Intersection of Race, Ethnicity, and Sex in New Functional Limitations after Injury: Black and Hispanic Female Survivors at Greater Risk.

BACKGROUND: The impact of disparities at the intersection of multiple marginalized social identities is poorly understood in trauma. We sought to evaluate the joint effect of race, ethnicity, and sex on new functional limitations 6 to 12 months postinjury. STUDY DESIGN: Moderately to severely injured patients admitted to one of three Level I trauma centers were asked to complete a phone-based survey assessing functional outcomes 6 to 12 months postinjury. Multivariate adjusted regression analyses were used to compare functional limitations by race and ethnicity alone, sex alone, and the interaction between both race and ethnicity and sex. The joint disparity and its composition were calculated across race and sex strata. RESULTS: Included were 4,020 patients: 1,621 (40.3%) non-Hispanic White male patients, 1,566 (39%) non-Hispanic White female patients, 570 (14.2%) Black or Hispanic/Latinx male patients, and 263 (6.5%) Black or Hispanic/Latinx female patients (BHF). The risk-adjusted incidence of functional limitations was highest among BHF (50.6%) vs non-Hispanic White female patients (39.2%), non-Hispanic White male patients (35.8%), and Black or Hispanic male patients (34.6%; p < 0.001). In adjusted analysis, women (odds ratio 1.35 [95% CI 1.16 to 1.57]; p < 0.001) and Blacks or Hispanic patients (odds ratio 1.28 [95% CI 1.03 to 1.58]; p = 0.02) were more likely to have new functional limitations 6 to 12 months postinjury. When sex and race were analyzed together, BHF were more likely to have new functional limitations compared with non-Hispanic White male patients (odds ratio 2.12 [1.55 to 2.90]; p < 0.001), with 63.5% of this joint disparity being explained by the intersection of race and ethnicity and sex. CONCLUSION: More than half of the race and sex disparity in functional limitations experienced by BHF is explained by the unique experience of being both minority and a woman. Intermediate modifiable factors contributing to this intersectional disparity must be identified.

Leadership Development Among Junior Surgery Residents: Communication and Perception.

INTRODUCTION: Leadership is necessary for effective health care teams, particularly for surgeons. Trainees similarly must acquire foundational leadership skills to maximize effectiveness. However, surgical leadership is rarely formally assessed, particularly for junior trainees. We aimed to establish themes of communication, perception and engagement styles, as well as strengths and weaknesses among junior surgical residents at a single institution. METHODS: The Data Dome Inc. (datadome.com) DISC personality assessment was administered in 2018-2021 to junior residents at an academic general surgery training program at a single institution. Resident demographics were recorded, and themes from deidentified reports were analyzed by year (PGY-1 and PGY-2) using JMP 16 Pro Text Explorer. RESULTS: PGY-1 communication was most frequently described as "accomplished best by well-defined avenues" with "duties and responsibilities of others who will be involved explained" in "friendly terms." PGY-2 communication involved "deal [ing] with people," "strong feelings about a particular problem," and being "good at giving verbal and nonverbal feedback." In ideal environments, PGY-1s self-perceived as "good listener [s]," "good-natured," and "team player [s]." However, under stress, PGY-1s were perceived by others as "poor listener [s]," "self-promoter [s]," "detached," and "insensitive." In ideal environments, PGY-2s were also "good listener [s]," "good-natured," and "team player [s]." However, under stress, PGY-2 external perception was "overly confident," "poor listener [s]," and "self-promoter [s]." CONCLUSIONS: Clear expectations, friendly work environments, and opportunities to succeed are key to effectively train junior surgical residents. In environments where time is often a limited resource, surgical simulation, stress training, and standardized teaching methods from attending surgeons are needed to develop competent trainees.

Mediastinal parathyroidectomy: Utilization of a multidisciplinary, robotic-assisted transthoracic approach in challenging cases.

BACKGROUND: The majority of ectopic mediastinal parathyroid adenomas are accessible transcervically and those not amenable to this approach pose a significant clinical and technical challenge. METHODS: Retrospective review of transthoracic robot-assisted mediastinal parathyroidectomy (TTRMP) for primary hyperparathyroidism between 2012 and 2019 at a single institution. RESULTS: 16 patients underwent TTRMP, 63% were female with a mean age of 64 ± 2.0 years. Nine of 16 had prior parathyroidectomy; 80% had persistent disease and a mean 2.8-year delay from index operation until TTRMP. Locations included: intrathymic (8), AP window (4), carina (3), and retroesophageal (1). Two patients underwent parathyroid reimplantation. Mean post-operative calcium and PTH were 9.2 ± 0.2 mg/dL and 20.2 ± 5.6 pg/mL, respectively. Complications included: temporary hypocalcemia (4), permanent hypocalcemia (1), DVT (1), hoarseness (1), and subcostal neuralgia (1). CONCLUSION: In experienced hands, TTRMP is a safe and effective approach to mediastinal parathyroids not accessible transcervically. A multidisciplinary approach should be used in reoperative cases.

Recurrent Pneumonia? A Case of Availability Bias and Anchoring.

Invasive mucinous adenocarcinoma is a multi-centric adenocarcinoma that accounts for less than 5% of all lung cancer diagnoses. The most common presenting symptoms (cough, sputum production, and chest pain) in conjunction with its radiographic findings (patchy, multi-lobar infiltrates) make invasive mucinous adenocarcinoma challenging to distinguish from both infectious and inflammatory pneumonia. However, due to its aggressive nature, invasive mucinous adenocarcinoma should be considered if a presumed case of pneumonia lacks symptoms of infection (e.g., fever, leukocytosis) and/or does not respond to antibiotics. We report the case of a 75-year-old male who was admitted in the setting of a presumed case of recurrent pneumonia, which had failed to respond to prior antibiotic therapy. Further workup, including trans-bronchial biopsy, confirmed mucinous adenocarcinoma with a lepidic pattern. This case highlights the importance of establishing a broad differential in the setting of unresolved pneumonia following appropriate antibiotic coverage.

Phenazine derivatives cause proteotoxicity and stress in C. elegans.

It is widely recognized that bacterial metabolites have toxic effects in animal systems. Phenazines are a common bacterial metabolite within the redox-active exotoxin class. These compounds have been shown to be toxic to the soil invertebrate Caenorhabditis elegans with the capability of causing oxidative stress and lethality. Here we report that chronic, low-level exposure to three separate phenazine molecules (phenazine-1-carboxylic acid, pyocyanin and 1-hydroxyphenazine) upregulated ER stress response and enhanced expression of a superoxide dismutase reporter in vivo. Exposure to these molecules also increased protein misfolding of polyglutamine and α-synuclein in the bodywall muscle cells of C. elegans. Exposure of worms to these phenazines caused additional sensitivity in dopamine neurons expressing wild-type α-synuclein, indicating a possible defect in protein homeostasis. The addition of an anti-oxidant failed to rescue the neurotoxic and protein aggregation phenotypes caused by these compounds. Thus, increased production of superoxide radicals that occurs in whole animals in response to these phenazines appears independent from the toxicity phenotype observed. Collectively, these data provide cause for further consideration of the neurodegenerative impact of phenazines.

RTCB-1 mediates neuroprotection via XBP-1 mRNA splicing in the unfolded protein response pathway.

Parkinson's disease (PD), the second most prevalent neurodegenerative disorder, is characterized by the degeneration of dopamine (DA) neurons and age-dependent formation of protein inclusions that contain the α-synuclein (α-syn) protein. RNA interference (RNAi) screening using Caenorhabditis elegans identified RTCB-1, an uncharacterized gene product, as one of several significant modifiers of α-syn protein misfolding. RTCB-1 is the worm ortholog of the human HSPC117 protein, a component of RNA trafficking granules in mammalian neurons. Here we show that RTCB-1 protects C. elegans DA neurons from age-dependent degeneration induced by human α-syn. Moreover, neuronal-specific RNAi depletion of rtcb-1 enhanced α-syn-induced degeneration. Similar results were obtained when worms were exposed to the DA neurotoxin 6-hydroxydopamine. HSPC117 has been characterized recently as an essential subunit of the human tRNA splicing ligase complex. tRNA ligases have alternative functions in RNA repair and nonconventional mRNA splicing events. For example, in yeast, unconventional splicing of HAC1, a transcription factor that controls the unfolded protein response (UPR), is mediated by a tRNA ligase. In C. elegans, we demonstrate that RTCB-1 is necessary for xbp-1 (worm homolog of HAC1) mRNA splicing. Moreover, using a RNA ligase-dead mutant, we determine that the ligase activity of worm RTCB-1 is required for its neuroprotective role, which, in turn, is mediated through XBP-1 in the UPR pathway. Collectively, these studies highlight the mechanistic intersection of RNA processing and proteostasis in mediating neuroprotection.