The regulation of cardiovascular activity by the parasympathetic nervous system plays an important role in sleep-onset insomnia. Weak vagal modulation and blunted baroreflex sensitivity were evident in this insomnia subtype, which indicates that difficulty in initiating sleep can independently affect morning cardiovascular function.
  We sought to assess the relationship between Leapfrog minimum volume standards, Hospital Safety Grades, and Magnet recognition with outcomes among patients undergoing rectal, lung, esophageal, and pancreatic resection for cancer.
 
  Standard Analytical Files linked with the Leapfrog Hospital Survey and the Leapfrog Safety Scores Denominator Files were used to identify Medicare patients who underwent surgery for cancer from 2016 to 2017. Multivariable logistic regression analysis was used to examine textbook outcomes relative to Leapfrog volume, safety grades, and Magnet recognition.
 
  Among 26,268 Medicare beneficiaries, 7,491 (28.5%) were treated at hospitals meeting the quality trifactor (Leapfrog, safety grade A, and Magnet recognition) vs 18,777 (71.5%) at hospitals not meeting ≥1 designation. Patients at trifactor hospitals had lower odds of complications (odds ratio= 0.83, 95% confidence interval 0.76-0.89), prolonged duration of stay (odds ratio= 0.89, 95% confidence interval 0.82-0.97), and higher odds of experiencing textbook outcome (odds ratio= 1.12, 95% confidence interval 1.06-1.19). Patients undergoing surgery for lung (odds ratio= 1.19, 95% confidence interval 1.10-1.30) and pancreatic cancer (odds ratio= 1.37, 95% confidence interval 1.21-1.55) at trifactor hospitals had higher odds of textbook outcome, whereas this effect was not noted after esophageal (odds ratio= 1.16, 95% confidence interval 0.90-1.48) or rectal cancer (odds ratio= 1.11, 95% confidence interval 0.98-1.27) surgery. Leapfrog minimum volume standards mediated the effect of the quality trifactor on patient outcomes.
 
  Quality trifactor hospitals had better short-term outcomes after lung and pancreatic cancer surgery compared with nontrifactor hospitals.
 Quality trifactor hospitals had better short-term outcomes after lung and pancreatic cancer surgery compared with nontrifactor hospitals.
  The PowerFlow implantable apheresis intravenous port is a venous access device for therapeutic apheresis procedures. In this case review article, we identify key similarities and differences between apheresis PowerFlow ports and traditional ports. We also list strategies that emergency departments can implement to aid in correct port identification.
 
  Using a case review format, we describe the clinical presentation of a 33-year-old female with neuromyelitis optica who was evaluated in the emergency department for an acute exacerbation. She had a history of outpatient apheresis procedures that made use of bilateral PowerFlow ports. Mistaken for a conventional port, the right PowerFlow port was accessed with a Huber needle rather than the appropriate catheter-over-needle device. On infusion of intravenous fluids, the patient experienced pain and swelling. Ultimately, the port malfunctioned and was eventually replaced.
 
  A subsequent root cause analysis identified opportunities for education and aids to improve port identification. To this end, strategies were implemented to appropriately identify the PowerFlow port using at least 2 of the following methods (1) look in the patient's chart for record of an implantable apheresis intravenous port; (2) check the port identification card, bracelet, or keychain issued at insertion; (3) palpate the port to look for the rounded top and hollow concave entry point; and (4) use x-ray or fluoroscopy to identify radiopaque port markers.
 
  When a patient with a history of apheresis procedures presents with an implanted port, steps should be taken to ensure correct identification and access.
 When a patient with a history of apheresis procedures presents with an implanted port, steps should be taken to ensure correct identification and access.
  Primary spontaneous pneumothorax (PSP) commonly occurs in adolescents, most commonly in males, and has recurrence rates between 20% and 60%. Surgical therapy has long been debated regarding its role in preventing recurrence, with no current consensus on guidelines for care. The purpose of this study is to examine the effect of treatment type on recurrence rates in pediatric PSP.
 
  This is a single-institution, institutional review board-approved retrospective analysis of patients aged 1 to 18 diagnosed with their first occurrence of PSP between 2009 and 2017. Patient demographics, hospital course, and outcomes over a 2-y period were collected. Patients were divided into nonoperative (oxygen therapy only) management, chest tube placement, and surgical management. The primary outcome was the recurrence rate.
 
  Sixty-four patients diagnosed with PSP met inclusive criteria. The mean age was 15.5, and 48 (75%) of patients were men.  https://www.selleckchem.com/products/tenapanor.html  Twenty-one patients (33%) underwent nonoperative treatment, 24 patients (37.5%) un adolescents was found to be 23.4% after 2-y follow-up. Smaller-sized pneumothoraces were associated with higher rates of recurrence, but treatment type did not significantly affect recurrence rates.
  More effective chemotherapy regimens combined with metastasectomy have improved overall survival (OS) in several cancer populations. The value of liver resection (LR) in breast cancer liver metastasis (BCLM) remains controversial. We sought to investigate the role of LR in BCLM as a therapeutic option in patients with isolated liver metastasis.
 
  The National Cancer Data Base (NCDB) was queried for patients with BCLM diagnosed from 2010 to 2014. The primary outcome was the OS. Kaplan-Meier and Cox proportional hazards regression were performed for intergroup comparison.
 
  A total of 9244 patients with BCLM were included. The median age was 58y (IQR 49-68y). Of them, 2632 (28.5%) patients had isolated liver metastasis, 1957 (78.2%) received chemotherapy, 93 (3.6%) underwent LR, and only 83 (3.2%) received chemotherapy and LR. Median OS for the entire cohort and for patients with isolated BCLM was 18.3mo and 29mo, respectively. Chemotherapy with LR was associated with superior OS compared to chemotherapy alone (69.