Impact of Language Discordance on Surgical Resident Workflow.

OBJECTIVE: To characterize the impact of language discordant patient encounters on resident workflow during morning rounds. DESIGN: The time required for a patient encounter was measured in a cohort of patients on an acute care and trauma service. Language concordance was recorded, and for language discordant encounters, a subset utilized a call-ahead strategy in order to facilitate obtaining a phone-based or video-based interpreter. SETTING: Acute care and trauma service in a Level 1 trauma center located in New York City. PARTICIPANTS: About 833 patient encounters were observed, with no patient identifiers recorded other than the data as noted above. RESULTS: Durations of English-speaking and language concordant encounters were 123.6 ± 89.6 seconds and 129.4 ± 95.8 seconds, respectively, which were not statistically different (p = 0.95). In comparison to the English-speaking group, both the unfacilitated language discordant patients (258.3 ± 189.7 seconds) and the facilitated language discordant patients (193.0 ± 91.1 seconds) were statistically different (p < 0.001). There was a statistical difference between these 2 groups of language discordant patients (p = 0.023). CONCLUSIONS: Language discordant encounters take twice as long as a language concordant encounter. A call-ahead strategy was able to reduce the time required for language discordant encounters. Further strategies to reduce time of encounter would benefit surgical workflow during morning rounds.

Anomalous Feeding of the Left Upper Lobe.

We report the case of a 53-year-old woman who presented with massive hemoptysis. Computed tomographic angiography revealed an anomalous vessel arising from the abdominal aorta, coursing anteriorly and through the diaphragm, and feeding the left upper lobe. At operation the vessel was found to anastomose to the left upper lobe lingula, which contained multiple vascular abnormalities and arteriovenous fistulas. The vessel was ligated, and the affected portion of the left upper lobe was resected. Anomalous systemic arterial supply of an upper lobe is an especially rare form of a Pryce type 1 abnormality. Recognition of these unusual anatomic variants is crucial to successful treatment and avoidance of adverse events.

Benign imitation of malignancy: avoiding resection in immunoglobulin g4-related lung disease.

We report the case of a 32-year-old woman who presented with cough, pleuritic pain, and a solitary lung mass. Computed tomography demonstrated a 3.7-cm spiculated right lower lobe mass, and 18-fluoro-deoxy-glucose positron emission tomography/computed tomography demonstrated significant hypermetabolism, both most suggestive of invasive adenocarcinoma. The results of fine needle aspirate biopsy favored a benign inflammatory process. Video-assisted thoracoscopic surgery right lower lobectomy was performed, and histopathologic examination of the mass was consistent with immunoglobulin G4-related disease (IgG4-RD). A definitive diagnosis of IgG4-RD often requires correlating several nonspecific findings with surgical lung biopsy. We discuss important diagnostic and treatment considerations for pulmonary IgG4-RD.

Functional modular dissection of DEBS1-TE changes triketide lactone ratios and provides insight into Acyl group loading, hydrolysis, and ACP transfer.

The DEBS1-TE fusion protein is comprised of the loading module, the first two extension modules, and the terminal TE domain of the Saccharopolyspora erythraea 6-deoxyerythronolide B synthase. DEBS1-TE produces triketide lactones that differ on the basis of the starter unit selected by the loading module. Typical fermentations with plasmid-based expression of DEBS1-TE produce a 6:1 ratio of propionate to isobutyrate-derived triketide lactones. Functional dissection of the loading module from the remainder of DEBS1-TE results in 50% lower titers of triketide lactone and a dramatic shift in the production to a 1:4 ratio of propionate to isobutyrate-derived products. A series of radiolabeling studies of the loading module has shown that transfer from the AT to the ACP occurs much faster for propionate than for isobutyrate. However, the equilibrium occupancy of the AT favors isobutyrate such that propionate is outcompeted for ACP occupancy. Thus, propionyl-ACP is the kinetic product, while isobutyryl-ACP is the thermodynamic product. A slowed transfer from the loading domain ACP to first-extension module KS due to functional dissection of DEBS1-TE allows this isobutyryl-ACP-favored equilibrium to be realized and likely accounts for the observed shift in triketide lactone products.

Biosynthesis of salinosporamides from alpha,beta-unsaturated fatty acids: implications for extending polyketide synthase diversity.

A new series of coenzyme A-tethered polyketide synthase extender units were discovered in relation to the biosynthesis of the salinosporamide family of anticancer agents from the marine bacterium Salinispora tropica. In vivo and in vitro experiments revealed that the crotonyl-CoA reductase/carboxylase SalG has broad substrate tolerance toward 2-alkenyl-CoAs that give rise to the salinosporamide C-2 substitution pattern.

Biosynthesis of the salinosporamide A polyketide synthase substrate chloroethylmalonyl-coenzyme A from S-adenosyl-L-methionine.

Polyketides are among the major classes of bioactive natural products used to treat microbial infections, cancer, and other diseases. Here we describe a pathway to chloroethylmalonyl-CoA as a polyketide synthase building block in the biosynthesis of salinosporamide A, a marine microbial metabolite whose chlorine atom is crucial for potent proteasome inhibition and anticancer activity. S-adenosyl-L-methionine (SAM) is converted to 5'-chloro-5'-deoxyadenosine (5'-ClDA) in a reaction catalyzed by a SAM-dependent chlorinase as previously reported. By using a combination of gene deletions, biochemical analyses, and chemical complementation experiments with putative intermediates, we now provide evidence that 5'-ClDA is converted to chloroethylmalonyl-CoA in a 7-step route via the penultimate intermediate 4-chlorocrotonyl-CoA. Because halogenation often increases the bioactivity of drugs, the availability of a halogenated polyketide building block may be useful in molecular engineering approaches toward polyketide scaffolds.