Chief Resident Indirect Supervision in Training Safety Study: Is a Chief Resident General Surgery Service Safe for Patients?

OBJECTIVE: There has been concern expressed amongst the medical educational community regarding the readiness of general surgery residents in the United States to be competent practicing attendings upon graduation and that limited autonomy may be a contributing factor to this unpreparedness. The purpose of this study was to evaluate an RRC-accredited general surgery residency chief resident acute care surgery service with indirect supervision of cases in terms of safety and outcomes compared to traditional general surgeon cases with direct supervision. The study focused on common general surgical procedures, specifically cholecystectomies, appendectomies, and inguinal and ventral hernia repairs. DESIGN: A retrospective review was conducted of patient data from August 2016 to June 2018 to review all patients 16 years old and older who had received one of the following procedures: appendectomy, cholecystectomy, inguinal hernia repair, or ventral hernia repair. Patient characteristics, procedure type, procedure time, estimated blood loss, complications, length of hospital stay, 30-day readmission, 30-day ED visit, need for reoperation, and mortality were compared between attending direct supervision and chief resident indirect supervision surgery services. SETTING: A single institution associated with a community based-university associated hybrid general surgery residency was included in this study. PARTICIPANTS: Patients aged 16 years or older who underwent one of the operations of interest and were discharged between the dates of August 2016 and June 2018. The operations were performed by, or indirectly supervised by, attendings who were both private surgeons and also covered the chief resident service. RESULTS: A total of 1000 cases were reviewed, with a total of 960 included in the final data after exclusions applied. Of the 960 cases included, 68.4% were traditional attending surgeon cases with direct supervision and 31.6% were chief resident service cases with indirect supervision. A total of 161 appendectomies, 396 cholecystectomies, 201 inguinal hernias and 202 ventral hernias were included. Overall, patients in the chief resident service were more often minorities (27.7 vs. 9.4%, p < 0.001), female (56.4 vs. 44.6%, p = 0.001), younger (40 vs. 55 years, p < 0.001), had a higher BMI (31.2 vs. 29.6, p = 0.018), and a lower ASA class (class 1+2 was 86.4 vs. 65.6%, p < 0.001). The median Charleson Comorbidity Index of the chief resident service patients was lower than that of the attending service (0 vs. 2, p < 0.001). Chief resident service cases were also more often urgent cases (40.6 vs. 22.8%, p < 0.001). Overall, the 30-day complication rate was similar between the two services (5.6 vs. 5.8%, p = 1.000). Complications observed from chief resident service and attending service supervised cases included pneumonia (0.3 vs. 0.5%, p = 1.000), surgical site infection (2.3 vs. 1.5%, p = 0.389), UTI (1.0 vs. 0.6%, p = 0.685), acute kidney injury (0.0 vs. 0.8%, p = 0.333), small bowel obstruction (0.0 vs. 0.6%, p = 0.314), cerebrovascular accident (0.0 vs. 0.2%, p = 1.000), and hematoma/seroma (2.3 vs. 1.7%, p = 0.500). There were no statistically significant differences in procedure-specific complications between services. There was one 30-day mortality in the study population, in the attending service group. CONCLUSIONS: This study's data suggest that a chief resident acute care surgery service with indirect supervision of cases is safe in this community with regards to appendectomies, cholecystectomies and hernia repairs.

Development and Use of Personalized Bacteriophage-Based Therapeutic Cocktails To Treat a Patient with a Disseminated Resistant Acinetobacter baumannii Infection.

Widespread antibiotic use in clinical medicine and the livestock industry has contributed to the global spread of multidrug-resistant (MDR) bacterial pathogens, including Acinetobacter baumannii We report on a method used to produce a personalized bacteriophage-based therapeutic treatment for a 68-year-old diabetic patient with necrotizing pancreatitis complicated by an MDR A. baumannii infection. Despite multiple antibiotic courses and efforts at percutaneous drainage of a pancreatic pseudocyst, the patient deteriorated over a 4-month period. In the absence of effective antibiotics, two laboratories identified nine different bacteriophages with lytic activity for an A. baumannii isolate from the patient. Administration of these bacteriophages intravenously and percutaneously into the abscess cavities was associated with reversal of the patient's downward clinical trajectory, clearance of the A. baumannii infection, and a return to health. The outcome of this case suggests that the methods described here for the production of bacteriophage therapeutics could be applied to similar cases and that more concerted efforts to investigate the use of therapeutic bacteriophages for MDR bacterial infections are warranted.

Complete Genome Sequence of Enterotoxigenic Escherichia coli Myophage Murica.

Murica is an rv5-like myophage that infects enterotoxigenic Escherichia coli. Pathogenic E. coli strains are responsible for many intestinal diseases, and phages that infect these bacteria may prove useful in preventing severe health issues. The following is a report of the complete genome sequence of Murica and its important features.

Complete Genome Sequence of Bacillus megaterium Myophage Mater.

Bacillus megaterium is a ubiquitous, soil inhabiting Gram-positive bacterium that is a common model organism and is used in industrial applications for protein production. The following reports the complete sequencing and annotation of the genome of B. megaterium myophage Mater and describes the major features identified.