Primary total knee arthroplasty in a patient with a chronic extensor mechanism deficiency

AbstractA 44-year-old female presented with a chief complaint of left knee pain and dysfunction. The patient had a complex surgical history including patellar fracture repair, subsequent patellar ligament repair, and ultimately allograft reconstruction which was complicated by septic arthritis requiring graft resection. On presentation to our clinic, she was noted to have significant degenerative disease in addition to chronic extensor mechanism deficiency. She underwent primary total knee arthroplasty with concomitant tibial tubercle osteotomy and advancement. The patient has had an excellent result postoperatively including return of full range of motion without residual extensor lag

Total Knee Arthroplasty Assessments Should Include Strength and Performance-Based Functional Tests to Complement Range-of-Motion and Patient-Reported Outcome Measures

Range of motion (ROM) and pain often define successful recovery after total knee arthroplasty (TKA), but these routine clinical outcomes correlate poorly or not at all to functional capacity after TKA. The purpose of this Perspective is to underscore the importance of muscle strength and performance-based functional tests in addition to knee ROM and patient-reported outcome (PRO) measures to evaluate outcomes after TKA. Specifically: (1) muscle strength is the rate-limiting step for recovery of function after TKA; (2) progressive rehabilitation targeting early quadriceps muscle strengthening improves outcomes and does not compromise ROM after TKA; (3) ROM and PROs fail to fully capture functional limitations after TKA; and (4) performance-based functional tests are critical to evaluate function objectively after TKA. This Perspective also addresses studies that question the need for or benefit of physical therapy after TKA because their conclusions focus only on ROM and PRO measures. Future research is needed to determine the optimal timing, delivery, intensity, and content of physical therapy

Coronal Alignment in TKA: Traditional Principles Versus New Concepts

Background: Up to 20% of total knee arthroplasty (TKA) patients are not satisfied with their outcome, and coronal alignment is considered an important variable in attaining a well-functioning TKA. Neutral mechanical alignment is not necessarily the anatomic norm and has led some surgeons to advocate a shift in defining and attaining the optimal coronal component alignment. Our aim was to review the different coronal alignment paradigms of TKA and summarize the historical and contemporary outcomes of different alignment techniques. Methods: A systematic review was performed in March 2017 via PubMed using the search terms: coronal alignment, kinematic alignment, and total knee replacement using Boolean “and” in-between terms. Relevant results were then reviewed, analyzed and summarized  Conclusions: Early clinical outcomes of kinematically aligned TKAs are promising, but long-term clinical results are unknown. Clinical, laboratory, and retrieval studies suggest that mechanical varus in TKA, especially involving the tibial component, may result in earlier failure. Kinematic alignment with boundaries may be an optimal strategy for patients with pre-operative constitutional varus or congenital tibia vara

Analysis of Rock Varnish from the Mojave Desert by Handheld Laser-Induced Breakdown Spectroscopy

Laser-induced breakdown spectroscopy (LIBS) is a form of optical emission spectroscopy that can be used for the rapid analysis of geological materials in the field under ambient environmental conditions. We describe here the innovative use of handheld LIBS for the in situ analysis of rock varnish. This thinly laminated and compositionally complex veneer forms slowly over time on rock surfaces in dryland regions and is particularly abundant across the Mojave Desert climatic region of east-central California (USA). Following the depth profiling examination of a varnished clast from colluvial gravel in Death Valley in the laboratory, our in situ analysis of rock varnish and visually similar coatings on rock surfaces was undertaken in the Owens and Deep Spring valleys in two contexts, element detection/identification and microchemical mapping. Emission peaks were recognized in the LIBS spectra for the nine elements most abundant in rock varnish—Mn, Fe, Si, Al, Na, Mg, K, Ca and Ba, as well as for H, Li, C, O, Ti, V, Sr and Rb. Focused follow-up laboratory and field studies will help understand rock varnish formation and its utility for weathering and chronological studies

Ferrets exclusively synthesize Neu5Ac and express naturally humanized influenza A virus receptors

Mammals express the sialic acids ​N-acetylneuraminic acid (​Neu5Ac) and ​N-glycolylneuraminic acid (​Neu5Gc) on cell surfaces, where they act as receptors for pathogens, including influenza A virus (IAV). ​Neu5Gc is synthesized from ​Neu5Ac by the enzyme cytidine monophosphate-N-acetylneuraminic acid hydroxylase (CMAH). In humans, this enzyme is inactive and only ​Neu5Ac is produced. Ferrets are susceptible to human-adapted IAV strains and have been the dominant animal model for IAV studies. Here we show that ferrets, like humans, do not synthesize ​Neu5Gc. Genomic analysis reveals an ancient, nine-exon deletion in the ferret CMAH gene that is shared by the Pinnipedia and Musteloidia members of the Carnivora. Interactions between two human strains of IAV with the sialyllactose receptor (sialic acid—α2,6Gal) confirm that the type of terminal sialic acid contributes significantly to IAV receptor specificity. Our results indicate that exclusive expression of ​Neu5Ac contributes to the susceptibility of ferrets to human-adapted IAV strains

Phasevarion Mediated Epigenetic Gene Regulation in Helicobacter pylori

Many host-adapted bacterial pathogens contain DNA methyltransferases (mod genes) that are subject to phase-variable expression (high-frequency reversible ON/OFF switching of gene expression). In Haemophilus influenzae and pathogenic Neisseria, the random switching of the modA gene, associated with a phase-variable type III restriction modification (R-M) system, controls expression of a phase-variable regulon of genes (a “phasevarion”), via differential methylation of the genome in the modA ON and OFF states. Phase-variable type III R-M systems are also found in Helicobacter pylori, suggesting that phasevarions may also exist in this key human pathogen. Phylogenetic studies on the phase-variable type III modH gene revealed that there are 17 distinct alleles in H. pylori, which differ only in their DNA recognition domain. One of the most commonly found alleles was modH5 (16% of isolates). Microarray analysis comparing the wild-type P12modH5 ON strain to a P12ΔmodH5 mutant revealed that six genes were either up- or down-regulated, and some were virulence-associated. These included flaA, which encodes a flagella protein important in motility and hopG, an outer membrane protein essential for colonization and associated with gastric cancer. This study provides the first evidence of this epigenetic mechanism of gene expression in H. pylori. Characterisation of H. pylori modH phasevarions to define stable immunological targets will be essential for vaccine development and may also contribute to understanding H. pylori pathogenesis

Utilization of inhaled nitric oxide after surgical repair of truncus arteriosus: A multicenter analysis

BackgroundElevated pulmonary vascular resistance (PVR) is common following repair of truncus arteriosus. Inhaled nitric oxide (iNO) is an effective yet costly therapy that is frequently implemented postoperatively to manage elevated PVR.ObjectivesWe aimed to describe practice patterns of iNO use in a multicenter cohort of patients who underwent repair of truncus arteriosus, a lesion in which recovery is often complicated by elevated PVR. We also sought to identify patient and center factors that were more commonly associated with the use of iNO in the postoperative period.DesignRetrospective cohort study.Setting15 tertiary care pediatric referral centers.PatientsAll infants who underwent definitive repair of truncus arteriosus without aortic arch obstruction between 2009 and 2016.InterventionsDescriptive statistics were used to demonstrate practice patterns of iNO use. Bivariate comparisons of characteristics of patients who did and did not receive iNO were performed, followed by multivariable mixed logistic regression analysis using backward elimination to identify independent predictors of iNO use.Main ResultsWe reviewed 216 patients who met inclusion criteria, of which 102 (46%) received iNO in the postoperative period: 69 (68%) had iNO started in the operating room and 33 (32%) had iNO initiated in the ICU. Median duration of iNO use was 4 days (range: 1‐21 days). In multivariable mixed logistic regression analysis, use of deep hypothermic circulatory arrest (odds ratio: 3.2; 95% confidence interval: 1.2, 8.4) and center (analyzed as a random effect, p = .02) were independently associated with iNO use.ConclusionsIn this contemporary multicenter study, nearly half of patients who underwent repair of truncus arteriosus received iNO postoperatively. Use of iNO was more dependent on individual center practice rather than patient characteristics. The study suggests a need for collaborative quality initiatives to determine optimal criteria for utilization of this important but expensive therapy.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/152533/1/chd12849_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/152533/2/chd12849.pd

Multicenter Analysis of Early Childhood Outcomes Following Repair of Truncus Arteriosus

Background Literature describing morbidity and mortality following truncus arteriosus repair is predominated by single-center reports. We created and analyzed a multicenter dataset to identify risk factors for late mortality and right ventricle-to-pulmonary artery (RV-PA) conduit reintervention for this patient population. Methods We retrospectively collected data on children who underwent repair of truncus arteriosus without concomitant arch obstruction at 15 centers between 2009 and 2016. Cox regression survival analysis was conducted to determine risk factors for late mortality, defined as death occurring after hospital discharge and greater than 30 days after surgery. Probability of any RV-PA conduit reintervention was analyzed over time using Fine-Gray modelling. Results We reviewed 216 patients, with median follow-up of 2.9 years (range:0.1-8.8). Operative mortaility occurred in 15 patients (7%). Of the 201 survivors, there were 14 (7%) late deaths. DiGeorge syndrome (HR:5.4; 95%CI:1.6-17.8) and need for postoperative tracheostomy (HR:5.9; 95%CI:1.8-19.4) were identified as independent risk factors for late mortality. At least one RV-PA conduit catheterization or surgical reintervention was performed in 109 patients (median time to reintervention:23 months, range:0.3-93). Risk factors for reintervention included use of pulmonary or aortic homografts versus Contegra® bovine jugular vein conduits (HR:1.9; 95%CI:1.2,3.1) and smaller conduit size (HR per mm/m2:1.05; 95%CI:1.03,1.08). Conclusions In a multicenter dataset, DiGeorge syndrome and need for tracheostomy postoperatively were found to be independent risk factors for late mortality after repair of truncus arteriosus, while risk of conduit reintervention was independently influenced by both initial conduit type and size

Assessing 21st century contaminants of concern using integrative passive sampling devices to obtain more meaningful and cost effective data on impacts from stormwater runoff

In many cases stormwater compliance monitoring is labor intensive, expensive, and largely unsuccessful in providing the data needed to support stormwater management goals. In addition, data from manual grab sampling and automated composite sampling are rarely collected in a manner that provides the information required to identify sources of contamination, evaluate the effectiveness of Best Management Practices, and inform effective decision making. Furthermore, monitoring is often driven by the need to meet low concentration benchmarks for metals and other constituents that do not take into account loading into the receiving waters, resulting in arbitrary monitoring requirements (monthly or seasonally) that are not tied to the driving forces within the watershed such as hydrology (flow regime), weather (storm events and antecedent dry periods), and upland land use and cover. To help address these issues, passive sampling devices including Diffusive Gradients in Thin films (DGT) for metals and Polar Organic Chemical Integrative Samples (POCIS) for a wide range of household, personal care, pharmaceutical, and endocrine disrupting compounds are being used to monitor stormwater runoff. In the Puget Sound a network of monitoring stations was established in Sinclair and Dyes Inlets to assess runoff from industrial areas of Naval Base Kitsap as well as commercial, residential, and rural areas within the watershed. Passive samplers were co-located with autosamplers to provide a direct comparison with grab and composite sampling. Preliminary results from multiple DGT deployments showed that time-dependent variability in stormwater impacts on ambient metal concentrations could be detected on small time scales, as well as over multiple days of rainfall. The POCIS samplers showed that a wide range of organic compounds could be reliably detected from the surveillance monitoring which should prove very useful for finger printing likely sources of contamination in stormwater runoff in the areas monitored