Role of surgery in the management of otogenic meningitis.

Meningitis is a life-threatening complication of otitis media. The appropriate management and the role of surgical intervention are still controversial, and there are no evidence-based guidelines in this regard. We report three cases of otogenic meningitis, initially treated with parenteral antibiotics and myringotomy, followed by surgery. Two patients had an emergency mastoidectomy and one patient underwent surgery one month post-recovery due to the suspicion of bone erosion on a computed tomography scan. In two cases, a canal wall up procedure was performed, and one patient underwent revision of a radical mastoidectomy. In all cases, no pus or granulations were seen in the mastoid. Two patients fully recovered and one patient died. We review the literature and critically discuss the role, timing and preferred type of surgery for otogenic meningitis.

[Fournier's gangrene as a delayed complication of closed hemorrhoidectomy].

BACKGROUND: Fournier's gangrene is recognized as a synergistic necrotizing fasciitis of the perineum and abdominal wall along with the scrotum and penis in men and the vulva in women. The major sources of Fournier's Gangrene are dermatologic, anorectal and genitourinary infections. Although anorectum is remarkably rich in bacterial flora, transanal procedures are generally free of infectious or septic complications. Nevertheless, five cases of Fournier's gangrene post hemorrhoidectomy have been published. OBJECTIVE: To report a case of Fournier's gangrene as a delayed complication of closed hemorrhoidectomy and to demonstrate the management of such complication. PATIENT: A sixty-six years old male who had undergone an uncomplicated closed hemorrhoidectomy was readmitted to the hospital on postoperative day 7 for fever, perirectal erythema and tenderness accompanied by a dirty brown discharge from the wound. The patient was treated with fluid resuscitation and broad-spectrum antibiotics. Radical debridement of the perianal and scrotal region was performed accompanied by diverting colostomy. Four months later a reconstruction of the perianal area was performed by meshed split thickness skin graft and the colostomy was closed. CONCLUSIONS: Fournier's gangrene is a rare immediate or delayed complication of hemorrhoidectomy. A review of the limited available literature suggests that neither the surgical technique nor the medical history of the patient have an influence on the development of such a rare and fatal complication.

Right-left correlation of the sympathetically induced fluctuations of photoplethysmographic signal in diabetic and non-diabetic subjects.

Photoplethysmography (PPG) records the cardiac-induced changes in tissue blood volume by light-transmission measurements. The baseline and amplitude of the PPG signal show very low-frequency (VLF) spontaneous fluctuations, which are mediated by the sympathetic nervous system, and high correlation between right and left extremities of healthy subjects. As sympathetic neuropathy is one of the diabetic complications, the right-left correlation of the PPG fluctuations was examined in diabetic patients. The PPG signal was simultaneously measured in the two index fingers and the two second toes of 35 diabetic patients and 33 non-diabetic subjects. For each PPG pulse, the baseline and amplitude were determined, and the right-left correlation coefficients of the VLF fluctuations in the baseline and amplitude were derived. The VLF fluctuations in the baseline showed high right-left correlation, both for fingers (0.93 +/- 0.05) and toes (0.93 +/- 0.06), for the non-diabetic subjects, and significantly lower correlation (0.78 +/- 0.22 and 0.84 +/- 0.17, respectively) for the diabetic patients. Similar results were obtained for the amplitude VLF fluctuations. The right-left correlation coefficients for diabetic patients decreased with the disease duration for the toe baseline and toe amplitude fluctuations and correlated with heart rate response to deep breathing for the finger baseline and toe amplitude fluctuations. The right-left correlation coefficients of the PPG fluctuations provide a simple and convenient means for assessing the adequacy of the sympathetic nervous system function.

Acute mastoiditis in infancy: the Soroka experience: 1990-2000.

UNLABELLED: Acute mastoiditis (AM) is an uncommon but serious complication of acute otitis media (AOM). In the pre-antibiotic era, AM was seen more frequently than it is today, but it was rare in infants. However, in the last two decades an increase in the incidence of AM in infancy has been reported in the literature. During the years 1990-2002, we treated 113 patients with 128 episodes of AM; of them, 24 were infants (median age 6 months; 18 males) who suffered from 26 episodes of AM. Twenty developed AM as a complication of their first episode of AOM. One of the four infants with a prior history of AOM suffered from common variable immunodeficiency. A significant increase in the incidence of AM in infants was recorded during the study period (P = 0.01). The most common presenting clinical signs were post-auricular swelling and fever >38 degrees C (77% and 77%, respectively, of all patients). Seventeen episodes of AM were not treated with prior antibiotics. Tympanocentesis was performed in all episodes of AM. Middle ear fluid culture was positive in 17 (65%) of the 26 AM episodes. The most common pathogens cultured were Streptococcus pneumoniae (10 infants, 58% of all pathogens, 3/10 intermediately susceptible to penicillin) followed by Streptococcus pyogenes (4, 23%), non-typable H. influenzae (2, 12%) and S. aureus (1, 6%). Temporal bone CT showed bone destruction in 14 patients; 3 infants had subperiosteal abscesses and 3 lateral sinus thrombosis. Ten infants underwent mastoid surgery due to non-resolution of symptoms and signs with antibiotic therapy. Eight underwent cortical mastoidectomy with two patients undergoing ventilation tube introduction only. The remainder of the infants healed with conservative treatment. CONCLUSIONS: (1) A significant increase in the incidence of AM in infants was recorded over the last decade, though a specific reason for this trend remains uncertain; (2) Most of the cases of AM followed the infant's initial AOM episode, and most of the infants had not received prior antibiotic therapy; (3) The clinical signs and symptoms of AM were more severe in infants than in older patients; (4) While S. pneumonia was the most common pathogen isolated in middle ear fluid cultures, the involvement of S. pyogenes in AM was higher than that reported in AOM.

Sympathetically induced spontaneous fluctuations of the photoplethysmographic signal.

The photoplethysmographic signal shows very low-frequency (VLF) spontaneous fluctuations that have been shown to be mediated by the sympathetic nervous system. In the current study, the photoplethysmographic signal was simultaneously measured in the two index fingers and the two second toes of 54 healthy male subjects. For each photoplethysmographic pulse, two parameters were derived: the pulse amplitude and its baseline, which are related to the arterial wall compliance and to the arterial blood volume, respectively. The baseline and the amplitude VLF fluctuations showed high right-left correlation both for hands (mean +/- SD 0.94 +/- 0.05 and 0.92 +/- 0.07, respectively) and for feet (0.90 +/- 0.08 and 0.89 +/- 0.07, respectively) that only slightly depended on the subject's age. Lower correlation was found between the hand and the foot (0.73 +/- 0.12 and 0.72 +/- 0.12 for the baseline and the amplitude, respectively). For each hand and foot the baseline and the amplitude VLF fluctuations were also correlated, with the baseline fluctuations lagging the amplitude fluctuations by 3-20 pulses. The amplitude-baseline correlation and the standard deviation of the amplitude or the baseline divided by its mean significantly decreased with age. The VLF fluctuations of the photoplethysmographic parameters and the correlation coefficients between them provide better understanding of the autonomic nervous regulation of the blood circulation.

The difference in pulse transit time to the toe and finger measured by photoplethysmography.

Blood pressure pulse wave velocity (PWV) is a parameter which is related to arterial distensibility. Its direct assessment, by measuring the appearance time of a pressure pulse in two sites along an artery and the distance between the two sites, is complicated and inaccurate. In the current study, pulse transit time (PTT) to the toes and fingers of 44 normotensive male subjects was measured by photoplethysmography (PPG) and ECG. The arrival time of the pulses at the toe and finger was determined from the foot of the systolic rise of the PPG signal, i.e. at end-diastolic time. Two parameters, which are related to PWV, were tested: the time delay between the ECG R-wave and the arrival time of the pulses at the toe (E-T PTT), and the difference in the transit time of the blood pressure pulses between the toe and finger (T-F PTTD). E-T PTT and T-F PTTD decreased as functions of the subject's age and systolic blood pressure (SBP), but their dependence on the diastolic blood pressure (DBP) was not statistically significant. The decrease of the PTT parameters with age is attributed to the direct structural decrease of the arterial compliance with age and not to functional effects associated with the increase of the blood pressure with age, since the PTT parameters did not depend on DBP though the measurements were performed at end-diastole.