Methods of alignment in total knee arthroplasty, systematic review.

Introduction: Although total knee arthroplasty (TKA) is a very frequent surgery, one in five patients is not completely satisfied. Mechanical alignment (MA) is the most popular technique for implanting TKA. However, to improve clinical outcomes, new techniques that aim to rebuild the native alignment of the knee have been developed. Objective: The aim of this study is to perform a systematic review of the available clinical trials and observational studies comparing clinical and radiological outcomes of different methods of alignment (kinematic, anatomic, functional) to MA. Methods: A systematic review is performed comparing results of patient reported outcome measures (PROMs) questionnaires (WOMAC, OKS, KSS, KOOS, FJS), radiological angles (HKA, mLDFA, MPTA, JLOA, femoral rotation and tibial slope) and range of motion (ROM). Results: Kinematic and functional alignment show a slight tendency to obtain better PROMs compared to mechanical alignment. Complication rates were not significantly different between groups. Nevertheless, these results are not consistent in every study. Anatomic alignment showed no significant differences compared to mechanical alignment. Conclusion: Kinematic alignment is an equal or slightly better alternative than mechanical alignment for patients included in this study. However, the difference between methods does not seem to be enough to explain the high percentage of dissatisfied patients. Studies implementing lax inclusion and exclusion criteria would be needed to resemble conditions of patients assisted in daily surgical practice. It would be interesting to study patient's knee phenotypes, to notice if any method of alignment is significantly better for any constitutional deviation.

Knee Buckling as an Atypical Adverse Effect of Clozapine: A Case Report.

Clozapine has become a widely popular and effective medication in the treatment of refractory schizophrenia and refractory bipolar disorder. Although the use of clozapine proves to be an effective resort, it has to be closely monitored due to its narrow therapeutic range and multiple dangerous adverse effects. In rare cases, clozapine has been known to cause an antagonistic myoclonic jerk that leads to knee buckling. Here, we present the case of a 29-year-old female who is being treated for schizoaffective disorder, bipolar, manic type, who reported two instances of knee buckling associated with falls while taking clozapine.

Negative pressure suction test: An intraoperative airway maneuver to assess effectiveness of surgical correction of tracheobronchomalacia.

BACKGROUND: Surgical correction of tracheobronchomalacia (TBM) has evolved greatly over the past decade, with select pediatric institutions establishing dedicated surgery and anesthesia teams to navigate the complexities and challenges of surgical airway repairs. Although anesthetic techniques have evolved internally over many years to improve patient safety and outcomes, many of these methods remain undescribed in literature. TECHNIQUE: In this article, we describe the intraoperative negative pressure suction test. This simulates the negative pressure seen in awake and spontaneously breathing patients, including the higher pressures seen during coughing which induce airway collapse in patients with TBM. Also known as the Munoz maneuver in surgical literature, this test has been performed on over 300 patients since 2015. DISCUSSION: The negative pressure suction test allows for controlled intraoperative assessment of surgical airway repairs, replaces the need for risky intraoperative wake-up tests, increases the chances of a successful surgical repair, and improves anesthetic management for emergence and extubation. We provide a guide on how to perform the test and videos demonstrating its efficacy in intraoperative airway evaluation. CONCLUSIONS: As surgeries to repair TBM become more prevalent in other pediatric institutions, we believe that pediatric patients and anesthesia providers will benefit from the insights and methods described here.

Effect of Posterior Tracheopexy on Risk of Recurrence in Children after Recurrent Tracheo-Esophageal Fistula Repair.

BACKGROUND: A recurrent tracheo-esophageal fistula can complicate esophageal atresia and tracheo-esophageal fistula (TEF) repair in children. Therapeutic approaches and the rate of recurrence vary widely. Most reports are limited by small cohorts and short-term follow-up, and rates of re-recurrence are substantial, making it difficult to select the treatment of choice. We aimed to review our experience with the treatment of recurrent TEF using posterior tracheopexy, focusing on operative risks and long-term outcomes. STUDY DESIGN: We conducted a retrospective review of patients with esophageal atresia TEF with recurrent TEF treated at 2 institutions from 2011 to 2020. We approach recurrent TEFs surgically. Once the TEF is divided and repaired, the membranous trachea is sutured to the anterior longitudinal ligament of the spine (posterior tracheopexy) and the esophagus is rotated into the right chest (rotational esophagoplasty), separating the suture lines widely. To detect re-recurrence, patients undergo endoscopic surveillance during follow-up. RESULTS: Sixty-two patients with a recurrent TEF were surgically treated (posterior tracheopexy/rotational esophagoplasty) at a median age of 14 months. All had significant respiratory symptoms. On referral, 24 had earlier failed endoscopic and/or surgical attempts at repair. Twenty-nine required a concomitant esophageal anastomotic stricturoplasty or stricture resection. Postoperative morbidity included 3 esophageal leaks, and 1 transient vocal cord dysfunction. We have identified no recurrences, with a median follow-up of 2.5 years, and all symptoms have resolved. CONCLUSIONS: The surgical treatment of recurrent TEFs that incorporates a posterior tracheopexy and rotational esophagoplasty is highly effective for preventing re-recurrence with low perioperative morbidity.

Intraoperative Recurrent Laryngeal Nerve Monitoring During Pediatric Cardiac and Thoracic Surgery: A Mini Review.

Objective: Review techniques for intraoperative recurrent laryngeal nerve (RLN) monitoring during pediatric surgery for esophageal atresia, tracheoesophageal fistula, tracheobronchomalacia, and cardiac surgery. Summary Background Data: Literature was reviewed for reports of intraoperative recurrent laryngeal nerve monitoring in cervical, thoracic, and cardiac surgical procedures which place the RLNs at risk for injury. Methods: Review paper. Results: The RLN is at risk during pediatric surgery for esophageal atresia, tracheoesophageal fistula, tracheobronchomalacia, and cardiac surgery. Intraoperative nerve monitoring has decreased rates of RLN injury in thyroid surgery. Intraoperative RLN monitoring techniques appropriate for pediatric surgery are discussed, including endotracheal tubes with integrated surface electrodes, adhesive surface electrodes for smaller endotracheal tubes, endolaryngeal electrodes, and automatic periodic continuous intra-operative stimulation. Conclusions: Multiple techniques exist to monitor the RLN in children undergoing cervical, cardiac, and thoracic surgery. Monitoring the RLN during procedures that place the RLNs at risk may help decrease the rate of RLN injury.

Population Pharmacokinetics of Intraperitoneal Bupivacaine Using Manual Bolus Atomization Versus Micropump Nebulization and Morphine Requirements in Young Children.

BACKGROUND: Intraperitoneal (IP) administration of local anesthetics is used in adults and children for postoperative analgesia after laparoscopic surgery. Population pharmacokinetics (PK) of IP bupivacaine has not been determined in children. Objectives of this study were (1) to develop a population PK model to compare IP bupivacaine administered via manual bolus atomization and micropump nebulization and (2) to assess postoperative morphine requirements after intraoperative administration. We hypothesized similar PK profiles and morphine requirements for both delivery methods. METHODS: This was a prospective, sequential, observational study. After institutional review board (IRB) approval and written informed parental consent, 67 children 6 months to 6 years of age undergoing robot-assisted laparoscopic urological surgery received IP bupivacaine at the beginning of surgery. Children received a total dose of 1.25 mg/kg bupivacaine, either diluted in 30-mL normal saline via manual bolus atomization over 30 seconds or undiluted bupivacaine 0.5% via micropump nebulization into carbon dioxide (CO2) insufflation tubing over 10-17.4 minutes. Venous blood samples were obtained at 4 time points between 1 and 120 minutes intraoperatively. Samples were analyzed by liquid chromatography with mass spectrometry. PK parameters were calculated using noncompartmental and compartmental analyses. Nonlinear regression modeling was used to estimate PK parameters (primary outcomes) and Mann-Whitney U test for morphine requirements (secondary outcomes). RESULTS: Patient characteristics between the 2 delivery methods were comparable. No clinical signs of neurotoxicity or cardiotoxicity were observed. The range of peak plasma concentrations was 0.39-2.44 µg/mL for the manual bolus atomization versus 0.25-1.07 µg/mL for the micropump nebulization. IP bupivacaine PK was described by a 1-compartment model for both delivery methods. Bupivacaine administration by micropump nebulization resulted in a significantly lower Highest Plasma Drug Concentration (Cmax) and shorter time to reach Cmax (Tmax) (P < .001) compared to manual bolus atomization. Lower plasma concentrations with less interpatient variability were observed and predicted by the PK model for the micropump nebulization (P < .001). Adjusting for age, weight, and sex as covariates, Cmax and area under the curve (AUC) were significantly lower with micropump nebulization (P < .001). Regardless of the delivery method, morphine requirements were low at all time points. There were no differences in cumulative postoperative intravenous/oral morphine requirements between manual bolus atomization and micropump nebulization (0.14 vs 0.17 mg/kg; P = .85) measured up to 24 hours postoperatively. CONCLUSIONS: IP bupivacaine administration by micropump nebulization demonstrated lower plasma concentrations, less interpatient variability, low risk of toxicity, and similar clinical efficacy compared to manual bolus atomization. This is the first population PK study of IP bupivacaine in children, motivating future randomized controlled trials to determine efficacy.

Interaction of phenolic compounds with bovine serum albumin (BSA) and α-amylase and their relationship to astringency perception.

The ability of grape seed extracts to bind to bovine serum albumin (BSA) and α-amylase was studied by fluorescence quenching of protein intrinsic fluorescence and nephelometry. The influence of grape seed ripeness on astringency was also evaluated. From the spectra obtained, the modified Sterm-Volmer (K(app)) and the bimolecular quenching constants were calculated. Results showed that grape seed extracts had good affinity for proteins. The association strength of tannin-protein interactions varied with changes in tannin structure associated with the degree of ripeness affecting the binding/quenching process. In all cases studied, higher values of K(app) were obtained in samples at harvest which have greater ability to bind to proteins than have samples at post-veraison time. Nephelometric assays show the same trend as do fluorescence quenching studies. A possible explanation for this is that, as seeds ripen, their tannins increase in molecular mass, which relates to an increase in hydrophobicity of the molecules, and this increases protein affinity. However, that is contrary to the reported decrease in astringency of grape seeds during maturity. This indicates that tannin-protein interactions are not the only explanation for the complex sensations of astringency of grape seeds.

Preliminary study to determine the phenolic maturity stage of grape seeds by computer vision.

The applications of computer vision technology for acquiring and analysing images have been extended to the quality evaluation in food industry. This technique involves great advantages for the objective, rapid, non-contact and automated quality inspection and control. The aim of this work was to evaluate the potential of the computer vision to determine the phenolic maturity stage of grape seeds. Up to 21 phenolic compounds were determined by HPLC-DAD-MS in order to obtain reference values to develop the model. The CIELAB parameters, area, aspect, roundness, length, width and heterogeneity of seeds were analysed using a DigiEye(®) system. The technique reported in this work can be a good and rapid tool for taking decisions at harvest time. Notwithstanding, a comprehensive study should be made in order to develop more robust models.

Liquid chromatographic-mass spectrometric analysis of anthocyanin composition of dark blue bee pollen from Echium plantagineum.

Dark blue bee pollen samples from pollinic type Echium plantegineum were analysed in order to identify and quantify their anthocyanin pigments. Five samples were collected from different apicultural Spanish regions and the anthocyanin composition was determined by HPLC with diode array and MS detection. Eight different pigments were identified, the principal anthocyanin being petunidin-3-O-rutinoside. The other pigments found were delphinidin, cyanidin and petunidin-3-O-glucoside; delphinidin, cyanidin, peonidin and malvidin-3-O-rutinoside and cyanidin-3-(6"-malonylglucoside). The anthocyanin content ranged from 45 to 80 mg/100 g of blue pollen, which could represent a significant source of phytochemicals. Minor variations in the anthocyanin profiles were found, which could be explained by the geographical differences between collection regions.

Operación de Pickrell en el adulto / Pickrells operation in adults

Se presentan dos enfermos adultos tratados exitosamente con el procedimiento de Pickrell y colaboradores. Se aconseja denominar a dicho procedimiento técnica de Richard-Pickrell en justicia a la prioridad del autor francés. Se propicia la técnica por su sencillez, fácil realización y buenos resultados, previa selección cuidadosa de los pacientes. Debe realizarse, agotadas las posibilidades de técnicas que actúan localmente y previo exámen funcional. Los resultados obtenidos convierten a este procedimiento como uno de los más eficaces entre las mioplastías. Se sugiere la posibilidad de una variante de la técnica de Richard-Pickrell, usando ambos músculos rectos internos, para la reconstrucción del esfínter.(AU)

Operación de Pickrell en el adulto / Pickrell's operation in adults

Se presentan dos enfermos adultos tratados exitosamente con el procedimiento de Pickrell y colaboradores. Se aconseja denominar a dicho procedimiento técnica de Richard-Pickrell en justicia a la prioridad del autor francés. Se propicia la técnica por su sencillez, fácil realización y buenos resultados, previa selección cuidadosa de los pacientes. Debe realizarse, agotadas las posibilidades de técnicas que actúan localmente y previo exámen funcional. Los resultados obtenidos convierten a este procedimiento como uno de los más eficaces entre las mioplastías. Se sugiere la posibilidad de una variante de la técnica de Richard-Pickrell, usando ambos músculos rectos internos, para la reconstrucción del esfínter.