Clinical/otologic score before and during treatment of acute otitis media.

OBJECTIVES: To determine clinical characteristics of AOM at presentation and during therapy according to specific etiologies. PATIENTS AND METHODS: 1003 patients studied during 1996-2001 in antibiotic efficacy studies underwent tympanocentesis and middle ear fluid culture at enrollment and on Day 4-6 (in initially culture-positive patients only). We used a clinical/otologic (CO) score for evaluating severity of fever, irritability and tympanic membrane redness and bulging (0-3 each parameter, maximal score=12). RESULTS: Seven hundred sixty-three patients had positive cultures with 392 (39%) Haemophilus influenzae, 198 (20%) Streptococcus pneumoniae and 173 (17%) mixed H. influenzae and S. pneumoniae infection. Mean CO score was higher in culture-positive versus culture-negative patients (8.21+/-2.17 vs. 7.73+/-2.32, p=0.003) regardless of isolated organism. A marked improvement in CO score was observed on Day 4-6 in all patients: 1.83+/-2.18 in children initially culture-positive and 0.9+/-1.67 in those initially culture-negative (p<0.001). The improvement was greater in patients with eradication versus those with bacteriological failure (CO score 1.52+/-1.82 vs. 2.77+/-2.85, p<0.001). CONCLUSIONS: CO score before treatment, after bacterial eradication or in bacteriologic failures are similar in bacterial AOM and are not predictive of the etiology of the disease.

Cerebral venous sinus surgery for epilepsy 60 years ago.

The recent singular advances in the past 20 years in the medical and surgical treatment for epilepsy stand in marked contrast to the limited therapeutic methods available earlier in this century. George W. Swift, MD, one of the earliest neurosurgeons in Seattle, Wash, interpreted the anatomic and physiologic data of his time and concluded that impaired cerebral venous blood flow was responsible for recurrent seizures. Accordingly, he advocated and practiced decompression of the transverse sinuses. Although his operation was not practiced by his peers, a review of this procedure provides a past perspective of earlier advances and therapies for epilepsy.

Spinal cord infarction.

Spinal cord infarction occurs infrequently and may have diverse causes. It is necessary to establish whether an intrinsic or extrinsic lesion is responsible for the impaired cord function. Although therapy is limited at this time, the long-term prognosis is not necessarily unfavorable.

Benefits, shortcomings, and costs of EEG monitoring.

A 5-year experience with 562 carotid endarterectomies, using electroencephalogram (EEG) monitoring and selective shunting, was reviewed. EEG changes occurred in 102 patients (18%). The frequency of EEG changes, as related to cerebral vascular symptoms, was as follows: transient ischemic attacks, seven per cent (19/259); completed strokes, 37% (36/98); vertebral basilar insufficiency, 24% (32/135); asymptomatic, 21% (15/71). Patients with contralateral carotid occlusion exhibited EEG changes in 37% (28/76) of operations. Fifteen patients suffered perioperative strokes (2.6%). Nine of the 15 were associated with a technical problem of either thrombosis of the internal carotid artery (five) or emboli (four). Technical problems were more common when shunts were used (five per cent) than when they were not (0.9%). Patients who suffered strokes prior to surgery were more at risk to develop a perioperative stroke (three per cent) than those not suffering prior strokes (0.3%). The EEG did not change in three patients who had lacunar infarcts prior to surgery and who awoke with a worsened deficit. Our series does not clearly establish the advantages of EEG monitoring, which is expensive (+375/patient) and may not detect ischemia in all areas of the brain. However, the use of shunts may introduce a risk of stroke due to technical error that is equal or greater than the risk of stroke due to hemodynamic ischemia. Since the need for protection is unpredictable by angiographic or clinical criteria, the benefit of EEG monitoring may be in reducing the incidence of shunting in those patients whose tracing remains normal after clamping. The decision to shunt, however, when there is electrical dysfunction after carotid clamping should be based not only on the EEG but also on the clinical signs and computed tomography (CT) scan. Our data does not show a net benefit in selective shunting unless the patient has sustained a stroke prior to surgery.

[Late cerebral radionecrosis after conventional irradiation of cerebral tumors]. / Radionécrose cérébrale tardive après irradiation conventionnelle des tumeurs cérébrales.

It is recognized that excessive irradiation for extra and intracranial tumor may be followed by delayed radiation necrosis of the brain. In recent years this untoward response has also been observed after conventional radiation therapy. Three patients are reported who had this irradiation complication. One had been treated for an ethmoidal sinus adenocarcinoma and another had a craniopharyngioma. The third had an astrocytoma of the pons. All developed their symptoms about a year after irradiation. Marked clinical deterioration of two patients was accompanied by brain edema and shift of midline structures. The patient who had received irradiation for ethmoidal adenocarcinoma was successfully treated by decompression and removal of the necrotic brain tissue. A later episode of recurrence of symptoms was treated successfully with prednisone. A similar favorable response with steroid therapy was evident in the patient who had x-ray therapy for craniopharyngioma. The third patient who had a pontine astrocytoma developed a leukoencephalopathy and severe changes in blood brain barrier function before her death. Pathologic changes were most profound in the white matter where a heterogeneous necrosis was encountered. In areas of severe necrosis no axis cylinders were present. Macrophages were rarely noted. Vascular changes were marked and consisted of endothelial hypertrophy, hyperplasia and neovascularization. Alterations in immunity, oligodendrocyte function and vascular changes have been independently evoked as possible causes of delayed radiation necrosis of brain. None of these alone however appears sufficient to account for the severe white matter reaction which may be delayed for years.(ABSTRACT TRUNCATED AT 250 WORDS)

Ocular bobbing in encephalitis.

Abnormal eye movements described as ocular bobbing are most often encountered in the setting of pontine vascular disease. This report deals wih the onset and course of ocular bobbing in a young woman who had encephalitis confirmed by biopsy. Unusual eye movements developed during progressive deterioration of brain and brain stem function which led to coma. The eye movements occurred spontaneously and could also be triggered by cutaneous stimulation of the face, head, extremities, and auditory canals. The patient recovered fully over a period of several months.

Dejerine-Sottas disease revisited.

The fundamental clinical and pathologic findings associated with Dejerine-Sottas disease were reported in a series of three communications at the turn of the century. The salient pathologic observations made at that time regarding the characteristics of hypertrophic neuropathy occurring in infancy are recalled and reviewed in light of more recent studies.

Pain perception: modification of threshold of intolerance and cortical potentials by cutaneous stimulation.

Cutaneous electrical stimulation temporarily raises the threshold of intolerance for pain elicited by electric shock. Similar stimulation suppresses the somatosensory cortical evoked potential.