In-Office Needle Arthroscopy with Meniscal Repair for Meniscal Lesions of the Knee

Meniscal injuries are a common cause of knee pain and are often an indication for knee arthroscopy, the most common orthopedic surgical procedure in the United States. In-office needle arthroscopy (IONA) is a described technique with the ability to diagnose and treat meniscal injuries in the office. IONA allows for diagnosis and treatment at a significantly deceased cost, with both quicker patient recovery, and improved patient satisfaction. The purpose of this technical report is to describe the technique for performing in-office needle arthroscopy for meniscal injuries of the knee, including the technique for obtaining adequate local anesthesia, proper indications, adequate visualization, and the advantages of performing these procedures in the office rather than the operating room.

In-Office Needle Arthroscopy of the Knee With Lateral Parapatellar Retinacular Release

The lateral patellofemoral joint, composed of multiple soft-tissue structures, balances the knee by aiding patella tracking, stability, and force distribution. Arthroscopic lateral release is a well-described procedure that addresses patellofemoral knee pain and, in cases with patellar instability, may be combined with medial stabilization. In-office needle arthroscopy is an up-trending technique that simultaneously diagnoses and treats patellofemoral pathology in the office, leading to a quicker patient recovery, reduced cost, and improved patient satisfaction. The purpose of this Technical Note is to describe in-office needle arthroscopy technique to address patellofemoral pain and lateral patellar mal-tracking, with special consideration for achieving adequate local anesthesia, proper indications, adequate visualization, and the advantages of performing these procedures in the office rather than the operating room.

Editorial Commentary: Large, Deep, and Cystic Osteochondral Lesions of the Talus May Be Better Treated With Bone Grafting Techniques or Autologous Osteochondral Transplantation Rather Than Bone Marrow Stimulation

Osteochondral lesions of the talus are a challenging problem to treat. Debridement with bone marrow stimulation has represented the mainstay of treatment for the injuries, with good to excellent results reported. However, some patients do not do well with simple debridement and bone marrow stimulation, which yields a surface of fibrocartilage rather than articular cartilage. Recent studies have focused on prognostic indicators of successful treatment with bone marrow stimulation techniques, including lesion size, ankle stability, lesion location, containment, and the presence of a cyst, among others. The presence of a large bone cyst may be an indication for a more aggressive approach. Cystic lesions may be better suited for bone grafting techniques or articular cartilage replacement procedures (e.g., autologous osteochondral transplantation). Of importance, lesions larger than 90-100 mm sq and deeper than 7.5 mm may be similarly treated.

Reproducible and Effective Biceps Tenodesis Method Utilizing In-Office Nano-Arthroscopy

Biceps tendinopathy is a common cause of chronic anterior shoulder pain characterized by altered joint mechanics with considerable deficits in range of motion secondary to pain. The benefits of in-office nano-arthroscopy (IONA) include the ability to diagnosis and treat biceps tendinopathy, quicker patient recovery, reduced cost, and improved patient satisfaction. The purpose of this technical report is to describe the technique for performing IONA for biceps tendinopathy (biceps tenotomy/biceps tenodesis), with special consideration for obtaining adequate local anesthesia, proper indications, adequate visualization, and the advantages of performing these procedures in the office rather than the operating room.

In-Office Needle Arthroscopy With Cartilage Allograft Extracellular Matrix Application for Cartilage Lesions of the Knee

Chondral and osteochondral lesions of the knee are a common cause of pain, mechanical symptoms, and swelling for patients. The benefits of in-office needle arthroscopy (IONA) include the ability to diagnose and treat chondral or osteochondral lesions in the office, quicker patient recovery, reduced cost, and improved patient satisfaction. The purpose of this technical note is to describe the technique for performing in-office needle arthroscopy for chondral or osteochondral contained lesions of the knee, with special consideration of the technique for obtaining adequate local anesthesia, proper indications, adequate visualization, and the advantages of performing these procedures in the office rather than the operating room.

In-Office Nano-Arthroscopy of the Shoulder with Acromioplasty

Subacromial decompression with acromioplasty is among the most commonly performed shoulder procedures. The advantages of in-office nano-arthroscopy include the capability of diagnosing and treating subacromial impingement, swifter patient recovery, improved cost-effectiveness, and superior patient satisfaction. The purpose of this technical report is to describe our technique for performing in-office nano-arthroscopy for subacromial decompression (subacromial bursectomy and acromioplasty), with a particular focus on appropriate indications, providing sufficient local anesthesia, optimizing visualization, and discussing the advantages of the in-office setting compared to the operating room.

Paediatric ankle cartilage lesions: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle

BACKGROUND

The evidence supporting best practice guidelines in the field of cartilage repair of the ankle are based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on "Pediatric Ankle Cartilage Lesions" developed at the 2019 International Consensus Meeting on Cartilage Repair of the Ankle.

METHODS

Forty-three international experts in cartilage repair of the ankle representing 20 countries convened to participate in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within four working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterised as follows: consensus: 51-74%; strong consensus: 75-99%; unanimous: 100%.

RESULTS

A total of 12 statements on paediatric ankle cartilage lesions reached consensus during the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. Five achieved unanimous support, and seven reached strong consensus (>75% agreement). All statements reached at least 84% agreement.

CONCLUSIONS

This international consensus derived from leaders in the field will assist clinicians with the management of paediatric ankle cartilage lesions.

Anterior Talofibular Ligament Augmentation With Internal Brace in the Office Setting

The anterior talofibular ligament (ATFL) is the most frequently injured lateral ligament of the ankle, and up to 20% of patients with ankle sprains may require surgical intervention to correct chronic lateral ankle instability. There has been increased interest in arthroscopic lateral ankle ligament repair techniques to minimize postoperative pain and expedite recovery. Additionally, the use of suture-tape augmentation may allow for improved recovery in those with ATFL reconstruction. The goal of this Technical Note is to describe the steps to performing in-office needle arthroscopy using suture tape as an internal brace for an ATFL deficient ankle. We also include an accompanying discussion on indications and opportunities afforded by an in-office procedure over the traditional operating room suite.

Osteochondral Lesions of the Tibial Plafond and Ankle Instability With Ankle Cartilage Lesions: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle

BACKGROUND

An international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to present the consensus statements on osteochondral lesions of the tibial plafond (OLTP) and on ankle instability with ankle cartilage lesions developed at the 2019 International Consensus Meeting on Cartilage Repair of the Ankle.

METHODS

Forty-three experts in cartilage repair of the ankle were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 4 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed on in unanimous fashion within the working groups. A final vote was then held.

RESULTS

A total of 11 statements on OLTP reached consensus. Four achieved unanimous support and 7 reached strong consensus (greater than 75% agreement). A total of 8 statements on ankle instability with ankle cartilage lesions reached consensus during the 2019 International Consensus Meeting on Cartilage Repair of the Ankle. One achieved unanimous support, and seven reached strong consensus (greater than 75% agreement).

CONCLUSION

These consensus statements may assist clinicians in the management of these difficult clinical pathologies.

LEVEL OF EVIDENCE

Level V, mechanism-based reasoning.

In-Office Needle Arthroscopy for Anterior Ankle Impingement

Anterior ankle impingement is a common cause of chronic ankle pain characterized by altered joint mechanics with considerable deficits in range of motion. The benefits of in-office nano arthroscopy (IONA) include the ability to diagnosis and treat anterior ankle impingement, quicker patient recovery, reduced cost, and improved patient satisfaction. The purpose of this technical report is to describe the technique for performing in-office nano arthroscopy for anterior ankle impingement, with special consideration of the technique for obtaining adequate local anesthesia, proper indications, adequate visualization, and the advantages of performing these procedures in the office rather than the operating room.

Achilles Paratenon Needle Tendoscopy in the Office Setting

Achilles tendinopathy is a common inflammatory condition of the Achilles tendon prevalent in the athletic population in which patients present with pain, swelling, and reduced performance exacerbated by physical activity. Operative intervention using either open or percutaneous approaches has traditionally been performed after failure of nonoperative treatment, but less invasive modalities that include endoscopic approaches have been increasingly used. This Technical Note highlights our technique for Achilles paratenon needle tendoscopy in the wide-awake office setting, with accompanying indications for use, advantages, and technical pearls.

Needle Arthroscopy Cheilectomy for Hallux Rigidus in the Office Setting

Hallux rigidus is a progressive degenerative process of the first metatarsophalangeal joint characterized by altered joint mechanics and formation of dorsal osteophytes. Cheilectomy is the preferred operative intervention at early stages. Technologic advances, patient preference, and cost considerations combine to stimulate the development of minimally invasive and in-office interventions. This Technical Note highlights our technique for needle arthroscopy cheilectomy for hallux rigidus, which can be used either in the operating room or in the wide-awake office setting.

Posterior Hindfoot Needle Endoscopy in the Office Setting

Posterior hindfoot disorders encompass a spectrum of bony, cartilaginous, and soft-tissue pathology. Traditional open surgical techniques have been increasingly replaced by less-invasive arthroscopic and endoscopic approaches. Recent innovations such as the advent of the needle arthroscope continue to push the boundary of minimally invasive interventions. This Technical Note highlights our technique for posterior hindfoot needle endoscopy for common posterior hindfoot pathologies in the wide-awake office setting, including indications, advantages, and technical pearls.

In-Office Needle Tendoscopy of the Peroneal Tendons

In-office needle tendoscopy (IONT) can be used for the diagnosis and treatment of several peroneal tendon pathologies including peroneal tendon tendinopathy, tears, and instability. Benefits of IONT for peroneal tendon disorders include the ability to dynamically evaluate peroneal tendon stability, quicker patient recovery, reduced cost, and improved patient satisfaction. Several studies have suggested that tendoscopic treatment may avoid several complications related to open treatment of peroneal tendon pathologies, including scar formation and groove stenosis. The purpose of the present report is to describe the technique for performing IONT for common peroneal tendon pathologies. This Technical Note describes the techniques for obtaining adequate anesthesia and performing IONT, indications, and advantages of performing these procedures in the office rather than in the operating room.

In-Office Needle Tendoscopy of the Tibialis Posterior Tendon with Concomitant Intervention

Tendoscopy has been recognized to be a useful technique in the diagnosis and treatment of early tibialis posterior tendon (TPT) dysfunction. Although open surgical procedures for advanced TPT disease have led to excellent outcomes, disagreement persists concerning the correct management algorithm for early TPT dysfunction. Recent developments in needle tendoscopy have provided a minimally invasive option for direct evaluation and intervention throughout the forefoot, midfoot, and hindfoot. The goal of this manuscript is to describe the technique for performing in-office needle tendoscopy targeting the TPT with a discussion of indications and opportunities afforded by an in-office procedure over the traditional operating room suite.

Scaffold-Based Therapies: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle

BACKGROUND

The evidence supporting best practice guidelines in the field of cartilage repair of the ankle are based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on "Scaffold-Based Therapies" developed at the 2017 International Consensus Meeting on Cartilage Repair of the Ankle.

METHODS

Seventy-five international experts in cartilage repair of the ankle representing 25 countries and 1 territory were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 11 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; unanimous, 100%.

RESULTS

A total of 9 statements on scaffold-based therapies reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. One achieved unanimous support, 8 reached strong consensus (greater than 75% agreement), and 1 was removed because of redundancy in the information provided. All statements reached at least 80% agreement.

CONCLUSIONS

This international consensus derived from leaders in the field will assist clinicians with applying scaffold-based therapies as a treatment strategy for osteochondral lesions of the talus.

LEVEL OF EVIDENCE

Level V, expert opinion.

Debridement, Curettage, and Bone Marrow Stimulation: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle

BACKGROUND

The evidence supporting best practice guidelines in the field of cartilage repair of the ankle are based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions based on the best available evidence on key topics within cartilage repair of the ankle. The purpose of this article is to report the consensus statements on "Debridement, Curettage and Bone Marrow Stimulation" developed at the 2017 International Consensus Meeting on Cartilage Repair of the Ankle.

METHODS

Seventy-five international experts in cartilage repair of the ankle representing 25 countries and 1 territory were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 11 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; unanimous, 100%.

RESULTS

A total of 14 statements on debridement, curettage, and bone marrow stimulation reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. One achieved unanimous support, 12 reached strong consensus (greater than 75% agreement), and 1 achieved consensus. All statements reached at least 72% agreement.

CONCLUSIONS

This international consensus derived from leaders in the field will assist clinicians with debridement, curettage and bone marrow stimulation as a treatment strategy for osteochondral lesions of the talus.

Osteochondral Autograft: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle

BACKGROUND

Treatment guidelines for cartilage lesions of the talus have been based on both low quality and low levels of evidence. Therefore, an international consensus group of experts was convened to collaboratively advance toward consensus opinions on key topics regarding cartilage lesions of the talus. The purpose of this consensus article is to explain the process and delineate the consensus statements derived from this consensus meeting on the use of "osteochondral autograft" for osteochondral lesions of the talus.

METHODS

Seventy-five international experts in cartilage repair of the ankle representing 25 countries and 1 territory were convened and participated in a process based on the Delphi method of achieving consensus. Questions and statements were drafted within 11 working groups focusing on specific topics within cartilage repair of the ankle, after which a comprehensive literature review was performed and the available evidence for each statement was graded. Discussion and debate occurred in cases where statements were not agreed upon in unanimous fashion within the working groups. A final vote was then held, and the strength of consensus was characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; and unanimous, 100%.

RESULTS

A total of 14 statements on osteochondral autograft reached consensus during the 2017 International Consensus Meeting on Cartilage Repair of the Ankle. Two achieved unanimous support, 11 reached strong consensus (greater than 75% agreement), and 1 achieved consensus. All statements reached at least 67% agreement.

CONCLUSIONS

This international consensus derived from leaders in the field will assist clinicians with osteochondral autograft as a treatment strategy for osteochondral lesions of the talus.

Osteochondral Defects of the Talus: Current Management Dilemmas

Osteochondral defects or lesions of the talus represent a management challenge. Arthroscopic débridement is the treatment of choice for patients with an osteochondral lesion of the talus in whom nonsurgical treatment fails. Although surgeons have a better understanding of the risk factors for failed débridement in patients with an osteochondral lesion of the talus, the treatment of patients in whom a high risk for failed débridement exists and patients in whom débridement fails is controversial. Surgeons should understand the current adjunct therapies available for the management of osteochondral lesions of the talus, including cartilage preparations, platelet-rich plasma, bone marrow aspirate, bone graft or bone graft substitutes, and whole bone cartilage transfer (osteochondral autograft transfer); however, evidence for the use of one adjunct therapy more than another is lacking.

Arthroscopic anterior talofibular ligament repair for lateral instability of the ankle

Although several arthroscopic procedures for lateral ligament instability of the ankle have been reported recently, it is difficult to augment the reconstruction by arthroscopically tightening the inferior extensor retinaculum. There is also concern that when using the inferior extensor retinaculum, this is not strictly an anatomical repair since its calcaneal attachment is different to that of the calcaneofibular ligament. If a ligament repair is completed firmly, it is unnecessary to add argumentation with inferior extensor retinaculum. The authors describe a simplified technique, repair of the lateral ligament alone using a lasso-loop stitch, which avoids additionally tighten the inferior extensor retinaculum. In this paper, it is described an arthroscopic anterior talofibular ligament repair using lasso-loop stitch alone for lateral instability of the ankle that is likely safe for patients and minimal invasive.

LEVEL OF EVIDENCE

Therapeutic study, Level V.

Consensus in chronic ankle instability: aetiology, assessment, surgical indications and place for arthroscopy

Ankle sprains are the most common injuries sustained during sports activities. Most ankle sprains recover fully with non-operative treatment but 20-30% develop chronic ankle instability. Predicting which patients who sustain an ankle sprain will develop instability is difficult. This paper summarises a consensus on identifying which patients may require surgery, the optimal surgical intervention along with treatment of concomitant pathology given the evidence available today. It also discusses the role of arthroscopic treatment and the anatomical basis for individual procedures.

Surgical treatment of osteochondral lesions of the talus

When conservative treatment is unsuccessful, there are many surgical options to treat patients with symptomatic chronic osteochondral lesions of the talus. The chosen treatment depends on the patient's symptoms, clinical examination findings, preoperative imaging results, and whether prior surgery was unsuccessful. It is important to be aware of treatment alternatives such as marrow stimulation, osteochondral autograft or allograft plugs, autologous chondrocyte implantation, and newer techniques currently being investigated outside the United States.

Evidence-based indications for ankle arthroscopy

PURPOSE

The purpose of this study was to review the literature to provide a comprehensive description of the Level of Evidence available to support the surgical technique of ankle arthroscopy for the current generally accepted indications and assign a grade of recommendation for each of them.

METHODS

A comprehensive review of the literature was performed (in August 2008) by use of the PubMed database. The abstracts from these searches were reviewed to isolate literature that described therapeutic studies investigating the results of different ankle arthroscopic treatment techniques. All articles were reviewed and assigned a classification (I-IV) of Level of Evidence. An analysis of the literature reviewed was used to assign a grade of recommendation for each current generally accepted indication for ankle arthroscopy.

RESULTS

There exists fair evidence-based literature (grade B) to support a recommendation for the use of ankle arthroscopy for the treatment of ankle impingement and osteochondral lesions and for ankle arthrodesis. Ankle arthroscopy for ankle instability, septic arthritis, arthrofibrosis, and removal of loose bodies is supported with only poor-quality evidence (grade C). Treatment of ankle arthritis, excluding isolated bony impingement, is not effective and therefore this indication is not recommended (grade C against). Finally, there is insufficient evidence-based literature to support or refute the benefit of arthroscopy for the management of synovitis and fractures (grade I).

CONCLUSIONS

There exists adequate evidence-based literature to support the surgical technique of ankle arthroscopy for most current generally accepted indications; however, further studies in this area are needed.

LEVEL OF EVIDENCE

Level IV, systematic review.

Arthroscopic ankle arthrodesis

Surgical options are limited for the patient who has symptomatic severe ankle joint degeneration that is unresponsive to nonoperative treatment. Arthrodesis of the tibiotalar joint is a procedure that can produce a pain-free ankle that can withstand the rigors of daily life, even in a young, high-demand, working individual. Minimally invasive orthopedic techniques have been applied to ankle arthrodesis, and arthroscopic ankle fusion has been shown to be an effective technique to achieve tibiotalar arthrodesis, with high rates of fusion and low rates of complication. This article covers indications, contraindications, and procedural techniques for arthroscopic ankle arthrodesis. Results of arthroscopic versus open ankle arthrodesis are compared.

Arthroscopic ankle arthrodesis

The obvious socioeconomic advantages are quite dramatic, with early weight-bearing and AFO immobilization allowing patients an early return to work. Outpatient surgery is a cost-effective benefit. Patient satisfactions as well as comfort are greatly enhanced, requiring only oral pain medication. All patients have tolerated their postoperative regimen and same-day discharge. Arthroscopic subtalar arthrodesis is a technically demanding procedure that requires some rather advanced arthroscopic skills to perform. Joint access is tight, restricted, and requires small instrumentation. Deformities cannot be corrected; therefore, at this stage, a fusion in situ must be considered. The learning curve is certainly far steeper because of the smaller patient population available for enhancing surgical skills. Overall, this procedure has stood the test of time and follow-up. The results appear to be excellent in terms of patient satisfaction, fusion rate time until union, and postoperative morbidity. The recognition and enhancement of this technique as well as the development of more advanced technology will certainly allow this arthroscopic subtalar arthrodesis technique to mature even further over time.

Legg-Perthes disease in children under 6 years old

A roentgenographic review was made of 109 patients with unilateral Legg-Perthes disease, all of whom had experienced onset of symptoms prior to their sixth birthday. Roentgenograms taken at the time of healing and at final follow-up were grouped according to Catterall classification and modified Mose rating. The parameters measured were epiphyseal index, center-edge angle, extrusion index, epiphyseal quotient, and center-edge quotient. Average age at final follow-up was 12 years. A change in Mose rating between assessments at healing and final follow-up occurred in 16% of patients, with most of them showing improvement, supporting the concept that femoral heads in young children have the capacity to remodel. However, 24% of patients with Catterall III and IV disease had a poor result at final follow-up. Despite early onset of Legg-Perthes disease, patients with involvement of greater than half the femoral head are at risk for poor roentgenographic result.

Meniscoid lesions of the ankle

The frequent use of arthroscopy has increased the orthopedic community's awareness of meniscoid lesions of the ankle and its ability to treat these lesions. This article defines the pathologic lesion and reviews the literature and case reports.

Review article: metronidazole and the anaerobic gut flora

Metronidazole is a nitro-imidazole drug which was discovered nearly 30 years ago. Metronidazole has remained the mainstay of anti-anaerobic therapy following a change observation that its activity included anaerobic organisms. The predominant human reservoir of these anaerobic organisms is the gastrointestinal tract. In this review, the anaerobic flora and their pathogenic potential are described. The main characteristics of metronidazole and the role of selective decontamination of the gastrointestinal tract are also discussed.

Maternal origin of 15q11-13 deletions in Angelman syndrome suggests a role for genomic imprinting

Six persons with the classical Angelman syndrome (AS) phenotype and de novo deletions of chromosome 15q11-q13 were studied to determine the parental origin of the chromosome deletion. Four of the 6 patients had informative cytogenetic studies and all demonstrated maternal inheritance of the deletion. These findings, together with other reported cases of the origin of the chromosome 15 deletion in AS, suggest that deletion of the maternally contributed chromosome leads to the AS phenotype. This contrasts with the Prader-Willi syndrome (PWS) in which a similar deletion of the paternally contributed chromosome 15 is observed. In deletion cases, a parental gamete effect such as genomic imprinting may be the best model to explain why apparently identical 15q11-q13 deletions may develop the different phenotypes of AS or PWS.

Cytogenetic survey for autistic fragile X carriers in a mental retardation center

A cytogenetic survey of 67 individuals previously identified as having mental retardation and autistic behaviors revealed 1 person (1.5%) with the fragile X chromosome (fra[X]) and 3 (4.5%) with autosome abnormalities. This low prevalence of fra(X) indicates that most persons with fra(X) in this mental retardation center did not have autistic behaviors severe enough to be identified as a secondary psychiatric diagnosis. The presence of other chromosomal abnormalities is consistent with the known causal heterogeneity of autism in mental retardation populations.

Incidence of 15q deletions in the Angelman syndrome: a survey of twelve affected persons

Prometaphase chromosome study of 12 persons with an established diagnosis of the Angelman syndrome demonstrated that 5 had a 15q12 deletion appearing similar to that commonly observed in the Prader-Willi syndrome. Phenotype-karyotype correlation did not show any obvious clinical differences between those with and those without the deletion and no clinical overlap between Angelman and Prader-Willi syndrome was apparent. Our survey suggests that 15q12 deletions are frequent in Angelman syndrome but presence of the deletion does not appear to distinguish different clinical phenotypes. Experience with the cytogenetic study of Prader-Willi syndrome predicts that considerable complexity will emerge between the presence of 15 chromosome abnormalities and clinical expression of Angelman syndrome.

Cefixime, in-vitro activity, pharmacokinetics and tissue penetration

The in-vitro activity of cefixime was studied with clinical isolates and compared with that of other agents. Cefixime exhibited good activity against the Enterobacteriaceae, Haemophilus influenzae, and Neisseria gonorrhoeae, including beta-lactamase producing strains. Activity was also high against Streptococcus pneumoniae and group A and group B beta-haemolytic streptococci. Staphylococcus aureus, faecal streptococci, anaerobic bacteria and Pseudomonas aeruginosa were not susceptible. Activity against susceptible isolates was comparable to cefotaxime and was normally superior to cefuroxime, cephalexin and amoxycillin. The pharmacokinetics of cefixime were studied in six healthy male volunteers, each receiving a 400 mg oral dose following an overnight fast. Tissue penetration of the antibiotic was estimated with a cantharides-induced blister method. The mean serum elimination half-life was 3.8 h, the mean peak concentration was 3.7 mg/l. Penetration into tissue fluid was rather slow [Tmax 6.7 h) but percentage penetration was high (132.6%). Urinary excretion was low with a 24 h recovery rate of less than 20%, though the concentrations achieved in urine exceeded the MICs of most common urinary tract pathogens for up to 24 h post-dose.

Pharmacokinetics and tissue penetration of orally administered lomefloxacin

The pharmacokinetics of the quinolone lomefloxacin were determined following a single 400-mg oral dose given to each of six male volunteers. Concentrations in serum, urine, and cantharidin-induced inflammatory fluid were determined by a microbiological assay. Samples from two volunteers were also assayed by high-performance liquid chromatography. The mean peak level in serum, 4.7 micrograms/ml, was attained within 1 h of administration. The mean elimination half-life from serum was 7 h. Inflammatory fluid was penetrated rapidly, with a mean peak level of 3.5 micrograms/ml occurring after 2.7 h. The mean recovery of lomefloxacin from urine over 48 h was 76% of the administered dose. There was a minor peak on the high-performance liquid chromatography trace, suggesting a small amount of unidentified metabolite. This was present only in urine; no detectable metabolites were found in serum. This study suggests that either once-daily or twice-daily dosage of lomefloxacin should be sufficient to treat urinary or systemic infections, respectively, caused by susceptible pathogens.

Diagnosing Pneumocystis carinii pneumonia by cytological examination of bronchoalveolar lavage fluid: report of 15 cases

Sixty episodes of pneumonia occurring in 53 immunosuppressed patients were investigated by bronchoalveolar lavage. Pneumocystis carinii was diagnosed on 15 (25%) occasions. In all cases the Papanicolaou stained lavage fluid presented a distinctive appearance and contained abundant, often biphasic, staining, "honeycomb" debris, and few alveolar macrophages. The Grocott methenamine silver technique confirmed the presence of characteristic cystic organisms in the debris in all 15 instances. Cysts containing internal sporozoites were identified in Gram stained material only with difficulty. Neither May-Grünwald-Giemsa stain nor fluorescence microscopy under ultraviolet light were effective for routine investigation.

New antimicrobials

Two groups of compounds, the beta-lactams and the quinolones, account for the main developments in antimicrobials in the last 5 years. Efforts to overcome emerging problems of resistance and to broaden further the spectrum of similar existing agents have been the main impetus to the pharmaceutical industry, though some compounds have also been developed with a narrow spectrum intended for specific pathogens. This article reviews antibiotics that have recently become available in the UK and also discusses compounds that are undergoing clinical trials at present.

Current problems of chemotherapy of infections with coagulase-negative staphylococci

A review is given of current problems in the chemotherapy of infections caused by coagulase-negative staphylococci. Along with the recent increase in the number of these infections has come the realisation that such infections may be difficult to treat. The sites of infection caused by coagulase-negative staphylococci are considered and recent advances in the understanding of the molecular biology of these organisms reviewed. Appropriate antibiotic therapy for individual infections is discussed, likewise the contribution the laboratory can make to ensure that the most effective antibiotics are used.

Investigation of an outbreak of infection with Acinetobacter calcoaceticus in a special care baby unit

During a period of 6 months, an 'epidemic strain' of Acinetobacter calcoaceticus was isolated from 10 pre-term neonates in a special care baby unit (scbu). Of these, nine had pulmonary infections. The tenth was found to have conjunctival colonization only. The 'epidemic strain' was characterized by serotyping, biotyping, bacteriocin typing and antibiograms. An identical strain was isolated from an 'Ambu' resuscitation device but not from other environmental samples or from staff on the unit. The outbreak ceased after the colonized resuscitator was removed and an appropriate disinfection policy implemented for the replacement resuscitators.

External rhinoplasty

The external rhinoplasty approach extends the usual marginal nasal incisions to include a notched transcolumellar incision. This maneuver enhances surgical exposure for the analysis and correction of all types of nasal bone, nasal septum and nasal cartilage deformities. Nasal septal perforation, nasal bone grafting and hypophysectomy my be operated upon through this excellent avenue of exposure.

Larynx injected with polytef paste

A patient with inoperable lung cancer developed left-sided laryngeal paralysis. Her dysphonia, difficulty with swallowing, aspiration of secretions, and diminished cough reflex were improved with intracordal polytef injection for the remainder of her life. The foreign body reaction to the implant showed giant cells, few lymphocytes, and no polymorphonuclear leukocytes. This reaction may be described as a bland, chronic type consistent with the age of the implant. No areas of florid, acute reaction were found. Extrusion of part of the polytef through the cricothyroid space was observed. There were no signs of unfavorable tissue reaction, intolerance, or carcinogenicity. In a second case, part of the polytef paste exuded over the thyroid gland and was misinterpreted as a thyroid nodule. Excised 11 months after injection, the foreign body reaction appeared to be of a more acute type.