Acquired Morgagni hernia following coronary artery bypass graft (CABG) with successful robotic repair of hernia.

INTRODUCTION AND IMPORTANCE: Morgagni hernia is an uncommon type of diaphragmatic hernia and commonly presents as a congenital disease. Acquired Morgagni hernias following open cardiac surgery are exceedingly rare and only reported in the pediatric population. CASE PRESENTATION: The patient is a 70-year-old female who presented with complaints of shortness of breath and cough one year following a coronary artery bypass graft (CABG). A chest CT scan showed a large Morgagni type diaphragmatic hernia with herniated transverse colon occupying the anterior mediastinum as well as the right hemi-thorax. This hernia was successfully repaired using transabdominal robotic approach with complete resolution of patient's symptoms. CLINICAL DISCUSSION: This is the first reported case of acquired Morgagni type diaphragmatic hernia in an adult following open cardiac surgery. The potential etiologies for this hernia include distal extension of the median sternotomy and involvement of the anterior diaphragm, iatrogenic injury to the attenuated anterior diaphragm during pericardial window creation, or pericardial drain placement. Operative repair is the mainstay of treatment and is usually performed with a transabdominal approach since it is thought to be less challenging and allows for evaluation of the entire abdominal cavity. If primary repair cannot be achieved, then synthetic mesh may be needed to obtain a tension free and durable repair. CONCLUSION: We present a case of acquired Morgagni type diaphragmatic hernia in an adult following open cardiac surgery that was successfully repaired using a transabdominal robotic approach.

Socio-demographic and -economic factors associated with 30-day readmission for conditions targeted by the hospital readmissions reduction program: a population-based study.

BACKGROUND: Early hospital readmissions remain common in patients with conditions targeted by the CMS Hospital Readmission Reduction Program (HRRP). There is still no consensus on whether readmission measures should be adjusted based on social factors, and there are few population studies within the U.S. examining how social characteristics influence readmissions for HRRP-targeted conditions. The objective of this study was to determine if specific socio-demographic and -economic factors are associated with 30-day readmissions in HRRP-targeted conditions: acute exacerbation of chronic obstructive pulmonary disease, pneumonia, acute myocardial infarction, and heart failure. METHODS: The Nationwide Readmissions Database was used to identify patients admitted with HRRP-targeted conditions between January 1, 2010 and September 30, 2015. Stroke was included as a control condition because it is not included in the HRRP. Multivariate models were used to assess the relationship between three social and economic characteristics (gender, urban/rural hospital designation, and estimated median household income within the patient's zip code) and 30-day readmission rates using a hierarchical two-level logistic model. Age-adjusted models were used to assess relationship differences between Medicare vs. non-Medicare populations. RESULTS: There were 19,253,997 weighted index hospital admissions for all diagnoses and 3,613,488 30-day readmissions between 2010 and 2015. Patients in the lowest income quartile (≤$37,999) had an increased odds of 30-day readmission across all conditions (P < 0.0001). Female gender and rural hospital designation were associated with a decreased odds of 30-day readmission for most targeted conditions (P < 0.05). Similar findings were also seen in patients ≥65 years old. CONCLUSIONS: Socio-demographic and -economic factors are associated with 30-day readmission rates and should be incorporated into tools or interventions to improve discharge planning and mitigate against readmission.

Hemodynamic, Echocardiographic, and Sedative Effects of Oral Gabapentin in Healthy Cats.

The study objective was to evaluate sedative, hemodynamic, and echocardiographic effects of cats receiving single-dose, oral gabapentin. A prospective, double-blinded, placebo-controlled, crossover study was conducted with 10 client-owned cats. Vital parameters, physical exam, blood pressure, echocardiography, and sedation scoring were performed at each visit within 2 hr of receiving either a placebo or gabapentin capsule. Vital parameters, blood pressure recordings, and echocardiographic measurements were compared between baseline, gabapentin, and placebo; interobserver agreement for sedation scoring and correlation between variables were also evaluated. Seven of 10 cats exhibited mild sedation within 120 min after receiving gabapentin, and no adverse events occurred. Significant differences were detected with two-dimensional fractional shortening (P = .022), left ventricular internal diameter in systole using M-mode (P = .014), and left atrial volume (P < .0001). Interobserver agreement for sedation scoring was near-perfect (κ = 0.84). No significant correlation was found for gabapentin dosage and sedation score. Single-dose oral gabapentin is well tolerated in healthy cats and produces a modest decrease in several echocardiographic parameters of systolic function; however, all affected variables remained within established reference ranges. These results suggest gabapentin may be an appropriate sedative to administer before echocardiography in cats necessitating mild sedation.

Readmissions and costs among younger and older adults for targeted conditions during the enactment of the hospital readmission reduction program.

BACKGROUND: The Hospital Readmissions Reduction Program (HRRP) was introduced to reduce readmission rates among Medicare beneficiaries, however little is known about readmissions and costs for HRRP-targeted conditions in younger populations. The primary objective of this study was to examine readmission trends and costs for targeted conditions during policy implementation among younger and older adults in the U.S. METHODS: We analyzed the Nationwide Readmission Database from January 2010 to September 2015 in younger (18-64 years) and older (≥65 years) patients with acute myocardial infarction (AMI), heart failure (HF), pneumonia, and acute exacerbations of chronic obstructive pulmonary disease (AECOPD). Pre- and post-HRRP periods were defined based on implementation of the policy for each condition. Readmission rates were evaluated using an interrupted time series with difference-in-difference analyses and hospital cost differences between early and late readmissions (≤30 vs. > 30 days) were evaluated using generalized linear models. RESULTS: Overall, this study included 16,884,612 hospitalizations with 3,337,266 readmissions among all age groups and 5,977,177 hospitalizations with 1,104,940 readmissions in those aged 18-64 years. Readmission rates decreased in all conditions. In the HRRP announcement period, readmissions declined significantly for those aged 40-64 years for AMI (p < 0.0001) and HF (p = 0.003). Readmissions decreased significantly in the post-HRRP period for those aged 40-64 years at a slower rate for AMI (p = 0.003) and HF (p = 0.05). Readmission rates among younger patients (18-64 years) varied within all four targeted conditions in HRRP announcement and post-HRRP periods. Adjusted models showed a significantly higher readmission cost in those readmitted within 30 days among younger and older populations for AMI (p < 0.0001), HF (p < 0.0001), pneumonia (p < 0.0001), and AECOPD (p < 0.0001). CONCLUSION: Readmissions for targeted conditions decreased in the U.S. during the enactment of the HRRP policy and younger age groups (< 65 years) not targeted by the policy saw a mixed effect. Healthcare expenditures in younger and older populations were significantly higher for early readmissions with all targeted conditions. Further research is necessary evaluating total healthcare utilization including emergency department visits, observation units, and hospital readmissions in order to better understand the extent of the HRRP on U.S. healthcare.

A systematic review of the impact of antifungal stewardship interventions in the United States.

BACKGROUND: Antimicrobial resistance is a widely recognized public health threat, and stewardship interventions to combat this problem are well described. Less is known about antifungal stewardship (AFS) initiatives and their influence within the United States. The purpose of this study was to evaluate evidence on the impact of AFS interventions on clinical and performance measures. METHODS: A systematic review of English language studies identified in the PubMed and EMBASE databases was performed through November 2017. The review was conducted in accordance with PRISMA. Search terms included antifungal stewardship, antimicrobial stewardship, Candida, candidemia, candiduria, and invasive fungal disease. Eligible studies were those that described an AFS program or intervention occurring in the US and evaluated clinical or performance measures. RESULTS: Fifty-four articles were identified and 13 were included. Five studies evaluated AFS interventions and reported clinical outcomes (mortality and length of stay) and performance measures (appropriate antifungal choice and time to therapy). The remaining eight studies evaluated general stewardship interventions and reported data on antifungal consumption. All studies were single center, quasi-experimental with varying interventions across studies. AFS programs had no impact on mortality (3 of 3 studies), with an overall rate of 27% in the intervention group and 23% in the non-intervention group. Length of stay (5 of 5) was also similar between groups (range, 9-25 vs. 11-22). Time to antifungal therapy improved in 2 of 5 studies, and appropriate choice of antifungal increased in 2 of 2 studies. Antifungal consumption was significantly blunted or reduced following stewardship initiation (8 of 8), although a direct comparison between studies was not possible due to a lack of common units. CONCLUSION: The available evidence suggests that AFS interventions can improve performance measures and decrease antifungal consumption. Although this review did not detect improvements in clinical outcomes, significant adverse outcomes were not reported.

Microwave and micronization treatments affect dehulling characteristics and bioactive contents of dry beans (Phaseolus vulgaris L.).

BACKGROUND: Heat pretreatment is considered the first step in grain milling. This study therefore evaluated microwave and micronization heat treatments in improving the dehulling characteristics, phenolic composition and antioxidant and α-amylase activities of bean cultivars from three market classes. RESULTS: Heat treatments improved dehulling characteristics (hull yield, rate coefficient and reduced abrasive hardness index) depending on bean cultivar, whereas treatment effects increased with dehulling time. Micronization increased minor phenolic components (tartaric esters, flavonols and anthocyanins) of all beans but had variable effects on total phenolic content depending on market class. Microwave treatment increased α-amylase inhibitor concentration, activity and potency, which were strongly correlated (r² = 0.71, P < 0.0001) with the flavonol content of beans. Heat treatment had variable effects on the phenolic composition of bean hulls obtained by abrasive dehulling without significantly altering the antioxidant activity of black and pinto bean hulls. Principal component analysis on 22 constituents analyzed in this study demonstrated the differences in dehulling characteristics and phenolic components of beans and hulls as major factors in segregating the beneficial heat treatment effects. CONCLUSION: Heat treatment may be useful in developing novel dietary fibers from beans with variable composition and bioactivity with a considerable range of applications as functional food ingredients.

Suppressor analysis points to the subtle role of the LAG1 ceramide synthase gene in determining yeast longevity.

Individual yeast cells display a finite replicative capacity. LAG1 was identified as a gene that is differentially expressed during the yeast replicative life span and was shown to play a role in determining yeast longevity. This gene is not essential, but simultaneous deletion of LAG1 and its close homologue LAC1 is lethal. Lag1p and Lac1p have been found to be an essential component of ceramide synthase. In this study, multicopy suppressors of the lethality of a lag1delta lac1delta double mutant were isolated to help clarify the role of LAG1 in yeast longevity. The two multicopy suppressors YBR183w (YPC1) and YPL087w (YDC1) encode ceramidases unrelated to Lag1p and Lac1p, which were previously found to support the reverse reaction of ceramide synthesis. Multiple copies of YPC1 were much more efficient than YDC1 in rescuing cell growth. They were also much more effective in rescuing the life span of a lag1delta lac1delta double mutant, sustaining a life span approaching that obtained by the restoration of LAG1 expression. Neither deletion of LAC1 nor overexpression of YPC1 had a detectable effect on wild-type life span. However, the overexpression of LAG1 had a bimodal effect on longevity, with moderate expression resulting in increased longevity and with higher expression curtailing life span. These results suggest that subtle changes in ceramide/sphingolipid metabolism are important in determining yeast longevity. They also indicate that Lag1p plays a special role in this relationship. Homologues of Lag1p have been identified in higher eukaryotes, including human, raising the possibility that ceramide and other sphingolipid metabolites play a wider role in biological aging.