Role of mastoid pneumatization in temporal bone fractures.

BACKGROUND AND PURPOSE: The mastoid portion of the temporal bone has multiple functional roles in the organism, including regulation of pressure in the middle ear and protection of the inner ear. We investigated whether mastoid pneumatization plays a role in the protection of vital structures in the temporal bone during direct lateral trauma. MATERIAL AND METHODS: The study was performed on 20 human temporal bones isolated from cadavers. In the study group formed by 10 temporal bone samples, mastoid cells were removed and the resulting neocavities were filled. The mastoids were maintained intact in the control group. All samples were impacted at the same speed and kinetic energy. The resultant temporal bone fractures were evaluated by CT. RESULTS: Temporal squama fractures were 2.88 times more frequent, and mastoid fractures were 2.76 times more frequent in the study group. Facial nerve canal fractures were 6 times more frequent in the study group and involved all the segments of the facial nerve. Carotid canal fractures and jugular foramen fractures were 2.33 and 2.5 times, respectively, more frequent in the study group. CONCLUSIONS: The mastoid portion of the temporal bone plays a role in the absorption and dispersion of kinetic energy during direct lateral trauma to the temporal bone, reducing the incidence of fracture in the setting of direct trauma.

Severe heart disease complicating pregnancy does not preclude a favourable pregnancy outcome: 15 years' experience in a single centre.

Heart disease (HD) in pregnancy remains a major cause of non-obstetric maternal and neonatal mortality and morbidity. This study describes the outcome in 164 pregnant women with HD (158 deliveries in women in New York Heart Association (NYHA) Classes 1 and 2; 17 in NYHA Classes 3 and 4) who received good antenatal care and benefitted from a specific protocol and experience of a dedicated staff. There were no maternal or neonatal deaths; 46 women were diagnosed peripartum. Based on a sub-division into NYHA categories, and when sub-divided by HD, there were no statistically significant differences between groups with regard to maternal age, gestational age at admission or at delivery, birth weight, 5 min Apgar scores, mode of delivery (caesarean delivery), senior obstetric/anaesthesiology staff in attendance or delivery during day/working hours. There was a higher incidence of pre-term deliveries in women with rheumatic heart disease and Marfan syndrome (p = 0.06) relative to others. Babies of women with coronary heart disease had prolonged postpartum course in the NICU (p = 0.0001) and longer total hospital stays for the mother. In conclusion, well-managed, motivated mothers with HD who benefit from comprehensive antenatal care, and are managed primarily by their obstetric and anaesthesia teams, can aspire to a good outcome for themselves and their babies.

Spontaneous external fistula of a hydatid liver cyst in a diabetic patient.

BACKGROUND: The liver is the most common site of hydatid disease. Complications like cyst rupture and infection may occur, sites of rupture including: bile ducts, gastrointestinal tract, bronchi, peritoneal and pleural cavity. Rupture into the subcutaneous tissue followed by external fistula is an extremely rare complication. CASE REPORT: A 71-year-old diabetic woman was referred for a progressive growing mass in the right hypochondrium, with a central fistula draining clear liquid with cystic elements and white membranes. No history of fever or jaundice was present. Abdominal ultrasound (followed by CT scan) revealed a liver hydatid cyst in the right lobe, in contact with the anterior abdominal wall, and a parietal fistula track. Cystic fluid exam showed protoscolices and serological ELISA test was positive for hydatid disease. At surgery, the lesion was approached through an incision starting from the fistula site. Partial cystectomy and external drainage of the residual cavity were performed. The fistula track was totally resected. After an uneventful recovery and six months of anti - parasitic treatment, the patient is symptoms- free (3 years after surgery). CONCLUSIONS: Spontaneous cyst-cutaneous fistula is an extremely rare complication of hydatid liver cyst, usually occurring silently, in elder people. Surgery is required to achieve complete evacuation of the cyst contents and resolution of the residual cavity. To the best of our knowledge, this is the seventh case published, and the first one in the Romanian literature.

Klebsiella bacteraemia: community versus nosocomial infection.

In the period 1988-1993, 241 patients had Klebsiella bacteraemia at our medical centre. The annual number of patients with positive blood cultures increased from 306 in 1988 to 622 in 1993, representing a 4.5-6% positivity rate of drawn cultures. After E. coli, Klebsiella was the leading cause of Gram-negative bacteraemia. During this period, the absolute number of Klebsiella bacteraemia increased from 25 in 1988 to 84 in 1993; this represents a true increase in Klebsiellaa bacteraemia, from 6-7% of positive cultures in the late 1980s to 12-13% in more recent years. There were 210 cases with K. pneumoniae and 31 with K. oxytoca. A representative sample of 80 records was retrieved and subdivided into two groups: community-acquired Klebsiella bacteraemia (CAKB) vs. hospital-acquired Klebsiella bacteraemia (HAKB). Urinary tract infection was the underlying source of 58% of CAKB vs 28% of HAKB (p < 0.01); pneumonia occurred significantly more often in HAKB (25%) than in CAKB (7%) (p < 0.01). In HAKB, as compared to CAKB, serious manifestations of illness were more common, e.g. shock (65% vs. 37%, p < 0.046) and respiratory failure (45% vs. 20%, p < 0.046). Overall mortality was 32%, 22% of patients with CAKB died vs. 42% of those with HAKB (p < 0.05). Multiple drug resistance was very common: only 57% of all Klebsiella strains were susceptible to gentamicin, 66% to ceftriaxone, 70% to ciprofloxacin, and 83% to amikacin. The susceptibility rates of Klebsiella spp isolated from patients with HAKB were significantly lower (p < 0.001). Sepsis due to multiple-drug-resistant Klebsiellaa has become frequent, carrying significant morbidity and mortality. Restriction of broad-spectrum antimicrobials in the hospital and the community as well as implementation of infection control measures are needed to contain this problem.