Robotic-assisted repair of an anterior diaphragmatic hernia secondary to Xiphoidectomy.

Anterior diaphragmatic hernias manifest when a diaphragmatic defect permits abdominal contents to enter the thoracic cavity. They may be congenital or acquired; when acquired, the typical etiology is traumatic injury. Without treatment, they risk incarceration or strangulation. A 55-year-old male with a history of xiphoidectomy during sternotomy for cardiac disease was incidentally found to have an anterior diaphragmatic hernia on a screening chest CT (computed tomography) scan. He developed gastric obstruction shortly after an outpatient surgical consultation. He was admitted to the hospital, and further workup revealed a right-sided type-4 diaphragmatic hernia with an incarcerated colon, antrum, and pylorus. Nasogastric decompression was performed, followed by robotic-assisted transabdominal preperitoneal (r-TAPP) repair with mesh. He recovered without complications. There are currently no reports in the literature of an anterior diaphragmatic hernia secondary to a xiphoidectomy. This case demonstrates the successful use of r-TAPP for this rare presentation of an anterior diaphragmatic hernia.

What's in a Number? Assessing the Burden of Diverticular Disease.

MINI-ABSTRACT: In this prospective observational cohort of patients with a history of diverticulitis, we assessed the correlation between the diverticulitis quality of life survey (DVQOL) and other patient-reported expressions of disease measures including work and activity impairment, and contentment with gastrointestinal-related health. Then, we assessed whether the DVQOL is better correlated with these measures than diverticulitis episode count. Our study results showed that the DVQOL has a stronger correlation with other disease measures than diverticulitis episode count, and our findings support the broader use of the DVQOL in assessing the burden of diverticulitis and monitoring response to management.

Impact of a pharmacist-driven recombinant zoster vaccine administration program.

OBJECTIVE: To determine whether a pharmacist-driven recombinant zoster vaccine (RZV) administration pilot program within a human immunodeficiency virus/infectious diseases clinic setting increased the completion of the 2-dose series when compared with standard care. METHODS: In this retrospective cohort study, the patients enrolled in a pharmacist-driven RZV administration pilot program (intervention) were compared with those in provider-directed RZV education (standard care) for completion of the 2-dose vaccine series. RESULTS: One hundred nineteen patients were included (standard care [n = 84], intervention intention to treat [ITT, n = 35], and intervention modified ITT [mITT, n = 23]). There was increased completion of the 2-dose vaccine series in the intervention cohort compared with the standard care cohort (ITT 66% and mITT 100% vs. 23%; P < 0.001). CONCLUSION: The pharmacist-driven RZV administration program resulted in increased completion of the 2-dose series. However, the revenue generated did not justify the cost of a pharmacist salary for the allocated time commitment.

Comparison of Pharmacist-Directed Management of Multiplex PCR Blood Culture Results with Conventional Microbiology Methods on Effective and Optimal Therapy within a Community Hospital.

Multiplex PCR combined with a pharmacist-driven reporting protocol was compared to the standard of care within a community hospital to evaluate initial changes after notification of a positive blood culture. The intervention group demonstrated decreased times to changes in antimicrobial therapy (P = 0.0081), increased changes to optimal antimicrobial therapy (P = 0.013), and decreased vancomycin use for coagulase-negative staphylococcus contaminants (P < 0.01) with multiplex PCR implementation and pharmacist intervention.

Sustainable, effective implementation of a surgical preprocedural checklist: an "attestation" format for all operating team members.

BACKGROUND: Adoption ofa preprocedural pause (PPP) associated with a checklist and a team briefing has been shown to improve teamwork function in operating rooms (ORs) and has resulted in improved outcomes. The format of the World Health Organization Safe Surgery Saves Lives checklist has been used as a template for a PPP. Performing a PPP, described as a "time-out," is one of the three principal components, along with a preprocedure verification process and marking the procedure site, of the Joint Commission's Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. However, if the surgeon alone leads the pause, its effectiveness may be decreased by lack of input from other operating team members. METHODS: In this study, the PPP was assessed to measure participation and input from operating team members. On the basis of low participation levels, the pause was modified to include an attestation from each member of the team. RESULTS: Preliminary analysis of our surgeon-led pause revealed only 54% completion of all items, which increased to 97% after the intervention. With the new format, operating team members stopped for the pause in 96% of cases, compared with 78% before the change. Operating team members introduced themselves in 94% of cases, compared with 44% before the change. Follow-up analysis showed sustained performance at 18 months after implementation. CONCLUSIONS: A preprocedural checklist format in which each member of the operating team provides a personal attestation can improve pause compliance and may contribute to improvements in the culture of teamwork within an OR. Successful online implementation of a PPP, which includes participation by all operating team members, requires little or no additional expense and only minimal formal coaching outside working situations.

Maternal HLA class II compatibility in men with systemic lupus erythematosus.

OBJECTIVE: Maternal-fetal cell transfer during pregnancy can lead to long-lasting microchimerism, which raises the question of whether microchimerism sometimes contributes to autoimmune disease later in life. In an experimental model, transfusion of parental lymphocytes homozygous for major histocompatibility complex alleles results in systemic lupus erythematosus (SLE). We identified male patients with SLE and healthy male subjects and their mothers in order to investigate the mother-son HLA relationship in SLE risk. Male subjects were selected in order to avoid confounding due to fetal microchimerism, which may occur in women. METHODS: HLA genotyping for DRB1, DQA1, and DQB1 was conducted for sons and their mothers. Thirty men with SLE and their mothers were compared with 76 healthy men and their mothers. RESULTS: Sons with SLE were HLA-identical with their mothers (bidirectionally compatible) for the basic HLA-DRB1 groups encoded by DRB1*01 through DRB1*14 more often than were healthy sons (odds ratio [OR] 5.0, P = 0.006). Each DRB1 group contains multiple allelic variants; male patients with SLE and their mothers often were identical for both DRB1 allelic variants (OR 3.2, P = 0.08). For DQA1 and DQB1, the ORs were 2.3 (P = 0.08) and 2.0 (P = 0.21), respectively. When analysis was limited to male subjects with SLE-associated HLA genes (encoding HLA-DR2 or HLA-DR3), the differences further increased for DRB1 basic groups (OR 7.2, P = 0.01), DRB1 alleles (OR 15.0, P = 0.018), DQA1 6.4 (P = 0.006), and DQB1 (OR 5.7, P = 0.027). No increase in (unidirectional) compatibility of the mother from the son's perspective was observed at any locus. CONCLUSION: We observed increased bidirectional HLA class II compatibility of male SLE patients and their mothers compared with healthy men and their mothers. This observation implies that maternal microchimerism could sometimes be involved in SLE and therefore merits further investigation.

Male microchimerism in women without sons: quantitative assessment and correlation with pregnancy history.

PURPOSE: Fetal microchimerism, derived from fetal cells that persist after pregnancy, is usually evaluated by tests for male microchimerism in women who gave birth to sons. We investigated male microchimerism in women without sons and examined correlation with prior pregnancy history. Immunologic consequences of microchimerism are unknown. We studied healthy women and women with rheumatoid arthritis (RA). METHODS: Y-chromosome-specific real-time quantitative polymerase chain reaction was used to test peripheral blood mononuclear cells of 120 women (49 healthy and 71 with RA). Results were expressed as the number of male cells that would be equivalent to the total amount of male DNA detected within a sample containing the equivalent of 100000 female cells. RESULTS: Male microchimerism was found in 21% of women overall. Healthy women and women with RA did not significantly differ (24% vs 18%). Results ranged from the DNA equivalent of 0 to 20.7 male cells per 100000 female cells. Women were categorized into 4 groups according to pregnancy history. Group A had only daughters (n = 26), Group B had spontaneous abortions (n = 23), Group C had induced abortions (n = 23), and Group D were nulligravid (n = 48). Male microchimerism prevalence was significantly greater in Group C than other groups (8%, 22%, 57%, 10%, respectively). Levels were also significantly higher in the induced abortion group. CONCLUSIONS: Male microchimerism was not infrequent in women without sons. Besides known pregnancies, other possible sources of male microchimerism include unrecognized spontaneous abortion, vanished male twin, an older brother transferred by the maternal circulation, or sexual intercourse. Male microchimerism was significantly more frequent and levels were higher in women with induced abortion than in women with other pregnancy histories. Further studies are needed to determine specific origins of male microchimerism in women.