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While the safety of rapid recovery total joint arthroplasty is well established, less is known about its impact on postoperative care utilization patterns. We wished to examine whether same-day discharge—and its associated presumed reduction in hospital-based postoperative care and education—translates to the need for more postoperative support during the 1-year recovery period. A retrospective review of 1,237 total hip arthroplasty (THA) and 1,710 total knee arthroplasty (TKA) patients who had 0- or 1-day length of stay (LOS) from January 2020 to October 2023 was conducted. The primary outcome was the number of follow-up visits with total joint arthroplasty providers at our institution during the 1-year postoperative period. Secondary outcomes included 30-day emergency department returns, readmissions, 1-year physical therapy utilization, and improvement in Patient-Reported Outcomes Measurement Information System Physical Function scores at 6 to 12 months postoperatively. Bivariate and multivariable analyses were performed to compare outcomes between 0-day and 1-day LOS THA and TKA patients. In both the THA and TKA populations, 0-day LOS patients were younger, had a lower average body mass index, were more likely to be White, men, and had an American Society of Anesthesiologists score < 3 than 1-day LOS patients. After controlling for differences between groups, no significant differences in the number of one-year follow-up visits, physical therapy visits, emergency department returns, or readmissions were seen between 0 and 1-day THA or TKA patients. In TKA patients, 1-day LOS was associated with lower improvements in Patient-Reported Outcomes Measurement Information System Physical Function scores. After risk adjustment, same-day discharge of THA and TKA patients did not result in increased resource utilization during the one-year postoperative period. In the setting of a coordinated joint arthroplasty program with nurse navigator support, same-day discharge can be safely performed without increasing the need for postoperative care in appropriately selected patients undergoing both THA and TKA. [ABSTRACT FROM AUTHOR]

Several studies have suggested that spinal anesthesia gives superior outcomes for primary total joint arthroplasty (TJA). However, there is a lack of available data regarding contemporary general anesthesia (GA) approaches for revision TJA utilized at high-volume joint arthroplasty centers. We retrospectively reviewed a series of 850 consecutive revision TJAs (405 revision total hip arthroplasties and 445 revision total knee arthroplasties) performed over 4 years at a single institution that uses a contemporary GA protocol and reported on the lengths of stay, early recovery rates, perioperative complications, and readmissions. Of the revision arthroplasty patients, 74.4% (632 of 850) were discharged on postoperative day 1 and 68.5% (582 of 850) of subjects were able to participate in physical therapy on the day of surgery. Only 6 patients (0.7%) required an intensive care unit stay postoperatively. The 90-day readmission rate over this time was 11.3% (n = 96), while the reoperation rate was 9.4% (n = 80). While neuraxial anesthesia is commonly preferred when performing revision TJA, we have demonstrated favorable safety and efficiency metrics utilizing GA in conjunction with contemporary enhanced recovery pathways. Our data support the notion that modern GA techniques can be successfully used in revision TJA. [ABSTRACT FROM AUTHOR]

A shift toward same-day discharge (SDD) in primary elective total knee arthroplasty (TKA) and total hip arthroplasty (THA) has created a need to optimize patient selection and improve same-day recovery pathways. The objectives of this study were (1) to identify our institution's most common causes for failed SDD, and (2) to evaluate risk factors associated with failed SDD. A retrospective review of SDD patients undergoing primary TKA or THA from January 2021 to September 2022 was conducted. Reasons for SDD failure were recorded and differences between successful and failed SDD cases were assessed via a multivariate logistic regression. Overall, 85.3% (651 of 753) of patients included were successful SDDs. Failed SDD occurred in 16.8% (74 of 441) of TKA and 11.8% (38 of 322) of THA cases. Primary reasons included failure to clear physical therapy (33.0%, 37 of 112), postoperative hypotension (20.5%, 23 of 112), and urinary retention (16.9%, 19 of 112). Analysis revealed that overall failed SDD cases were more likely to have had prior opioid use and a longer surgical time. Failed TKA SDD cases were more likely to have had a longer surgical time and not have receive a preoperative nerve block, while failed THA SDD cases were more likely to be older. The SDD selection criteria and pathways continue to evolve, with multiple factors contributing to failed SDD. Improving patient selection algorithms and optimizing post-operative pathways can enhance the ability to successfully choose SDD candidates. III. [ABSTRACT FROM AUTHOR]

To assess whether a preoperative bilateral thoracic paravertebral block (TPVB) would improve postoperative analgesia in infants and small children undergoing open cardiac surgery in the protocol of an ultra-fast track cardiac anesthesia (UFTCA). A single-center, prospective, randomized, controlled study. At a tertiary children's medical center. A total of 180 children undergoing cardiac surgery, aged 1 month to 3 years. Patients are allocated randomly to TPVB and parent- and/or nurse-controlled intravenous analgesia (PNCA) group (Group T) or PNCA group (Group P). The primary outcome is the postoperative pain scores. The secondary outcome are intraoperative consumption of sufentanil, time to extubation, using of neostigmine, cumulative total and invalid PCA attempts in 24 and 48 hours after surgery, hospitalization characteristics, perioperative blood glucose, postoperative arterial oxygen partial pressure, arterial carbon dioxide partial pressure (PaCO 2) and brain natriuretic peptide (BNP). The postoperative pain scores within 24 hours, intraoperative consumption of sufentanil, total, and invalid PCA attempts in 24 and 48 hours, perioperative blood glucose and BNP on the seventh day in Group T were all significantly lower than those in Group P (p < 0. 001). The time to extubation, the use of neostigmine, and PaCO 2 on the sixth hour, postoperatively, were significantly smaller in Group T than those in Group P (p < 0. 05). There were no significant differences in the hospitalizations between the 2 groups. A combination of bilateral single dose TPVB and PNCA pain management is superior to a PNCA pain management alone in infants and small children undergoing open cardiac surgery and contributes to a rapid recovery with preferable perioperative outcomes in the protocol of UFTCA. [ABSTRACT FROM AUTHOR]

To explore the effect of a short-term, hospital-based, multimodal preoperative prehabilitation intervention on perioperative functional ability of patients with gynecological malignant tumors. According to the order in which they underwent surgery, 97 patients were divided into the control group (48 cases) and the intervention group (49 cases). The control group was given routine preoperative guidance, whereas the intervention group was given short-term multimodal prehabilitation guidance on the basis of the control group intervention. The 6-min walk test was performed on the day of admission to the hospital, the day before surgery, and the 30th day after surgery. Compared with the control group, the intervention group had significantly better 6-min walk distance and superior physical and psychological status on the day before surgery and the 30th day after surgery (P < 0.001). For three consecutive days after surgery, the quality of recovery in the intervention group was significantly higher than that in the control group (P < 0.001), and the first ambulation time and exhaust time were achieved earlier in the intervention group than in the control group (P < 0.05). The preoperative intervention group showed improved preoperative exercise ability and reduced anxiety in patients with gynecological cancer. Furthermore, this intervention improved the overall health of patients and accelerated their postoperative recovery. • This study designed a prehabilitation strategy for gynecological tumor patients. • This strategy is a short-term multimodal prehabilitation intervention program. • The strategy improves the overall health of patients and promotes their recovery. • The strategy offers new ideas to improve the health of gynecologic tumor patients. [ABSTRACT FROM AUTHOR]

As perioperative protocols have improved, there has been a reduction in the rates of key complications after hip and knee arthroplasty. Likewise, as we have been able to make patients more comfortable postoperatively, hospital length of stay has decreased and in some centers, hip and knee arthroplasty is now routinely performed as an outpatient. While the number of surgeons offering this option and patients choosing to have procedures performed as an outpatient grows, many questions revolve around this movement. This article will review the data supporting outpatient arthroplasty, the business and legal aspects involved, if surgeons can align with their hospital to offer these services, and how tightly knit and highly organized teams are key to the success of safely offering hip and knee arthroplasty on an outpatient basis. [ABSTRACT FROM AUTHOR]

The low-temperature NO 2 gas sensors with ultra-high response are more helpful for their real-time and accurate monitoring in complex environment, however, the relevant reports are very less. Herein, we firstly prepared graphitic carbon nitride (g-C 3 N 4) by pyrolysis of inexpensive melamine, which was used as template and directly soaked into SnCl 4 ethanol/water solution. Afterwards, the immersed precursors were calcined to generate different SnO 2 -based materials. Among, the morphology of g-C 3 N 4 /SnO 2 -5 calcined at 500 °C is lamella structure composed of trace g-C 3 N 4 and small-size SnO 2 nanoparticles, which possesses narrow mesopores, large specific surface area, rich oxygen vacancy defects, as well as high concentration of surface O 2 - (ad) species. Under the synergy of multiple favorable factors, g-C 3 N 4 /SnO 2 -5 sensor exhibits ultra-high response (S = 12171) for 10 ppm NO 2 gas at 92 °C, which is 1.93 times than that of SnO 2 -6 sensor. It is also the highest response value among reported g-C 3 N 4 /metal oxide composites. In addition, this sensor has fast recovery time (5 s), low detection limit, good moisture resistance and stability. Thus, the simple g-C 3 N 4 template method provides a new strategy for the fabrication of gas sensors with highly efficient sensing ability. [Display omitted] • The trace g-C 3 N 4 /SnO 2 lamella was simply prepared by the pyrolysis of immersed lamellar g-C 3 N 4 template. • The g-C 3 N 4 /SnO 2 -5 sensor achieved ultra-high response and fast recovery of NO 2 gas at low temperature. • The excellent performance stems from the synergism of lamella structure, trace g-C 3 N 4 doping and rich oxygen vacancies. • The simple g-C 3 N 4 template method provides a new horizon for synthesizing other metal oxides with ultra-high response. [ABSTRACT FROM AUTHOR]

Background: Several variables are known to correlate with the successful completion of short-stay total hip arthroplasty (THA) protocols. The role of psychological factors remains unclear. We investigated the interaction between patient-reported measures of psychological fitness and successful completion of a short-stay THA protocol.Methods: We performed a prospective cohort study of patients undergoing elective anterior total hip arthroplasty enrolled in a short-stay protocol (success defined as LOS ≤1 midnight versus failed, LOS >1 midnight). Psychological fitness was measured using the Patient-Reported Outcomes Measurement Information System (PROMIS) domains for self-efficacy, depression, anxiety, emotional support, and the ability to participate in social roles. PROMIS scores, patient demographics, and surgical factors were assessed for a relationship with failure to complete short-stay protocol.Results: Patients that failed to complete the short-stay protocol had higher mean pre-operative PROMIS depression scores (50.8 vs 47.1, P = .025) and anxiety scores (53.6 vs 49.2, P = .008) and higher postoperative PROMIS depression (48.19 vs 43.49, P = .003) and anxiety scores (51.7 vs 47.1, P = .01). Demographic and surgical variables did not correlate with the successful completion of the short-stay protocol. That seventy-six percent of the patients did not adhere to the short-stay protocol was due to the inability to complete a physical therapy standardized safety assessment.Conclusion: Higher levels of preoperative and postoperative anxiety and depression in otherwise psychologically healthy patients, is associated with an increased risk of failure to complete a short-stay protocol following THA. Targeted interventions are needed to facilitate rapid recovery in patients with psychological barriers to early mobilization. [ABSTRACT FROM AUTHOR]

Background: This study sought to determine the total amount of time committed to planned and unplanned episodes of care related to primary, unilateral total joint arthroplasty (TJA), relative to a growth in outpatient TJA.Methods: All primary, unilateral TJA procedures performed over a 7-year period by a single surgeon at a single institution were retrospectively reviewed. Time dedicated to planned work was calculated over each episode of care, from surgery scheduling to 90 days postoperatively. All telephone inquiries and readmissions involving the surgeon's direct input, over the episode of care, constituted time dedicated to unplanned work.Results: Between 2012 and 2018, as the proportion of outpatient TJAs increased, the average planned episode-of-care time per patient decreased from 412 minutes to 361 minutes. Despite a 108% increase in the total number of outpatient TJAs between 2017 and 2018 (51/432 (11.8%) to 106/555 (19.1%); P = .002), neither the average number of unplanned telephone inquiries (4.6 ± 3.8 vs 4.2 ± 3.7; P = .124), nor the mean time per patient required to respond to calls (23.1 ± 19.4 vs 21.2 ± 18 minutes, P = .135) differed. Between 2017 and 2018, the average total episode-of-care time per patient decreased from 403 minutes (376 planned + 27 unplanned) to 387 minutes (361 planned + 26 unplanned).Conclusion: Despite an increase in outpatient TJA, the average time required for planned and unplanned patient care remained relatively constant. The growth of outpatient TJA nationally should not trigger a change in Centers for Medicare and Medicaid Services benchmarks. [ABSTRACT FROM AUTHOR]

Background: The introduction of bundled funding for total knee arthroplasty (TKA) has motivated hospitals to improve quality of care while minimizing costs. The aim of our quality improvement project is to reduce the acute hospitalization length of stay to less than 2 days and decrease the percentage of TKA patients discharged to inpatient rehabilitation using an enhanced recovery after surgery bundle.Methods: This study used a before-and-after design. The pre-intervention period was January to December 2017 and the post-intervention period was January 2018 to August 2019. A root cause analysis was performed by a multidisciplinary team to identify barriers for rapid recovery and discharge. Four new interventions were chosen as part of an improvement bundle based on existing local practices, literature review, and feasibility analysis: (1) perioperative peripheral nerve block; (2) prophylactic antiemetic medication; (3) avoidance of routine preoperative urinary catheterization; and (4) preoperative patient education.Results: The pre-intervention and post-intervention groups included 232 and 383 patients, respectively. Mean length of stay decreased from 2.82 to 2.13 days (P < .001). The need for inpatient rehabilitation decreased from 20.2% to 10.7% (P = .002). Mean 24-hour oral morphine consumption decreased from 60 to 38 mg (P < .001). The percentage of patients experiencing moderate-to-severe pain and postoperative nausea and vomiting within the first 24 hours decreased by 25% and 15%, respectively (P < .001). Thirty-day emergency department visits following discharge decreased from 12.9% to 7.3% (P = .030).Conclusion: Significant improvements in the recovery of patients after TKA were achieved by performing a root cause analysis and implementing a multidisciplinary, patient-centered enhanced recovery after surgery bundle.Level Of Evidence: Level III. [ABSTRACT FROM AUTHOR]

Background: Advances in perioperative care have enabled early discharge and outpatient primary total joint arthroplasty (TJA). However, the safety of early discharge after revision TJA (rTJA) remains unknown and the COVID-19 pandemic will force decreased hospitalization. This study compared 90-day outcomes in patients undergoing aseptic rTJA discharged the same or next day (early) to those discharged 2 or 3 days postoperatively (later).Methods: In total, 530 aseptic rTJAs performed at a single tertiary care referral center (December 5, 2011 to December 30, 2019) were identified. Early and later discharge patients were matched as closely as possible on procedure type, sex, American Society of Anesthesiologists physical status classification, age, and body mass index. All patients were optimized using modern perioperative protocols. The rate of 90-day emergency department (ED) visits and hospital admissions was compared between groups.Results: In total, 183 early discharge rTJAs (54 hips, 129 knees) in 178 patients were matched to 183 later discharge rTJAs (71 hips, 112 knees) in 165 patients. Sixty-two percent of the sample was female, with an overall average age and body mass index of 63 ± 9.9 (range: 18-92) years and 32 ± 6.9 (range: 18-58) kg/m2. There was no statistical difference in 90-day ED visit rates between early (6/178, 3.4%) and later (11/165, 6.7%) discharge patients (P = .214). Ninety-day hospital admission rates for early (7/178, 3.9%) and later (4/165, 2.4%) discharges did not differ (P = .545).Conclusion: Using modern perioperative protocols with appropriate patient selection, early discharge following aseptic rTJA does not increase 90-day readmissions or ED visits. As hospital inpatient capacity remains limited due to COVID-19, select rTJA patients may safely discharge home the same or next day to preserve hospital beds and resources for more critical illness. [ABSTRACT FROM AUTHOR]

Background: As health care costs continue to rise, same-day and rapid discharge have become popular options for total hip arthroplasty (THA). However, it remains unclear if there is a difference between within-a-day discharge and early discharge for 1-year clinical outcomes.Methods: Data were collected from the Humana insurance database using the PearlDiver Patient Records Database from 2007 to 2017, identifying patients receiving a primary THA. Patients were then stratified into three groups: (1) discharge within a day (length of stay [LOS] <24 hours), (2) rapid discharge (LOS: 1-2 days), and (3) traditional discharge (LOS: 3-4 days). The outcomes assessed were all-cause revision surgery, periprosthetic joint infection, prosthetic loosening, prosthetic dislocation, and periprosthetic fracture at 1 year postoperatively.Results: In total, 40,038 patients met inclusion criteria. Among those, 754 (1.88%) patients were discharged within a day, 13,670 (34.14%) patients were in the rapid discharge cohort, and 25,614 (63.97%) patients were in the traditional discharge cohort. After multivariate analysis, no significant differences were observed between the within-a-day discharge group and either the rapid discharge or the traditional discharge group. Rapid discharge patients were at decreased risk of periprosthetic joint infection (odds ratios: 0.747, 95% confidence interval: 0.623-0.896) and readmission (odds ratios: 0.778; 95% confidence interval: 0.735-0.824, P < .001) compared with traditional discharge patients.Conclusions: No significant differences were observed in the one-year outcomes of primary THA between within-a-day discharge patients, rapid discharge, and traditional discharge. For those that qualify after careful selection, outpatient THA might be a feasible alternative to the traditional inpatient THA. [ABSTRACT FROM AUTHOR]

La réalisation d'une prothèse totale de hanche a connu une vraie révolution ces dernières années avec la démocratisation de la réhabilitation améliorée après chirurgie (RAAC) allant jusqu'à la réalisation de cette procédure en chirurgie ambulatoire. Ces évolutions ont été rendues possibles par le développement des techniques chirurgicales mini-invasives et l'amélioration des modalités anesthésiques. Le « parcours patient » a été transformé pour permettre aux structures de soin adaptées de réaliser ces interventions chirurgicales lourdes en hospitalisations de courte durée. Différents critères de prise en charge RAAC ont été déterminés et sont à rechercher dès la première consultation chirurgicale pour s'assurer de l'éligibilité du patient à une sortie précoce. Ensuite, l'information et l'accompagnement doivent être minutieusement orchestrés par les différents acteurs de soin, pour que le patient et son entourage adhèrent et se préparent à cette prise en charge. Au cours de l'intervention, la collaboration entre équipe chirurgicale et anesthésique est primordiale. L'objectif pour le chirurgien est l'utilisation de techniques mini-invasives, la limitation du drainage et la gestion des saignements peropératoires, conjointement avec l'anesthésiste. L'infiltration d'anesthésiques locaux lors de la procédure chirurgicale permet une diminution de la consommation d'antalgiques postopératoire et donc des effets indésirables liés à ces traitements, ce qui reste une des priorités de l'anesthésiste. En postopératoire, le jeûne doit être le plus court possible et le premier lever est fait par le kinésithérapeute dès les premières heures après le retour en chambre. La gestion antalgique est primordiale pour permettre un premier lever sans douleur qui donne confiance au patient. Il peut ainsi envisager un retour rapide à son domicile. Ce retour doit être encadré par l'appel ou le passage d'une infirmière formée qui s'assure du bon déroulement des suites opératoires, rassure le patient et vérifie la prise médicamenteuse. La réhabilitation améliorée après chirurgie orthopédique devient progressivement le « gold standard » avec, depuis quelques années, la pratique de PTH en ambulatoire de façon courante. Cette pratique permet de dispenser des soins de qualité sans augmenter le risque de complications postopératoires. Les avantages sont nombreux pour le patient qui retrouve une autonomie et un confort de vie plus précoce et pour le système de santé qui diminue les coûts liés à l'hospitalisation par la diminution des durées de séjour. Total hip arthroplasty has experienced a real evolution in recent years with the democratization of rapid recovery and outpatient surgery for this procedure. These evolutions have been made possible by the development of minimally invasive surgical techniques and the improvement of anesthetic modalities. The patient's journey has been transformed to allow appropriate care structures to perform these heavy surgeries in short-term hospitalizations. Different rapid recovery management criteria have been identified, starting from the first surgical consultation, to ensure the eligibility of the patient for early discharge. The information of the patient and his accompaniment must be carefully orchestrated so that the patient and his entourage adhere and prepare for this care. During the procedure, the coaction between surgical team and anesthetic is essential. The goal for the surgeon is the use of minimally invasive techniques, drainage limitation and perioperative bleeding management, in conjunction with the anesthetist. The infiltration of local anesthetics during the surgery reduces postoperative analgesics and therefore their side effects, which remains one of the priorities of the anesthesiologist. In the postoperative period, stand up is done with the help of the physiotherapist in the first hours after returning to the room. Analgesic management is essential to allow the patient to get up without pain in order to make him confident. He can thus consider a quick return home. This return must be framed by the call, or the survey of a trained nurse, who ensures the smooth postoperative period, comfort the patient and check the drug intake. Rapid recovery is gradually becoming the "gold standard" with, in recent years, routine completion of total hip replacement in outpatients. This practice provides quality care without increasing the risk of postoperative complications. The benefits are numerous for the patient, who regains his life comfort earlier, and for the health system, which reduces the costs associated with long hospitalization. [ABSTRACT FROM AUTHOR]

Postoperative pain relief for total knee arthroplasty is an important concern for clinicians who seek to decrease pain, side effects associated with narcotics, increase mobility, and decrease hospital length of stay for total knee arthroplasty (TKA) patients. In today's day in age where patients and clinicians are looking to decrease length of stay and desire to take total knee replacement to the ambulatory surgery setting, appropriate and safe analgesia is paramount. The purpose of this study was to evaluate the analgesic efficacy of implementing a single shot adductor canal block (ACB) protocol in patients undergoing primary TKA by a single surgeon already using a multimodal analgesia protocol at a high volume community hospital. 75 patients who received a single shot ACB were compared to 75 patients that did not receive an ACB with respect to post-operative NRS pain scores and narcotic consumption. After addition of an ACB there was a 90% reduction in NRS pain scores in the PACU and a 38% reduction at 12 and 24-h post-operatively which were all statistically significant. Total post-operative morphine milligram equivalent (MME) decreased by 51%, after addition of an ACB, which was also statistically significant. The administration of an ACB as an adjunct to a multimodal pain protocol for primary TKA patients is effective at minimizing post-operative pain and narcotic consumption, and plays a critical role in facilitating fast track and same day discharge in our practice. [ABSTRACT FROM AUTHOR]

Post anesthesia care units (PACU) await return of motor function in lower extremities, prior to discharge for patients undergoing spinal anesthesia. The purpose of this study was to assess the impact of a newly utilized recovery protocol that facilitated early discharges of patients undergoing total hip and knee arthroplasties (THA/TKA) to the floor before full motor recovery from spinal anesthesia is achieved. A total of 647 patients undergoing spinal anesthesia for primary THA (n = 190) and TKA (n = 457) were divided into 2 groups: (1) Early PACU discharge group: patients with partial or full motor blockade at discharge. (2) Control PACU discharge group: patients with full motor recovery at discharge. Readiness for discharge was assessed using a modified Aldrete Score system. The primary outcome was incidences of hypotension or rapid responses post-operatively. There was no significant difference in the incidence of hypotension between the two groups (1.4 versus 1.39%, P = 1.0) and zero rapid responses were noted. Early discharge shortened mean PACU LOS time from 86.50 minutes to 70.27 minutes (P <.01). There was no difference in the incidence of nausea (0.55 versus 0%; P =.51) ordizziness (2.22 versus 0.35%; P =.09). In this retrospective observational study, we found that early PACU discharge did not result in an increase in hemodynamic consequences on the surgical floor. Thus, discharge from PACU can be safely and more expeditiously performed without waiting for return of motor function in patients receiving spinal anesthesia for THA/TKA using a modified Aldrete Score recovery protocol. [ABSTRACT FROM AUTHOR]

In this study, an anaerobic ammonium oxidation (anammox) reactor, which was inhibited by a salinity of 50 g NaCl L−1 during a long-term experiment, was rapidly restarted by decreasing the salinity to 20 g NaCl L−1 and adding biomass. The effects of exposure time and shock concentrations on the anammox reactor indicate that anammox granular sludge has a high tolerance to salinity and strong ability for self-recovery. The nitrogen removal efficiency was higher than 50% after exposure to 50 g NaCl L−1 for 66 h. To shorten the time taken for effluent nitrogen concentrations to attain national standards (GB18918-2002) after the anammox reactor was shocked with NaCl, reactor performance (i.e., recovery) after the addition of K+, glycine betaine, Fe2+, and hydroxylamine were compared after the reactor was inhibited by 80 g NaCl L−1. The results indicate that hydroxylamine was the best reversal agent. The recovery time of the anammox reactor could be shortened by 50% following the addition of hydroxylamine. The most favorable NH 2 OH-N/NO 2 −-N concentration ratio for improving nitrogen removal of anammox was 1:11. The abundances of Planctomycetes and its genera Candidatus Kuenenia and Brocadiaceae_g_unclassified increased after repeated salinity shock–recovery phases, indicating that Candidatus Kuenenia and Brocadiaceae_g_unclassified are able to adapt to NaCl shocking and recovery. Unlabelled Image • Decreasing salinity and increasing extra biomass are good ways to restart anammox. • Anammox sludges can have high tolerance to salinity and a strong self-recovery ability. • Hydroxylamine, rather than GB, is the best reversal agent under high salinity stress. • Anammox bacteria can adapt to NaCl shocking-recovery processes gradually. [ABSTRACT FROM AUTHOR]

Background: In an attempt to decrease costs without increasing complication burden, the development of rapid recovery protocols has led to an increased push for decreased length of hospital stay (LOS) following total hip arthroplasty (THA). The purpose of this study was to analyze trends in LOS and complications following THA over a 10-year period.Methods: Using the National Surgical Quality Improvement Program registry from 2006 to 2016, we identified all patients who underwent primary THA. Patients were placed into 3 cohorts based on the year of surgery (2006-2009 [N = 3873], 2010-2013 [N = 45,992], 2014-2016 [N = 86,099]). Differences in LOS, operative time, readmission rates, and 30-day postoperative medical complications were compared using bivariate and multivariate analyses.Results: Multivariate regression analysis identified a significant decrease in LOS in days for the 2010-2013 cohort (3.2 ± 4.8, P < .001) and 2014-2016 cohort (2.7 ± 2.5, P < .001) compared to the 2006-2009 cohort (3.8 ± 2.5). Despite decreasing LOS, there were significantly lower complications in the later cohorts, with significantly lower rates of all complications (5.27% [2006-2009], 3.77% [2009-2013], 3.14% [2013-2016]), sepsis (0.70%, 0.31%, 0.16%), and urinary tract infection (1.94%, 1.23%, 0.83%) using both bivariate and multivariate analyses (P < .001). In addition, there was no significant difference in unplanned 30-day readmissions (3.66% [2010-2013] vs 3.5% [2014-2016], P = .142).Conclusion: Over the last decade, there has been a decrease in LOS and an improved short-term complication profile for THA. With continually increasing rates of utilization of THA along broader patient demographics, these changes are important to help mitigate the costs of higher volume. [ABSTRACT FROM AUTHOR]

Background: Reduced hospital stay programs for total knee arthroplasty (TKA) are being implemented in order to increase patient satisfaction and reduce healthcare costs. Although elderly patients are often included in these pathways, there have been limited data on whether older patients can safely be discharged within a day after TKA. The purpose of this study is to compare perioperative complications following primary TKA with ≤1 day in the hospital in patients aged ≥80 compared to <80 years old in the National Surgical Quality Improvement Program database.Methods: Patients who underwent primary TKA with hospital length of stay ≤1 day were identified in the 2005-2016 National Surgical Quality Improvement Program database. These patients were separated into 2 age groups: <80 and ≥80 years old. Preoperative and procedural characteristics were compared. Multivariate regressions were used to compare risk for perioperative adverse events and readmission. Independent risk factors for serious adverse events following such TKAs were identified.Results: In total, 17,191 (<80 year olds) and 1005 (≥80 year olds) cases were identified. Of these patients, 1750 cases were discharged the same day. Multivariate analysis revealed only higher risk for 30-day readmission and nonhome discharge in ≥80 compared to <80 year olds. Notably, the octogenarians had a significantly higher rate of nonsurgical site-related readmissions. Independent risk factors for serious adverse events include only American Society of Anesthesiologists score ≥3 and not patient age.Conclusion: These data suggest that, although octogenarians can safely be discharged in ≤1 day, greater postdischarge care may be warranted to reduce the rate of nonsurgical site-related readmissions. [ABSTRACT FROM AUTHOR]

Background: As total hip arthroplasty (THA) gains popularity in ambulatory surgery centers, it is important to understand the causes of failed same-day discharge (SDD). The purpose of this study is to (1) identify reasons for an overnight stay among patients selected as candidates for SDD following THA and (2) determine what pre-operative factors are more common among patients who fail SDD.Methods: This is a prospective cohort study of patients undergoing THA who were identified as candidates for SDD (<75 years, ambulate without walker, American Society of Anesthesiologists score 1-3, body mass index <40 kg/m2, and agreed to SDD pre-operatively). The primary outcome was the reason for not discharging home on the same day of surgery. Secondary outcomes included the proportion of patients who failed SDD and any pre-operative patient characteristics that could be linked to failed SDD.Results: Seventy-eight of 106 (74%) patients pre-selected for SDD were successfully discharged per protocol. Of the 28 (26%) patients who failed SDD, the most common reasons for failure were patient preference (12), dizziness or hypotension (8), failure to clear physical therapy (5), urinary retention (2), and pain management (1). There was a higher percentage of patients in the failed SDD group who reported multiple allergies (P = .02), anxiety/depression (P = .24), obstructive sleep apnea (P = .38), and rheumatoid arthritis (P = .02).Conclusion: SDD is a viable option for surgeons interested in rapid recovery THA. In a pool of patients selected for SDD, the main cause of SDD failure was a change in patient preference post-operatively, despite having agreed to SDD pre-operatively and meeting all discharge criteria. [ABSTRACT FROM AUTHOR]

Embedded systems experience execution interruption due to power failures. After a power failure restarts, recovering the interrupted program from the initial state may lead to non-termination execution. To rapid recovery of program execution under power failures, the execution states are backed up by non-volatile memory (NVM) under power failures for embedded systems. However, frequent checkpoints will shorten the lifetime of the NVM and result in significant NVM write overhead, leading to low energy utilization in a power cycle. In this paper, we propose an incremental checkpoint approach called Call-Stack-Based to mitigate the NVM write overhead. It does not introduce additional run-time overhead when compared to other state-of-the-art methods. We introduce the pseudo-function call-stack-based strategy to further mitigate non-termination issues during execution. Simultaneously, we also propose an adaptive call-stack-based optimization strategy, a technique aimed at optimizing checkpoints within loops to enhance overall performance. To further prevent the NVM contents from becoming cluttered and taking up unnecessary space, we introduce a method to clean up irrelevant data on the NVM that is not required for restoration. In conclusion, the evaluation results demonstrate an average reduction of 99.88% and 88.71% in NVM write overhead for Call-Stack-Based backup compared to the Always-Based and Step-Based, respectively. [ABSTRACT FROM AUTHOR]

Background: Rapid recovery programs are now aimed to reduce costs of hip and knee arthroplasties by discharging patients directly home, shortening hospital length of stay (LOS), and reducing readmission rates. Although patients aged 80 years and older are included in the Medicare bundle, little work has been performed to determine if older patients can safely participate in rapid recovery programs.Methods: We retrospectively reviewed 2482 patients undergoing primary and revision total hip and knee arthroplasties (THA and TKA) who all participated in a multifaceted rapid recovery program. The goals of this program were next day discharge to home without the use of home services or post-acute care admission. We examined the hospital LOS and the percentage of patients discharged home as well as 90-day readmission rates to determine efficacy and safety of this program in the patients aged 80 years and older.Results: Octogenarians receiving primary THA and TKA were discharged home >90% of the time with LOSs <2 days and low readmission rates. Revision THA and TKA patients aged 80 years and older were discharged home about 70% of the time with significantly longer LOSs than patients aged more than 80 years. The revision THA patients aged more than 80 years had the highest readmission rates.Conclusion: Patients aged more than 80 years can successfully and safely participate in rapid recovery programs. [ABSTRACT FROM AUTHOR]

Background: This study was aimed at assessing the risk of readmission for Medicare patients discharged home within a day of total knee arthroplasty (TKA) compared to those discharged on day 2 or beyond in a community medical center.Methods: A hospital inpatient database was queried for all unilateral, primary TKAs performed on patients 65 years or older from January 1, 2013, to December 31, 2015. A total of 2287 patients met the study criteria, of which 1502 were discharged within a day (short stay), and 785 were discharged on day 2 or beyond (traditional stay). The main outcome measures were all-cause 30-day and unplanned 90-day readmissions.Results: Short-stay patients did not experience a higher 30-day readmission rate (1.1%) compared to the traditional-stay patients (2.7%), nor did they experience a higher rate of unplanned 90-day readmissions (1.7% vs 3.6%). The short-stay group had more favorable demographics compared to the traditional-stay group. Logistic regression results revealed that none of the demographic factors considered had a statistically significant impact on 30-day readmission odds for either group. For unplanned 90-day readmissions, the results showed that for the short-stay patients, with the exception of age, none of the other demographic factors had significant impact on readmission odds and none were significant for the traditional-stay group.Conclusion: Our results suggest that the Medicare patients meeting discharge criteria and discharged home within a day of TKA do not have an increased risk of 30-day and 90-day readmission. [ABSTRACT FROM AUTHOR]

Background: There is an increasing interest in outpatient total hip arthroplasty (THA), as there are perceived benefits to the patient, insurer, and overall healthcare system. However, the safety of outpatient total joint arthroplasty has not been studied.Methods: Five hundred forty-nine patients who underwent mini-posterior THA at a freestanding independent ambulatory surgical center (ASC) were reviewed. All patients were discharged to home on the day of surgery.Results: The average age of the patients was 54.4 years (range 27-73). The average American Society of Anesthesiologists score was 1.6 (range 1-3). Of the 549 patients, 3 (0.5%) admitted from the surgery center to our local hospital. One patient was admitted for pain control after failing to disclose his long-term high-dose narcotic dependence, one patient was admitted for an acetabular component migration identified on postoperative x-ray, and one patient was admitted for hypotension, bradycardia, and an acute polyarthralgia exacerbation. An additional patient was seen 2 days after surgery in a local emergency department for oversedation secondary to narcotics and later discharged to home.Conclusion: Outpatient THA at an ASC is safe and effective when performed on the appropriately indicated patient. There were 4 visits to the hospital within 2 days of surgery. Only 1 was related to medical events, 2 were pain control and/or medication-related and the final was technique-related. Known orthopedic complications including infection, dislocation, and deep vein thrombosis appear consistent with the literature for a series of this size. Same day discharge THA in an ASC is safe and reproducible. [ABSTRACT FROM AUTHOR]

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Background: The optimal dosage and timing of tranexamic acid (TXA) in total knee arthroplasty (TKA) are undetermined. The purpose of this study was to explore the effect of multiple boluses of intravenous TXA on hidden blood loss (HBL), inflammatory response, and knee function after primary TKA without tourniquet.Methods: A total of 151 patients were randomly divided into 3 groups to receive single bolus of 20 mg/kg IV-TXA before skin incision (group A), or another bolus of 10 mg/kg IV-TXA 3 hours later (group B), or another 2 boluses of 10 mg/kg IV-TXA 3 hours and 6 hours later (group C). TKAs without tourniquet were operated by 1 single surgeon. The primary outcomes were HBL and maximum hemoglobin drop. Other outcome measurements such as total blood loss, transfusion rate, inflammation markers (C-reactive protein, interleukin 6), visual analog scale pain score, limb swelling ratio, Hospital for Surgery Score, range of motion, length of hospital stay (LOH), and deep venous thrombosis were also compared.Results: The mean HBL and maximum Hb drop in group C (467.6 ± 305.9 and 20.9 ± 9.3) was lower than those in group A (763.0 ± 373.3, P < .001; 28.7 ± 12.2, P < .001) and group B (637.5 ± 303.5, P = .010; 25.2 ± 8.4, P = .036). However, such differences were not detected between groups A and B (P = .058 and P = .080, respectively). The mean value of total blood loss in the groups A, B, and C were 967.2 ± 380.1, 803.7 ± 321.8, and 677.6 ± 326.0 mL, respectively, with a significant intergroup difference (P < .001). The mean serum level of C-reactive protein and interleukin 6 in group C were lower than those in group A and group B on postoperative days 1 and 2. The visual analog scale pain score and swelling ratio were also lower in group C than in the other 2 groups with statistical significance on POD 1-3. Moreover, the Hospital for Surgery Score, range of motion, and LOH were better in group C. No episodes of transfusion or deep venous thrombosis had occurred.Conclusion: Multiple boluses of IV-TXA can effectively reduce HBL after primary TKA without tourniquet. What is the most important is that, by adding another bolus of IV-TXA, patients can gain a smaller decline of Hb, less postoperative inflammatory response, less pain, less knee swelling, better knee function, and shorter LOH. [ABSTRACT FROM AUTHOR]

Minimally invasive approaches to total hip arthroplasty have received much attention from both the lay press as well as the orthopaedic community. The potential for enhanced recovery and improved pain control in the perioperative period are in high demand from patients. We present a transgluteal approach to total hip arthroplasty as an alternative to the direct anterior approach that has the potential to maintain all of the possible benefits of a soft tissue sparing approach with a lower risk profile. [ABSTRACT FROM AUTHOR]

Much has been written and talked about in both the lay press as well as orthopaedic journals regarding the potential for enhanced recovery in anterior total hip arthroplasty. It is our feeling that the evidence regarding this claim is weak at best, and that the approach has a high complication rate in many surgeon’s hands. We propose the elements of leading to enhance recovery as it applies to all approaches to total hip arthroplasty and propose alternative means to achieve them. [ABSTRACT FROM AUTHOR]

We sought to investigate the impact of incremental perioperative recovery protocol changes on hospital LOS and readmission rates associated with primary THAs. A total of 1751 cases were assigned to one of four protocol cohorts across 13 years: traditional, enhanced pain management, early mobility, and rapid recovery (RR). LOS significantly decreased between sequential eras and by 52% between the traditional and RR pathways (IRR = 0.48; 95% CI 0.44, 0.53; P < 0.0001) without an overall increase in 30-day readmission rates ( P = 0.13). The odds of readmission for THAs performed under the RR pathway were almost one-third those of the traditional era (OR = 0.36; 95% CI 0.14, 0.93; P = 0.04). Accelerated clinical care protocols should be considered for most patients undergoing primary THA. [ABSTRACT FROM AUTHOR]

Increasing participation in alternative payment models such as episode-of-care has become a driving force to improve outcomes while decreasing cost. Reducing the hospital length of stay and discharging patients to home have been shown to decrease readmissions, thereby achieving these goals. The purpose of this study was to determine if utilization of a patient management support system, TAVHealth™ in our clinical pathway would reduce our readmission rates during the episode-of-care. We retrospectively reviewed 1874 total joint arthroplasties, 1281 TJAs in the pre-TAVHealth™ group (2009–2012) and 593 TJRs in the post TAVHealth™ group (2013–2014). Despite a low length of stay (1.2 days) there was a significant reduction in readmissions from 205 (16.0%) to 54 (9.2%) with incorporation of this patient management support system into our clinical pathway. [ABSTRACT FROM AUTHOR]

Summary: Awareness of enhanced recovery has moved swiftly since the Enhanced Recovery Partnership Programme was launched in 2009 as a joint venture between the Department of Health, NHS Improvement, NHS Institute for Innovation and Improvement, and the national Cancer Action Team. The innovative approach to elective surgery has demonstrated improved patient experience and clinical outcomes while also achieving efficiency savings, increased quality and productivity, and decreased length of stay. [Copyright &y& Elsevier]

Summary: The use of enhanced recovery pathways within elective surgery has increased in recent years but uptake outside of specialist centres is still slow, despite the growing evidence base to support their introduction. This article will briefly outline what is meant by an enhanced recovery pathway (ERP) and outline the central characteristics and features which make up an ERP. The procedural details and results of an orthopaedic ERP which has been used in 2391 consecutive hip and knee joint replacement patients at a NHS district general hospital within the United Kingdom will then be outlined. The results of this unit illustrate that when a standardised, multi-disciplinary pathway is implemented and managed correctly, dramatic reductions to length of stay can be achieved. In combination, high levels of both staff and patient satisfaction are achieved along with good clinical outcomes. It is proposed that if such ways of working are implemented in other hospitals major economic and capacity savings could be realised at the same time as improving patient care. [Copyright &y& Elsevier]

Abstract: Recommendations for routine screening for colorectal cancer with colonoscopy are likely to substantially increase the demand for provision of sedation for these procedures. Because of this burgeoning caseload and associated economic constraints, it is unlikely that anesthesiologists will be available for all such procedures, particularly those involving average-risk patients. Thus, sedative agents that can be safely administered by nonanesthesiologists, appropriately trained in monitoring and managing the patient''s airway, are desperately needed. New concepts in sedation for colonoscopy include enhanced mechanisms for drug delivery such as patient-controlled sedation/analgesia and target-controlled infusion, along with the development of new drugs such as a modified cyclodextrin-based formulation of propofol and fospropofol disodium (Aquavan Injection), a water-soluble prodrug of propofol. [Copyright &y& Elsevier]

The End Permian Mass Extinction (EPME, ca. 252 Ma) is considered as the most severe biodiversity crisis in the Phanerozoic, affecting more than 90% of marine species and 75% of terrestrial species. In recent years, ichnological analysis has emerged as a proxy to better understand the paleoenvironmental changes associated with this event, as well as their effect(s) on the biota and its recovery. This study focuses on the ichnological analysis of an extended upper Permian – Lower Triassic succession from the DD-1 core, drilled in Deltadalen, Central Spitsbergen. Variations in degree of bioturbation and ichnodiversity across the Permian-Triassic transition allow for the characterization of pre-, syn -, and post-EPME phases. Pre-EPME is characterized by a high degree of bioturbation (BI = 5), and a diverse trace fossil assemblage (13 ichnotaxa) with abundant Nereites , frequent Planolites and Phycosiphon , and the more or less local record of Asterosoma , Bergaueria, Chondrites , Macaronichnus , Palaeophycus , Taenidium , Teichichnus , Thalassinoides, Zoophycos , meniscate horizontal burrows and undifferentiated vertical traces, indicative of oxygenated bottom and pore-waters, as well as high nutrient availability in the benthic habitat. The EPME was followed by an interval characterized by the scarcity (BI = 1) or even absence (BI = 0) of trace fossils. The decrease in ichnodiversity was abrupt at first and more progressive subsequently, as the conditions were inhospitable (i.e., very low oxygenation) in the benthic habitat. In this context, short-lasting episodes of improved paleoenvironmental conditions (from anoxia to dysoxia) allowed for intermittent colonization of the substrate. The post-EPME interval is characterized by a gradual recovery of the trace maker community in terms of abundance (BI from 1 to 5) and ichnodiversity (total of 10 ichnotaxa), revealing a relatively rapid reestablishment of favourable paleoenvironmental conditions for the benthic habitat, with better‑oxygenated bottom and pore-waters, as well as improved nutrient availability at or just below the seafloor. This new ichnological information highlights (i) the absence of a total extinction of the trace-maker community, despite a marked reduction in abundance and ichnodiversity during the EPME, and (ii) the rapid recovery of the benthic fauna during the Induan Age, ca. 150 kyr after the EPME occurred. • Ichnological analysis of Permian-Triassic boundary transition has been conducted Pre-, syn- and post-EPME phases have been differentiated EPME reveals decreasing in abundance and ichnodiversity, but not total extinction Gradual post-EPME is relatively rapid Oxygen and nutrient availability are the major paleoenvironmental condition [ABSTRACT FROM AUTHOR]

Rapid recovery after total joint arthroplasty requires patients to get ahead and stay ahead or the four impediments to early rehabilitation and discharge: volume depletion, blood loss, pain, and nausea. Adequate volume resuscitation starts before entering the operating room and focuses on intravenous fluids rather than red blood cell transfusion. Tranexamic acid limits blood loss and reduces the need for most other blood management systems. Rapid recovery pain management focuses on minimizing parenteral opioids. A short-acting spinal with a peri-articular local anesthetic injection is reliable, reproducible, and safe. Patients at risk for post-operative nausea are treated with anti-emetic medications and perioperative dexamethasone. These interventions reflect a transition from the sick-patient model to the well-patient model and make rapid recovery joint arthroplasty a reality in 2015 [ABSTRACT FROM AUTHOR]

Elements of a successful comprehensive joint replacement program include preoperative education, joint class or camps, office support, and follow-up staff and systems. To meet the demand for consistent and safe outpatient joint replacement discharges, these elements must be optimized and, in many cases, enhanced beyond standard procedures. The office and staff protocols that support the outpatient joint replacement patient before and after surgery are as important as the surgery itself. There are unique consequences, or "ripple effects", of speeding patient recovery after joint replacement surgery and proceeding to early discharges. By understanding these differences and by being proactive, rather than reactive, the enhanced protocols can provide a safe and successful outpatient experience. [ABSTRACT FROM AUTHOR]

• Stored nitrifying granules were rapidly recovered by adding exogenous nitrifying bacteria. • Nitrogen degradation kinetics of nitrifying granules were fitted. • The recovered granules were transported and reused in another laboratory 1085 km away. Autotrophic nitrifying granular sludge (ANGS) was stored at room temperature for 40 days, and the stored granules were recovered by adding exogenous nitrifying bacteria within 27 days. Properties of ANGS deteriorated during the wet storage, and obvious granular breakage was observed during the recovery process. However, the granular debris gradually changed into compact granules because of attached growth of exogenous nitrifying bacteria. Simultaneous partial nitrification and denitrification was achieved by the recovered ANGS: ammonia nitrogen removal efficiency was always larger than 90 %, and 45 %–60 % total inorganic nitrogen was removed from the 27th day. K s and u max of ammonia oxidizing bacteria (AOB) were 460.66 mg/L and 0.128 h−1, respectively, which were much greater than those of nitrite oxidizing bacteria (1.12 mg/L and 0.024 h−1), indicating that AOB had high affinity with ammonia. To verify the feasibility of remote usage of ANGS, the recovered ANGS was transported to another laboratory 1085 km away and recovered within 10 days, indicating that ANGS can be reused after long-distance transportation. [ABSTRACT FROM AUTHOR]

Introduction/Background The Osteoarthritis Research Society International recommends evaluating physical function in gonarthrosic patients after a total knee arthroplasty using tests such as timed up and go (TUG) and six-minute walking test (6MWT). In 1991, Berman et al. found that strength was not fully recovered until two years after surgery. Our aim was to demonstrate the results in physical function and isokinetic muscular strength of gonarthrosis patients prior to undergoing surgery and three months after a total knee arthroplasty (TKA). Material and method Prospective study (September 2016–December 2017) of patients with gonarthrosis awaiting a total knee arthroplasty surgery. Variables recorded: gender, age, dominant hand, operated side, body mass index (BMI), walking aids. Measured outcomes before surgery and three months afterwards: Visual Analogue Scale (VAS) at rest and active, TUG, 6MWT and mean peak torque (PT) of isokinetic strength of quadriceps and hamstrings between the TKA side and the unaffected knee at 60°/s. Data analysis of means and percentages. Means compared using Student t and non-parametric tests. Statistical significance was set at P < 0.05. Results Forty-four patients, 36.4% male. Mean age 67.8 ± 6.5. Mean BMI 30.3 ± 6.7; 63.6% of the individuals used walking aids before surgery and 84.1% did not use them after surgery. The results obtained on VAS and physical function prior to surgery and three months after the intervention were. A decrease of strength in the affected quadriceps and a significant decrease of strength in the affected hamstrings were observed. However the strength of the unaffected quadriceps increased slightly and the unaffected hamstrings strength did not vary. Conclusion Three months after a TKA surgery, even though there was a descent in muscular strength in the affected limb, our patients experienced an improvement in physical function possibly due to pain decrease. [ABSTRACT FROM AUTHOR]

Total joint arthroplasty procedures have been demonstrated to be effective in the treatment of end stage hip and knee arthritis. The purpose of this paper is to outline various processes utilized to assess the outcomes of rapid recovery programs and to outline areas where future research and metrics will be beneficial in demonstrating the effectiveness of these programs. We have highlighted the use of large databases [NIS (National Inpatient Sample) and NSQIP (National Surgical Quality Improvement Program)] to help identify patients who are candidates for the rapid recovery approach. Continued thorough investigation should not only justify rapid recovery, but also move traditional joint arthroplasty programs to more efficient cost effective care once appropriate metrics are identified that support the need for resources for rapid recovery programs. [ABSTRACT FROM AUTHOR]