Simultaneous presence of massive chyloperitoneum and chylothorax and its successful management

The incidence of massive chylous ascites and chylothorax after aortofemoral bypass grafting (AFBG) procedure is unknown. Leakage of chyle results in severe malnutrition and infection which can be life threatening. Because of the rarity of disease, the definitive guideline on management of such extensive accumulation of chyle is lacking. We present a case of a 68- year-old gentleman who developed large chylous ascites and chylous pleural effusions causing respiratory distress. His history was significant for aortofemoral bypass graft procedure 8 weeks prior to index presentation. He was successfully managed with chylous fluid drainage, judicious use of diuretics, adherence to a low-fat diet, and supplementation with medium-chain triglycerides

Synthesis, isomerisation and biological properties of mononuclear ruthenium complexes containing the bis[4(4 '-methyl-2,2 '-bipyridyl)]-1,7-heptane ligand

A series of mononuclear ruthenium(II) complexes containing the tetradentate ligand bis[4(4’-methyl-2,2’- bipyridyl)]-1,7-heptane have been synthesised and their biological properties examined. In the synthesis of the [Ru(phen’)(bb7)]2+ complexes (where phen’ = 1,10-phenanthroline and its 5-nitro-, 4,7-dimethyland 3,4,7,8-tetramethyl- derivatives), both the symmetric cis-α and non-symmetric cis-β isomers were formed. However, upon standing for a number of days (or more quickly under harsh conditions) the cis-β isomer converted to the more thermodynamically stable cis-α isomer. The minimum inhibitory concentrations (MIC) and the minimum bactericidal concentrations (MBC) of the ruthenium(II) complexes were determined against six strains of bacteria: Gram-positive Staphylococcus aureus (S. aureus) and methicillin-resistant S. aureus (MRSA); and the Gram-negative Escherichia coli (E. coli) strains MG1655, APEC, UPEC and Pseudomonas aeruginosa (P. aeruginosa). The results showed that the [Ru(5-NO2phen)- (bb7)]2+ complex had little or no activity against any of the bacterial strains. By contrast, for the other cisα-[Ru(phen’)(bb7)]2+ complexes, the antimicrobial activity increased with the degree of methylation. In particular, the cis-α-[Ru(Me4phen)(bb7)]2+ complex showed excellent and uniform MIC activity against all bacteria. By contrast, the MBC values for the cis-α-[Ru(Me4phen)(bb7)]2+ complex varied considerably across the bacteria and even within S. aureus and E. coli strains. In order to gain an understanding of the relative antimicrobial activities, the DNA-binding affinity, cellular accumulation and water–octanol partition coefficients (log P) of the ruthenium complexes were determined. Interestingly, all the [Ru(phen’)- (bb7)]2+ complexes exhibited stronger DNA binding affinity (Ka ≈ 1 × 107 M−1 ) than the well-known DNAintercalating complex [Ru(phen)2(dppz)]2+ (where dppz = dipyrido[3,2-a:2’,3’-c]phenazine)

The HOSPITAL score and LACE index as predictors of 30 day readmission in a retrospective study at a university-affiliated community hospital

Introduction Hospital readmissions are common, expensive, and a key target of the Medicare Value Based Purchasing (VBP) program. Validated risk assessment tools such as the HOSPITAL score and LACE index have been developed to identify patients at high risk of hospital readmission so they can be targeted for interventions aimed at reducing the rate of readmission. This study aims to evaluate the utility of HOSPITAL score and LACE index for predicting hospital readmission within 30 days in a moderate-sized university affiliated hospital in the midwestern United States. Materials and Methods All adult medical patients who underwent one or more ICD-10 defined procedures discharged from the SIU-SOM Hospitalist service from Memorial Medical Center (MMC) from October 15, 2015 to March 16, 2016, were studied retrospectively to determine if the HOSPITAL score and LACE index were a significant predictors of hospital readmission within 30 days. Results During the study period, 463 discharges were recorded for the hospitalist service. The analysis includes data for the 432 discharges. Patients who died during the hospital stay, were transferred to another hospital, or left against medical advice were excluded. Of these patients, 35 (8%) were readmitted to the same hospital within 30 days. A receiver operating characteristic evaluation of the HOSPITAL score for this patient population shows a C statistic of 0.75 (95% CI [0.67–0.83]), indicating good discrimination for hospital readmission. The Brier score for the HOSPITAL score in this setting was 0.069, indicating good overall performance. The Hosmer–Lemeshow goodness of fit test shows a χ2 value of 3.71 with a p value of 0.59. A receiver operating characteristic evaluation of the LACE index for this patient population shows a C statistic of 0.58 (95% CI [0.48–0.68]), indicating poor discrimination for hospital readmission. The Brier score for the LACE index in this setting was 0.082, indicating good overall performance. The Hosmer–Lemeshow goodness of fit test shows a χ2 value of 4.97 with a p value of 0.66. Discussion This single center retrospective study indicates that the HOSPITAL score has superior discriminatory ability when compared to the LACE index as a predictor of hospital readmission within 30 days at a medium-sized university-affiliated teaching hospital. Conclusions The internationally validated HOSPITAL score may be superior to the LACE index in moderate-sized community hospitals to identify patients at high risk of hospital readmission within 30 days

REFORMULATION OF LEGAL REGULATIONS CONCERNING ALCOHOLIC BEVERAGES IN BALI WITH LEGAL CERTAINTY AND BENEFIT

Legal arrangements regarding control, supervision, determination of areas/places of sale, authority to issue alcoholic beverage permits and provisions regarding the regulation of traditional alcoholic beverages have urgency, considering that Bali is one of the domestic and international tourist destinations. That traditional alcoholic drinks are also used as a complementary means of religious ceremonies. Researchers see that there has been a legal vacuum after Presidential Regulation No. 74 of 2013 was issued concerning Control and Supervision of Alcoholic Beverages. This situation can certainly raise the issue of legal uncertainty. This article is a normative legal research, using a statutory, historical, and conceptual approach. The research results show that Presidential Regulation (Perpres) No. 74 of 2013 and Law no. 23 of 2014 explicitly regulates control, supervision, determination of places to sell alcoholic and traditional alcoholic beverages and regulates the authority to grant business licenses. Regulations regarding alcoholic beverages have been regulated in laws and presidential regulations, these provisions should be followed up immediately by issuing regional regulations as the implementation of the regulations above, based on the principle of hierarchy, thereby providing legal certainty and providing benefits to the wider community

Legal Arrangement Concerning Regional Unit Price Standards Its Impact to Financial and Administrative Rights of Regional People's Representative Council

Constitution in the government system of the Republic of Indonesia adheres the concept of trias politica, which is a concept stating that power is not transferred to the same person/institution, to prevent abuse of power and to guarantee human rights of citizens. The concept of trias politica is applied in the form of three institutions, namely executive, legislative and judicial institutions. These three institutions have different duties, rights, obligations, and responsibilities according to their authority.  It turns out, however that the aim of preventing abuse of power by means of power distribution is not running well and there has been an overlap of authority among the institutions. This research is the author's study of the Legal Arrangements concerning Regional Unit Price Standards upon the issuance of Presidential Regulation Number. 33 of 2020 concerning Regional Unit Price Standards, its impact to Financial and Administrative Rights of the chairman and members of the Regional People's Representative Council. It is a normative legal research applying statutory approach, conceptual and comparative approaches. It was concluded that the placement of legislature as a quasi-executive results in the legislature shall comply with every regulation issued by the executive, this causes in an overlap of authority between the executive and the legislative institution

Reducing 30-Day Rehospitalization Rates Using a Transition of Care Clinic Model in a Single Medical Center

Background. Rehospitalization for medical patients is common. Multiple interventions of varying complexity have been shown to be effective in achieving that goal with variable results in the literature. For medical patients discharged home, no single intervention implemented alone has been shown to have a sustainable effect in preventing rehospitalization. Objective. To study the effect of a transition of care clinic model on the 30-day rehospitalization rate in a single medical center. Methods. Retrospective observational analysis of adult patients discharged home from Memorial Medical Center from September 1, 2014, through December 31, 2014. The primary outcome was to compare hospital readmission rates between patients who followed up with a transition of care (TOC) clinic and those who did not. Results. The study population included 378 patient discharges. A total of 40 patients (10.6%) were readmitted to the hospital within 30 days of discharge. Patients who attended the TOC clinic had a significantly lower 30-day readmission rates (3.8% versus 11.7%). A Cox regression analysis showed that the TOC clinic attendance had a significant negative predication for readmission (HR 0.186, 95% CI 0.038–0.898, P=0.038). Conclusion. Adopting a TOC model after discharging medical patients has reduced the readmission rates in our study

Cetuximab-Associated Crescentic Diffuse Proliferative Glomerulonephritis

Cetuximab-induced nephrotoxicity is very rare, occurring in less than 1% of colorectal cancer patients and not defined in other populations. We report a rare case of crescentic diffuse proliferative glomerulonephritis (GN) that developed in close temporal association with cetuximab treatment. A 65-year-old female recently completed chemotherapy with cetuximab treatment for moderately differentiated oral squamous cell carcinoma. She was admitted with acute renal failure and nephrotic-range proteinuria. Laboratory data showed serum creatinine of 6.6 mg/dl and urinalysis showed proteinuria, moderate hemoglobinuria, hyaline casts (41/LPF), WBC (28/HPF), and RBC (81/HPF). Serologic studies were negative for ANA, anti-GBM, ANCA, hepatitis B, and hepatitis C. Serum C3 and C4 level were normal. Renal biopsy showed crescentic diffuse proliferative GN with focal features of thrombotic microangiopathy. Patient was started on cyclophosphamide and steroids. Her renal function did not improve on day 8 and she was started on hemodialysis. Previous reports suggest that EGFR-targeting medications can possibly trigger or exacerbate an IgA-mediated glomerular process leading to renal failure. This case suggests that cetuximab therapy may have triggered or exacerbated a severe glomerular injury with an unfavorable outcome. Treating physicians should maintain a high degree of caution and monitor renal function in patients on EGFR inhibitors

A fractured inferior vena cava filter strut migrating to the left pulmonary artery

Inferior vena cava filters are increasingly used in patients with recurrent venous thromboembolism who are contraindicated to anticoagulation. Migration of a broken strut to the pulmonary artery is a very rare complication of these filters. We report the case of an 83-year-old female who experienced this complication with the migratory strut remaining in the same position for years. This case provides evidence that such filters probably have higher rates of complications than what has been thought that remain asymptomatic. The indications and the management of complications of such devices need to be studied further