Learning from Power Signals: An Automated Approach to Electrical Disturbance Identification within a Power Transmission System.

As power quality becomes a higher priority in the electric utility industry, the amount of disturbance event data continues to grow. Utilities do not have the required personnel to analyze each event by hand. This work presents an automated approach for analyzing power quality events recorded by digital fault recorders and power quality monitors operating within a power transmission system. The automated approach leverages rule-based analytics to examine the time and frequency domain characteristics of the voltage and current signals. Customizable thresholds are set to categorize each disturbance event. The events analyzed within this work include various faults, motor starting, and incipient instrument transformer failure. Analytics for fourteen different event types have been developed. The analytics were tested on 160 signal files and yielded an average accuracy of 99%. Continuous nominal signal data analysis was performed using an approach called the cyclic histogram. The cyclic histogram process is intended to be integrated into the digital fault recorders themselves in order to facilitate the detection of subtle signal variations that are too small to trigger a disturbance event and that can occur over hours or days. In addition to reducing memory requirements by a factor of 320, it is anticipated that cyclic histogram processing will aid in identifying incipient events and identifiers. This project is expected to save engineers time by automating the classification of disturbance events and increasing the reliability of the transmission system by providing near real-time detection and identification of disturbances as well as prevention of problems before they occur.

Intrinsic and extrinsic drivers of shape variation in the albatross compound bill.

Albatross are the largest seabirds on Earth and have a suite of adaptations for their pelagic lifestyle. Rather than having a bill made of a single piece of keratin, Procellariiformes have a compound rhamphotheca, made of several joined plates. Drivers of the shape of the albatross bill have not been explored. Here we use three-dimensional scans of 61 upper bills from 12 species of albatross to understand whether intrinsic (species assignment & size) or extrinsic (diet) factors predict bill shape. Diet is a significant predictor of bill shape with coarse dietary categories providing higher R2 values than dietary proportion data. We also find that of the intrinsic factors, species assignment accounts for ten times more of the variation than size (72% versus 6.8%) and that there is a common allometric vector of shape change between all species. When considering species averages in a phylogenetic framework, there are significant Blomberg's K results for both shape and size (K = 0.29 & 1.10) with the first axis of variation having a much higher K value (K = 1.9), reflecting the split in shape at the root of the tree. The influence of size on bill shape is limited, with species assignment and diet predicting far more of the variation. The results show that both intrinsic and extrinsic factors are needed to understand morphological evolution.

Diving into a dead-end: asymmetric evolution of diving drives diversity and disparity shifts in waterbirds.

Diving is a relatively uncommon and highly specialized foraging strategy in birds, mostly observed within the Aequorlitornithes (waterbirds) by groups such as penguins, cormorants and alcids. Three key diving techniques are employed within waterbirds: wing-propelled pursuit diving (e.g. penguins), foot-propelled pursuit diving (e.g. cormorants) and plunge diving (e.g. gannets). How many times diving evolved within waterbirds, whether plunge diving is an intermediate state between aerial foraging and submarine diving, and whether the transition to a diving niche is reversible are not known. Here, we elucidate the evolutionary history of diving in waterbirds. We show that diving has been acquired independently at least 14 times within waterbirds, and this acquisition is apparently irreversible, in a striking example of asymmetric evolution. All three modes of diving have evolved independently, with no evidence for plunge diving as an intermediate evolutionary state. Net diversification rates differ significantly between diving versus non-diving lineages, with some diving clades apparently prone to extinction. We find that body mass is evolving under multiple macroevolutionary regimes, with unique optima for each diving type with varying degrees of constraint. Our findings highlight the vulnerability of highly specialized lineages during the ongoing sixth mass extinction.

Evolution of the bovid cranium: morphological diversification under allometric constraint.

The role of environmental selection in generating novel morphology is often taken for granted, and morphology is generally assumed to be adaptive. Bovids (antelopes and relatives) are widely differentiated in their dietary and climatic preferences, and presumably their cranial morphologies are the result of adaptation to different environmental pressures. In order to test these ideas, we performed 3D geometric morphometric analyses on 141 crania representing 96 bovid species in order to assess the influence of both extrinsic (e.g. diet, habitat) and intrinsic (size, modularity) factors on cranial shape. Surprisingly, we find that bovid crania are highly clumped in morphospace, with a large number of ecologically disparate species occupying a very similar range of morphology clustered around the mean shape. Differences in shape among dietary, habitat, and net primary productivity categories are largely non-significant, but we found a strong interaction between size and diet in explaining shape. We furthermore found no evidence for modularity having played a role in the generation of cranial differences across the bovid tree. Rather, the distribution of bovid cranial morphospace appears to be mainly the result of constraints imposed by a deeply conserved size-shape allometry, and dietary diversification the result of adaptation of existing allometric pathways.

The impact of increased outpatient telehealth during COVID-19: Retrospective analysis of patient survey and routine activity data from a major healthcare system in England.

In response to societal restrictions due to the COVID-19 pandemic, a significant proportion of physical outpatient consultations were replaced with virtual appointments within the Bristol, North Somerset and South Gloucestershire healthcare system. The objective of this study was to assess the impact of this change in informing the potential viability of a longer-term shift to telehealth in the outpatient setting. A retrospective analysis was performed using data from the first COVID-19 wave, comprising 2998 telehealth patient surveys and 143,321 distinct outpatient contacts through both the physical and virtual medium. Four in five specialities showed no significant change in the overall number of consultations per patient during the first wave of the pandemic when telehealth services were widely implemented. Of those surveyed following virtual consultation, more respondents 'preferred' virtual (36.4%) than physical appointments (26.9%) with seven times as many finding them 'less stressful' than 'more stressful'. In combining both patient survey and routine activity data, this study demonstrates the importance of using data from multiple sources to derive useful insight. The results support the potential for telehealth to be rapidly employed across a range of outpatient specialities without negatively affecting patient experience.

Morphometric and genetic evidence for four species of gentoo penguin.

Gentoo penguins (Pygoscelis papua) are found across the Southern Ocean with a circumpolar distribution and notable genetic and morphological variation across their geographic range. Whether this geographic variation represents species-level diversity has yet to be investigated in an integrative taxonomic framework. Here, we show that four distinct populations of gentoo penguins (Iles Kerguelen, Falkland Islands, South Georgia, and South Shetlands/Western Antarctic Peninsula) are genetically and morphologically distinct from one another. We present here a revised taxonomic treatment including formal nomenclatural changes. We suggest the designation of four species of gentoo penguin: P. papua in the Falkland Islands, P. ellsworthi in the South Shetland Islands/Western Antarctic Peninsula, P. taeniata in Iles Kerguelen, and a new gentoo species P. poncetii, described herein, in South Georgia. These findings of cryptic diversity add to many other such findings across the avian tree of life in recent years. Our results further highlight the importance of reassessing species boundaries as methodological advances are made, particularly for taxa of conservation concern. We recommend reassessment by the IUCN of each species, particularly P. taeniata and P. poncetii, which both show evidence of decline.

Historical Perspectives on Colorectal Trauma Management.

The authors discuss the history and evolution of management of traumatic wounds to the colon and rectum, summarizing early management parallel with the history of armed conflict followed by the increase in research and management interest by civilian centers in the post-Vietnam era. They explore the strong opinions of the early thought-leaders such as DeBakey and Ogilvie, detailing factors that may have impacted their views. The current literature on optimal management of both colon and rectal trauma is reviewed, including the contentious debate over which patients may benefit from diversion. Current organ injury staging and clinical practice guidelines are also reviewed, as well as lessons learned by the U.S. military in recent conflicts in Iraq and Afghanistan. Understanding of the evolution of colon and rectal trauma management, as well as the current literature, will help surgeons in their decision-making and management of these challenging injuries.

Cancer vaccines in colon and rectal cancer over the last decade: lessons learned and future directions.

INTRODUCTION: Great advances have been made in screening for and treatment of colorectal cancer (CRC), but recurrence rates remain high and additional therapies are needed. There is great excitement around the field of immunotherapy and many attempts have been made to bring immunotherapy to CRC through a cancer vaccine. Areas covered: This is a detailed review of the last decade's significant CRC vaccine trials. Expert commentary: Monotherapy with a CRC vaccine is likely best suited for adjuvant therapy in disease free patients. Vaccine therapy elicits crucial tumor infiltrating lymphocytes, which are lacking in microsatellite-stable tumors, and therefore may be better suited for these patients. The combination of CRC vaccines with checkpoint inhibitors may unlock the potential of immunotherapy for a much broader range of patients. Future studies should focus on vaccine monotherapy in correctly selected patients and combination therapy in more advanced disease.

Acute health care resource utilization for ileostomy patients is higher than expected.

BACKGROUND: Patients requiring an ileostomy following colorectal surgery are at risk for increased health-care utilization after discharge. Prior studies evaluating postoperative ileostomy care may underestimate health-care utilization by reporting only "same-institution" readmission rates. OBJECTIVE: The aim of this study was to determine the rates of health-care utilization of new ostomates within 30 days of discharge in a multicenter environment. DESIGN: This is a retrospective cohort study. SETTINGS: This study was conducted at acute-care, community hospitals in California, Florida, Nebraska, and New York. PATIENTS: Adult patients who underwent colorectal surgery with primary anastomosis, colostomy, or ileostomy between July 2009 and September 2010 were identified. MAIN OUTCOME MEASURES: The primary outcome measured was hospital-based acute care, defined as hospital readmission or emergency department visit, at any hospital within 30 days of surgery. Multivariate regression models were used to compare the outcomes across groups. RESULTS: Overall, 75,136 patients underwent colectomy with most receiving a primary anastomosis (79.3%), whereas colostomies were created in 12.8% and ileostomies were created in 8.0%. Diagnoses of colorectal cancer (36.1%) or diverticular disease (22.0%) were most common. Patients with a colostomy (18.8%; adjusted odds ratio [AOR], 1.23 [95% CI, 1.17-1.30]) or ileostomy (36.1%; AOR, 2.28 [95% CI 2.15-2.42]) were significantly more likely than patients with a primary anastomosis (16.2%) to have a hospital-based acute-care encounter within 30 days of discharge. Among patients undergoing ileostomy, postoperative infection, renal failure, and dehydration were the most common diagnoses for hospital-based acute-care events. Overall, 20% of these encounters occurred at hospitals other than where the index surgery occurred. LIMITATIONS: Coding accuracy, the inability to capture events occurring in physician offices, and the retrospective study design were limitations of the study. CONCLUSIONS: Patients undergoing colorectal surgery with an ileostomy return to the hospital after discharge twice as frequently as those with a primary anastomosis or colostomy, often to hospitals other than the primary institution. As postdischarge health-care utilization becomes a measured quality metric, it is increasingly important to help these patients to safely transition to home.

A variation in the value of colectomy for cancer across hospitals: mortality, readmissions, and costs.

INTRODUCTION: Although hospital variation in costs and outcomes has been described for patients undergoing operation, the relationship between them is unknown. The purpose of this study was to evaluate this relationship among patients undergoing colon resection for cancer and identify characteristics of "high-quality, low-cost" hospitals. METHODS: We identified adult patients who underwent colon resection for cancer in California, Florida, and New York from 2009 to 2010. We estimated hospital-level, risk-standardized 30-day hospital costs, in-hospital mortality rates, and 30-day readmission rates by using hierarchical generalized linear models. Costs were compared between hospitals identified as low, average, and high performers. RESULTS: The final sample included 14,790 patients discharged from 389 hospitals. After adjusting for case mix, variation was noted in risk-standardized costs (median = $26,169, inter-quartile range [IQR] = $6,559), in-hospital mortality (median = 1.8%, IQR = 2.3%), and 30-day readmission (12.2%, IQR = 0.7%) rates. Minimal correlation was noted between a hospital's costs and outcomes, with similar costs noted across hospital performance groups (low = $25,994 vs average = $26,998 vs high = $25,794, P = .19). High-quality, low-cost hospitals treated a greater percentage of Medicare beneficiaries, approached fewer cases laparoscopically, and trended toward greater volume. CONCLUSION: Hospital costs are not correlated with outcomes in this population. More work is needed to identify means of providing high-quality care at lesser costs.

Outcomes and costs associated with robotic colectomy in the minimally invasive era.

BACKGROUND: Robotic-assisted surgery has become increasingly common; however, it is unclear if its use for colectomy improves in-hospital outcomes compared with the laparoscopic approach. OBJECTIVE: The aim of the study is to compare in-hospital outcomes and costs between patients undergoing robotic or laparoscopic colectomy. DESIGN: This study is a retrospective review of the 2008 to 2009 Nationwide Inpatient Sample. SETTINGS, PATIENTS, INTERVENTIONS: All adult patients who underwent an elective robotic or laparoscopic colectomy in hospitals performing both procedures (N = 2583 representing an estimated 12,732 procedures) were included. MAIN OUTCOME MEASURES: Outcomes included intraoperative and postoperative complications, length of stay, and direct costs of care. Regression models were used to compare these outcomes between procedural approaches while controlling for baseline differences in patient characteristics. RESULTS: Overall, 6.1% of patients underwent a robotic procedure. Factors associated with robotic-assisted colectomy included younger age, benign diagnoses, and treatment at a lower-volume center. Patients undergoing robotic and laparoscopic procedures experienced similar rates of intraoperative (3.0% vs 3.3%; adjusted OR = 0.88 (0.35-2.22)) and postoperative (21.7% vs 21.6%; adjusted OR = 0.84 (0.54-1.30)) complications, as well as risk-adjusted average lengths of stay (5.4 vs 5.5 days, p = 0.66). However, robotic-assisted colectomy resulted in significantly higher costs of care ($19,231 vs $15,807, p < 0.001). Although the overall postoperative morbidity rate was similar between groups, the individual complications experienced by each group were different. LIMITATIONS: A limitation of this study is the potential miscoding of robotic cases in administrative data. CONCLUSIONS: Robotic-assisted colectomy significantly increases the costs of care without providing clear reductions in overall morbidity or length of stay. As the use of robotic technology in colon surgery continues to evolve, critical appraisal of the benefits offered in comparison with the resources consumed is required.

Combat readiness for the modern military surgeon: data from a decade of combat operations.

OBJECTIVE: Hundreds of general surgeons from the army, navy, and air force have been deployed during the past 10 years to support combat forces, but little data exist on their preparedness to handle the challenging injuries that they are currently encountering. Our objective was to assess operative and operational experience in theater with the goal of improving combat readiness among surgeons. METHODS: A detailed survey was sent to 246 active duty surgeons from the army, navy, and air force who have been deployed at least once in the past 10 years, requesting information on cases performed, perceptions of efficacy of predeployment training, knowledge deficits, and postdeployment emotional challenges. Survey data were kept confidential and analyzed using standard statistical methods. RESULTS: Of 246 individuals, 137 (56%) responded and 93 (68%) have been deployed two or more times. More than 18,500 operative procedures were reported, with abdominal and soft tissue cases predominating. Many surgeons identified knowledge or practice gaps in predeployment vascular (46%), neurosurgical (29.9%), and orthopedic (28.5%) training. The personal burden of deployment manifested itself with both family (approximately 10% deployment-related divorce rate) and personal (37 surgeons [27%] with two or more symptoms of posttraumatic stress syndrome) stressors. CONCLUSION: These data support modifications of predeployment combat surgical training to include increased exposure to open vascular procedures and curriculum traditionally outside general surgery (neurosurgery and orthopedics). The acute care surgical model may be ideal for the military surgeon preparing for deployment. Further research should be directed toward identifying factors contributing to psychological stress among military medics.

Standardized pretreatment breast MRI--accuracy and influence on mastectomy decisions.

BACKGROUND AND OBJECTIVES: Routine pretreatment breast magnetic resonance imaging in newly diagnosed cancer patients remains controversial. We assess MRI accuracy and influence on mastectomy decisions after institution of standardized pretreatment MRI. METHODS: A prospectively collected database of 74 consecutive new invasive breast cancer patients with pretreatment breast MRI was reviewed for treatment choice, radiologic, and pathologic results. Thirty-eight of 72 patients with available surgical records underwent mastectomy. Mastectomy preoperative and operative electronic records were reviewed for treatment decision analysis. RESULTS: Seventeen of 72 (23.6%) invasive breast cancer patients were likely influenced to undergo mastectomy by new information from MRI. MRI reported that the multifocal/multicentric (MF/MC) rate was 20 of 72 (27.8%) versus 19 of 72 (26.4%) by surgical pathology. MRI sensitivity for MF/MC disease was 89.5% versus 11.8% for mammography. MRI specificity was 84.2%. All three false positives declined recommended preoperative biopsies. MRI MF/MC diagnosis highly correlated with pathology results, P < 0.001. CONCLUSIONS: Increased mastectomy rate from 29 to 52.8% after standardization of pre-treatment breast MRI for invasive cancer is largely due to MRI findings of increased extent of disease. These MRI findings correlate well with pathologic findings and appear to justify the performance of mastectomies in these patients.

Current US military operations and implications for military surgical training.

BACKGROUND: Since 2001, US military surgeons have deployed frequently, with many surgeons deploying within 1 year of graduating residency. The purpose of this study was to evaluate readiness of recent graduates to manage combat-related injuries and to make recommendations for improvements in training military surgeons. STUDY DESIGN: We reviewed casualties treated at the 31st Combat Support Hospital in Baghdad from December 2003 to November 2004. We identified 3,426 wounded patients; of these, 2,648 (77.3%) required an operative procedure. There were 2,788 patients (81.4%) who sustained penetrating injuries. The most common procedures performed were debridement of wounds (39%), skeletal fixation (14.7%), and exploratory laparotomy (11.4%). Common procedures were compared with 15 case logs from the ACGME database for our institution from 2005 to 2009. RESULTS: Graduating residents averaged 973 cases during residency (range 867 to 1,293, median 921). This included experience with most procedures encountered except nephrectomy (1.5 procedures per resident [PPR]), craniotomy (1.1 PPRs), inferior vena cava injury (1.1 PPRs), bladder repair (0.87 PPR), and duodenal injury (0.6 PPR). Residents had minimal experience with skeletal fixation and external genital trauma. CONCLUSIONS: Recent surgical residency graduates are prepared for deployment in support of US military operations for the majority of injuries encountered. However, familiarization with procedures that fall outside the traditional general surgical curriculum would improve their ability to treat these injuries. To enhance experience with rare injuries, cadaver studies and animal models may serve as training tools before deployment.

Sterile intra-abdominal fluid collection associated with seprafilm use.

Postoperative abdominal adhesions are a significant cause of morbidity and expenditure of healthcare resources. As a result, numerous substances have been studied in an effort to reduce the incidence of adhesive disease. Seprafilm, a hyaluronate-based bioresorbable membrane, has been the subject of considerable research and has been found to be both safe and effective in reducing postoperative adhesions. We report three cases of the development of sterile abdominal fluid collection after the use of Seprafilm in colorectal surgery.