Osteochondral lesions of the talus: aspects of current management.

Osteochondral lesions (OCLs) occur in up to 70% of sprains and fractures involving the ankle. Atraumatic aetiologies have also been described. Techniques such as microfracture, and replacement strategies such as autologous osteochondral transplantation, or autologous chondrocyte implantation are the major forms of surgical treatment. Current literature suggests that microfracture is indicated for lesions up to 15 mm in diameter, with replacement strategies indicated for larger or cystic lesions. Short- and medium-term results have been reported, where concerns over potential deterioration of fibrocartilage leads to a need for long-term evaluation. Biological augmentation may also be used in the treatment of OCLs, as they potentially enhance the biological environment for a natural healing response. Further research is required to establish the critical size of defect, beyond which replacement strategies should be used, as well as the most appropriate use of biological augmentation. This paper reviews the current evidence for surgical management and use of biological adjuncts for treatment of osteochondral lesions of the talus.

Trends in the provision of primary care dental general anaesthesia in the north of England, 1991/92 to 1994/95.

AIM: To investigate trends in the provision of primary care dental general anaesthesia (PCDGA) and any association with dental caries. DESIGN: Cross-sectional analysis of data about the provision of PCDGA in the general dental service and community dental service from 1991/92 to 1994/95. SETTING: The former North Western, Mersey, Northern and Yorkshire regions. METHOD: The combined rates of PCDGAs in the general dental service and community dental service, from 1991/92 to 1994/95 were calculated and compared with the levels of caries from the NHS dental epidemiology programme. RESULTS: All regions except the North Western had a lower rate at the end of the 1991 study but only the Northern region had a lower rate in 1994/95 than in 1993/94. Only weak correlations were found between the PCDGA rate in a health authority and the level of dental caries. CONCLUSIONS: PCDGA rates did not continue to decline during the period of this study. One of the principal recommendations of the Poswillo report was that the use of general anaesthesia should be avoided wherever possible. Other initiatives, perhaps the development of criteria for selection of patients, may be necessary if further reductions in PCDGA rates are to be achieved.

Enhancing research utilization by clinical nurse specialists.

A research utilization forum for clinical nurse specialists was initiated in the early 1990s in two service settings. The primary purpose of this voluntary, small-group strategy was to help master's-prepared clinicians gain knowledge and skills regarding the systematic use of research findings. This article describes the forum strategy and its conceptual base. It also reviews outcomes related to program objectives, utilization competencies, and case reports of subsequent clinical nurse specialist research utilization behavior.

The risks of transmission of acute hepatitis A and B virus infection in an urban centre.

In a large urban centre of a developed nation, 63 household contacts of 20 index cases with acute hepatitis A virus infection and 95 household contacts of 29 index cases with acute hepatitis B virus infection were prospectively followed for 2 years to document the risk of acquiring acute hepatitis from the index case. Twenty-one of 63 (33%) hepatitis A virus household contacts had serologic evidence of previous hepatitis A virus infection on the initial serum sample. Of the remaining 42 susceptible individuals, 22 (52%) were or became IgM anti-HAV positive within 6 months of the diagnosis in the index case. With respect to hepatitis B virus infection, 18/95 (17%) household contacts had serologic evidence of previous hepatitis B virus infection on the initial serum sample. Of the remaining 77 susceptible individuals, four (5%) had or developed serologic evidence of acute hepatitis B virus infection (IgM anti-hepatitis B core antigen positive) during the 2 years of follow up. In three of these four individuals, acquisition of hepatitis B virus was apparent within 6 months of the diagnosis in the index case. The results of this study indicate that in this urban centre, the risk of acquiring acute hepatitis A virus infection from index cases within the household is approximately 10 times greater than that for acute hepatitis B virus infection. These results support the need for continued passive and/or active immunization against hepatitis A and B virus infection in susceptible household contacts.

A phase II study of crisnatol mesylate in patients with ovarian carcinoma.

Fourteen patients with advanced ovarian cancer received a 72 hour infusion of a new DNA intercalator, crisnatol mesylate, administered intravenously. There was no evidence of antitumor efficacy. A syndrome of nausea and vomiting associated with vertigo, dizziness and ataxia was observed in nearly all patients. Two of the patients developed severe CNS toxicity manifested in one by a grand-mal seizure and in the other by peripheral neuropathy. Further explorations into the potential efficacy of crisnatol mesylate administered intraperitoneally are underway.

Acquisition of competence for floral development in Nicotiana buds.

Grafting experiments were used to investigate the relative roles of strength of flowering signal(s) and competence of buds to respond to flowering signal(s) in the development of photoperiodic and day-neutral species of Nicotiana. At the time of commitment to floral development, a flowering signal (inhibitory or promotive) could reach a critical level or terminal buds could gain competence to perceive and-or respond to an existing signal. The latter hypothesis appears to be true for day-neutral N. tabacum L. cv. Wisconsin 38, while signal strength appears to be a more critical factor for long-day N. silvestris L. Nicotiana tabacum and N. silvestris differ in terms of signal intensity at anthesis of the terminal flower. Stocks of N. silvestris promote more rapid flowering in seedling scions of both genotypes. Terminal buds of seedlings of both genotypes have the same competence to respond to the signal affecting floral development. The competence of the terminal bud of both species to respond to this signal(s) changes as a function of age.

Iatrogenic disease in hospitalized elderly veterans.

To help determine whether or not the elderly are at unusually high risk for hospital-related complications, a study was made of consecutive admissions involving 48 patients less than 65 years old (mean 50.3 years) and 174 patients more than 65 years old (mean 73.1 years). They were prospectively followed during their hospital stays, and were monitored daily. According to admission data, they were classified as : Group 1, likely to die soon after admission; Group II, likely to die within a year; Group III, likely to live longer than a year. Complications were listed under the causal factors: trauma, infection, hospital procedures, drugs, and miscellaneous. About 90 per cent of all 222 patients in both age categories were in Group III. The overall complication rates were 29 per cent for patients under 65, and 45 per cent for those over 65 (P less than 0.05). For the under-65 Group III patients, the rates were 17 per cent and 42 per cent for medical and surgical patients, respectively; for the over-65 patients, the rates were 40 per cent (medical) and 43 per cent (surgical). This indicated a major increase in complications among medical patients more than 65 years old. Procedure-related problems were most common among surgical patients under 65. For over-65 patients, the complication rates for procedure-related, trauma, miscellaneous, infection, and drug toxicity categories were fairly evenly distributed within the range of 16.8-12.8 per cent, in that order. Major psychiatric deterioration was observed in 10.7 per cent of patients over 65, but in none of the younger subjects. Drug toxicity and traumatic complications were also more common in the older patients. These data confirm the disproportionately high incidence of iatrogenic diseases in hospital patients over the age of 65. Several of these complications are amenable to control.