Hybrid aortic arch and frozen elephant trunk reconstruction: bridging the gap between conventional and total endovascular arch repair

Introduction: Novel endovascular techniques hope to offer patients aortic arch repair with reduced morbidity compared to conventional arch surgery; however, current endovascular strategies remain challenged by the proximal seal zone, higher stroke rates, long-term durability and select anatomy. Hybrid arch repair offers patients a less invasive alternative that can treat more distal aorta than conventional arch repair yet still be performed via standard sternotomy.

Areas covered: This review will discuss the current evidence and future development of hybrid aortic arch and frozen elephant trunk reconstruction. Several approaches to hybrid arch repair are summarized, including the off-label use of thoracic endovascular stent-grafts and commercially manufactured hybrid grafts. Technical considerations and clinical outcomes with each approach will be addressed along with advantages and disadvantages.

Expert commentary: Hybrid arch repair will undergo continued refinement as our ability to provide a less-invasive alternative to conventional open arch repair grows. Evolution to allow for improved head vessel branch sizing, improved frozen elephant trunk deployment accuracy, monitoring to prevent paraplegia and utilization of intraoperative image guidance in hybrid operating rooms is necessary. The potential exists for hybrid approaches to arch pathology to completely supplant conventional surgery, while avoiding the potential deleterious complications of total endovascular repair.     

Trends for Neonatal Deaths in Nepal (2001–2016) to Project Progress Towards the SDG Target in 2030, and Risk Factor Analyses to Focus Action

Introduction

Nepal has made considerable progress on improving child survival during the Millennium Development Goal period, however, further progress will require accelerated reduction in neonatal mortality. Neonatal survival is one of the priorities for Sustainable Development Goals 2030. This paper examines the trends, equity gaps and factors associated with neonatal mortality between 2001 and 2016 to assess the likelihood of Every Newborn Action Plan (ENAP) target being reached in Nepal by 2030.

Methods

This study used data from the 2001, 2006, 2011 and 2016 Nepal Demographic and Health Surveys. We examined neonatal mortality rate (NMR) across the socioeconomic strata and the annual rate of reduction (ARR) between 2001 and 2016. We assessed association of socio-demographic, maternal, obstetric and neonatal factors associated with neonatal mortality. Based on the ARR among the wealth quintile between 2001 and 2016, we made projection of NMR to achieve the ENAP target. Using the Lorenz curve, we calculated the inequity distribution among the wealth quintiles between 2001 and 2016.

Results

In NDHS of 2001, 2006, 2011 and 2016, a total of 8400, 8600, 13,485 and 13,089 women were interviewed respectively. There were significant disparities between wealth quintiles that widened over the 15 years. The ARR for NMR declined with an average of 4.0% between 2001 and 2016. Multivariate analysis of the 2016 data showed that women who had not been vaccinated against tetanus had the highest risk of neonatal mortality (adjusted odds ratio [AOR] 3.38; 95% confidence interval [CI] 1.20–9.55), followed by women who had no education (AOR 1.87; 95% CI 1.62–2.16). Further factors significantly associated with neonatal mortality were the mother giving birth before the age of 20 (AOR 1.76; CI 95% 1.17–2.59), household air pollution (AOR 1.37; CI 95% 1.59–1.62), belonging to a poorest quintile (AOR 1.37; CI 95% 1.21–1.54), residing in a rural area (AOR 1.28; CI 95% 1.13–1.44), and having no toilet at home (AOR 1.21; CI 95% 1.06–1.40). If the trend of neonatal mortality rate of 2016 continues, it is projected that the poorest family will reach the ENAP target in 2067.

Conclusions

Although neonatal mortality is declining in Nepal, if the current trend continues it will take another 50 years for families in the poorest group to attain the 2030 ENAP target. There are different factors associated with neonatal mortality, reducing the disparities for maternal and neonatal care will reduce mortality among the poorest families.

     

Adoptive transfer of tolerance induced by ICRC bacilli against Mycobacterium leprae in mice

ICRC bacilli, the cultivable leprosy-derived mycobacteria, isolated from lepromatous nodules of leprosy patients were found to be immunogenic in BALB/c mice at a dose of 2 X 10(7) acid-fast bacilli when injected by the intradermal (i.d.) route. The sensitization to lepromin and ICRC antigens was measured by the foot pad enlargement (FPE) method. The same dose of bacilli when injected by intravenous (i.v.), intraperitoneal, and subcutaneous routes induced immune tolerance in mice as indicated by reduction in the FPE to the test antigens. The spleen cells obtained after i.v. injection of ICRC bacilli/Mycobacterium leprae after adoptive transfer brought about suppression of delayed-type hypersensitivity in sensitized as well as nonsensitized recipients, indicating production of suppressor cells after i.v. injection. Similarly, the tolerance induced by i.v. injection of M. leprae in mice could be partially converted to immunity by i.d. sensitization with live BCG and two strains of ICRC bacilli (C-44 and C-75).     

Mycobacterium bovis BCG vaccination modulates TNF-alpha production after pulmonary challenge with virulent Mycobacterium tuberculosis in guinea pigs

Tumor necrosis factor-alpha (TNF-alpha) plays critical and opposing roles in the pathogenesis of tuberculosis (TB). We examined the effects of Mycobacterium bovis BCG vaccination on TNF-alpha production in three distinct guinea pig leukocyte populations before and after pulmonary infection with M. tuberculosis H37Rv. Following BCG vaccination alone, and following challenge, bronchoalveolar lavage cells (BALC), resident peritoneal cells (PC), and splenocytes (SPC) were stimulated with purified protein derivative (PPD). Before virulent challenge, BCG vaccination clearly enhanced the ability of BALC, PC and SPC to produce TNF-alpha in response to PPD stimulation ex vivo. Following challenge, the TNF-alpha production of all three leukocyte populations from BCG-vaccinated animals remained relatively constant at pre-challenged levels. In sharp contrast, 5 weeks post-challenge, all three leukocyte populations from unvaccinated animals produced very high amounts of TNF-alpha in response to PPD. Three weeks post-challenge, SPC from one of the unvaccinated animals produced higher levels of TNF-alpha but the others produced lower levels of TNF-alpha than BCG-vaccinated animals. As expected, BCG vaccination reduced the levels of virulent mycobacteria in both the lungs and spleens. Thus, BCG vaccination allows guinea pigs to modulate TNF-alpha levels in conjunction with a reduction in bacillary loads in their tissues.     

Hydatid cyst in the right ventricular outflow tract: Successful surgical outcome of a rare entity

Echinococcosis is endemic in India but heart is an uncommon site of presentation of hydatid cyst. We report a case of a young female with hydatid cyst of right ventricular outflow tract who was operated through median sternotomy under cardiopulmonary bypass and entire cyst was successfully removed. The preoperative diagnosis was confirmed by histopathology of the excised specimen.     

Neurological illness following treatment with fludarabine.

Fludarabine is a comparatively new drug for the treatment of low-grade lymphoid malignancy. This report describes five cases of unusual neurological illnesses occurring after treatment with fludarabine. These suggest that caution should be exercised in patients receiving fludarabine who develop neurological abnormalities, with prompt investigation and if necessary cessation of the drug.