Association of Women Leaders with Women Program Director and Trainee Representation Across US Academic Internal Medicine.

BACKGROUND: Women are underrepresented within internal medicine (IM). Whether women leaders attract women trainees is not well explored. OBJECTIVE: To characterize leader and trainee gender across US academic IM and to investigate the association of leader gender with trainee gender. DESIGN: Cross-sectional study. PARTICIPANTS: Leaders (chairs, chiefs, program directors (PDs)) in 2018 and trainees (residents, fellows) in 2012-2016 at medical school-affiliated IM and seven IM fellowship programs. EXPOSURE: Leadership (chair/chief and program director; and, for resident analyses, fellow) gender. MAIN MEASURES: Our primary outcome was percent women trainees (IM residents and, separately, subspecialty fellows). We used standard statistics to describe leadership and trainee gender. We created separate multivariable linear regressions to evaluate associations of leader gender and percent women fellows with percent women IM residents. We then created separate multivariable multilevel models (site as a random effect) to evaluate associations of leader gender with percent women subspecialty fellows. KEY RESULTS: Our cohort consisted of 940 programs. Women were 13.4% of IM chairs and <25% of chiefs in each fellowship subspecialty (cardiology: 2.6%; gastroenterology: 6.6%; pulmonary and critical care: 10.7%; nephrology: 14.4%; endocrinology: 20.6%; hematology-oncology: 23.2%; infectious diseases: 24.3%). IM PDs were 39.7% women; fellowship PDs ranged from nearly 25% (cardiology and gastroenterology) to nearly 50% (endocrinology and infectious disease) women. Having more women fellows (but not chairs or PDs) was associated with having more women residents (0.3% (95% CI: 0.2-0.5%) increase per 1% fellow increase, p<0.001); this association remained after adjustment (0.3% (0.1%, 0.4%), p=0.001). In unadjusted analyses, having a woman PD (increase of 7.7% (4.7%, 10.6%), p<0.001) or chief (increase of 8.9% (4.6%, 13.1%), p<0.001) was associated with an increase in women fellows; after adjustment, these associations were lost. CONCLUSIONS: Women held a minority of leadership positions in academic IM. Having women leaders was not independently associated with having more women trainees.

Tuberin Regulates Prostaglandin Receptor-Mediated Viability, via Rheb, in mTORC1-Hyperactive Cells.

Tuberous sclerosis complex (TSC) is a tumor-suppressor syndrome affecting multiple organs, including the brain, skin, kidneys, heart, and lungs. TSC is associated with mutations in TSC1 or TSC2, resulting in hyperactivation of mTOR complex 1 (mTORC1). Clinical trials demonstrate that mTORC1 inhibitors decrease tumor volume and stabilize lung function in TSC patients; however, mTOR inhibitors are cytostatic not cytocidal, and long-term benefits and toxicities are uncertain. Previously, we identified rapamycin-insensitive upregulation of cyclooxygenase 2 (PTGS2/COX2) and prostaglandin E2 (PGE2) production in TSC2-deficient cells and postulated that the action of excess PGE2 and its cognate receptors (EP) contributes to cell survival. In this study, we identify upregulation of EP3 (PTGER3) expression in TSC2-deficient cells, TSC renal angiomyolipomas, lymphangioleiomyomatosis lung nodules, and epileptic brain tubers. TSC2 negatively regulated EP3 expression via Rheb in a rapamycin-insensitive manner. The EP3 antagonist, L-798106, selectively suppressed the viability of TSC2-deficient cells in vitro and decreased the lung colonization of TSC2-deficient cells. Collectively, these data reveal a novel function of TSC2 and Rheb in the regulation of EP3 expression and cell viability.Implications: Therapeutic targeting of an aberrant PGE2-EP3 signaling axis may have therapeutic benefit for TSC patients and for other mTOR-hyperactive neoplasms. Mol Cancer Res; 15(10); 1318-30. ©2017 AACR.

Psychosis: call a surgeon? A rare etiology of psychosis requiring resection.

OBJECTIVE: Anti-N-methyl-d-aspartate receptor encephalitis is a rare but emerging cause of autoimmune encephalitis. Our objective is to present a case of this rare disease while highlighting the importance of an aggressive search for underlying malignancy as well as the common mischaracterization of primary psychiatric illness that occurs in these patients. METHODS: A young Caucasian female with no known psychiatric history presented with acute onset of seizures and psychosis. RESULTS: Magnetic resonance imaging abdomen and pelvis showed a 6-mm ovarian teratoma which was not visualized on initial computed tomographic scans. Pathology was consistent with a mature teratoma. Both serum and cerebrospinal fluid N-methyl-d-aspartate receptor antibodies were positive. CONCLUSION: An exhaustive search for underlying malignancy and specifically ovarian teratoma in young women should be completed in these patients. Diagnosis often is delayed given the prominent psychiatric manifestations and providers should be aware and strongly consider this in younger women with acute onset of neuropsychiatric symptoms.

Freestanding emergency departments and the trauma patient.

BACKGROUND: Freestanding emergency departments (FEDs) continue to grow in number and more research is needed on these facilities. OBJECTIVE: We sought to characterize the types of injuries and patients who initially presented to two FEDs and were transferred to the main tertiary care ED for trauma team consult and admission. METHODS: This retrospective cohort descriptive study examined medical records of adult trauma patients who were initially seen at an FED and then transferred to the main ED. All patients who received a trauma consultation were included. Data collection included demographics, initial mode of transport to the ED, injury, mechanism of injury, ED, hospital course and outcome. RESULTS: Mean age was 61.8 ± 23.8, 96.7% were Caucasian and 52.5% were male. Mode of transport to the FEDs included private vehicle (46.4%) and emergency medical services (53.6%). The main injury mechanisms were fall from standing (51.9%) and fall from an object (16%). A total of 12.7% were from motor vehicle accidents and 6.6% presented from bicycle and all-terrain vehicle accidents. Blunt traumatic injuries accounted for 97.8% (n = 177) patients. Computed tomography scanning was performed on 90.1% of patients. Median ED length of stay was 189 min. Mean hospital length of stay was 3 days and 2.2% (n = 4) of patients died from their injuries. CONCLUSIONS: Understanding the patients and traumatic injuries that present to FEDs will guide training and identify resources needed for patients requiring additional care at a trauma center.

Door-to-balloon times from freestanding emergency departments meet ST-segment elevation myocardial infarction reperfusion guidelines.

BACKGROUND: Freestanding emergency departments (FEDs) introduce a challenge to physicians who care for the patient with an ST-segment elevation myocardial infarction (STEMI) because treatment is highly time dependent. FEDs have no percutaneous coronary intervention (PCI) capabilities, which necessitates transfer to a PCI-capable facility or fibrinolysis. STUDY OBJECTIVE: Our aim was to determine the proportion of STEMI patients who arrived to an FED and were subsequently transferred for PCI and met the door-to-balloon reperfusion guidelines of 90 min. METHODS: This was a dual-center retrospective cohort review of all patients 18 years and older who were diagnosed with an STEMI and presented to the main hospital-affiliated FEDs. Electronic medical records and emergency medical services documentation were reviewed for all cases since the opening of the FEDs in July 2007 and August 2009, respectively. Key time points were abstracted and statistical evaluation was performed using Fisher's exact test. RESULTS: A total of 47 patients met inclusion criteria. Median door-to-transport time was 34 min (interquartile range [IQR] 15 min). Median transport time from the FEDs to the main hospital catheterization laboratory was 21 min (IQR 5 min). Median arrival at the catheterization laboratory-to-balloon time was 25 min (IQR 13 min). Median total door-to-balloon time was 83 min (IQR 10.5 min), with 78.7% meeting the American Heart Association's recommended guidelines of ≤ 90 min. CONCLUSION: STEMI patients initially seen at two FEDs achieved door-to-balloon time goals of < 90 min.