Background: Early 2014, Kaiser Permanente decided to adopt an innovative model for network-based allied healthcare for persons with Parkinson's disease (PD), based on the principles of the Dutch ParkinsonNet. Objective: We present the interventions that were performed to implement this method at Kaiser Permanente and we show the first outcomes based on these interventions. Methods: In this study, 57 physical therapists, 18 speech therapists and 20 occupational therapists, as well as 13 medical centers across the state of California were included. Nine interventions were performed more or less simultaneously, including training and education of healthcare providers and patients, a train the trainer curriculum, organizing IT, streamlining referral processes and building networks. Results: At the start, less than 30% of the patients within the Southern California Region received specialized allied health treatment (consisting of, i.e., gait training, voice training or guidance in activities of daily life). After one year, almost 55% of patients received specialized allied health treatment. In the second year, this number increased to just under 67%, suggesting a sustained concentration of care (the second core component of networked care). This can be seen as a first indicator for successful implementation of the ParkinsonNet network at Kaiser Permanente. Conclusions: The importance of these findings lies in the fact that a healthcare innovation that proved effective in one country can be transferred successfully to another country and to another healthcare system.

months after randomization) mortality was lower in the EVAR groups (46 of 1393 vs 73 of 1390 deaths; P ¼ .010), primarily because the 30-day operative mortality was lower in the EVAR groups (16 deaths vs 40 for open repair). Later (#3 years), the survival curves converged and remained so to 8 years with a nonsignificant shift of the hazard ratio in favor of open repair. At 5 years, the estimated survival rate was 73.6% in both groups. Beyond 3 years, aneurysm-related mortality was significantly higher in the EVAR groups (19 deaths vs 3 for open repair; P ¼ .010). Patients with moderate renal dysfunction or previous coronary artery disease had no early survival advantage with EVAR. None of the morphologic aneurysm characteristics, smoking, diabetes, basal metabolic index, age, or gender was associated with mortality. Those with peripheral artery disease (ABI <0.9) had lower mortality under open repair (39 vs 62 deaths; P ¼ .022) in the period from 6 months to 4 years after randomization. The overall rates of reintervention were higher in the EVAR group (range, 5.1%-8.5%) than the open group (range, 1.9%-4.6%). The commonest complications after EVAR was a type II endoleak (325 patients [11.7%]), with correction deemed necessary in 22.8%. The second most common was a type I endoleak (120 [4.3%]) and received early intervention in 65.8%. For those 37 patients with reported sac rupture, the median time to rupture was 3.5 years. All but 19 had a known graft endoleak or migration before rupture, of which approximately two-thirds had been addressed. The 30-day mortality with rupture was 62%.Comments: This meta-analysis confirms the fact that EVAR is not the definitive repair that an open operation provides. It may well benefit those with a limited life expectancy such as the elderly and others who are less able to weather the stresses of an open operation. In some patients (significant renal impairment and coronary artery disease), EVAR may not even provide an early mortality advantage. In addition, an open operation may well be the best therapy for the young and healthy. No matter, if you chose to treat a patient with an abdominal aortic aneurysm with EVAR, surveillance is critical to reduce aneurysmrelated deaths in the mid-and long-term. This may change with improved devices, but for now, this is the crucial clinical message.

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mucinous neoplasm (IPMN) and intraductal tubulopapillary neoplasm (ITPN) involves the entire pancreas, and total pancreatectomy is necessary for patients with such tumors to achieve cure.Herein, we illustrate the case of the patient with multifocal pancreatic cancers who underwent total pancreatectomy. The disease turned out to be derived from IPMN by histologic examination in the resected specimen. Methods: The patient was an 82-year-old woman who presented with epigastric pain and CT showed large pancreatic body mass. The staging work-up revealed at least 5 PET-avid lesions throughout the entire pancreas without extra-pancreatic metastasis, and EUS-FNA confirmed them as adenocarcinoma. Thus, total pancreatectomy was recommended. Results: Upon the exploration, there was no evidence of metastatic disease, and IOUS confirmed all pancreatic lesions identified by preoperative scans. Total pancreatectomy was completed uneventfully in 560 minutes with blood loss of 430 cc. Her postoperative course was uncomplicated. The pathology showed multifocal pancreatic cancers derived from IPMN. ITPN was ruled out by presence of MUC5AC expression on immunohistochemistry. Conclusion: The video described the technical detail of our total pancreatectomy and some useful tricks including SMA-first approach and left kidney mobilization to minimize blood loss and to maintain good exposure for dissection plane in the left side.