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This cohort study of data from the Surveillance, Epidemiology, and End Results 18 database examines the incidence of anaplastic large-cell lymphoma of the breast in the US from 2000 to 2018.

ImportanceO6-methylguanine-DNA methyltransferase (MGMT [OMIM 156569]) promoter methylation (mMGMT) is predictive of response to alkylating chemotherapy for glioblastomas and is routinely used to guide treatment decisions. However, the utility of MGMT promoter status for low-grade and anaplastic gliomas remains unclear due to molecular heterogeneity and the lack of sufficiently large data sets.ObjectiveTo evaluate the association of mMGMT for low-grade and anaplastic gliomas with chemotherapy response.Design, Setting, and ParticipantsThis cohort study aggregated grade II and III primary glioma data from 3 prospective cohort studies with patient data collected from August 13, 1995, to August 3, 2022, comprising 411 patients: MSK-IMPACT, EORTC (European Organization of Research and Treatment of Cancer) 26951, and Columbia University. Statistical analysis was performed from April 2022 to January 2023.ExposureMGMT promoter methylation status.Main Outcomes and MeasuresMultivariable Cox proportional hazards regression modeling was used to assess the association of mMGMT status with progression-free survival (PFS) and overall survival (OS) after adjusting for age, sex, molecular class, grade, chemotherapy, and radiotherapy. Subgroups were stratified by treatment status and World Health Organization 2016 molecular classification.ResultsA total of 411 patients (mean [SD] age, 44.1 [14.5] years; 283 men [58%]) met the inclusion criteria, 288 of whom received alkylating chemotherapy. MGMT promoter methylation was observed in 42% of isocitrate dehydrogenase (IDH)–wild-type gliomas (56 of 135), 53% of IDH-mutant and non-codeleted gliomas (79 of 149), and 74% of IDH-mutant and 1p/19q-codeleted gliomas (94 of 127). Among patients who received chemotherapy, mMGMT was associated with improved PFS (median, 68 months [95% CI, 54-132 months] vs 30 months [95% CI, 15-54 months]; log-rank P MGMT, 1.95 [95% CI, 1.39-2.75]; P P P = .01). After adjusting for clinical factors, MGMT promoter status was associated with chemotherapy response in IDH–wild-type gliomas (aHR for PFS, 2.15 [95% CI, 1.26-3.66]; P = .005; aHR for OS, 1.69 [95% CI, 0.98-2.91]; P = .06) and IDH-mutant and codeleted gliomas (aHR for PFS, 2.99 [95% CI, 1.44-6.21]; P = .003; aHR for OS, 4.21 [95% CI, 1.25-14.2]; P = .02), but not IDH-mutant and non-codeleted gliomas (aHR for PFS, 1.19 [95% CI, 0.67-2.12]; P = .56; aHR for OS, 1.07 [95% CI, 0.54-2.12]; P = .85). Among patients who did not receive chemotherapy, mMGMT status was not associated with PFS or OS.Conclusions and RelevanceThis study suggests that mMGMT is associated with response to alkylating chemotherapy for low-grade and anaplastic gliomas and may be considered as a stratification factor in future clinical trials of patients with IDH–wild-type and IDH-mutant and codeleted tumors.

This cohort study uses national surveillance data to describe the incidence and risk of squamous cell carcinoma after postmastectomy implant reconstruction in women with breast cancer.

Ferroptosis is mediated by lipid peroxidation of phospholipids containing polyunsaturated fatty acyl moieties. Glutathione, the key cellular antioxidant capable of inhibiting lipid peroxidation via the activity of the enzyme glutathione peroxidase 4 (GPX-4), is generated directly from the sulfur-containing amino acid cysteine, and indirectly from methionine via the transsulfuration pathway. Herein we show that cysteine and methionine deprivation (CMD) can synergize with the GPX4 inhibitor RSL3 to increase ferroptotic cell death and lipid peroxidation in both murine and human glioma cell lines and in ex vivo organotypic slice cultures. We also show that a cysteine-depleted, methionine-restricted diet can improve therapeutic response to RSL3 and prolong survival in a syngeneic orthotopic murine glioma model. Finally, this CMD diet leads to profound in vivo metabolomic, proteomic and lipidomic alterations, highlighting the potential for improving the efficacy of ferroptotic therapies in glioma treatment with a non-invasive dietary modification.

The Athletic Trainers’ Self-Confidence Scale (ATSCS) is a nine-item Likert-scale questionnaire assessing the respondent’s level of agreement with statements regarding confidence in recognizing and managing exertional heat illnesses. Test–retest reliability of this instrument has not yet been established. The purpose of this study was to investigate the internal consistency, test–retest reliability, and minimum detectable change score for the composite score of the ATSCS. A total of 18 professional master of science in athletic training students (nine first-year and nine second-year students) completed the ATSCS at three testing sessions with 48 hr between sessions. The nine items of the ATSCS demonstrated good internal consistency (α = .86; 95% confidence interval [.78, .94]). The composite scores of the ATSCS demonstrated moderate test–retest reliability (intraclass correlation coefficient = .75; 95% confidence interval [.497, .893]). The calculated minimal detectable change for the composite change score was 6.19. The ATSCS has good internal reliability as well as test–retest reliability. These results display that the tool will provide consistent, reliable results of changes in athletic training students’ self-confidence.

One mechanism that cancer cells use to evade natural killer cell immune surveillance is by expressing high levels of sialoglycans, which bind to Siglec-9, a glyco-immune checkpoint molecule on NK cells. This binding inhibits NK cell cytotoxicity.

Background Although exercise has been shown to improve cancer survivorship in other communities, cancer exercise studies among Native American communities are rare. We sought to adapt a Navajo-tailored cancer exercise pilot program to serve a broader Native American cancer community. Methods Tribal experts representing 10 different Tribal Nations were engaged in small focus groups (n=2–4) to assess program materials for cultural appropriateness and adaptation to expand tribal inclusiveness. Facilitated by a trained Native American interviewer, focus groups were provided a primer survey and then reviewed intervention materials (protocols, incentives, logo, flyers, etc.). Consensus was reached by the research team on all program adaptations. Results The program name, Restoring Balance, layout, graphics, and symbols were considered culturally appropriate overall. Program exercises and biomarker measurements were viewed as valuable to health improvements in the community. Important color, linguistic, and logistic program modifications were recommended to improve cultural alignment. The order of incentive items was revised to highlight restoration and the logo rotated to align with the four corners of the earth, an important cultural element. Linguistic modifications primarily related to prior traumatic research experiences in Native American communities where data had been taken without adequate community benefit or permission. Program emphasis should be on nurturing, added value and giving. Conclusion and Relevance The methodology used for cultural expert review was successful in eliciting adaptations to expand the tribal inclusiveness of Restoring Balance. Culture, as well as historically traumatic research experiences, among Native American populations must be considered when adapting health promotion programming.

This cohort study examines the risk of anaplastic large cell lymphoma (ALCL) following postmastectomy implant reconstruction among US women with breast cancer and ductal carcinoma in situ (DCIS).

Hemorrhage remains a leading cause of death among trauma patients. Resuscitative endovascular balloon occlusion of the aorta has grown in popularity as an efficient, less invasive alternative to managing patients with noncompressible hemorrhage. The aim of this study to investigate the clinical outcomes of resuscitative endovascular balloon occlusion of the aorta use in adult civilian trauma patients with and without concomitant traumatic brain injury.This a secondary analysis of the American College of Surgeons Trauma Quality Improvement Program database from the years 2015 to 2017 of adult trauma patients with and without traumatic brain injury and who had a resuscitative endovascular balloon occlusion of the aorta. Patients who were deceased on arrival, required resuscitative thoracotomy, or had missing information regarding traumatic brain injury status were excluded. Multivariable risk adjustment was performed. The primary outcome was inpatient mortality.Of 2,352,542 patients, 199 met the criteria for inclusion in the final analysis. resuscitative endovascular balloon occlusion of the aorta + traumatic brain injury patients were significantly more likely to have a lower Glasgow Coma Scale ≤8 (82.4% vs 54.4%, P.001) and systolic blood pressure (89 ± 37.4 vs 107.2 ± 39.7; P = .002), and higher injury severity score25 (83.5% vs 65.8%, P = .01) compared with resuscitative endovascular balloon occlusion of the aorta/non-traumatic brain injury patients. No differences in odds of inpatient mortality (62.4% vs 50.9%, P = .11) or complications (17.7% vs 11.4%, P = .21) were observed between groups. Subgroup analysis based on mechanism of injury, trauma center level, teaching hospital status, and pelvic fracture status also did not show any differences in mortality.Inpatient mortality with resuscitative endovascular balloon occlusion of the aorta use does not differ between patients with or without concomitant traumatic brain injury, despite those with traumatic brain injury having significantly higher injury severity and more severe hypotension on intake.

Lung cancer has been the most common cancer worldwide for several decades. The outcomes of patients with locally advanced lung cancer remain dismal, and only a minority of patients survive more than 5 years. However, tumor therapeutic resistance mechanisms are poorly studied. Identification of therapeutic resistance pathways in lung cancer in order to increase the sensitivity of lung tumor cells to therapeutic agents is a crucial but challenging need. To identify novel genes that modulate the response to platinum-based therapy, we performed a genome-wide high-throughput ribonucleic acid interference (RNAi) screen via transfection of human lung cancer (PC9) cells with a viral short hairpin RNA (shRNA) library. We further validated a potential target via 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) and clonogenic survival assays on PC9 and A549 lung tumor cells transfected with small interfering RNAs (siRNAs) to successfully downregulate protein expression and then treated with increasing doses of cisplatin or X-ray radiation. We determined protein expression by immunohistochemistry (IHC) after chemoradiotherapy and analyzed gene expression-based survival outcomes in two cohorts of human non-small-cell lung cancer (NSCLC) patients. The screen identified several targets involved in epithelial-to-mesenchymal transition (EMT), including Smurf1, Smurf2, YAP1, and CEBPZ, and glycolytic pathway proteins, including PFKFB3. Furthermore, we found that the small molecule proteasome inhibitor bortezomib significantly downregulated Smurf2 in lung cancer cells. The addition of bortezomib in combination with cisplatin and radiation therapy in PC9 and A549 cells led to an increase in deoxyribonucleic acid (DNA) double-strand breaks with increased numbers of γ-H2AX-positive cells and upregulation of apoptosis. Finally, we found that Smurf2 protein expression was upregulated in situ after treatment with cisplatin and radiation therapy in a relevant cohort of patients with stage III NSCLC. Additionally, Smurf2 gene expression was the strongest predictor of survival in patients with squamous NSCLC after chemotherapy or chemoradiotherapy. We successfully identified and validated Smurf2 as both a common modulator of resistance and an actionable target in lung cancer. These results suggest the urgent need to investigate clinical Smurf2 inhibition via bortezomib in combination with cisplatin and radiation for patients with locally advanced NSCLC.

OBJECTIVE Genomic analysis in neurooncology has underscored the importance of understanding the patterns of survival in different molecular subtypes within gliomas and their responses to treatment. In particular, diffuse gliomas are now principally characterized by their mutation status (IDH1 and 1p/19q codeletion), yet there remains a paucity of information regarding the prognostic value of molecular markers and extent of resection (EOR) on survival. Furthermore, given the modern emphasis on molecular rather than histological diagnosis, it is important to examine the effect of maximal resection on survival in all gliomas with 1p/q19 codeletions, as these will now be classified as oligodendrogliomas under the new WHO guidelines. The objectives of the present study were twofold: 1) to assess the association between EOR and survival for patients with oligodendrogliomas in the National Cancer Database (NCDB), which includes information on mutation status, and 2) to demonstrate the same effect for all patients with 1p/19q codeleted gliomas in the NCDB. METHODS The NCDB was queried for all cases of oligodendroglioma between 2004 and 2014, with follow-up dates through 2016. The authors found 2514 cases of histologically confirmed oligodendrogliomas for the final analysis of the effect of EOR on survival. Upon further query, 1067 1p/19q-codeleted tumors were identified in the NCDB. Patients who received subtotal resection (STR) or gross-total resection (GTR) were compared to those who received no tumor debulking surgery. Univariable and multivariable analyses of both overall survival and cause-specific survival were performed. RESULTS EOR was associated with increased overall survival for both histologically confirmed oligodendrogliomas and all 1p/19q-codeleted–defined tumors (p < 0.001 and p = 0.002, respectively). Tumor grade, location, and size covaried predictably with EOR. When evaluating tumors by each classification system for predictors of overall survival, facility setting, age, comorbidity index, grade, location, chemotherapy, and radiation therapy were all shown to be significantly associated with overall survival. STR and GTR were independent predictors of improved survival in historically classified oligodendrogliomas (HR 0.83, p = 0.18; HR 0.69, p = 0.01, respectively) and in 1p/19q-codeleted tumors (HR 0.49, p < 0.01; HR 0.43, p < 0.01, respectively). CONCLUSIONS By using the NCDB, the authors have demonstrated a side-by-side comparison of the survival benefits of greater EOR in 1p/19q-codeleted gliomas.

Background The data on resuscitative endovascular balloon occlusion of the aorta (REBOA) use continue to grow with its increasing use in trauma centers. The data in her last 5 years have not been systematically reviewed. We aim to assess current literature related to REBOA use and outcomes among civilian trauma populations. Methods A literature search using PubMed, EMBASE, and JAMA Network for studies regarding REBOA usage in civilian trauma from 2016 to 2020 is carried out. This review followed preferred reporting items for systematic reviews and meta-analysis guidelines. Results Our search yielded 35 studies for inclusion in our systematic review, involving 4073 patients. The most common indication for REBOA was patient presentation in hemorrhagic shock secondary to traumatic injury. REBOA was associated with significant systolic blood pressure improvement. Of 4 studies comparing REBOA to non-REBOA controls, 2 found significant mortality benefit with REBOA. Significant mortality improvement with REBOA compared to open aortic occlusion was seen in 4 studies. In the few studies investigating zone placement, highest survival rate was seen in patients undergoing zone 3. Overall, reports of complications directly related to overall REBOA use were relatively low. Conclusion REBOA has been shown to be effective in promoting hemodynamic stability in civilian trauma. Mortality data on REBOA use are conflicting, but most studies investigating REBOA vs. open occlusion methods suggest a significant survival advantage. Recent data on the REBOA technique (zone placement and partial REBOA) are sparse and currently insufficient to determine advantage with any particular variation. Overall, larger prospective civilian trauma studies are needed to better understand the benefits of REBOA in high-mortality civilian trauma populations. Study Type Systematic Review. Level of evidence III- Therapeutic.

Highlights • Blunt thoracic aortic injuries are life threatening and require urgent intervention. • Rare presentation of a blunt thoracic aortic injury in a patient with an aberrant right subclavian artery off the aortic arch distal to the takeoff of the left subclavian artery. • An aberrant right subclavian artery originating from the aortic arch, distal to the left subclavian artery is an anatomic variant that adds significant complexity to TEVAR., Introduction Blunt thoracic aortic injuries (BTAIs) are an uncommon traumatic injury that if not treated promptly, can result in death. We present the case of a BTAI with aberrant aortic anatomy. Presentation of case A 60-year-old female was involved in a motor vehicle crash where she suffered significant polytrauma including a BTAI. She was also found to have an aberrant right subclavian artery originating from the aortic arch. Thoracic Endovascular Aortic Repair (TEVAR) with a right common carotid artery to right subclavian artery bypass was accomplished. She required three more vascular surgical interventions, two for persistent type II endoleak and the third for left upper extremity acute limb ischemia. She had a 2-month hospital course for her devastating injuries and was eventually discharged home. A follow-up CT angiogram showed a stable thoracic aortic arch stent. Discussion BTAIs are uncommon in the trauma population. In our patient who had an aberrant right subclavian artery, further procedures were required in the form of a right common carotid artery to right subclavian artery bypass and embolizations to resolve endoleaks. Conclusion Blunt thoracic aortic injuries are life threatening and require urgent intervention. TEVAR is associated with better outcomes. An aberrant right subclavian artery originating from the aortic arch, distal to the left subclavian artery is an anatomic variant that adds significant complexity to TEVAR. TEVAR is still an option for repair of blunt thoracic aortic injuries despite anatomic variations as open repair still carries an increased risk of morbidity and mortality.

Background Hemorrhage accounts for >30% of trauma-related mortalities. Use of resuscitative endovascular balloon occlusion of the aorta (REBOA) for temporary hemostasis in the civilian population remains controversial. We aim to investigate REBOA practices through analysis of surgeon and trauma center characteristics, implementation, patient characteristics, and overall opinions. Methods An anonymous 30-question standardized online survey on REBOA use was administered to active trauma surgeon members of the Eastern Association for the Surgery of Trauma. Results A total of 345 responses were received, and 130/345 (37.7%) reported REBOA being favorable, 42 (12.2%) reported REBOA unfavorably, and 173 (50.1%) were undecided. The majority of respondents (87.6%) reported REBOA performance in the trauma bay. 170 (49.3%) of respondents reported having deployed REBOA at least once over the past 2 years. 80.0% reported blunt trauma being the most common mechanism of injury in REBOA patients. Resuscitative endovascular balloon occlusion of the aorta deployment in zone 3 of the aorta was significantly higher in patients reported to suffer a pelvic fracture or pelvic hemorrhage, whereas REBOA deployment in zone 1 was significantly higher among patients reported to suffer hepatic, splenic, or other intra-abdominal hemorrhage ( P < .05). Conclusion Among survey respondents, frequency of REBOA use was low along with knowledge of clear indications for use. While current REBOA usage among respondents appeared to model current guidelines, additional research regarding REBOA indications, ideal patient populations, and outcomes is needed in order to improve REBOA perception in trauma surgeons and increase frequency of use.

Background Physician scientists who are also Editorial Board members or Associate Editors may prefer publishing in their own journal and therefore create an environment for conflicts of interest to arise. Objectives To assess the relationship between the number of peer-reviewed publications in surgical journals in which authors serve as Editorial Board Members and Associate Editors and their total number of annual publications. Materials and methods A cross-sectional study utilizing PubMed was performed regarding the total annual number of peer-reviewed publications by Editorial Board Members/Associate Editors and the number published in their respective affiliated journals from 2016 to 2019. Significance defined as p 0.05). Conclusions We found significant associations between the total number of annual peer-reviewed publications by Editorial Board Members/Associate Editors and number of annual peer-reviewed publications by their affiliated surgical journals. The implementation and enforcement of a standardized double-blind review process and mandatory reporting of any potential conflicts of interest can reduce possible bias and promote a fair and high-quality peer-review process., Highlights • Editorial Board Members and Associate Editors of some surgical journals are significantly more likely to publish in their own affiliated journals. • To minimize potential conflicts of interest, journals should commit to double-blinded evaluations of prospective manuscripts and disclose any associated conflicts of interest to avoid bias and maxmize the quality of the peer review process. • Manuscript evaluations should be based solely on academic merit and impact.

Highlights • These two cases highlight the limitations in current grading systems, particularly in the context of gallbladder size. • We propose modifications to the PGS to include not only abnormal anatomy but instances of distorted gallbladder anatomy due to inflammation and/or the large to giant size in order to account for the increased risk of complications. • Both distorted gallbladder anatomy and giant gallbladder size can make laparoscopic cholecystectomy a challenge, and thus warrant contribution to overall clinical grade. • While the PGS, Tokyo Guidelines, and AAST grading scales are validated grading scales for acute cholecystitis, additional modifications can further characterize different types of acute cholecystitis to better guide patient management.

Introduction The literature remains unclear on the development, consequences, and interventions for burnout in resident populations. We aim to identify the prevalence and nuances of reported burnout in general surgery resident physicians to better understand which factors contribute the greatest risk. Methods A 42-question anonymous online survey was distributed by the Association of Program Directors in Surgery (APDS) to general surgery resident physicians. ANOVA, chi-square and multinomial regression analyses were performed with significance defined as p, Highlights • Burnout as self-reported by general surgery residents is exceptionally high. • Risk factors associated with increased reporting of burnout include female gender, community affiliated teaching hospitals, and increased work hours. • Residents reporting burnout are more likely to consider leaving the medical field altogether, report their burnout affects their ABSITE performance and aspects of daily life.

Estrogen receptor–positive breast tumors, which initially respond effectively to endocrine therapy, progress due to acquired endocrine therapy resistance, including genomic alterations in estrogen receptor alpha (ESR1). A recent study has suggested that there is a sufficient number of preexisting ESR1 mutations acting as an intrinsic resistance mechanism to warrant primary screening. We determined the incidence of de novo ESR1 mutations in hormone-positive treatment-naïve primary breast tumors using 12 publicly available international datasets in the cBioPortal. The prevalence of mutation was statistically significantly lower in treatment-naïve primary tumors (n = 6 of 3682, 0.16%) than in metastatic (n = 156 of 1089, 14.3%, 2-sided P

Background Food insecurity is associated with increased morbidity and mortality in people with human immunodeficiency virus (HIV) on antiretroviral therapy, but its relationship with immune dysregulation, a hallmark of HIV infection and comorbidity, is unknown. Methods In 241 women participating in the Women’s Interagency HIV Study, peripheral blood mononuclear cells were characterized by flow cytometry to identify cell subsets, comprising surface markers of activation (%CD38+HLADR+), senescence (%CD57+CD28−), exhaustion (%PD-1+), and co-stimulation (%CD57− CD28+) on CD4+ and CD8+ T cells. Mixed-effects linear regression models were used to assess the relationships of food insecurity with immune outcomes, accounting for repeated measures at ≤3 study visits and adjusting for sociodemographic and clinical factors. Results At the baseline study visit, 71% of participants identified as non-Hispanic Black, 75% were virally suppressed, and 43% experienced food insecurity. Food insecurity was associated with increased activation of CD4+ and CD8+ T cells, increased senescence of CD8+ T cells, and decreased co-stimulation of CD4+ and CD8+ T cells (all P 40 copies/mL and CD4 Conclusions Food insecurity may contribute to the persistent immune activation and senescence in women with HIV on antiretroviral therapy, independently of HIV control. Reducing food insecurity may be important for decreasing non–AIDS-related disease risk in this population.

Background and objectives With the rate of physician suicide increasing, more research is needed to implement adequate prevention interventions. This study aims to identify trends and patterns in physician/surgeon suicide and the key factors influencing physician suicide. We hope such information can highlight areas for targeted interventions to decrease physician suicide. Methods Review of Centers for Disease Control and Preventions National Violent Death Reporting System (NVDRS) for 2003 to 2017 of physician and dentists dying by suicide. Twenty-eight medical, surgical, and dental specialties were included. Results Nine hundred five reported suicides were reviewed. Physician suicides increased from 2003 to 2017. Majority surgeons' suicides were middle-aged, White males. Orthopedic surgeons had the highest prevalence of suicide among surgical fields (28.2%). Black/African American surgeons were 56% less likely [odds ratio (OR) = 0.44, 95% confidence interval (CI): 0.06-3.16] and Asian/Pacific Islander were 438% more likely (OR = 5.38, 95% CI: 2.13-13.56) to die by suicide. Surgeons were 362% more likely to have a history of a mental disorder (OR = 4.62, 95% CI: 2.71-7.85), were 139% more likely to use alcohol (OR = 2.39, 95% CI: 1.36-4.21), and were 289% more likely to have experienced civil/legal issues (OR = 3.89, 95% CI: 1.36-11.11). Conclusions The prevalence of physician suicide increased over the 2003 to 2017 time-frame with over a third of deaths occurring from 2015 to 2017. Among surgeons, orthopedics has the highest prevalence of reported suicide. Risk factors for surgeon suicide include Asian/Pacific Islander race/ethnicity, older age, history of mental disorder, alcohol use, and civil/legal issues.

Highlights • Despite hemodynamic stability on presentation, pediatric patients suffering GSW injuries should undergo extensive assessment to rule out any significant internal injuries. • Renal laceration can be successfully managed with conservative observation in hemodynamically stable patients., Introduction Trauma remains the leading cause of mortality in the pediatric population. Penetrating thoracic injuries can result in devastating trauma to multiple organ systems. When these injuries occur, prompt diagnosis and swift treatment of internal organ injury are of utmost importance. Case presentation A 13-year-old male presented to our Trauma Center after sustaining a gunshot wound (GSW) to the left chest. Despite his hemodynamic stability on presentation, CT scan revealed multiple injuries including splenic and renal lacerations. Exploratory laparotomy resulted in splenectomy, but no intervention was performed for the renal laceration. Instead, clinical monitoring alone was sought. Patient was discharged on hospital day 13 in stable condition. Discussion Pediatric penetrating injuries secondary to GSWs can impact multiple organ systems. Despite hemodynamic stability on presentation, adequate staging of internal damage with CT allowed a targeted approach. In our case, non-operative management of the renal injury was implemented after hemorrhage control of his additional injuries. Failure to have done so would have inevitably complicated his overall management and made kidney salvage not feasible. Conclusion Prompt diagnosis and treatment are required in order to prevent significant morbidity and mortality in the pediatric patient from GSW-mediated penetrating thoracic injuries. Despite hemodynamic stability on presentation, patients should be emergently assessed for severe injury, with immediate surgical management as needed. Failure to do so could lead to rapid clinical deterioration, and inability to enact other conservative measures that lead to positive outcomes.

Highlights • This is a rare case of traumatic enucleation of the right globe sustained after an assault. • Traumatic enucleation requires significant retro-ocular force to cause globe separation from the surrounding supportive structures within the orbit. • Optic nerve avulsion from traumatic enucleation can cause contralateral visual deficits such as temporal hemianopia in the uninjured eye. • Current open and closed globe injury classification systems are not applicable to traumatic enucleation indicating the need for new system development to guide treatment options., Introduction Ocular trauma is a common occurrence in trauma settings but often occurs with little to no effect on the vision of the patient. Traumatic enucleation is a rare but devastating injury. Case presentation A 40-year-old male presented to our trauma center after an assault resulting in right globe enucleation. CT confirmed absence of the globe with disruption of the ipsilateral orbital contents and distal optic nerve disruption. The patient was started on intravenous antibiotics and the right orbit was packed. He was taken to the operating room for exploration of the right orbit and placement of an implant. His remaining hospital course was unremarkable. Discussion Documented mechanisms of injury for traumatic enucleation are diverse, but often involve significant retro-ocular force to completely dislodge the globe from the orbit. Optic nerve avulsion may cause associated optic nerve chiasm damage leading to temporal hemianopia in the uninjured contralateral eye. Treatment involves stabilization and preparation for future implant placement. Conclusion Traumatic enucleation is extremely rare. Development of a grading system applicable to traumatic enucleation may be helpful in guiding management in this complex patient population.

Education is essential for lowering cases of Angiostrongyliasis in Hawaii. A professional development course on rat lungworm disease (RLWD) prevention was offered to Hawaii K-12 teachers during the 2018–2019 school year. Fourteen teachers, 11 from Hawaii Island and three from Maui, representing grades K, 2, 6–8, and 10−12, completed workshops and activities and received course credit. Teachers reached 652 students and educated 86 teachers and staff and approximately 900 community members including parents. A pre-course survey showed 55% of teachers agreed to a basic understanding of rat lungworm and its impact on Hawaii; this increased to 100% post-course. A sixth-grade class was the first to document the arrival of a highly competent intermediate host of the rat lungworm in a new location, an important discovery that initiated community awareness and control efforts. Six, 1-day workshops were held in 2018–2019, each on one of the main Hawaiian Islands. These were attended by 106 participants including teachers, community educators, and interested individuals from agencies, non-profits, businesses and the private sector. Of participants surveyed, 100% responded the workshop improved their overall understanding of RLWD. Efforts are being made to continue these programmes.

Introduction Subclavian artery injury secondary to blunt trauma is rare and only a few cases have been documented in the literature. Subclavian arteries are protected by the clavicles, ribs, and chest wall. Clinical management and surgical approach vary depending on the specific injury. We present the case of a 50 year old male with blunt right subclavian transection. Case presentation A 50-year-old male presented after being struck by a train. On exam, the patient had open injuries to the right upper chest/extremity. CTA showed a transection of the mid right subclavian artery along with a long traumatic occlusion distal to the defect. The patient was taken to the operating room where median sternotomy with supraclavicular extension was used to expose the transected ends of the subclavian artery and successfully perform a bypass graft. After a long hospital stay, he had a near-full functional recovery. Discussion Blunt subclavian injury is rare and carries a high mortality. Adequate intervention requires prompt identification and proper surgical approach for repair. Median sternotomy offers the best approach to visualize the proximal right subclavian artery. Extension with a supraclavicular incision can be necessary for distal control. This approach offered timely intervention, which ultimately saved his life and allowed for return of pre-trauma functional status. Conclusion Prompt identification of subclavian artery injury is paramount as such injuries carry a high mortality. Median sternotomy with supraclavicular extension is an appropriate open surgical approach to successfully manage proximal right subclavian artery injuries., Highlights • Proximal right subclavian artery injuries secondary to blunt trauma are rare and often associated with significant comorbidities and higher mortality. • Prompt surgical intervention adequately prevented death in our patient and allowed for full functional recovery. • Management of such subclavian artery injuries typically require open surgical intervention given the extent of damage.

Electrostatic charging of hospital personnel and patients during various activities increases the risk of electrostatic discharge (ESD) malfunctions of medical devices and the likelihood of patients’ adverse events. Therefore, the test level for ESD immunity of medical devices, specified in the IEC 60601-1-2 standard needs to reflect the reasonably maximum electrostatic voltages during usage. This study investigated the effects of material combinations and relative humidity on the body voltage while performing two routine clinical activities of lying down on a hospital bed and transferring to a bed using a sliding board. The peak body voltages in nearly 50% of the lying down experiments and 40% of sliding tests exceeded the test voltage level in the IEC 60601-1-2 standard (i.e., 15 kV). Using cotton blankets in lying down experiments and nylon sheets during sliding experiments resulted in 50% and 40% larger median than the median including all combinations, respectively. Sliding boards with antistatic coating reduced the peak body voltage by 24% on average, however, 33% of the tests still exceeded 15 kV. Based on the findings, recommendations are provided for healthcare facilities and medical device manufacturers to mitigate the risks of ESD malfunctions.

BACKGROUND The American Board of Surgery In-training Examination (ABSITE) is an important marker of medical knowledge. It is unclear what factors predict or improve these scores. We evaluated demographics, United States Medical Licensing Examination (USMLE) step 1 and 2 scores, and surgical rotations during the intern year to determine if there were any correlations with the ABSITE performance. METHODS This was a multicenter retrospective review during a 6-y period, investigating the correlation and association of demographics, USMLE scores, and types of rotations on the ABSITE percentile score of interns. Demographics included age, gender, race/ethnicity, U.S. versus international/foreign medical graduate for stratified analyses. Descriptive analysis was performed with ANOVA, correlation was evaluated with 95% confidence interval, and significance was defined as P

Highlights • Development of a triad of intussusception, volvulus, and internal hernia after RYGB surgery is rare. • In patients with history of RYGB and acute abdomen, high suspicion for obstructive complications is required to allow for timely diagnosis and early surgical intervention. • Early surgical intervention of SBO secondary to RYGB was sufficient for preventing bowel necrosis and subsequent bowel resection., Introduction The Roux-en-y gastric bypass (RYGB) surgery is one of the most common and successful weight loss procedures. Procedure mortality is low, but intestinal complications account for a high percentage of associated morbidity. Internal hernias remain one of the most common complications while volvulus and intussusception are rare. Presentation of case A 22-year-old woman with a past surgical history of laparoscopic RYGB six years prior presented with a 12 -h history of abdominal pain. Exploratory laparotomy revealed concomitant volvulus, internal hernia and intussusception at the J-J anastomosis which was reduced without need for bowel resection. Her post-operative course was unremarkable and she was discharged home five days later. Discussion Many previous cases of intussusception related to RYGB surgery have required treatment with bowel resection secondary to delayed surgical intervention. Due to high variability in clinical presentation of post-RYGB obstruction, a high index of suspicion is necessary for prompt recognition. Early surgical intervention may prevent the need for bowel resection and improve patient outcomes. Conclusion This case represents an unusual complication of RYGB involving intussusception, internal hernia and volvulus that was successfully managed without need for bowel resection due to early identification and surgical intervention.

Highlights • “Giant” gallbladder development in the context of acute on chronic cholecystitis is extremely rare and may present with atypical symptoms secondary to mass effect. • Current grading systems for acute cholecystitis severity do not include assessment based on size making them insufficient in predicting “giant” gallbladder surgical prognosis. • Laparoscopic cholecystectomy was performed successfully despite the large gallbladder size without intraoperative/postoperative complications., Introduction Gallbladder disease is a common surgical pathology. Gallstones can remain asymptomatic or develop into an acute cholecystitis and need for surgical intervention. Significant enlargement of the gallbladder well beyond the normal volume is rare. Such “giant” gallbladders can affect feasibility of subsequent management options. Presentation of case An 80-year-old female presented to the emergency department with a two-day history of acute on chronic gastric reflux with nausea and vomiting. On examination, she had right upper quadrant abdominal pain. CT imaging identified an enormous gallbladder creating mass effect and compression on the distal stomach. She underwent successful laparoscopic cholecystectomy and was discharged from the hospital the next day, doing well. On two-week follow up, her reflux symptoms had completely resolved and she had no complaints. Discussion Giant gallbladders are a rare entity. Our patient’s case is unique in both its occurrence as well as presentation with predominant reflux symptoms secondary to mass effect by the enlarged gallbladder. Current cholecystitis grading systems do not utilize size as a means of predicting severity and risk of operative complications or difficulty of procedure. Laparoscopic cholecystectomy was a successful approach in managing this extreme pathology. Conclusion Updated classifications systems that include size and mass effect as a predictive measure are needed to better assess surgical outcomes, especially in “giant” gallbladder disease. Despite the large size and potential mass effect on surrounding structures, laparoscopic cholecystectomy can still be attempted if no other contraindications exist.

Previous reports demonstrated that severe acute respiratory syndrome coronavirus (SARS-CoV-2) binding immunoglobulin G levels did not increase significantly between the first and second doses of the BNT162b2 vaccine in previously infected individuals. We tested neutralizing antibodies (nAbs) against SARS-CoV-2 Delta and Omicron variants after the first and second doses of this vaccine in infection-naive and previously infected individuals. Delta, but not Omicron, nAb titers significantly increased from the first to the second dose in both groups of individuals. Importantly, we found that Omicron nAb titers were much lower than Delta nAb titers and that even after 2 doses of vaccine, 17 of 29 individuals in the infection-naive group and 2 of 27 in the previously infected group did not have detectable Omicron nAb titers. Infection history alone did not adequately predict whether a second dose resulted in adequate nAb. For future variants of concern, the discussion on the optimal number of vaccine doses should be based on studies testing for nAb against the specific variant.

Supplemental Material, sj-pdf-2-asu-10.1177_0003134820988813 for REBOA Use, Practices, Characteristics, and Implementations Across Various US Trauma Centers by Mason Sutherland, Aaron Shepherd, Kyle Kinslow, Mark McKenney and Adel Elkbuli in The American Surgeon

Supplemental Material, sj-pdf-2-asu-10.1177_0003134820988813 for REBOA Use, Practices, Characteristics, and Implementations Across Various US Trauma Centers by Mason Sutherland, Aaron Shepherd, Kyle Kinslow, Mark McKenney and Adel Elkbuli in The American Surgeon

Supplemental Material, sj-pdf-1-asu-10.1177_0003134820988813 for REBOA Use, Practices, Characteristics, and Implementations Across Various US Trauma Centers by Mason Sutherland, Aaron Shepherd, Kyle Kinslow, Mark McKenney and Adel Elkbuli in The American Surgeon

Wage theft harms workers and their families directly, but also diminishes the collective bargaining power of workers by depressing hourly wages in the impacted industries and occupations. This has a ripple effect on the State’s economy, since it forces workers to rely on increasingly strained public assistance programs, which ultimately affects taxpayers. The theft of workers’ earned wages is an epidemic that costs workers billions of dollars across various industries. In Santa Clara County alone, our analysis of federal, state, and local datasets found a total of 25,856 reported wage theft cases across industries. These cases affected 32,826 employees and amounted to $128,871,256 in total wage theft that is still unpaid—or an average of $3,926 per employee. This report demonstrates that wage theft remains rampant in Santa Clara County due to insufficient government enforcement. Despite the progress that the state and local governments have made to combat the problem, workers continue to face wage theft in huge numbers. Even those who successfully file claims against their employers, enduring legal proceedings that can take months or years, largely fail to collect the back wages they are awarded. The crisis of wage theft has only worsened in the age of COVID-19, which has also exacerbated labor trafficking, health and safety violations, job losses, pay decreases, and retaliation against workers. In this report, the Santa Clara County Wage Theft Coalition recommends state and local policies to (1) protect worker health and safety amid the pandemic, (2) prevent wage theft and strengthen enforcement, and (3) increase worker power and employer accountability.

Supplemental Material, sj-pdf-1-asu-10.1177_0003134820972985 for Resuscitative Endovascular Balloon Occlusion of Aorta: A Systematic Review by Kyle Kinslow, Aaron Shepherd, Mark McKenney and Adel Elkbuli in Journal of The American Surgeon

Supplemental material, sj-docx-1-hpp-10.1177_15248399221131318 for Formative Evaluation and Adaptation of a Navajo Cancer Survivor Physical Activity Intervention to Serve a Broader Native American Cancer Survivor Community by Jennifer W. Bea, Brenda Charley, Taylor Lane, Brian Kinslow, Hendrik ‘Dirk’ de Heer, Etta Yazzie, Janet Yellowhair, Jennifer Hudson, Betsy C. Wertheim and Anna L. Schwartz in Health Promotion Practice

Introduction: Solitary fibrous tumor/hemangiopericytoma (SFT/HPC) of the central nervous system (CNS) is a rare meningeal tumor. Given the absence of prospective or randomized data, there are no standard indications for radiotherapy. Recently, the NRG Oncology and EORTC cooperative groups successfully accrued and completed the first prospective trials evaluating risk-adapted adjuvant radiotherapy strategies for meningiomas. Using a similar framework, we sought to develop prognostic risk categories that may predict the survival benefit associated with radiotherapy, using two large national datasets. Methods: We queried the National Cancer Database (NCDB) and the Surveillance, Epidemiology, and End Results (SEER) databases for all newly diagnosed cases of SFT/HPC within the CNS. Risk categories were created, as follows: low risk—grade 1, with any extent of resection (EOR) and grade 2, with gross–total resection; intermediate risk—grade 2, with biopsy/subtotal resection; high risk—grade 3 with any EOR. The Kaplan–Meier method and Cox proportional hazards regressions were used to determine the association of risk categories with overall and cause-specific survival. We then determined the association of radiotherapy with overall survival in the NCDB, stratified by risk group. Results: We identified 866 and 683 patients from the NCDB and SEER databases who were evaluated, respectively. In the NCDB, the 75% survival times for low- (n = 312), intermediate- (n = 239), and high-risk (n = 315) patients were not reached, 86 months (HR 1.60 (95% CI 1.01–2.55)), and 55 months (HR 2.56 (95% CI 1.68–3.89)), respectively. Our risk categories were validated for overall and cause-specific survival in the SEER dataset. Radiotherapy was associated with improved survival in the high- (HR 0.46 (0.29–0.74)) and intermediate-risk groups (HR 0.52 (0.27–0.99)) but not in the low-risk group (HR 1.26 (0.60–2.65)). The association of radiotherapy with overall survival remained significant in the multivariable analysis for the high-risk group (HR 0.55 (0.34–0.89)) but not for the intermediate-risk group (HR 0.74 (0.38–1.47)). Similar results were observed in a time-dependent landmark sensitivity analysis. Conclusion: Risk stratification based on grade and EOR is prognostic of overall and cause-specific survival for SFT/HPCs of the CNS and performs better than any individual clinical factor. These risk categories appear to predict the survival benefit from radiotherapy, which is limited to the high-risk group and, potentially, the intermediate-risk group. These data may serve as the basis for a prospective study evaluating the management of meningeal SFT/HPCs.

Often, research on the efficacy of postsecondary workforce programs does not convey their impact on true social mobility. The purpose of this study is to investigate project-based Career and Technical Education (CTE) workforce pathways in Silicon Valley. This study takes a step towards better understanding what constitutes the metrics that explain functioning pathways. In contributing to Project-Based Learning (PBL) theory, Amaral et al. (2015) found that seven PBL essentials form good learning outcomes; Creghan and Adair-Creghan (2015) then showed a measurable outcome of PBL is higher attendance, to which Plasman and Gottfried (2020), using a case of Applied STEM CTE (AS-CTE), framed attendance as a predictor of the efficacy of a workforce pathway. Recommendation: Through ethnography, the investigators observed that when social mobility was added as a metric of high quality PBL with AS-CTE in a predictive ontology framework of education success, an improved level of attendance was observed. The authors conclude that using the seven essentials and social mobility as a metric of PBL helps explain the observation of PBL���s improved efficacy. Hence, social mobility should be a metric of PBL AS-CTE program outcomes., Journal of Problem Based Learning in Higher Education, Vol. 9 No. 1 (2021): Special Issue: Exploring the Near-future or Next Practice of PBL

Often, research on the efficacy of postsecondary workforce programs does not convey their impact on true social mobility. The purpose of this study is to investigate project-based Career and Technical Education (CTE) workforce pathways in Silicon Valley. 1 This study takes a step towards better understanding what constitutes the metrics that explain functioning pathways. In contributing to Project-Based Learning (PBL) theory, Amaral et al. (2015) found that seven PBL essentials form good learning outcomes; Creghan and Adair-Creghan (2015) then showed a measurable outcome of PBL is higher attendance, to which Plasman and Gottfried (2020), using a case of Applied STEM CTE (AS-CTE), framed attendance as a predictor of the efficacy of a workforce pathway. Recommendation: Through ethnography, the investigators observed that when social mobility was added as a metric of high quality PBL with AS-CTE in a predictive ontology framework of education success, an improved level of attendance was observed. The authors conclude that using the seven essentials and social mobility as a metric of PBL helps explain the observation of PBL's improved efficacy. Hence, social mobility should be a metric of PBL AS-CTE program outcomes.

The biological mechanisms by which efavirenz (EFV) causes central nervous system (CNS) effects are unclear. The objective of this pilot study was to elucidate the mechanisms underlying these CNS effects by correlating well-described neuropsychological (NP) changes with neurometabolites and immunologic markers following switch off EFV.Two single-arm parallel switch studies among HIV-infected adults in Boston, USA, from 2015 to 2017.Twenty asymptomatic HIV-infected adults on EFV-containing regimens were switched to an integrase strand transfer inhibitor-based regimen for 8 weeks. NP assessments were conducted before and after switch and correlated with neurometabolite changes measured using magnetic resonance spectroscopy and immunological markers. All pre-EFV and post-EFV measures were evaluated using matched-paired analyses.NP testing demonstrated improvement in the domains of mood, cognition, and sleep off EFV. Magnetic resonance spectroscopy revealed decreases in the neurometabolite glutathione level (P = 0.03), a marker of oxidative stress after switch. Inhibitory neuronal activity as reflected by gamma-amino butyric acid levels increased (P = 0.03), whereas excitatory neurotransmitters glutamine + glutamate (Glx) and aspartate decreased (P = 0.04, 0.001). Switching off EFV was also associated with changes in inflammatory markers; plasma markers sCD14 (P = 0.008) decreased, whereas I-FABP and TNFRI levels increased (P = 0.05, 0.03). Cellular markers CD4 and CD8 HLA-DR-/CD38 subsets both increased (P = 0.05, 0.02).Even asymptomatic participants showed improvements in NP parameters when switched off EFV. These improvements were associated with decreased CNS oxidative stress and excitatory neuronal activity. Changes in immune activation biomarkers suggested overall decreased inflammation. EFV may exert CNS effects through oxidative and inflammatory pathways, providing insight into possible mechanisms of EFV neurotoxicity.

National guidelines recommend maximal safe resection of low-grade and high-grade oligodendrogliomas. However, there is no level 1 evidence to support these guidelines, and recent retrospective studies on the topic have yielded mixed results. To assess the association between extent of resection (EOR) and survival for oligodendrogliomas in the general U.S. population. Cases diagnosed between 2004 and 2013 were selected from the Surveillance, Epidemiology, and End-Results (SEER) Program and retrospectively analyzed for treatment, prognostic factors, and survival times. Cases that did not undergo tumor de-bulking surgery (e.g. no surgery or biopsy alone) were compared to subtotal resection (resection) and gross-total resection (GTR). The primary end-points were overall survival (OS) and cause-specific survival (CSS). An external validation cohort with 1p/19q-codeleted tumors was creating using the TCGA and GSE16011 datasets. 3135 Cases were included in the final analysis. The 75% survival time (75ST) and 5-year survival rates were 47 months and 70.8%, respectively. Subtotal resection (STR, 75ST = 50 months) and GTR (75ST = 61 months) were associated with improved survival times compared to cases that did not undergo surgical debulking (75ST = 20 months, P