Osteochondritis dissecans: a diagnosis not to miss.

Osteochondritis dissecans is the most common cause of a loose body in the joint space in adolescent patients. Because clinical findings are often subtle, diagnosis requires a high index of suspicion. Limited range of motion may be the only notable clinical sign. The diagnosis is made by radiographic examination, and magnetic resonance imaging has a key role in determining the stability of the lesion. Conservative management is the mainstay of treatment for stable lesions. While the majority of patients respond to conservative treatment, those with unstable lesions require arthroscopic management.

Caring for patients with HIV disease: the experience of a generic hospice.

This study describes the experience of a generic hospice admitting people with advanced HIV disease over a 4-year period. Data were collected retrospectively for all patients with HIV disease admitted. The aim of the study was to review the number of referrals, the reason for referral, subsequent symptom control and multidisciplinary team involvement together with the outcome for these patients. Twenty-six patients were admitted for the first time. Two patients were female, 24 were male; median age was 36 years (range 25-58 years). Hospitals referred more patients than general practitioners (18 (70%) and 5 (20%) respectively), but most were from non-HIV specialist areas within hospitals (11 (42%)). The commonest reason for referral was locality, particularly in terms of ease of access. The most prevalent symptoms on admission were weakness, immobility and weight loss (77%, 73% and 62% respectively). These were not improved during admission. There was significant improvement in the control of other symptoms including pain, gastrointestinal disturbance, confusion and dyspnoea. Use of the full multidisciplinary team was high. Median length of stay was 19 days (range 1-77 days). Seventeen patients (65%) died on their first admission. This study confirms the high prevalence of symptomatology among patients with HIV disease. Many generic hospices can offer skilled multidisciplinary symptom control and psychosocial care, complementing other HIV specialist services. It is important that patients with HIV disease and specialist health care professionals working in the HIV field are made aware of what generic hospices are able to offer so that patients can make informed choices about their care.

Correlates of anesthetic properties in isolated spinal cord: cyclobutanes.

Two halogenated cyclobutanes, one anesthetic and one not, were compared on receptor-specific pathways in isolated neonatal rat spinal cord. The anesthetic 1-chloro-1,2,2-trifluorocyclobutane depressed the monosynaptic reflex (glutamate non-NMDA receptors) and abolished a slow ventral root potential (glutamate NMDA, non-NMDA and tachykinin receptors). This compound slightly enhanced the muscimol-evoked dorsal root potential (GABAA) but reversibly depressed the dorsal root potential elicited by dorsal root stimulation. The non-anesthetic 1,2-dichlorohexafluorocyclobutane increased monosynaptic reflex, depressed slow ventral root potential approximately 50%, had little effect on muscimol-evoked dorsal root potential, and irreversibly depressed dorsal root-evoked dorsal root potential. Hypoxia accounts for slow ventral root potential depression, but not monosynaptic reflex enhancement. In this preparation and for this pair of compounds, anesthetic properties are related to blockade of transmission at glutamate synapses, with a small component of GABAA enhancement. Monosynaptic reflex increase may be related to the non-anesthetic cyclobutane's convulsant and anti-anesthetic properties.

Propofol and barbiturate depression of spinal nociceptive neurotransmission.

Barbiturates are often described as non-analgesic or even hyperalgesic agents; the newer intravenous anesthetic agent propofol is said to be non-analgesic. Both propofol and barbiturates occupy sites on the GABAA receptor. The present study was designed to compare the effects of propofol and barbiturates on nociceptive-related neurotransmission in neonatal rat spinal cord; to search for actions that might be hyperalgesic; and to determine the extent to which propofol depression of nociceptive neurotransmission is mediated by GABAA receptors. The monosynaptic reflex, a slow ventral root potential (slow VRP) and the dorsal root potential (DRP) were recorded from isolated neonatal (1-5 days old) superfused rat spinal cords in response to electrical stimulation of a lumbar dorsal root. The slow VRP and the DRP are related to nociception. Propofol (0.5-10 microM), pentobarbital (1-10 microM), and thiopental (1-10 microM) reversibly depressed the slow VRP. Dose-response curves were monophasic and linear over this range. The monosynaptic reflex was unaffected. The GABAA agonist muscimol (0.2-1 microM) also depressed the slow VRP. Propofol and barbiturate slow VRP depression was antagonized by the GABAA antagonist bicuculline (1 microM). Propofol depressed the response evoked by direct application of substance P. The DRP is a GABAA-mediated depolarization of primary afferent nerve terminals that diminishes the effectiveness of nociceptive input. Propofol and thiopental increased electrically evoked DRP amplitude and increased the DRP evoked by application of muscimol. Both propofol and barbiturates thus depressed the nociceptive-related slow VRP and enhanced the antinociceptive DRP; their effective concentrations are at or close to the general anesthetic range for these agents. No anti-analgesic or hyperalgesic effect was observed. (ABSTRACT TRUNCATED AT 250 WORDS)

Substance P and NMDA receptor-mediated slow potentials in neonatal rat spinal cord: age-related changes.

Slow ventral root potentials (slow VRP's) recorded from 1- to 5-day-old rat spinal cords are implicated in nociception, but there is controversy over their origin and persistence in the adult. The present study investigated changes in the role of substance P and NMDA receptors in slow VRP generation during the postnatal period (1-21 days). Through 9 days, dorsal root stimulation elicits slow VRP's with typical peak amplitudes at 3-4 s, decay time constants of 18-20 s, and durations > 20 s. After 11 days, peak amplitude shortens to < 1 s, decay time constant 4-5 s, and duration < 10 s. At 1-6 days, slow VRP's are sensitive to the NMDA receptor antagonist APV and the substance P antagonists spantide and CP 96,345. After 11 days, APV sensitivity is retained, but spantide and ability of substance P to evoke a response are diminished. Abbreviated slow VRP's in post-11-day spinal cords appear to correspond to the early APV-sensitive component of long-duration slow VRP's in younger animals. Attempts to restore long-duration slow VRP's in 12- to 14-day-old rat cords by blocking various inhibitory mechanisms were not successful. The results suggest that a substance P response, some of which is mediated by NK1 receptors, is lost with maturation of the cord. Either a developmental role played by substance P changes with maturity, or the motor neurons of the isolated post-11-day cord lose the capacity to sustain large long-duration plateau potentials.