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New Crucial Literature: The Science You Need to Know

FIRST Data Indicate Medical Students Who Experience Call Are Better Prepared for Rigors of Residency

Engelhardt KE, Bilimoria KY, Johnson JK, et al. A National Mixed-Methods Evaluation of Preparedness for General Surgery Residency and the Association With Resident Burnout. JAMA Surg. 2020.

Choi JN, Stefanidis D, Dunnington GL. Preparedness for Residency: Now More Than Ever. JAMA Surg. 2020.

Because of increasing recognition of insufficient preparedness for residency, burnout, and attrition among surgical trainees, Engelhardt and colleagues used data from the FIRST (Flexibility In duty hour Requirements for Surgical Trainees) Trial, along with interviews of residents and surgery program directors, to determine factors in the medical school education experience that affect preparedness for residency and rates of burnout symptoms. The data analysis showed that residents who had experienced night call and/or sub-internship(s) as medical students were considered more prepared for residency training and experienced significantly less burnout than residents who were not exposed to these experiences.

In the discussion section of the article, the authors cited data to support the value of actual patient care experiences, including night call during medical school and mentoring from surgical faculty as ways to improve preparedness and reduce burnout. They also stressed that medical school requirements that restrict night call and other potentially valuable types of clinical experiences contribute to preparedness and burnout.

The accompanying editorial by Choi and colleagues emphasizes that an essential element of preparedness for surgical residency is the expectation that medical students provide direct patient care and make clinical decisions without continuous supervision in a demanding and tiring environment, and the resilience that can result from such experiences contributes to a successful surgical career. The authors stressed that all academic surgeons must ensure that medical students have these experiences.

Study Shows Preoperative Metformin May Reduce Mortality

Reitz KM, Marroquin OC, Zenati MS, et al. Association Between Preoperative Metformin Exposure and Postoperative Outcomes in Adults With Type 2 Diabetes. JAMA Surg. 2020:e200416.

George EL, Wren SM. Improving Outcomes After Surgery-An Old Medication With Unexpected Benefits. JAMA Surg. 2020:e200417.

Reitz and colleagues report propensity-matched data on more than 10,000 diabetic patients who underwent a major operation; that is, a procedure that requires general anesthesia and a postoperative inpatient admission in a single health system. The study sought to determine a possible effect of preoperative metformin use on postoperative outcomes, including mortality and rates of readmission. The study identified lower 90-day mortality and readmission rates in patients who had used metformin preoperatively.

The authors suggest that the anti-inflammatory effects of metformin might explain the observed reductions in mortality and readmissions. Additional data reported in the article showed evidence of reduced inflammation (reduced neutrophil to lymphocyte ratio) in patients who had taken metformin.

In the accompanying editorial, George and Wren note that metformin has now joined beta-blockers, statins, and immuno-nutrition as preoperative agents that are associated with reduced postoperative mortality and morbidity. They emphasize that metformin was used with statins in more than 60 percent of study participants, which raises the question of whether metformin alone is beneficial. They urge additional research.

Proper Draping during Cricothyroidotomy Can Reduce Aerosolization

Issa N, Liddy WE, Samant S, et al. Emergency cricothyroidotomy during the COVID-19 pandemic: How to suppress aerosolization. Trauma Surg Acute Care Open. 2020(5).

Cricothyroidotomy is a rare but often lifesaving procedure performed during emergency airway management of injured and critically ill patients. The procedure is associated with significant risk of exposure to aerosol droplets that may transmit the COVID-19 virus. Issa and colleagues note that clinical practice guidelines are available for procedures, such as a tracheostomy, bronchoscopy, endoscopy and other procedures required for treatment of COVID-19 patients but are lacking for cricothyroidotomy.

In this study, general surgeons and otolaryngologists evaluated three draping methods (X-ray cassette drape, dry versus wet operating room towels) to determine effectiveness of aerosol suppression, availability of equipment and ease of use. Aerosol suppression was assessed with fluorescein dye spray. Each surgeon performed simulated cricothyroidotomy using a porcine trachea with each of the draping methods. The results showed that all draping methods were effective in suppressing aerosolization; however, the wet towel drapes were judged superior because of availability and ease of use.

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