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Nov 8, 2019

In with the new

The story

The whispers about rotten surgery programs are louder than your alarm clock. Can a scathing new report hold program directors accountable?

The background

Since you’re probably reading this on your iPhone, you’re at least aware that it's not the 1950’s. But try telling that to attendings at the many surgery programs that cling to archaic work culture –  flouting of work hours, condescension, outright sexism – like Kanye to a Dino costume. Gender-based microagressions, in particular, are appallingly common and begin early in medical school. Things only get worse, from a burnout and harassment perspective, in residency, where around the clock hours raise the stakes.

The survey

Even the title 'Discrimination, Abuse, Harassment, and Burnout in Surgical Residency Training' understates how badly many programs have failed trainees. A 2018 cross-sectional survey of gen surg residents – 7,400 of them, or 99.3% of eligible residents – found that 32% reported gender-discrimination (including 65% of women), 17% reported racial discrimination, and 30% reported verbal or physical abuse. Patients and patient families were the main source of discrimination, but attending surgeons were the most frequent sources of sexual harassment (27%) and abuse (52%). Almost 5% of residents reported suicidal thoughts in the past year.
NEJM

The takeaway

Bad apple surgery programs need reform now, and program directors, governing bodies, and attendings can't claim ignorance. Perhaps most upsetting about these results is how little they surprise many in the field.

Say it on rounds

When calorie listings start to blur

You probably just finsihed night shift, but the message does seem to get lost. A study of ordering habits before and after implementation of mandatory calorie labeling on menus in 104 fast food franchises in the South found that calories decreased by 60 / transaction in the year after labels were put in place. Changes were most apparent in side dishes rather than entrees or beverages. Customers quickly got over the initial surprise, though, as calories / transaction increased toward pre-implementation levels within a year.
BMJ

When a positive AFB page interrupts date night 

There's never really a good time, to be fair. Final results from the phase 2b trial of the M72/AS01E tuberculosis vaccine found that vaccination decreased progression to pulmonary TB by 50% compared to placebo (0.3 vs. 0.6 cases per 100 person-years) among 3,300 adults in Kenya, South Africa, and Zambia with confirmed latent TB infection. The final efficacy rate was 49.7% over the 3-year study period. Though many think the vaccine is superior to BCG, larger studies are in store before widespread use.
NEJM

When it was a great hair day, until your isolation gown

A single-center prospective study of 100 high-risk (age > 60 with recent hospitalization involving antibiotics) inpatients receiving systemic antibiotics found that prophylaxis with oral vancomycin reduced healthcare facility-onset C. diff infection compared to no prophylaxis (0% vs. 12%). No patients in the treatment group developed new VRE colonization prior to discharge, side effects were minimal, and average costs were low ($26 per patient).
Clin Infect Dis

Brush up

Stimulant dependence

Cocaine and amphetamines are the world's 2 most widely used stimulants, and both have a use prevalence in North American of roughly 2%. Lifetime probability of dependence in the USA is 16% for past cocaine use and 11% for past amphetamine use. Polydrug use is common among injection drug users, including cocaine and heroin ('speedballs') and methamphetamine and heroin ('goofballs'). Like opioids, stimulant use is associated with suicides and overdose, but stimulants can also cause acute (MI and arrhythmias) and chronic (CAD and cardiomyopathy) cardiovascular pathology.

What's the evidence

For pharmacologic treatment of stimulant dependence? No medications have been approved to treat either cocaine or amphetamine dependence, but the search is on. A 2016 trial of sustained release dexamfetamine in 70 patients with heroin and cocaine dependence found that 12 weeks of daily treatment administered via supervised prescription reduced cocaine use frequency compared to placebo. Ketamine has also shown early promise.

What your ID friends are talking about

Though the South American pandemic is over, the first native Zika cases have been confirmed in France. Climate change is expected to bring more Zika to Europe.

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