Total knee arthroplasty in nonagenarians

Between 1976 and 1999, 3714 consecutive primary total knee arthroplasties (TKAs) were done at our institution. Of these, 20 (0.54%) TKAs were done in 18 patients who were > or =90 years old. The average follow-up period was 62.2 months. There was 1 postoperative death among the nonagenarians within 90 days of surgery. All patients had complete pain relief and excellent knee scores using the Knee Society clinical assessment scale. None had an excellent function score at final follow-up examination, however. Only 1 patient experienced any surgical complications; the patient had wound dehiscence. Five (26.3%) of the surviving 19 patients had medical complications. The average length of hospital stay was 10.1 days. Although TKA produced only moderate improvement in knee function for the nonagenarians, it produced excellent clinical improvement. TKA improved the patients' ability to manage the activities of daily living and their quality of life.     

Monoclonal antibody from vasectomized mouse identifies a conserved testis-specific antigen TSA70

Vasectomy results in the occlusion of testicular outflow, leading to autoimmunity characterized by the production of antisperm antibodies (ASA). Reports on the rise in ASA following vasectomy in several species are available; however, not much is known about the specific sperm autoantigens to which postvasectomy antibodies are directed. In the present study, monoclonal antibodies were generated using a vasectomized mouse. One of the monoclonal antibodies, D5E5, identified an approximately 70-kd antigen localized on the principal piece of the tail and also on the tip of the acrosome of mouse sperm. The cognate antigen was expressed postmeiotically in a stage-specific manner during spermiogenesis, starting from step 8 of elongating spermatids during spermiogenesis up to mature spermatozoa. The protein was conserved across the species, as observed by its presence in rat, bull, marmoset, and human sperm. Following capacitation, the antigen on the head was seen to shift to the acrosomal region and was lost after the acrosome reaction. However, the localization on tip of the acrosome still persisted, which indicates that the antigen may play a role post-acrosome reaction in sperm egg interaction. Resistance to Triton X-100 solubilization indicates that TSA70 could be an acrosomal matrix protein. In addition, we observed a significant reduction in forward progressive motility of mouse sperm treated in vitro with D5E5. In view of its testis specificity, acrosome and tail localization, and conserved nature, TSA70 is likely to play an important role in sperm function.     

General anaesthesia vs. conscious sedation for transfemoral aortic valve implantation: a single UK centre before‐and‐after study

Reported data suggest that 99% of transfemoral, transcatheter aortic valve implantations in the UK are performed under general anaesthesia. This before‐and‐after study is the first UK comparison of conscious sedation vs. general anaesthesia for this procedure. Patients who underwent general anaesthesia received tracheal intubation, positive pressure ventilation, radial arterial and central venous access and urinary catheterisation. Anaesthesia was maintained with propofol or sevoflurane. Patients who received conscious sedation had a fascia iliaca and ilioinguinal nerve block and low‐dose remifentanil infusion, without invasive monitoring or urinary catheterisation. Recruitment took place between August 2012 and July 2015, with a 6‐month crossover period between November 2013 and June 2014. A total of 88 patients were analysed, evenly divided between the two groups. Patients receiving conscious sedation had a shorter anaesthetic time (mean (SD) 121 (28) min vs. 145 (41) min; p < 0.001) and recovery room time (110 (50) min vs. 155 (48) min; p = 0.001), lower requirement for inotropes (4.6% vs 81.8%; OR (95% CI) 0.1 (0.002–0.050); p < 0.001) and a lower incidence of malignant dysrhythmia (0% vs 11.4%; p = 0.020). Conscious sedation appears a feasible alternative to general anaesthesia for this procedure and is associated with a reduced requirement for inotropic support and improved efficiency.     

Umbilical hernia repair in cirrhotic patients: utility of temporary peritoneal dialysis catheter

Umbilical herniorrhaphy in cirrhotic patients with ascites is associated with a significant morbidity, recurrence rate, and mortality and therefore is often managed expectantly. Operative repair is indicated if an ascites leak or infection develops. Surgeons must consider the management of postoperative ascites to reduce recurrence rates and complications. We present a unique method using temporary peritoneal dialysis catheter placement (PD). Eight patients with moderate to massive ascites underwent umbilical herniorrhaphy with concomitant peritoneal dialysis placement. Patients have been followed for 8 to 30 months. All patients had successful repair of their hernia with 1 recurrence at 6 months and 1 late death (14 months). Patients were able to effectively control ascites using the PD catheter at home. There were no postoperative infections. The placement of a temporary PD catheter during umbilical herniorrhaphy provides a method for effective control of ascites in patients with cirrhosis. The technique has several advantages including outpatient management during the postoperative period and for easy removal of the catheter when no longer needed.     

Airway management in adult patients with deep neck infections: a case series and review of the literature

Patients with deep neck infections, especially those with Ludwig's angina, may die as a result of airway management mishaps. Skillful airway management is critical, but a safe method of airway control in these patients is yet to be established. We subjected patients with deep neck infections to fiberoptic tracheal intubation by using topical anesthesia to provide general anesthesia for surgical interventions. Patient characteristics and techniques for intubations were recorded on a special data-collection form. Of the 26 patients, 17 had Ludwig's angina, and 9 had other types of deep neck infections. Three patients were tracheally intubated while in the sitting position, 2 in Fowler's position, and 21 in the supine position with the head up 10 degrees-15 degrees. Tracheal intubations were successful in 25 patients: 19 nasally and 6 orally. After surgery, seven patients were kept tracheally intubated, and five patients had tracheostomies. Complications were limited to three cases of mild epistaxis and four oversedations with transient hypoxemia. Twelve patients remembered part of the procedure, and two considered it unpleasant. Tracheal intubation with a flexible bronchoscope by using topical anesthesia is highly successful in adult patients with deep neck infections. Tracheostomy using local anesthesia is recommended if fiberoptic intubation is not feasible, if the clinician is not skillful in the use of awake fiberoptic intubation, or if intubation attempts have failed.     

Optimal cannula positioning of HeartMate 3 left ventricular assist device

Cannula position in HeartMate II and HeartWare left ventricular assist devices (LVADs) is associated with clinical outcome. This study aimed to investigate the clinical implication of the device positioning in HeartMate 3 LVAD cohort. Consecutive patients who underwent HeartMate 3 LVAD implantation were followed for one year from index discharge. At index discharge, chest X-ray parameters were measured: (a) cannula coronal angle, (b) height of pump bottom, (c) cannula sagittal angle, and (d) cannula lumen area. The association of each measurement of cannula position with one-year clinical outcomes was investigated. Sixty-four HeartMate 3 LVAD patients (58 years old, 64% male) were enrolled. In the multivariable Cox regression model, the cannula coronal angle was a significant predictor of death or heart failure readmission (hazard ratio 1.27 [1.01-1.60], P = .045). Patients with a cannula coronal angle ≤28° had lower central venous pressure (P = .030), lower pulmonary capillary wedge pressure (P = .027), and smaller left ventricular size (P = .019) compared to those with the angle >28°. Right ventricular size and parameters of right ventricular function were also better in the narrow angle group, as was one-year cumulative incidence of death or heart failure readmission (10% vs. 50%, P = .008). Narrow cannula coronal angle in patients with HeartMate 3 LVADs was associated with improved cardiac unloading and lower incidence of death or heart failure readmission. Larger studies to confirm the implication of optimal device positioning are warranted.     

Infant feeding practices of mothers in an urban area in Nepal.

Background: Child health in developing countries including Nepal is a matter of serious concern as the prevalence of malnutrition among children continues to be high with 48.6% of children under five in Nepal being underweight. Since infant feeding practices adopted by mothers play a major role in influencing health of these children, there is a need to study the infant feeding practices prevalent in different areas in order to have pragmatic approaches to solve this problem. Materials and methods: A cross sectional study was conducted among mothers who attended the immunization clinics of 18 wards of Pokhara municipality area. They were interviewed with a semi-structured questionnaire on various aspects of infant feeding. Result: A total of 168 mothers were interviewed and prevalence of breastfeeding was 99.4% (167). Only 43.5% of the mothers initiated breastfeeding within one hour of birth and 60.5% were practicing exclusive breastfeeding at 5 months. Almost 40% of the mothers started complementary feeding before the recommended age of 6 months and 22.5 % delayed introduction of complementary feeding beyond the recommended age. Conclusion: Breast feeding practices adopted by mothers of Pokhara urban area are still lacking in terms of late initiation of and early starting of complementary feeding. There is a need to educate the mothers regarding proper infant feeding practices. Key words: infant feeding, breastfeeding, weaning.