Feasibility of Fully Automated Hypnosis, Analgesia, and Fluid Management Using 2 Independent Closed-Loop Systems During Major Vascular Surgery: A Pilot Study.

Automated titration of intravenous anesthesia and analgesia using processed electroencephalography monitoring is no longer a novel concept. Closed-loop control of fluid administration to provide goal-directed fluid therapy has also been increasingly described. However, simultaneously combining 2 independent closed-loop systems together in patients undergoing major vascular surgery has not been previously detailed. The aim of this pilot study was to evaluate the clinical performance of fully automated hypnosis, analgesia, and fluid management using 2 independent closed-loop controllers in patients undergoing major vascular surgery before implementation within a larger study evaluating true patient outcomes.

A model species for agricultural pest genomics: the genome of the Colorado potato beetle, Leptinotarsa decemlineata (Coleoptera: Chrysomelidae).

The Colorado potato beetle is one of the most challenging agricultural pests to manage. It has shown a spectacular ability to adapt to a variety of solanaceaeous plants and variable climates during its global invasion, and, notably, to rapidly evolve insecticide resistance. To examine evidence of rapid evolutionary change, and to understand the genetic basis of herbivory and insecticide resistance, we tested for structural and functional genomic changes relative to other arthropod species using genome sequencing, transcriptomics, and community annotation. Two factors that might facilitate rapid evolutionary change include transposable elements, which comprise at least 17% of the genome and are rapidly evolving compared to other Coleoptera, and high levels of nucleotide diversity in rapidly growing pest populations. Adaptations to plant feeding are evident in gene expansions and differential expression of digestive enzymes in gut tissues, as well as expansions of gustatory receptors for bitter tasting. Surprisingly, the suite of genes involved in insecticide resistance is similar to other beetles. Finally, duplications in the RNAi pathway might explain why Leptinotarsa decemlineata has high sensitivity to dsRNA. The L. decemlineata genome provides opportunities to investigate a broad range of phenotypes and to develop sustainable methods to control this widely successful pest.

Practice and Outcomes of the Perioperative Surgical Home in a California Integrated Delivery System.

BACKGROUND: In this article, we report on the implementation and impact of a Perioperative Surgical Home (PSH) model for the total knee arthroplasty at an integrated delivery system (Kaiser Permanente). METHODS: A multidisciplinary committee developed and implemented a series of PSH protocols that included the entire continuum of care from the decision for surgery until 30 days after surgery. Five hundred forty-six subjects were included in the preimplementation phase (Fast Track [T-fast]), and 518 patients were included in the postimplementation phase (PSH). The primary end points of this report are hospital length of stay (LOS), postoperative skilled nursing facility (SNF) bypass rate, and 30-day readmission rate. We used a generalized linear model to assess the effect on LOS while adjusting for potential confounding variables. RESULTS: We found that patients assigned to the PSH pathway had a significantly shorter mean LOS compared with patients in the T-fast group (2.4 ± 2.1 days [confidence interval {CI}, 2.2-2.8] vs 3.4 ± 2.9 days [CI, 2.9-3.9]). The SNF bypass rate was significantly higher in the PSH group compared with the T-fast group (94% vs 80%, P = 0.00002, CI, -0.102 to -0.036). There was no difference in the 30 readmission rates between patients managed in the PSH track and the T-fast track (1.2% vs 0.98%). CONCLUSIONS: Introduction of the PSH into an integrated delivery system resulted in a simultaneous reduction of LOS and SNF admission for total knee arthroplasty patients.

Total Joint Replacement Perioperative Surgical Home Program: 2-Year Follow-Up.

BACKGROUND: Previously, our group successfully established one of the nation's first Perioperative Surgical Homes (PSHs) aimed at coordinating services to patients undergoing primary total hip arthroplasty (THA) and primary total knee arthroplasty (TKA). As we now focus on extending the PSH to other service lines within the hospital, the long-term sustainability of this practice model is an important factor to consider moving forward. METHODS: We prospectively collected data from all patients who underwent elective primary TKA and THA at our institution between October 1, 2012, and September 30, 2014. Prospectively collected data included length of stay (LOS), 30-day readmission rate, postoperative pain scores, and complications. RESULTS: During the 2-year period, there were 328 primary joint arthroplasty patients. Overall, the median LOS was significantly shorter in the second year of the PSH initiative (P = 0.03). Stratified by procedure, the median LOS for patients undergoing THA was significantly shorter in the second year (P = 0.02), whereas the median LOS for patients undergoing TKA did not differ between the 2 time periods. In the second year of the PSH initiative, significantly more patients were discharged home than to a skilled nursing facility compared with year 1 of the PSH initiative (P = 0.02). Readmission rates within 30 days after surgery to our institution were 0.9% (0.0-4.4) in the first year of the PSH initiative and 3.3% (confidence interval, 1.3%-7.2%) in the second year of the PSH initiative (P = not significant). Pain scores did not change significantly from year 1 to year 2 (P = not significant). CONCLUSIONS: Data for the second year of implementation demonstrate similarly positive results in LOS, pain control, discharge destination, readmission, transfusion rates, and complications.