Chas Parsons

Background: Trainees and attending surgeons alike have concerns about resident and fellow operative volume/breadth, competency, and overall readiness for practice. This is an important topic within surgical graduate medical education. Our goal was to analyze the change in general surgery trainee operative experience over time by postgraduate year. Methods: Institutional operative records from two corresponding three-month time periods in 2009 and 2018 at the residency program’s main hospital site were reviewed. Cases assisted on by general, vascular, or thoracic surgery trainees were included. The number of cases per level, combination of trainees in each case, and categories of cases were compared over time. Results: There were 1940 cases in 2009 and 1967 cases in 2018 over the respective time periods. The distribution of trainees was different (P .001), with a similar number of PGY-1 and fellow cases, a decrease in PGY-2 and PGY-5 cases, and an increase in PGY-3 and PGY-4 cases. The number of cases with two trainees, double scrubbed cases, increased from 19.6% to 26.8% (P .001). In addition, there were differences in the resident years that double scrubbed cases together, an increase in robotic and endovascular surgery, and a decrease in open cases. Conclusions: This analysis of cases shows that resident operative volume over approximately a decade has been largely preserved, with some change in the distribution of cases based on trainee level, an increase in cases with more than one trainee, and a rise of minimally invasive surgery with a corresponding decrease in open cases.

To the Editor: Inhibitors of sodium–glucose cotransporter 2 (SGLT2) decrease plasma glucose by blocking the reabsorption of glucose at the proximal tubule. 1,2 Case reports have suggested that SGLT2 inhibitors may be associated with an increased risk of diabetic ketoacidosis, which led to a warning from the Food and Drug Adminis­ tration (FDA) in May 2015. 3,4 The objective of our study was to assess the risk of diabetic ketoaci­ dosis after the initiation of an SGLT2 inhibitor. Using a large claims database of commercial­ ly insured patients in the United States (Truven MarketScan), we identified a cohort of adult pa­ tients (≥18 years of age) who had newly started treatment with either an SGLT2 inhibitor or a dipeptidyl peptidase­4 (DPP4) inhibitor between April 1, 2013, and December 31, 2014 (before the FDA warning). DPP4 inhibitors were chosen as the comparator medication because they are simi­ larly used as a second­line treatment for diabe­ tes but have no known association with diabetic ketoacidosis. We excluded patients with human immunodeficiency virus infection, end­stage renal disease, cancer, type 1 diabetes, or past diabetic ketoacidosis. Our primary outcome was hospitalization for diabetic ketoacidosis (using the primary position code of the International Classifi-cation of Diseases, Ninth Revision) within 180 days after the initiation of an SGLT2 inhibitor or a DPP4 inhibitor. We censored data for patients at the time that they discontinued the initial medi­ cation, had the outcome, lost insurance cover­ age, or died. We used 1:1 propensity­score matching to balance 46 characteristics of the patients and Cox regression to estimate hazard ratios and 95% confidence intervals for diabetic ketoacido­ sis within 180 days after treatment initiation. Predefined sensitivity analyses included shorter durations of follow­up (30 days and 60 days). All statistical analyses were performed with the use of the validated Aetion platform and R software, version 3.1.2. 5