is one of the main indications for liver transplantation (LT). The aim of the study is to define predictors for alcohol recidivism and to identify the outcome and quality of life of such patients. Material and methods. From March 2003 to July 2009, 226 patients underwent LT in our centre. In 53% liver cirrhosis was caused by alcohol abuse (sole/cofactor). Outcome and alcohol recidivism were assessed using patients' records, laboratory tests and interviews (patient, family members and family doctor). Furthermore, patients received an SF-36 quality of life and a self-designed questionnaire anonymously. Results. Mean follow-up after LT was 31 + 23 months. The 5-year survival rate after LT in patients with ALC was significantly better compared to patients with other indications (78 vs. 64%; p = 0.016). Quality of life of both patient groups was comparable. After LT, alcohol recidivism rate was 16%. Patients with an alcohol abstinence of < 3 months before LT had a significantly higher (p = 0.012) rate of alcohol recidivism in comparison to those with an abstinence of > 3 months. Another predictor for alcohol recidivism was the patients' non-acceptance of having an alcohol problem before LT (p = 0.001). Conclusions. ALC is a good indication for LT. An alcohol abstinence of < 3 months before LT and a non-acceptance of having an alcohol problem are strong predictors for alcohol recidivism after LT.

Hawn MT; Houston TK; Campagna EJ; Graham LA; Singh J; Bishop M et al. The attributable risk of smoking on surgical complications. Annals of Surgery 254(6): 914-920, 2011. (35 refs.)

Objective: This study aimed to assess the attributable risk and potential benefit of smoking cessation on surgical outcomes. Summary Background Data: Risk reduction with the implementation of surgical care improvement project process measures has been the primary focus for improving surgical outcomes. Little emphasis has been placed on preoperative risk factor recognition and intervention. Methods: A retrospective cohort analysis of elective operations from 2002 to 2008 in the Veterans Affairs Surgical Quality Improvement Program for all surgical specialties was performed. Patients were stratified by current, prior, and never smokers. Adjusted risk of complication and death was calculated using multilevel, multivariable logistic regression. Results: Of 393,794 patients, 135,741 (34.5%) were current, 71,421 (18.1%) prior, and 186,632 (47.4%) never smokers. A total of 6225 pneumonias, 11,431 deep and superficial surgical-site infections, 2040 thromboembolic events, 1338 myocardial infarctions, and 4792 deaths occurred within 30 days of surgery. Compared with both never and prior smokers individually and controlled for patient and procedure risk factors, current smokers had significantly more postoperative pneumonia, surgical-site infection, and deaths (P < 0.001 for all). There was a dose-dependent increase in pulmonary complications based on pack-year exposure with greater than 20 pack years leading to a significant increase in smoking-related surgical complications. Conclusions: This is the first study to assess the risk of current versus prior smoking on surgical outcomes. Despite being younger and healthier, current smokers had more adverse perioperative events, particularly respiratory complications. Smoking cessation interventions could potentially reduce the occurrence and costs of adverse perioperative events.

Katznelson R; Beattie WS. Perioperative smoking risk. (editorial). Anesthesiology 114(4): 734-736, 2011. (37 refs.)

Kent DE; Defazio JM. Improving survival of the paramedian forehead flap in patients with excessive tobacco use: The vascular delay. (editorial). Dermatologic Surgery 37(9): 1362-1364, 2011. (7 refs.)

This is a report of a 71 year old who smoked four packs of cigarettes per day, and who required surgery for morpheaform basal cell carcinoma on the nasal root, the usual surgical procedure involveda paramedian forehead flap. Rather than this procedure, an intermediate-stage procedure to improve blood flow. The number of cigarettes that are needed to interfere with wound healing is unclear. One study done on smokers with defects repaired using flap or full-thickness skin grafts showed that the risk of necrosis was negligible if the patients smoked one pack per day or less. For those smoking more than one pack per day, there was a substantially greater risk of necrosis. In summary, we have demonstrated the use of the PMFF in a heavy smoker successfully performed using a vascular delay. The indications, technique, and possible mechanisms of action of a vascular delay have been outlined. There is additional work that needs to be done to improve our understanding of the negative effect of smoking on cutaneous surgery and to improve the application of surgical delay.

2011, American Society of Dermatologic Surgery

Kork F; Neumann T; Spies C. Perioperative management of patients with alcohol, tobacco and drug dependency. Current Opinion in Anesthesiology 23(3): 384-390, 2010. (73 refs.)

Purpose of review: One in five patients in the perioperative setting has a alcohol use disorder (AUD), one in three patients has a nicotine use disorder (NUD) and one in 10 patients has a drug use disorder (DUD) with a high risk of dependency. Patients with dependencies challenge physicians with various complications within the perioperative setting. Recent findings: Adequate treatment of alcohol, nicotine and drug dependency during the perioperative and intraoperative course requires established screening tools in order to evaluate patients' susceptibility to developing complications. Particularly in these patients, secondary prevention and early treatment is warranted. Summary: Alcohol, nicotine and drug dependency are very treatable. Numerous effective therapeutic options are available and should be offered to patients. Intensive care treatment can be shortened or even avoided by initiating preventive measures. A multimodal approach includes implementation of screening tools, motivational interviewing, preoperative abstinence, individual anaesthesiological treatment, stress reduction preventing delirium and postoperative infection, prevention and treatment of withdrawal syndrome, replacement therapies and provision of preoperative or postoperative detoxification. The implementation rate is very low and urgently requires strategies for improvement.

Kozower BD; Lau CL; Phillips JV; Burks SG; Jones DR; Stukenborg GJ. A Thoracic Surgeon-Directed Tobacco Cessation Intervention. Annals of Thoracic Surgery 89(3): 926-930, 2010. (28 refs.)

Background. Thoracic surgeons receive little training in promoting tobacco cessation despite the impact of tobacco use on their patients. There are only a few prospective reports of tobacco cessation efforts involving thoracic surgeons in the scientific literature. The purpose of this study was to prospectively evaluate a brief tobacco cessation intervention offered by surgeons in an outpatient thoracic surgery clinic. Methods. Adult smokers from a single-institution thoracic surgery clinic were enrolled in a single-arm prospective pilot trial between January and December 2008. Patients received a 10-minute intervention including discussing their motivation for quitting, offering tobacco cessation medication, and promoting a free telephone quitline. The primary outcome was abstinence at 3 months. Univariate logistic regression identified factors associated with tobacco cessation. Results. Forty of 60 eligible smokers enrolled in the study. The mean age and standard deviation of participants was 52.1 +/- 12.6 years with a 39.9 +/- 11.2 pack-year smoking history. The 3-month quit rate was 35% (14 of 40). Fifty percent (20 of 40) of participants used at least one tobacco cessation medication. Only 7.5% (3 of 40) of patients called the quitline, but each of these participants quit smoking. Successful tobacco cessation was associated with a malignant diagnosis and being the only tobacco user in the home (odds ratio, 4.2; 95% confidence interval, 1.0 to 17.2; and odds ratio, 6.1; 95% confidence interval, 1.4 to 26.3, respectively). Conclusions. Thoracic surgeons can successfully implement a tobacco cessation program with an excellent rate of abstinence compared with reported cessation rates at 3 months from the literature. Further investigation with a larger sample size, longer follow-up, and improved utilization of the quitline is warranted.

Lashkarizadeh MR; Ashrafganguie M; Ashrafganguie M. Surgical management of femoral artery pseudoaneurysms secondary to drug abuse. Journal of the College of Physicians and Surgeons Pakistan 21(11): 672-675, 2011. (22 refs.)

Objective: To assess the outcome of surgical management of mycotic false aneurysms due to local injury after intravenous injection of drugs. Study Design: Case series. Place and Duration of Study: Department of Surgery, Kerman Medical School of Sciences, Kerman, Iran, from July 2001 to June 2009. Methodology: Twenty one consecutive patients presenting with infected femoral artery pseudoaneurysms (IFAPs) secondary to parenteral drug abuse treated in our department were studied. Data analyzed included demographic characteristics, modes of presentation, side of involvement, management and outcome. Results: All patients were male with mean age of 32.2 +/- 5.2 years. All presented with pain and swelling in the groin. Five patients presented with significant hemorrhage. The locations were the left side in 9 cases and the right side in 12 cases. The injured artery was the common femoral artery and its bifurcation. In 14 patients (64%), ligation-excision was carried out. In 5 patients (26%), primary repair of the artery with over-sewing was done. In 2 patients (10%), revascularization with saphenous interposition was carried out. Below-knee amputation was necessary in 1 patient who underwent ligation-excision. One patient died due to severe septicemia. Conclusion: Ligation of IFAPs is an effective, safe and simple option. Primary repair with preservation of the native vessel is suggested if infection is limited.

Law BF; Hettick JM; Hornsby-Myers J; Siegel PD. Reservations concerning second-hand fentanyl exposure in the operating room. Journal of Addictive Diseases 29(3): 282-283, 2010. (7 refs.)

Lindstrom D; Wladis A; Pekkari K. The thioredoxin and glutaredoxin systems in smoking cessation and the possible relation to postoperative wound complications. Wounds 22(4): 88-93, 2010. (32 refs.)

Background. Smoking cessation prior to surgery has proven to be an effective means of reducing wound complications. The underlying mechanisms are poorly-characterized. The present study is the first to investigate how short-term smoking cessation affects the thioredoxin and glutaredoxin systems. Methods. A total of 21 daily smokers scheduled for surgery were enrolled and randomized to smoking cessation intervention or control group. The main outcome measure was changes in plasma levels of thioredoxin (Trx) and glutaredoxin (Grx) following smoking cessation Secondary outcomes were changes in plasma levels of TNF-alpha, IL-1 beta, and IL-6. Results. Glutaredoxin levels in plasma increased after smoking cessation. The mean Grx difference between sample 2 and sample 1 among abstainers was 11 4 ng/mL; among smokers it was 0.6 ng/mL (P = 0.05). Among those with a postoperative complication there was a slight decrease (-0.9 ng/mL in mean) in glutaredoxin, which was not statistically Significant (P = 0.27). A change in thioredoxin levels in plasma after smoking cessation was not evident. Changes in cytokine levels before and after smoking cessation were not significant. Conchision. Short-term smoking cessation seems to increase plasma levels of Grx. The Trx system seems to be more robust against smoking toxicity. Fewer wound complications occurred in the smoking cessation group and glutaredoxin might be involved in the underlying mechanism.

Lopez-Valverde A; De Vicente J; Cutando A. The surgeons Halsted and Hall, cocaine and the discovery of dental anaesthesia by nerve blocking. British Dental Journal 211(10): 485-487, 2011. (23 refs.)

William Stewart Halsted is considered to be one of the most influential and innovative surgeons the USA has ever produced. His contributions to surgery are abundant, ranging from sophisticated surgical techniques in the field of breast surgery, surgery of the digestive apparatus and traumatological interventions, to the introduction of gloves in the operating theatre. Here we present Dr Halsted, together with his aide Dr Hall, as the discoverers of the technique for blocking the inferior alveolar nerve and the antero-superior dental nerve using cocaine as an anaesthetic. The anaesthetic technique, described perfectly by both surgeons in 1885, has been revolutionary in the practice of odontology since its introduction, offering dentists the possibility of performing invasive interventions to the maxillary without pain.

Lucey MR; Weinrieb RM. Alcohol and substance abuse. (review). Seminars in Liver Disease 29(1): 66-73, 2009

Alcoholic liver disease is an important cause of cirrhosis, liver-associated death, and need for liver transplant. Up to 50% of recipients use some alcohol, and perhaps 10% drink addictively. Careful evaluation by an addiction medicine specialist is the best predictive instrument before transplant surgery, whereas the 6-month rule lacks sensitivity and specificity. Addictive drinking, but not minor slips, is associated with increased mortality. There is no standard therapy for alcoholism in alcoholics waiting for a transplant or for those who have undergone a transplant. Stably abstinent, methadone-maintained opiate-dependent patients should continue methadone; are generally good candidates for liver transplant; and show low relapse rates. Pre- and post-transplant smoking rates are high and cause significant morbidity, and mortality. Transplant teams should encourage cessation treatments. Marijuana use in liver transplant recipients is common, although risks associated with this practice are unknown.

Malay DS. Cigarette smoking and foot and ankle surgery. (editorial). Journal of Foot & Ankle Surgery 50(5): 515-516, 2011. (21 refs.)

Mastracci TM; Carli F; Finley RJ; Muccio S; Warner DO. Effect of preoperative smoking cessation interventions on postoperative complications. (editorial). Journal of the American College of Surgeons 212(6): 1094-1096, 2011. (2 refs.)

Mnatzaganian G; Ryan P; Norman PE; Davidson DC; Hiller JE. Smoking, body weight, physical exercise, and risk of lower limb total joint replacement in a population-based cohort of men. Arthritis and Rheumatism 63(8): 2523-2530, 2011. (48 refs.)

Objective. To assess the associations of smoking, body weight, and physical activity with risk of undergoing total joint replacement (TJR) in a population-based cohort of men. Methods. A cohort study of 11,388 men that integrated clinical data with hospital morbidity data and mortality records was undertaken. The risk of undergoing TJR was modeled on baseline weight, height, comorbidity, socioeconomic status, years of smoking, and exercise in 3 separate age groups, using Cox proportional hazards regressions and competing risk regressions (CRRs). Results. Dose-response relationships between weight and risk of TJR and between smoking and risk of TJR were observed. Being overweight independently increased the risk of TJR, while smoking lowered the risk. The decreased risk among smokers was demonstrated in both Cox and CRR models and became apparent after 23 years of exposure. Men who were in the highest quartile (>= 48 years of smoking) were 42-51% less likely to undergo TJR than men who had never smoked. Tests for trend in the log hazard ratios (HRs) across both smoking and weight quantiles yielded significant P values. Vigorous exercise increased the hazard of TJR; however, the association reached statistical significance only in the 70-74-year-old age group (adjusted HR 1.64 [95% confidence interval 1.19-2.24]). Adjusting for Deyo-Charlson Index or Elixhauser's comorbidity measures did not eliminate these associations. Conclusion. Our findings indicate that being overweight and reporting vigorous physical activity increase the risk of TJR. This study is the first to demonstrate a strong inverse dose-response relationship between duration of smoking and risk of TJR. More research is needed to better understand the role of smoking in the pathogenesis of osteoarthritis.

Nasell H; Adami J; Samnegard E; Tonnesen H; Ponzer S. Effect of smoking cessation intervention on results of acute fracture surgery a randomized controlled trial. Journal of Bone And Joint Surgery. American Volume 92A(6): 1335-1342, 2010. (32 refs.)

Background: Tobacco smoking is a major health and economic concern and is also known to have a significant negative effect on surgical outcomes. The benefits of a smoking cessation intervention prior to elective orthopaedic surgery have been evaluated previously. Our aim was to assess whether a smoking cessation program, initiated during the acute hospitalization period and carried out for six weeks, could reduce the number of complications following emergency surgical treatment of fractures. Methods: In a multicenter, single-blinded, randomized, controlled clinical trial, 105 smokers with a fracture of the lower or upper extremity that needed acute surgical treatment were randomized to an intervention group (n = 50) or a control group (n = 55). The intervention group was offered a standardized smoking cessation program for six weeks, and all patients were followed at two to three weeks, four weeks, and six to twelve weeks. Results: The proportion of patients with at least one postoperative complication was significantly larger in the control group than it was in the intervention group (38% and 20%, respectively; p = 0.048). The development of two or more postoperative complications was also more common among the controls (p = 0.039). The rates of superficial wound infection, the most frequently recorded complication in both groups, were 20% and 8%, but this difference was not significant. A secondary analysis showed that the odds of having a complication were 2.51 times (95% confidence interval, 0.96 to 6.9 times) higher in the control group than in the intervention group, but this difference was not significant. Conclusions: Our results indicate that a smoking cessation intervention program during the first six weeks after acute fracture surgery decreases the risk of postoperative complications.

Park ER; Japuntich S; Temel J; Lanuti M; Pandiscio J; Hilgenberg J et al. A smoking cessation intervention for thoracic surgery and oncology clinics: A pilot trial. Journal of Thoracic Oncology 6(6): 1059- 1065, 2011. (49 refs.)

Introduction: Although most smokers diagnosed with lung cancer report that they want to quit smoking, many do not succeed. Smokers who quit when lung cancer is diagnosed have improved treatment efficacy, quality of life, and survival. Effective smoking cessation interventions targeted to thoracic oncology patients are needed. Methods: This pilot study examined the feasibility and potential efficacy of a 12-week program that combined smoking cessation counseling with varenicline. Seven-day point prevalence tobacco abstinence rates at the end of treatment were compared with a usual care control group. From January 2008 to August 2009, patients with a diagnosed or suspected thoracic malignancy were recruited at their initial visit to a thoracic surgeon or thoracic oncologist at Massachusetts General Hospital. Results: Of 1,130 patients screened, 187 (17%) were current smokers, and an additional 66 (6%) reported quitting within the past 6 months. One hundred sixteen (67%) of smokers were eligible, and 49 (42%) of eligible smokers enrolled (control group n = 17, intervention group n = 32). Intervention participants completed a median of nine counseling sessions; 50% of intervention participants completed the full varenicline course. At 12-week follow-up, biochemically validated 7-day point prevalence tobacco abstinence rates were 34.4% in the intervention group versus 14.3% in the control group (odds ratio = 3.14, 95% confidence interval = 0.59-16.62, p = 0.18). Conclusion: Our findings support the feasibility and acceptability of this program. At the end of treatment, quit rates were higher in the control group. Further testing is indicated to establish the efficacy of this treatment package in a randomized clinical trial.

Sandhu GS; Khattak M; Woodward RS; Hanto DW; Pavlakis M; Dimitri N et al. Impact of substance abuse on access to renal transplantation. Transplantation 91(1): 86-93, 2011. (41 refs.)

Background. With an ever-increasing demand for kidneys and limited supply pool, it is essential to understand the balance between utility and equity in transplant access. The goal of this project was to evaluate the association between recipient's substance abuse and renal transplant access in patients with end-stage renal disease (ESRD). Methods. We used data from the United States Renal Data System. The primary variables of interest were abuse of alcohol, tobacco, or illicit drugs based on information from Centers for Medicare & Medicaid Services form 2728. We analyzed three outcomes in Cox model: (1) being placed on the waiting list for renal transplantation or transplanted (whichever occurred first); (2) first transplant in patients who were placed on the waiting list; and (3) graft loss or mortality after transplant. In addition, we performed subgroup analysis based on age, race, sex, diabetic status, and donor type. Results. We analyzed 1,077,699 patients (age of ESRD onset 62.9 +/- 15.5 years, 54.1% males, 64.2% white, and 29.7% African American). When compared with those with no substance abuse, abusing all three substances was associated with reduced transplant access (hazard ratio 0.39, P<0.001 for wait listing/transplant; hazard ratio 0.67, P=0.019 for transplant). This trend was similar in most subgroups studied. Conclusion. We demonstrated that patients with ESRD abusing or dependent on tobacco, alcohol, or illicit drugs are less likely to be placed on the waiting list for kidney transplant; and once on the list are less likely to be transplanted. The possible utility justifications for such disparity and potential interventions are discussed.

Saules KK; Wiedemann A; Ivezaj V; Hopper JA; Foster-Hartsfield J; Schwarz D. Bariatric surgery history among substance abuse treatment patients: Prevalence and associated features. Surgery for Obesity and Related Disease 6(6): 615-621, 2010. (22 refs.)

Background: In 2006, Brighton Hospital (Brighton, Michigan), a comprehensive substance abuse treatment facility, began observing increasing admissions who reported a history of bariatric surgery. Data on the magnitude of this postoperative outcome is lacking. The hospital instituted procedures to better track this variable in the electronic medical records at admission to estimate the prevalence of bariatric surgery history among substance abuse treatment admissions. Methods: The data analyzed for the present report included the electronic medical record data obtained from 7199 patients admitted from 2006 to 2009 and the chart review data from 54 bariatric patients and 54 controls. Results: The findings suggested that 2-6% of recent admissions were positive for a bariatric surgery history. The substance abuse treatment patients with a bariatric surgery history were significantly more likely to be women and nonsmokers. The bariatric and nonbariatric patients were equally likely to have been diagnosed with alcohol dependence; however, bariatric patients were significantly more likely to also have a diagnosis of alcohol withdrawal. Relative to the matched control cases, the alcohol-dependent bariatric patients reported consuming a significantly greater maximum quantity of drinks per drinking day. Conclusion: A bariatric surgery history might be overrepresented in substance use programs and such patients' recovery efforts might pose unique challenges.

Seyidov TH; Elemen L; Solak M; Tugay M; Toker K. Passive smoke exposure is associated with perioperative adverse effects in children. Journal of Clinical Anesthesia 23(1): 47-52, 2011. (23 refs.)

Study Objective: To evaluate the frequency of respiratory adverse events during general anesthesia in children passively exposed to cigarette smoke (PSE). Design: Prospective, double blinded, observational study. Setting: Operating room and recovery room of a university hospital. Measurements: Data were collected from 385 children who underwent elective surgery during general anesthesia from June to November, 2008. PSE was identified by using the child's caregivers' information. Respiratory adverse events were recorded during anesthesia and post-anesthesia. Main Results: Technique of anesthesia induction and management, distribution of patients' age, gender, surgical procedures, and perioperative analgesic methods were similar in the PSE and non-PSE groups. Respiratory adverse events were reported in 58 patients (15.1%): 50 patients (21.4%) were in the PSE and 8 patients (5.3%) were in the non-PSE group (P = 0.00). The frequency of laryngospasm during anesthesia (P = 0.03) and hypersecretions in the recovery room (P = 0.00) were significantly increased in the PSE group. Conclusions: Children who are exposed to environmental tobacco smoke and who undergo general anesthesia seem to have an increased risk of respiratory complications in the recovery period rather than during anesthesia.

Shi Y; Warner DO. Brief preoperative smoking abstinence: Is there a dilemma? Anesthesia and Analgesia 113(6): 1348-1351, 2011. (26 refs.)

The concern that stopping smoking shortly (<8 weeks) before surgery increases postoperative pulmonary complications poses a barrier to tobacco use interventions in surgical patients. We show how this concern arose from a misinterpretation of initial studies and has remained in the medical literature despite the accumulation of later evidence. The persistence of unsubstantiated concepts is not uncommon and can have a significant impact on medical practice. Although it may take several weeks to derive pulmonary benefit from quitting, fear of an increase in pulmonary complications should not be a barrier for clinicians to help their patients quit smoking at any time before surgery.

Shi Y; Warner DO. Pediatric surgery and parental smoking behavior. Anesthesiology 115(1): 12-17, 2011. (24 refs.)

Background: Secondhand smoke exposure poses health risks to children, including increased risks for anesthesia. In adult smokers, surgery serves as a teachable moment to motivate quitting. For parents who smoke, having a child undergo surgery may also serve as a teachable moment for smoking behavioral change. This study determined if there is an association between children undergoing a surgical procedure and changes in their parents' smoking behavior. Methods: Secondary analyses were performed using logistic regression analysis of 2005 survey data from the National Health Interview Survey. Analyses included 9,289 parent respondents who provided information on both themselves and their children. Results: Of the sampled children, 1,112 (12.6%, 95% CI: 11.7, 13.4) lived in a home with at least one person who smoked inside in a usual week. In multivariate analysis of the relationship between parent and child surgical history in the past 12 months and smoking behavior, surgery in either the parent (odds ratio 2.19, 95% CI: 1.55, 3.08) or child (odds ratio 2.61, 95% CI: 1.56, 4.35) was associated with an increased likelihood of a quit attempt by the parent. However, these attempts were more likely to be successful if the parents (odds ratio 2.35, 95% CI: 1.35, 4.07), not their child (odds ratio 0.51, 95% CI: 0.20, 1.28), had surgery within the past 12 months. Conclusions: Parents who smoke were more likely to make a quit attempt within the past 12 months if their children had surgery within this time, but they were not more likely to succeed in maintaining abstinence and thus could benefit from assistance.

Shi Y; Warner DO. Surgery as a teachable moment for smoking cessation. Anesthesiology 112(1): 102-107, 2010. (38 refs.)

Background: A "teachable moment" is an event that motivates spontaneous behavior change. Some evidence suggests that major surgery for a smoking-related illness can serve as a teachable moment for smoking cessation. This study tested the hypotheses that surgery increases the likelihood of smoking cessation and that cessation is more likely after major surgical procedures compared with outpatient surgery. Methods: Secondary analyses were performed of longitudinal biennial survey data (1992-2004) from the nationally representative Health and Retirement Study of U.S. adults older than 50 yr, determining the relationship between the incidence of smoking cessation and the occurrence of surgery. Results: Five thousand four hundred ninety-eight individuals reported current smoking at enrollment, and 2,444 of them (44.5%) quit smoking during the period of examination. The incidence of quitting in smokers undergoing major surgery was 20.6/100 person-years of follow-up and 10.2/100 person-years in those undergoing outpatient surgery. In a multivariate negative binomial regression model, the incidence rate ratio of quitting associated with major surgery was 2.02 (95% CI: 1.67-2.44) and that of those associated with outpatient surgery was 1.28 (95% CI: 1.09-1.50). Estimates derived from national surgical utilization data show that approximately 8% of all quit events in the United States annually can be attributed to the surgical procedures analyzed. Conclusions: Undergoing surgery is associated with an increased likelihood of smoking cessation in the older U.S. population. Cessation is more likely in association with major procedures compared with outpatient surgery. These data support the concept that surgery is a teachable moment for smoking cessation.

Shi Y; Yu CH; Luo AL; Huang YG; Warner DO. Perioperative tobacco interventions by Chinese anesthesiologists practices and attitudes. Anesthesiology 112(2): 338-346, 2010. (32 refs.)

Background: The prevalence of cigarette smoking in China is high. Surgery provides an excellent opportunity for patients to quit smoking, and anesthesiologists can play an important role in tobacco control. However, little is known about the practices, knowledge, and attitudes of Chinese anesthesiologists regarding perioperative tobacco interventions. Methods: Chinese anesthesiologists were surveyed at a national meeting in 2009, with written questionnaires distributed to 800 practicing anesthesiologists. Results: The survey response rate was 60.3%, and 10% of respondents themselves smoked cigarettes. Most (73%) of them frequently or almost always asked about smoking status; 51% advised about the health risk of tobacco use; and 60% advised patients to quit. Compared with nonsmokers, smokers were significantly less likely to advise about the health risks of smoking and quitting. A high proportion of respondents had accurate perceptions of perioperative and long-term health risks of smoking. Although most respondents agreed that advising patients to quit is the responsibility of anesthesiologists and the perioperative period is a good time to help patients quit smoking, few knew how to counsel about smoking or help patients get the help they needed to quit. Nonetheless, most of the respondents were willing to learn about perioperative interventions and spend an extra 5 min to help patients quit smoking. Conclusions: Given their adequate knowledge of health risks of smoking, strong perception of responsibilities, and willingness to participate in tobacco control, Chinese anesthesiologists are poised to play a significant role in tobacco control in China that could improve perioperative outcomes and promote long-term health.

Singh JA; Houston TK; Ponce BA; Maddox G; Bishop MJ; Richman J et al. Smoking as a risk factor for short-term outcomes following primary total hip and total knee replacement in veterans. Arthritis Care & Research 63(10): 1365-1374, 2011. (54 refs.)

Objective. To assess the effect of smoking on postoperative complications following elective primary total hip replacement (THR) or primary total knee replacement (TKR). Methods. We used data from the national Veterans Affairs Surgical Quality Improvement Program to examine the association of smoking status at surgery with 30-day postoperative complication rates (including surgical site and other infections, pneumonia, stroke, myocardial infarction, mortality, and other complications) in veterans undergoing primary elective THR or TKR. Multilevel multivariable-adjusted logistic regression models, adjusted for age, race/ethnicity, work relative value units, American Society of Anesthesiology classification, and year of surgery, with additional adjustment for wound classification for surgical site infections, were used. Results. A total of 33,336 patients, 95% men and 80% white with a mean age of 64 years, underwent elective primary THR/TKR between October 2001 and September 2008. Fifty-seven percent never smoked, 19% were prior smokers, and 24% were current smokers. Current smokers undergoing THR/TKR were significantly more likely than never smokers to have surgical site infections (odds ratio [OR] 1.41, 95% CI 1.16-1.72), pneumonia (OR 1.53, 95% CI 1.10-2.14), stroke (OR 2.61, 95% CI 1.26-5.41), and 1-year mortality (OR 1.63, 95% CI 1.31-2.02). Prior smokers were significantly more likely than nonsmokers to have pneumonia, (OR 1.34, 95% CI 1.00-1.80), stroke (OR 2.14, 95% CI 1.12-4.10), and urinary tract infection (OR 1.26, 95% CI 1.02-1.55). Conclusion. Current smoking at the time of elective THR or TKR is associated with increased postarthroplasty complications, especially surgical site infections and pneumonia. Preoperative smoking cessation programs should be considered in patients undergoing elective THR or TKR.

Sorensen LT; Toft BG; Rygaard J; Ladelund S; Paddon M; James T; Taylor R et al. Effect of smoking, smoking cessation, and nicotine patch on wound dimension, vitamin C, and systemic markers of collagen metabolism. Surgery 148(5): 982-990, 2010. (61 refs.)

Background: Postoperative wound disruption and tissue-destructive disorders are more frequent in smokers than in nonsmokers. Impaired wound healing and altered connective tissue turnover are suggested mechanisms, but exact details remain unknown. Methods. Full-thickness, 5-mm punch biopsy wounds were made lateral to the sacrum in 48 smokers and were randomized double-blinded to continuous smoking, abstinence with transdermal nicotine patch (TNP), or abstinence with placebo patch and 30 never smokers. At 1, 4, 8, and 12 weeks, the wounds were excised and fixed for wound measurement, and blood was collected for measurement of vitamin C, procollagen I N-propeptide (PINP), matrix metalloproteinase 8 (MMP), MMP-9, neutrophils, and eosinophils. Results. One week after wounding, smokers' wounds were 3.1 +/- 0.1 mm (mean, standard error of the mean) wide and were 1.3 +/- 0.1 mm deep compared with the never smokers' wounds, measuring 3.7 +/- 0.1 mix wide and 1.5 +/- 0.1 mm deep (P < .01, respectively). Abstinent smokers' wounds were 3.3 +/- 0.1 mm wide (NS) and were 1.4 +/- 0.1 mm deep (P = .02 compared with smokers). In smokers, vitamin C and PINP were 50.5 +/- 9.0 mu mol/L and were 52.7 +/- 6.6 ng/mL, respectively, compared with 68.8 +/- 14.5 mu molL and 64.7 +/- 4.7 ng/mL in never smokers (P < .001 and P = .07). Both increased significantly after smoking cessation. Plasma MMP-8 and MMP-9 were correlated with neutrophil blood count, which significantly was affected by smoking status. No effect of TNP was found. Conclusion. Smokers have smaller, more superficial wounds and lesser blood levels of vitamin C and PIN]? Smoking cessation resulted in increased wound depth, vitamin C, and PINP as well as a decreased neutrophil blood count. These findings suggest that wound contraction and collagen metabolism are affected by a smoking-induced alteration in vitamin C turnover and by a change in inflammatory cell response.

Thomsen T; Tonnesen H; Okholm M; Kroman N; Maibom A; Sauerberg ML et al. Brief smoking cessation intervention in relation to breast cancer surgery: A randomized controlled trial. Nicotine & Tobacco Research 12(11): 1118-1124, 2010. (27 refs.)

Smokers are more prone to develop postoperative complications. Smoking cessation intervention beginning 4-8 weeks prior to surgery improves the postoperative outcome. Cancer patients, however, often undergo surgery less than 4 weeks after diagnosis. The primary objective of this study was therefore to examine if a brief smoking cessation intervention shortly before breast cancer surgery would influence postoperative complications and smoking cessation. A randomized controlled multicentre trial with blinded outcome assessment conducted at 3 hospitals in Denmark. One hundred and thirty patients were randomly assigned to brief smoking intervention (n = 65) or standard care (n = 65). The intervention followed the principles of motivational interviewing and included personalized nicotine replacement therapy aimed at supporting smoking cessation from 2 days before to 10 days after surgery. The overall postoperative complication rate (including seroma requiring aspiration) was 61% in both groups risk ratio (RR) 1.00 (95% CI 0.75-1.33). The wound complication rate was 44% versus 45%. The effect on perioperative smoking cessation was modest, 28% intervention versus 11% control group patients, RR 2.49 (95% CI 1.10-5.60). There was no effect on smoking cessation at 12 months, 13% versus 9%. Brief smoking intervention administered shortly before breast cancer surgery modestly increased self-reported perioperative smoking cessation without having any clinical impact on postoperative complications. The study adds to the body of evidence indicating that brief intervention has no clinical importance for surgical patients in regard to postoperative morbidity. Future studies should be designed to determine the optimal time of smoking cessation before surgery.

Thomsen T; Villebro N; Moller AM. Interventions for preoperative smoking cessation. Cochrane Database of Systematic Reviews 7: CD002294, 2010. (73 refs.)

Background: Smokers have a substantially increased risk of postoperative complications. Preoperative smoking intervention may be effective in decreasing this incidence, and surgery may constitute a unique opportunity for smoking cessation interventions. Objectives: The objective of this review was to assess the effect of preoperative smoking intervention on smoking cessation at the time of surgery and 12 months postoperatively and on the incidence of postoperative complications. Search strategy: The specialized register of the Cochrane Tobacco Addiction Group was searched using the free text and keywords (surgery) or (operation) or (anaesthesia) or (anesthesia). MEDLINE, EMBASE and CINAHL were also searched, combining tobacco- and surgery-related terms. Most recent search April 2010. Selection criteria: Randomized controlled trials that recruited people who smoked prior to surgery, offered a smoking cessation intervention, and measured preoperative and long-term abstinence from smoking and/or the incidence of postoperative complications. Data collection and analysis: The authors independently assessed studies to determine eligibility. Results were discussed between the authors. Main results: Eight trials enrolling a total of 1156 people met the inclusion criteria. One of these did not report cessation as an outcome. Two trials initiated multisession face to face counselling at least 6 weeks before surgery whilst six used a brief intervention. Nicotine replacement therapy (NRT) was offered or recommended to some or all participants in seven trials. Six trials detected significantly increased smoking cessation at the time of surgery, and one approached significance. Subgroup analyses showed that both intensive and brief intervention significantly increased smoking cessation at the time of surgery; pooled RR 10.76 (95% confidence interval (CI) 4.55 to 25.46, two trials) and RR 1.41 (95% CI 1.22 to 1.63, five trials) respectively. Four trials evaluating the effect on long-term smoking cessation found a significant effect; pooled RR 1.61 (95% CI 1.12 to 2.33). However, when pooling intensive and brief interventions separately, only intensive intervention retained a significant effect on long-term smoking cessation; RR 2.96 (95% CI 1.57 to 5.55, two trials). Five trials examined the effect of smoking intervention on postoperative complications. Pooled risk ratios were 0.70 (95% CI 0.56 to 0.88) for developing any complication; and 0.70 (95% CI 0.51 to 0.95) for wound complications. Exploratory subgroup analyses showed a significant effect of intensive intervention on any complications; RR 0.42 (95% CI 0.27 to 0.65) and on wound complications RR 0.31 (95% CI 0.16 to 0.62). For brief interventions the effect was not statistically significant but CIs do not rule out a clinically significant effect (RR 0.96 (95% CI 0.74 to 1.25) for any complication, RR 0.99 (95% CI 0.70 to 1.40) for wound complications). Authors' conclusions: There is evidence that preoperative smoking interventions including NRT increase short-term smoking cessation and may reduce postoperative morbidity. The optimal preoperative intervention intensity remains unknown. Based on indirect comparisons and evidence from two small trials, interventions that begin four to eight weeks before surgery, include weekly counselling, and use NRT are more likely to have an impact on complications and on long-term smoking cessation.

Tonnesen H; Faurschou P; Ralov H; Molgaard-Nielsen D; Thomas G; Backer V. Risk reduction before surgery. The role of the primary care provider in preoperative smoking and alcohol cessation. BMC Health Services Research 10: article 121, 2010. (40 refs.)

Background: Daily smokers and hazardous drinkers are high-risk patients, developing 2-4 times more complications after surgery. Preoperative smoking and alcohol cessation for four to eight weeks prior to surgery halves this complication rate. The patients' preoperative contact with the surgical departments might be too brief for the hospital to initiate these programmes. Therefore, it was relevant to evaluate a new clinical practice which combined the general practitioner's (GP) referral to surgery with a referral to a smoking and alcohol intervention in the surgical pathway. Methods: The design was an exploratory prospective trial. The outcome measured was the number of patients referred to a preoperative smoking and alcohol cessation programme at the same time as being referred for elective surgery by their GP. The participants consisted of 72 high-risk patients who were referred for elective surgery by 47 local participating GPs. The GPs, nurses, and specialists in internal medicine, prehabilitation and surgery developed new clinical practice guidelines based on the literature and interviews with 11 local GPs about the specific barriers for implementing a smoking and alcohol cessation programme. The role of the GP was to be the gatekeeper: identifying daily smokers and hazardous drinkers when referring them to surgery; handing out information on risk reduction; and referring those patients identified to a preoperative smoking and alcohol cessation programme. The role of the hospital was to contact these patients to initiate smoking and alcohol cessation at the hospital out-patient clinic for life-style intervention. Results: The GPs increased their referral to the smoking and alcohol cessation programme from 0% to 10% (7/72 patients) in the study period. Conclusion: The effect of the study was limited in integrating the efforts of primary care providers and hospital surgical departments in increasing the up-take of preoperative smoking and alcohol cessation programmes aimed at smokers and harmful drinkers referred for surgery. New strategies for cooperation between GPs and surgical departments are urgently needed.

Tonnesen H. Surgery and smoking at first and second hand: Time to act. (editorial). Anesthesiology 115(1): 1-3, 2011. (13 refs.)

Volk ML; Biggins SW; Huang MA; Argo CK; Fontana RJ; Anspach RR. Decision making in Liver Transplant Selection Committees: A multicenter study. Annals of Internal Medicine 155(8): 503-508, 2011. (18 refs.)

Background: To receive a liver transplant, patients must first be placed on a waiting list-a decision made at most transplant centers by a multidisciplinary committee. The function of these committees has never been studied. Objective: To describe decision making in liver transplant committees and identify opportunities for process improvement. Design: Observational multicenter study. Setting: 4 liver transplant centers in the United States. Participants: 68 members of liver transplant committees across the 4 centers. Measurements: 63 meetings were observed, and 50 committee members were interviewed. Recorded transcripts and field notes were analyzed by using standard qualitative sociologic methods. Results: Although the structure of the meetings varied by center, the process was uniform and primarily involved inductive reasoning to review possible reasons for patient exclusion. Patients were excluded if they were too well, too sick (in the setting of advanced liver disease), or too old or had nonhepatic comorbid conditions, substance abuse problems, or other psychosocial barriers. Dominant themes in the discussions included member angst over deciding who lived or died, a high correlation between psychosocial barriers to transplantation and the patient's socioeconomic status, and the influence of external forces on decision making. Unwritten center policies and confusion regarding advocacy versus stewardship roles were consistently identified as barriers to effective group decision making. Limitations: The use of qualitative methods provides broad understanding but limits specific inferences. The 4 centers may not reflect the practices of every transplant center nationwide. Conclusion: The difficult decisions made by liver transplant committees are reasonably consistent and well-intentioned, but the process might be improved by having more explicit written policies and clarifying roles. This may inform resource allocation in other areas of medicine.

Volk ML; Biggins SW; Huang MA; Argo CK; Fontana RJ; Anspach RR. Decision making in Liver Transplant Selection Committees: A multicenter study. Annals of Internal Medicine 155(8): 503-508, 2011. (18 refs.)

Background: To receive a liver transplant, patients must first be placed on a waiting list a decision made at most transplant centers by a multidisciplinary committee. The function of these committees has never been studied. Objective: To describe decision making in liver transplant committees and identify opportunities for process improvement. Design: Observational multicenter study. Setting: 4 liver transplant centers in the United States. Participants: 68 members of liver transplant committees across the 4 centers. Measurements: 63 meetings were observed, and 50 committee members were interviewed. Recorded transcripts and field notes were analyzed by using standard qualitative sociologic methods. Results: Although the structure of the meetings varied by center, the process was uniform and primarily involved inductive reasoning to review possible reasons for patient exclusion. Patients were excluded if they were too well, too sick (in the setting of advanced liver disease), or too old or had nonhepatic comorbid conditions, substance abuse problems, or other psychosocial barriers. Dominant themes in the discussions included member angst over deciding who lived or died, a high correlation between psychosocial barriers to transplantation and the patient's socioeconomic status, and the influence of external forces on decision making. Unwritten center policies and confusion regarding advocacy versus stewardship roles were consistently identified as barriers to effective group decision making. Limitations: The use of qualitative methods provides broad understanding but limits specific inferences. The 4 centers may not reflect the practices of every transplant center nationwide. Conclusion: The difficult decisions made by liver transplant committees are reasonably consistent and well intentioned, but the process might be improved by having more explicit written policies and clarifying roles. This may inform resource allocation in other areas of medicine.

Wendling A; Wudyka A. Narcotic addiction following gastric bypass surgery: A case study. Obesity Surgery 21(5): 680-683, 2011. (19 refs.)

Addictive behavior following gastric bypass surgery is widely discussed in the lay press, but published reports provide conflicting evidence regarding the prevalence of postoperative substance abuse among bariatric surgery patients. We present a case report of a Roux-en-Y gastric bypass patient who presented with recurrent and various pain and nausea complaints postoperatively. These symptoms resulted in multiple radiological and operative procedures before her narcotic addiction was identified. Physicians caring for bariatric surgical patients postoperatively need to be aware of this risk and need to be able to identify early signs of potential postoperative addictions.

Yagoubian B; Akkara J; Afzali P; Alfi DM; Olson L; Conell-Price J et al. Nicotine nasal spray as an adjuvant analgesic for third molar surgery. Journal of Oral and Maxillofacial Surgery 69(5): 1316- 1319, 2011. (14 refs.)

Purpose: To determine the efficacy of preoperatively administered nicotine nasal spray (3 mg) for analgesia after third molar (TM) surgery. Materials and Methods: A single-center, prospective, randomized, double-blind, crossover trial was conducted. The study population consisted of 20 nonsmoking patients referred to the Department of Oral and Maxillofacial Surgery of Columbia University College of Dental Medicine for extraction of all 4 TMs. Each patient received nicotine nasal spray or placebo spray before TM surgery. At a subsequent visit the contralateral TMs were removed with prior administration of the alternate treatment. For an hour postoperatively, subjects reported information on pain and nausea, and hemodynamic variables were recorded at 15-minute intervals. Telephone follow-up was recorded for 5 days postoperatively, where patients reported information on pain, nausea, and use of hydrocodone/acetaminophen as rescue analgesia. Results: Nicotine treatment was associated with a highly significant decrease in pain reported during the 5 days after TM surgery. There was no difference in the amount of hydrocodone/acetaminophen used or amount of nausea reported. There was a small but significant increase in heart rate after nicotine treatment compared with placebo during the first hour after surgery. There was no difference in blood pressure between groups. Conclusion: Pain is well controlled by hydrocodone/acetaminophen in most patients after TM surgery. However, there is significant variability in pain reported. Nicotinic agonists represent a new class of analgesic that can be considered for patients who are expected to have significant opioid-resistant pain after TM surgery. Caution should be used with patients in whom a small increase in heart rate would be deleterious.

Yee BE; Ahmed MI; Brugge D; Farrell M; Lozada G; Idupaganthi R et al. Second-hand smoking and carboxyhemoglobin levels in children: A prospective observational study. Pediatric Anesthesia 20(1): 82-89, 2010. (15 refs.)

Aim: To establish baseline noninvasive carboxyhemoglobin (COHb) levels in children and determine the influence of exposure to environmental sources of carbon monoxide (CO), especially environmental tobacco smoke, on such levels. Background: Second-hand smoking may be a risk factor for adverse outcomes following anesthesia and surgery in children (1) and may potentially be preventable. Patients and Methods: Parents and their children between the ages of 1-12 were enrolled on the day of elective surgery. The preoperative COHb levels of the children were assessed noninvasively using a CO-Oximeter (Radical-7 Rainbow SET Pulse CO-Oximeter; Masimo, Irvine, CA, USA). The parents were asked to complete an environmental air-quality questionnaire. The COHb levels were tabulated and correlated with responses to the survey in aggregate analysis. Statistical analyses were performed using the nonparametric Mann-Whitney and Kruskal-Wallis tests. P < 0.05 was statistically significant. Results: Two hundred children with their parents were enrolled. Children exposed to parental smoking had higher COHb levels than the children of nonsmoking controls. Higher COHb values were seen in the youngest children, ages 1-2, exposed to parental cigarette smoke. However, these trends did not reach statistical significance, and confidence intervals were wide. Conclusions: This study revealed interesting trends of COHb levels in children presenting for anesthesia and surgery. However, the COHb levels measured in our patients were close to the error margin of the device used in our study. An expected improvement in measurement technology may allow screening children for potential pulmonary perioperative risk factors in the future.

Zieger M; Luppa M; Matschinger H; Meisel HJ; Gunther L; Meixensberger J et al. Affective, anxiety, and substance-related disorders in patients undergoing herniated disc surgery. Social Psychiatry and Psychiatric Epidemiology 46(11): 1181-1190, 2011. (43 refs.)

At present only a small number of studies have investigated psychiatric comorbidity in disc surgery patients. Objectives of this study are (1) to examine the prevalence rate of comorbid affective, anxiety, and substance-related disorders in nucleotomy patients in comparison to the German general population and (2) to investigate associations between psychiatric comorbidity and socio-demographic and illness-related characteristics. The study refers to 349 consecutive disc surgery patients (response rate 87%) between the age of 18 and 55 years. The final study sample consists of 239 lumbar and 66 cervical nucleotomy patients. Face-to-face interviews were conducted approximately 3.45 days (SD 3.170) after disc surgery, during hospital stay. Psychiatric comorbidity was assessed by means of the Composite International Diagnostic Interview (CIDI-DIA-X). The corresponding data of the German general population were derived from the German National Health Interview and Examination Survey (GHS). 12-Month prevalence rates of any affective, anxiety or substance-related disorders range between 33.7% in cervical and 23.5% in lumbar disc surgery patients. Four-week prevalence rates of any affective, anxiety or substance disorder vary between 13.2% in cervical and 14.0% in lumbar nucleotomy patients. Disc surgery patients suffer more often from affective disorders and illicit substance abuse than the general population. Significant associations were found between psychiatric comorbidity and gender, as well as pain intensity. Disc surgery patients show a higher risk to suffer from mental disorders than the general population. The assessment of psychiatric distress and the assistance by mental health professionals should be considered during hospital and rehabilitation treatment.