Single Entry Point Research Articles

Excellent Outcomes of Large-Volume Epidural Blood Patch Using an Intravenous Catheter in 15 Consecutive Cases with Cerebrospinal Fluid Leak

The effects of large-volume epidural blood patch (EBP) remain unclear in patients with cerebrospinal fluid (CSF) leak. We report excellent outcomes from 15 consecutive CSF leak cases that underwent a large-volume EBP using an intravenous catheter from a single lumbar entry point, together with outcomes from 4 patients who underwent direct surgical closure or drip-and-rest therapy during the same period. Nineteen patients with idiopathic CSF leaks were enrolled in this study since November 2011 (12 women; mean age, 43.3 ± 14.0 years). Patient demographic data, radiologic findings, symptoms, administrated therapies, complications, and clinical courses were investigated retrospectively. Different types of headache were observed, including typical orthostatic headache alone (n= 10), orthostatic headache with chronic subdural hematoma (CSDH) (n= 3), and posture-unrelated headache accompanied with CSDH (n= 6). Regarding treatments, in 1 case, direct surgical closure was performed. In 15 cases, large-volume EBPs were performed, and the volume of injected blood was 44.8 ± 21.6 mL. The other 3 cases were treated by simple drip infusion regardless of the drainage for CSDH. Out of 9 cases with accompanied CSDH, recurrence of subdural hematoma was completely prevented by the application of an EBP after drainage in 5 cases and without drainage in 3 cases, and by simple intravenous drip-and-rest therapy after drainage in 1 case. Among 10 patients suffering from typical orthostatic headache alone, symptoms disappeared completely in 7 cases and were relieved in 3 cases. We demonstrate here a perfect control of spinal CSF leaks with the administration of a large-volume EBP through an intravenous catheter.

A Systemic Review on Single-Port and Multiport Laparoscopic Hernioplasty

Herniorrhaphy or Hernioplasty is the surgical treatment for hernia. This surgical procedure is mainly done using local or general anesthesia with laparoscope or conventional incision. Laparoscopic hernioplasty is the best suited laparoscopic technique for almost all the abdominal hernias. This technique has gained its approval in recent treatment and is being widely used. Despite the fact that it is for the most part of safe operation, postoperative complications are found to be less. The recovery time after the surgery is found to be 1 to 2 weeks. Single port laparoscopy is the marginally invasive surgical process where the surgery takes place by a single entry point mainly the umbilicus. This single port technique leaves only a single scar. Multiport laparoscopic technique is the traditional technique where it uses many entry points for operation. Thus the single port laparoscopic technique consists of many advantages like faster recovery time, less blood loss, less post-operative pain etc. This study systematically reviewed the existing literatures for comparing the single site over the multiport hernia repair. The outcomes like hospital stay, operative time, complications and blood loss are reviewed. The remedial advantages in the general management of hernia are reviewed in detail. This review concludes that the single port laparoscopic hernioplasty is the most advantaged technique than the multiport.

2276 Development of the expanded access oversight committee at Michigan Medicine

OBJECTIVES/SPECIFIC AIMS: Expanded Access is an avenue for patients with no available treatment options to access investigational drugs and devices for clinical therapy. This process requires physicians treating these patients to submit requests to the FDA and the local IRB, processes which are typically unfamiliar to clinicians. METHODS/STUDY POPULATION: With the goal of reducing burden and ensuring access to investigational products, Michigan Medicine established the Expanded Access Oversight Committee in January 2015. This committee brought together key stakeholders to develop appropriate policy and infrastructure to support these requests. RESULTS/ANTICIPATED RESULTS: Outcomes from this committee have resulted in a uniform process with a single point of entry for interested physicians and patients. With standardized policy implemented across the institution, a revised IRB application has been developed that is more tailored to Expanded Access and an informed consent document has been developed specific to the clinical use of investigational therapies. To ensure timely execution of these agreements, the contracts office has streamlined the process for negotiating Expanded Access agreements with manufacturing companies. Further development has begun with the Michigan Clinical Research Unit to provide space for clinical visits in Expanded Access cases, allowing for initiation of outpatient therapy. These changes have allowed Michigan Medicine to support triple the number of Expanded Access requests, including more than 45 Expanded Access requests in fiscal year 2018. DISCUSSION/SIGNIFICANCE OF IMPACT: Institutional support for Expanded Access requests within a large academic medical center is feasible and can increase access to investigational therapies bfor patients.

Rehabilitation and school services following traumatic brain injury in young children.

Preschool children have the highest incidence of emergency department visits for traumatic brain injury (TBI) with the majority discharged home without a single point of entry into follow-up services. This paper describes families' experience with service access following TBI. To describe parent reported service utilization following preschool TBI and examine predictors of service access. Participants (N = 80) were drawn from the first visit of a longitudinal study examining elementary school outcomes following TBI. Parents were interviewed about their service history. Descriptive statistics analyzed sample demographics. Logistic regression examined associations between injury related factors and service utilization. TBI participants had mild injuries (83%) and were either discharged to home or spent less than a week in the hospital. No TBI participants received inpatient rehabilitation and only a portion of the sample (26%) received outpatient treatment. Length of hospital stay was a significant predictor of service access (Wald = 4.33, df = 1, p = 0.040). All children were enrolled in preschool without accommodations. Currently no systematic continuum of care exists for children with TBI injured prior to elementary school, despite availability of healthcare, education and state based resources. Healthcare professionals in contact with young children can help with follow-up by educating parents about TBI effects on learning.

Tasmania’s child and family centres building parenting capability: a mixed methods study

ABSTRACTTasmania’s Child and Family Centres (Centres) provide a single entry point to early childhood services (ECS) and aim to improve the health and well-being, education and care of Tasmania’s children through supporting families and carers. This mixed methods study investigated the impact of Centres on parents’ confidence and competence. Centre users reported a slightly lower overall sense of parenting competence than non-users. There was no difference between Centre users and non-users in how they felt overall as a parent. Compared to non-Centre users, Centre users were more likely to report that ECS helped them develop new parenting skills. Centres supported parenting practices through a range of formal (i.e. parenting courses) and informal (i.e. role modelling) strategies. Centre users indicated that the combination of formal and informal parenting supports worked together to assist them build new parenting skills. The Centre model and partnership approach facilitates the development of positive parenting practices.

Degrees of Intrusion? A Survey of Cookies Used by UK Higher Education Institutional Websites and Their Implications

The use of institutional websites to represent Universities online is ubiquitous within the UK Higher Education sector. The institutional website provides a single point of entry for anyone seeking information about an institution; as a digital representation of the university, from elements of a prospectus to showcasing research outputs, its potential audience is wide ranging. However, the use of cookies potentially changes the relationship with the audience, as they allow tracking of users and targeted interactions with the institution particularly through social media platforms. While the use of such data collection and marketing is standard for commercial websites, to what extent is this appropriate and what are the implications for the Higher Education sector? This work-in-progress paper will provide an initial exploration of this question through a survey of cookies used by UK Higher Education institution websites.

The suite of small-angle neutron scattering instruments at Oak Ridge National Laboratory

Oak Ridge National Laboratory is home to the High Flux Isotope Reactor (HFIR), a high-flux research reactor, and the Spallation Neutron Source (SNS), the world's most intense source of pulsed neutron beams. The unique co-localization of these two sources provided an opportunity to develop a suite of complementary small-angle neutron scattering instruments for studies of large-scale structures: the GP-SANS and Bio-SANS instruments at the HFIR and the EQ-SANS and TOF-USANS instruments at the SNS. This article provides an overview of the capabilities of the suite of instruments, with specific emphasis on how they complement each other. A description of the plans for future developments including greater integration of the suite into a single point of entry for neutron scattering studies of large-scale structures is also provided.

Digital Humanities –Where are the Libraries?

The article deals with the place and role of the library in the digital age through the prism of digital Humanities. The article traces the history of the formation of a new interdisciplinary eld of research and its intersection with the activities of libraries. A promising direction of development is the creation of digital libraries that can take over the management of hugeows of knowledge and open data; provide the user with a single point of entry with access to a wide contextualized data communication

Bank Resolution and the Structure of Global Banks

We study the resolution of global banks by national regulators. Single-point-of-entry (SPOE) resolution, where loss-absorbing capital is shared across jurisdictions, is efficient but faces implementation constraints. First, when expected transfers across jurisdictions are too asymmetric, national regulators fail to set up SPOE resolution ex ante. Second, when required ex-post transfers are too large, national regulators ring-fence assets instead of cooperating in SPOE resolution. In this case, a multiple-point-of-entry (MPOE) resolution, where loss-absorbing capital is pre-assigned, is more robust. Our analysis highlights a fundamental link between efficient bank resolution, the operational structures, risks, and incentives of global banks.

Jug: Software for Parallel Reproducible Computation in Python

As computational pipelines become a bigger part of science, it is important to ensure that the results are reproducible, a concern which has come to the fore in recent years. All developed software should be able to be run automatically without any user intervention. In addition to being valuable to the wider community, which may wish to reproduce or extend a published analysis, reproducible research practices allow for better control over the project by the original authors themselves. For example, keeping a non-executable record of parameters and command line arguments leads to error-prone analysis and opens up the possibility that, when the results are to be written up for publication, the researcher will no longer be able to even completely describe the process that led to them. For large projects, the use of multiple computational cores (either in a multi-core machine or distributed across a compute cluster) is necessary to obtain results in a useful time frame. Furthermore, it is often the case that, as the project evolves, it becomes necessary to save intermediate results while down-stream analyses are designed (or re-designed) and implemented. Under many frameworks, this causes having a single point of entry for the computation becomes increasingly difficult. Jug is a software framework which addresses these issues by caching intermediate results and distributing the computational work as tasks across a network. Jug is written in Python without the use of compiled modules, is completely cross-platform, and available as free software under the liberal MIT license. Jug is available from: http://github.com/luispedro/jug.

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OBJECTIVES/SPECIFIC AIMS: The purpose of this study is to understand factors that are associated with identifying which eligible pregnant women in Baltimore City accept a referral for HV services. Taking into account demographic and obstetrical variables, we will examine the extent to which 13 medical and 14 psychosocial risk factors differentiate pregnant women who (1) accepted a HV referral, (2) could not be located, or (3) refused a HV referral. METHODS/STUDY POPULATION: In this observational study, we will use secondary data on 8172 pregnant women collected by Health Care Access Maryland (HCAM) between 2014 and 2016. HCAM is the single point of entry for all pregnant women in Baltimore City into HV. HV eligibility includes being a pregnant woman, residing in Baltimore City, being uninsured or receiving Medicaid, and being identified by a prenatal care provider who completed an assessment profile of the woman’s medical and psychosocial risk (prenatal risk assessment). The outcome variable, HV engagement status (ie, accepted referral, could not be located, refused referral), will be based on HCAM discharge codes. Medical risk factors include BMI, hypertension, anemia, asthma, sickle cell, diabetes, vaginal bleeding, genetic risk, sexually transmitted disease, last dental visit >1 year ago, and taking prescription medications. Psychosocial risk factors include current pregnancy unintended; <1 year since last delivery; late entry to prenatal care (>20 wk gestation); mental, physical, or developmental disability; history of abuse or violence within past 6 months; tobacco use; alcohol use; illegal substance use within the past 6 months; resides in home built before 1978; homelessness; lack of social/emotional support; exposure to long-term stress; lack of transportation; and history of depression or mental illness. All risk factor variables are categorical (yes/no). Control variables will include demographics (eg, age, race, ethnicity, marital status, educational level) and OB history (eg, history of preterm labor, history of fetal or infant death). We will conduct descriptive statistics to characterize the sample and look for interrelatedness among the risk factors. Where there is a high level of inter-relatedness we will consider combining or omitting variables to reduce redundancy. We will use multinomial regression to examine which medical and psychological factors are associated with referral category. RESULTS/ANTICIPATED RESULTS: We hypothesize that (a) women with more medical risk factors will be more likely to accept a referral for HV services, (b) women with more psychosocial risk factors will be more likely to refuse HV or not be located, and (c) certain risk factors, such as depression/mental illness, history of abuse/violence, illegal substance use, homelessness, and exposure to long-term stress will be the strongest predictors of not accepting HV referral and/or not being located. DISCUSSION/SIGNIFICANCE OF IMPACT: The translation of effective randomized control trials (RCTs) to successful implementation in community-based programs can be challenging. Community-based programs serving low-income communities typically lack the same resources available to recruit and retain participants in RCTs. And, exclusion criteria applied in RCTs are often not applied in real world implementation which can open program to participants with more complex social and medical characteristics. Findings from this study will inform the translation of evidence-based HV programs into real world settings through an enhanced understanding of the characteristics of women who are not engaged by HV programs. This will inform development of improved outreach methods that may more effectively engage at-risk women for prenatal HV services.

Interaction of an antecedent fluvial system with early normal fault growth: Implications for syn‐rift stratigraphy, western Corinth rift (Greece)

AbstractContinental ‘overfilled’ conditions during rift initiation are conventionally explained as due to low creation of accommodation compared with sediment supply. Alternatively, sediment supply can be relatively high from the onset of rifting due to an antecedent drainage system. The alluvial Lower Group of the western Plio–Pleistocene Corinth rift is used to investigate the interaction of fluvial sedimentation with early rifting. This rift was obliquely superimposed on the Hellenide mountain belt from which it inherited a significant palaeorelief. Detailed sedimentary logging and mapping of the well‐exposed syn‐rift succession document the facies distributions, palaeocurrents and stratigraphic architecture. Magnetostratigraphy and biostratigraphy are used to date and correlate the alluvial succession across and between fault blocks. From 3·2 to 1·8 Ma, a transverse low sinuosity braided river system flowed north/north‐east to east across east–west‐striking active fault blocks (4 to 7 km in width). Deposits evolved downstream from coarse alluvial conglomerates to fine‐grained lacustrine deposits over 15 to 30 km. The length scale of facies belts is much greater than, and thus not directly controlled by, the width of the fault blocks. At its termination, the distributive river system built small, stacked deltas into a shallow lake margin. The presence of a major antecedent drainage system is supported by: (i) a single major sediment entry point; (ii) persistence of a main channel belt axis; (iii) downstream fining at the scale of the rift basin. The zones of maximum subsidence on individual faults are aligned with the persistent fluvial axis, suggesting that sediment supply influenced normal fault growth. Instead of low accommodation rate during the early rift phase, this study proposes that facies progradation can be controlled by continuous and high sediment supply from antecedent rivers.

A hospital mass casualty exercise using city buses and a tent as a hybrid system for patient decontamination.

A hospital mass casualty simulation exercise testing feasibility of two city buses and a tent as a hybrid system for patient decontamination. Observational study of a single mass casualty simulation exercise involving patient decontamination SETTING: Held on May 26, 2016 at the Montreal General Hospital, a Level 1 Trauma center without a garage. Twenty-one medical staff including nurses, doctors, and patient attendants, and 30 volunteer-simulated patients. The foregrounds of the hospital were cordoned off to create a single-entry point for the simulated patients that were identified as contaminated (C) by staff wearing personal protective equipment. Non-contaminated patients were directed to a separate hospital entrance. C patients were triaged in Bus 1 to determine priority for decontamination. Bus 2 served as a holding area for stable patients awaiting decontamination. Patients were decontaminated in appropriate tent sections (non-ambulatory, ambulatory male or female) and then directed to the emergency department. Direct observation and participant feedback suggested that buses may provide adequate shelter for C patients. However, buses had limited capacity for non-ambulatory patients, who were not easily transported inside. Furthermore, areas of improvement were identified in communication, staffing, equipment, and coordination of operations. The use of city buses as triage and waiting zones prior to decontamination appears feasible for centers without a garage and facing unpredictable weather conditions. Further simulations are required for fine-tuning and testing real-time unfolding of tasks, ideally during an unannounced exercise.

The informatics capability maturity of integrated primary care centres in Australia

ContextIntegrated primary care requires systems and service integration along with financial incentives to promote downward substitution to a single entry point to care. Integrated Primary Care Centres (IPCCs) aim to improve integration by co-location of health services. The Informatics Capability Maturity (ICM) describes how well health organisations collect, manage and share information; manage eHealth technology, implementation, change, data quality and governance; and use “intelligence” to improve care. AimDescribe associations of ICM with systems and service integration in IPCCs. MethodsMixed methods evaluation of IPCCs in metropolitan and rural Australia: an enhanced general practice, four GP Super Clinics, a “HealthOne” (private-public partnership) and a Community Health Centre. Data collection methods included self-assessed ICM, document review, interviews, observations in practice and assessment of electronic health record data. Data was analysed and compared across IPCCs. FindingsThe IPCCs demonstrated a range of funding models, ownership, leadership, organisation and ICM. Digital tools were used with varying effectiveness to collect, use and share data. Connectivity was problematic, requiring “work-arounds” to communicate and share information. The lack of technical, data and software interoperability standards, clinical coding and secure messaging were barriers to data collection, integration and sharing. Strong leadership and governance was important for successful implementation of robust and secure eHealth systems. Patient engagement with eHealth tools was suboptimal. ConclusionsICM is positively associated with integration of data, systems and care. Improved ICM requires a health workforce with eHealth competencies; technical, semantic and software standards; adequate privacy and security; and good governance and leadership.

Single Port Robotic Assisted Sacrocolpopexy: Our Experience With the First 25 Cases.

In single-port surgery, the surgeon operates almost exclusively through a single entry point, typically the patient's navel, leaving only a single small scar. The aims of this study were to share some tips and tricks of single-port robotic-assisted sacrocolpopexy and to evaluate the learning curve of mastering the skills to operate this procedure. This is a retrospective study of the first 25 single-port; robotic-assisted sacrocolpopexy surgeries performed during July to December 2015 at Rambam Health Care Campus by a single surgeon.Primary points of interest included intraoperative bleeding, length of surgery, length of hospitalization, and surgical complications. The median age was 59 years (range, 35-74); the median "pelvic organ prolapse quantification" stage was 3 (range, 2-4). The median total operative time was 190 minutes (range, 114-308), and console time was 130 minutes (85-261). Comparisons between the first 15 cases and the following 10 cases demonstrated significant decreases in median total operative and console times: 226 minutes (range, 142-308) versus 156 minutes (range, 114-180), and 170 minutes (range, 85-261) versus 115 minutes (range, 90-270), respectively (P < 0.008). There were no intraoperative adverse events. Postoperative adverse events were also rare, including 1 case of small bowel adhesions that required a second laparoscopic surgery for adhesiolysis. After this incident, we peritonalized the mesh in all 13 successive cases; median time was 8 minutes (range, 5-15 minutes). Single-port robotic-assisted sacrocolpopexy is a feasible procedure with low complication rates, minimal blood loss and postsurgical pain, fast recovery, short hospitalization, and virtually scar-free results. Outcomes of long-term follow-up should be investigated.

A Hospital Mass Casualty Exercise using City Buses and a Tent as a Hybrid System for Patient Decontamination

Objective: A hospital mass casualty simulation exercise testing feasibility of two city buses and a tent as a hybrid system for patient decontamination. Design: Observational study of a single mass casualty simulation exercise involving patient decontamination Setting: Held on May 26, 2016 at the Montreal General Hospital, a Level 1 Trauma center without a garage. Patients, participants: Twenty-one medical staff including nurses, doctors, and patient attendants, and 30 volunteer-simulated patients. Interventions: The foregrounds of the hospital were cordoned off to create a single-entry point for the simulated patients that were identified as contaminated (C) by staff wearing personal protective equipment. Non-contaminated patients were directed to a separate hospital entrance. C patients were triaged in Bus 1 to determine priority for decontamination. Bus 2 served as a holding area for stable patients awaiting decontamination. Patients were decontaminated in appropriate tent sections (non-ambulatory, ambulatory male or female) and then directed to the emergency department. Results: Direct observation and participant feedback suggested that buses may provide adequate shelter for C patients. However, buses had limited capacity for non-ambulatory patients, who were not easily transported inside. Furthermore, areas of improvement were identified in communication, staffing, equipment, and coordination of operations. Conclusions: The use of city buses as triage and waiting zones prior to decontamination appears feasible for centers without a garage and facing unpredictable weather conditions. Further simulations are required for fine-tuning and testing real-time unfolding of tasks, ideally during an unannounced exercise.

EN-ROUTE AIRSPACE CAPACITY AND TRAFFIC FLOW ENHANCEMENT USING GENETIC ALGORITHMS

Air transportation industry has gone under a rapid and continuous growth for the last four decades. International Civil Aviation Organization (ICAO) and airlines anticipate that annual growth rate of air traffic will be 4.5-5.1% until 2030. Airspace capacity management becomes more critical for the safety, efficiency and sustainable growth of the industry. En-route areas cover the largest portion of the controlled airspace and are subdivided into small segments referred to as ‘en-route sectors’ usually monitored and controlled by a single air traffic controller in the relevant Area Control Center (ACC). When air traffic demand reaches or exceeds the available en-route sector capacity, serious aircraft delays occur at airports or in airspace and lead to system-wide congestions and interruptions in air traffic services, airline flight schedules and airport operations, and therefore result in increased operational costs, passenger dissatisfaction and air traffic controller workload. This study presents a multiple entry point assignment model based on a genetic algorithm to minimize delays and increase throughput of a generic high-altitude en-route sector. The proposed approach intends to use more flexible direct route configuration without changing the sector geometry and provide a framework for a decision support system for air traffic flow and capacity planning and management. The available single entry point sector configuration and its multiple entry point assignment alternatives were compared for various traffic scenarios. Multiple entry point configurations provided up to 10% increase in throughput and significant reductions in average delay per aircraft compared to the single point entry configuration.

Tasmania’s child and family centres: a place-based early childhood services model for families and children from pregnancy to age five

ABSTRACTTasmania’s child and family centres (Centres) provide a single entry point to early childhood services (ECS) for children and families living in amongst the most disadvantaged communities in Australia. This study investigated the impact of Centres on parents’ use and experiences of ECS using a mixed methods approach. The results showed that Centre users made more use of ECS than did non-users. Centre users also rated their experiences of ECS more positively than non-users. For example, Centre users were more likely to report that ECS were convenient and close, committed to helping, and worked closely with one another. Centre users identified Centres as informal, accessible, responsive, non-judgemental and supportive places where they felt valued, respected and safe. Parents experienced Centres as welcoming places that were helping them to develop positive child, family, school and community connections. These qualities appeared critical for facilitating parental access and engagement in ECS.

The Resolution of Distressed Financial Conglomerates

One of the most elegant legal innovations to emerge from the Dodd-Frank Wall Street Reform and Consumer Protection Act of 2010 is the FDIC’s single-point-of-entry (SPOE) initiative, whereby regulatory authorities will be in a position to resolve the failure of large financial conglomerates (corporate groups with regulated financial entities as subsidiaries) by seizing a top-tier holding company, downstreaming holding-company resources to distressed subsidiaries, wiping out holding-company shareholders while simultaneously imposing additional losses on holding-company creditors, and allowing the government to resolve the entire group without disrupting the business operations of operating subsidiaries (even those operating overseas) or risking systemic consequences for the broader economy. Although there is much to admire in the creativity underlying SPOE, the approach’s design also raises a host of novel and challenging questions of implementation. This chapter explores a number of these questions and elaborates upon the following points. First, in contrast to traditional approaches to resolving financial conglomerates, SPOE is premised on the continued support of all material operating subsidiaries, thereby potentially extending the scope of government support and thus posing the possibility of mission creep and expanded moral hazard. Second, SPOE contemplates the automatic downstreaming of resources to operating subsidiaries in distress, but effecting that support is likely to be more difficult than commonly understood. If too much support is positioned in advance, there may be inadequate reserves at the top level to support a single subsidiary that gets into an unexpectedly large amount of trouble. Alternatively, if too many reserves are retained at the holding-company level, commitments of subsidiary support may not be credible (especially to foreign authorities) and it may become difficult legally and practically to deploy those resources in times of distress. SPOE is most easy to envision operating in conjunction with the FDIC’s expanded authority under its Orderly Liquidation Authority (OLA) established under Title II of the Dodd-Frank Act. However, the act’s preferred regime for resolving failed financial conglomerates is the U.S. Bankruptcy Code (where Lehman was resolved) and not OLA. Several complexities could arise were a bankruptcy court today called upon to implement an SPOE resolution plan. While many legal experts are working on legislative proposals to amend the Bankruptcy Code to facilitate SPOE resolutions, there are a number of legal levers that federal authorities could deploy under current law to increase the likelihood that the SPOE strategy could be effected through traditional bankruptcy procedures. The task would be challenging and would require considerable advanced planning. But there are substantial benefits to be had from taking steps now to increase the likelihood that the bankruptcy option represents a viable and credible alternative for effecting SPOE transactions without resort to OLA and Title II of the Dodd-Frank Act.

The Resolution of Distressed Financial Conglomerates

One of the most elegant legal innovations to emerge from the Dodd-Frank Wall Street Reform and Consumer Protection Act of 2010 is the FDIC’s single-point-of-entry (SPOE) initiative, whereby regulatory authorities will be in a position to resolve the failure of large financial conglomerates (corporate groups with regulated financial entities as subsidiaries) by seizing a top-tier holding company, downstreaming holding-company resources to distressed subsidiaries, wiping out holding-company shareholders while simultaneously imposing additional losses on holding-company creditors, and allowing the government to resolve the entire group without disrupting the business operations of operating subsidiaries (even those operating overseas) or risking systemic consequences for the broader economy. Although there is much to admire in the creativity underlying SPOE, the approach’s design also raises a host of novel and challenging questions of implementation. This chapter explores a number of these questions and elaborates upon the following points. First, in contrast to traditional approaches to resolving financial conglomerates, SPOE is premised on the continued support of all material operating subsidiaries, thereby potentially extending the scope of government support and thus posing the possibility of mission creep and expanded moral hazard. Second, SPOE contemplates the automatic downstreaming of resources to operating subsidiaries in distress, but effecting that support is likely to be more difficult than commonly understood. If too much support is positioned in advance, there may be inadequate reserves at the top level to support a single subsidiary that gets into an unexpectedly large amount of trouble. Alternatively, if too many reserves are retained at the holding-company level, commitments of subsidiary support may not be credible (especially to foreign authorities) and it may become difficult legally and practically to deploy those resources in times of distress. SPOE is most easy to envision operating in conjunction with the FDIC’s expanded authority under its Orderly Liquidation Authority (OLA) established under Title II of the Dodd-Frank Act. However, the act’s preferred regime for resolving failed financial conglomerates is the U.S. Bankruptcy Code (where Lehman was resolved) and not OLA. Several complexities could arise were a bankruptcy court today called upon to implement an SPOE resolution plan. While many legal experts are working on legislative proposals to amend the Bankruptcy Code to facilitate SPOE resolutions, there are a number of legal levers that federal authorities could deploy under current law to increase the likelihood that the SPOE strategy could be effected through traditional bankruptcy procedures. The task would be challenging and would require considerable advanced planning. But there are substantial benefits to be had from taking steps now to increase the likelihood that the bankruptcy option represents a viable and credible alternative for effecting SPOE transactions without resort to OLA and Title II of the Dodd-Frank Act.