When all computers shut down: the clinical impact of a major cyber-attack on a general hospital.

Importance: Healthcare organizations operate in a data-rich environment and depend on digital computerized systems; thus, they may be exposed to cyber threats. Indeed, one of the most vulnerable sectors to hacks and malware is healthcare. However, the impact of cyberattacks on healthcare organizations remains under-investigated. Objective: This study aims to describe a major attack on an entire medical center that resulted in a complete shutdown of all computer systems and to identify the critical actions required to resume regular operations. Setting: This study was conducted on a public, general, and acute care referral university teaching hospital. Methods: We report the different recovery measures on various hospital clinical activities and their impact on clinical work. Results: The system malfunction of hospital computers did not reduce the number of heart catheterizations, births, or outpatient clinic visits. However, a sharp drop in surgical activities, emergency room visits, and total hospital occupancy was observed immediately and during the first postattack week. A gradual increase in all clinical activities was detected starting in the second week after the attack, with a significant increase of 30% associated with the restoration of the electronic medical records (EMR) and laboratory module and a 50% increase associated with the return of the imaging module archiving. One limitation of the present study is that, due to its retrospective design, there were no data regarding the number of elective internal care hospitalizations that were considered crucial. Conclusions and relevance: The risk of ransomware cyberattacks is growing. Healthcare systems at all levels of the hospital should be aware of this threat and implement protocols should this catastrophic event occur. Careful evaluation of steady computer system recovery weekly enables vital hospital function, even under a major cyberattack. The restoration of EMR, laboratory systems, and imaging archiving modules was found to be the most significant factor that allowed the return to normal clinical hospital work.

International registry on aortic balloon occlusion in major trauma: Partial inflation does not improve outcomes in abdominal trauma.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a method for temporary hemorrhage control used in haemodynamically unwell patients with severe bleeding. In haemodynamically unwell abdominal trauma patients, laparotomy remains the initial procedure of choice. Using REBOA in patients as a bridge to laparotomy is a novel option whose feasibility and efficacy remain unclear. We aimed to assess the clinical outcome in patients with abdominal injury who underwent both REBOA placement and laparotomy. METHODS: This is a retrospective study, including trauma patients with an isolated abdominal injury who underwent both REBOA placement and laparotomy, during the period 2011-2019. All data were collected via the Aortic Balloon Occlusion Trauma Registry database. RESULTS: One hundred and three patients were included in this study. The main mechanism of trauma was blunt injury (62.1%) and the median injury severity score (ISS) was 33 (14-74). Renal failure and multi-organ dysfunction syndrome (MODS) occurred in 15.5% and 35% of patients, respectively. Overall, 30-day mortality was 50.5%. Post balloon inflation systolic blood pressure (SBP) >80 mmHg was associated with lower 24-h mortality (p = 0.007). No differences in mortality were found among patients who underwent partial occlusion vs. total occlusion of the aorta. CONCLUSIONS: Our results support the feasibility of REBOA use in patients with isolated abdominal injury, with survival rates similar to previous reports for haemodynamically unstable abdominal trauma patients. Post-balloon inflation SBP >80 mmHg was associated with a significant reduction in 24-h mortality rates, but not 30-day mortality. Total aortic occlusion was not associated with increased mortality, MODS, and complication rates compared with partial occlusion.

When the lights go down in the delivery room: Lessons from a ransomware attack.

OBJECTIVE: To describe the challenges facing the obstetric division following a cyberattack and discuss ways of preparing for and overcoming another one. METHODS: A retrospective descriptive study conducted in a mid-sized medical center. Division activities, including the number of deliveries, cesarean sections, emergency room visits, admissions, maternal-fetal medicine department occupancy, and ambulatory encounters, from 2 weeks before the attack to 8 weeks following it (a total of 11 weeks), were compared with the retrospective period in 2019 (pre-COVID-19). In addition, we present the challenges and adaptation measures taken at the division and hospital levels leading up to the resumption of full division activity. RESULTS: On the day of the cyberattack, critical decisions were made. The media announced the event, calling on patients not to come to our hospital. Also, all elective activities other than cesarean deliveries were stopped. The number of deliveries, admissions, and both emergency room and ambulatory clinic visits decreased by 5%-10% overall for 11 weeks, reflecting the decrease in division activity. Nevertheless, in all stations, there were sufficient activities and adaptation measures to ensure patient safety, decision-making, and workflow of patients were accounted for. CONCLUSIONS: The risk of ransomware cyberattacks is growing. Healthcare systems at all levels should recognize this threat and have protocols for dealing with them once they occur.

Comparison of Sense of Humor and Burnout in Surgeons and Internal Medicine Physicians.

OBJECTIVES: We aimed to evaluate humor styles in surgeons and internists and investigate the association between humor and burnout. METHODS: A cross-sectional survey of physicians in surgical and medicine departments was conducted, assessing sense of humor and burnout using the Humor Styles Questionnaire and the Emotional Exhaustion subscale of the Maslach Burnout Inventory-Human Services Survey for Medical Personnel. RESULTS: For 131 surgeons and 72 internists, no differences in humor styles were found. A sense of personal accomplishment was more common among surgeons (P = 0.03) and rates of burnout were lower for surgeons (P = 0.02). Physicians with a higher-than-average score in affiliative and self-enhancing humor were less likely to suffer from burnout (P < 0.0001 and P = 0.03, respectively). CONCLUSIONS: Surgeons and internists have similar styles of humor. Surgeons suffer less from burnout. Affiliative and self-enhancing humor styles are associated with reduced burnout.

Is Diffuse Axonal Injury Different in Adults and Children? An Analysis of National Trauma Database.

BACKGROUND: Diffuse axonal injury (DAI) is typically associated with significant mechanisms of injury and the effects of acceleration-deceleration forces on brain tissues. The prognosis of DAI remains a matter of active investigation, but little is known about outcome differences between adult and pediatric populations with DAI. METHODS: We performed a retrospective cohort study involving blunt trauma patients with DAI between the years 1997 and 2018 from the Israeli National Trauma Registry. The patients were divided to pediatric (age <15 years) and adult (age >15 years) groups, with subsequent comparison of demographics and outcomes. RESULTS: Diffuse axonal injury was identified in 1983 patients, including 469 pediatric victims (23.6%) and 1514 adults (76.4%). Adults had higher Injury Severity Score (20.5% vs 13.2%, P = 0.0004), increased mortality (17.7% vs 13.4%, P < 0.0001), longer hospitalizations (58.4% vs 44.4%, P < 0.001), and higher rehabilitation need rates (56.4% vs 41.8%, P < 0.0001). Associated extracranial injuries were also more common in adults, particularly to the chest. CONCLUSIONS: Pediatric patients with DAI have improved outcomes and fewer associated injuries than adult counterparts.

Clinical Efficacy of Topical Nasal Pomegranate Fruit Extract for Chronic Rhinitis and Chronic Rhinosinusitis.

Objective: To evaluate the clinical efficacy of topical nasal Pomegranate Fruit Extract (PFE) for Chronic Rhinitis (CR), Chronic Rhinosinusitis with Nasal Polyposis (CRSwNP), and Chronic Rhinosinusitis without Nasal Polyposis (CRSsNP). Methods: Prospective, double-blinded, randomized study including 111 consecutive patients, between April 2012 and January 2017, afflicted by CRSwNP, CRSsNP, and CR. Patients from each group were randomly assigned to either PFE treatment or placebo twice daily for 30 days. Therapeutic efficacy was assessed by Ear Nose and Throat, blood and tomographic examinations, and the SNOT-20 questionnaire. Results: CR patients treated with PFE suffered significantly less from thick nasal discharge, difficulty falling asleep, reduced productivity, reduced concentration, and sadness (P = .004, P = .02, P = .03, P = .007 and P = .02, respectively). Conclusions: Topical nasal PFE was found to have some benefits for CR patients, however, not for CRS with or without Nasal Polyposis.

Spinal cord injury in the setting of traumatic thoracolumbar fracture is not reliably associated with increased risk of associated intra-abdominal injury following blunt trauma: An analysis of a National Trauma Registry database.

PURPOSE: There is a common opinion that spinal fractures usually reflect the substantial impact of injuries and therefore may be used as a marker of significant associated injuries, specifically for intra-abdominal injury (IAI). The impact of concomitant spinal cord injury (SCI) with the risk of associated IAI has not been well clarified. The aim of this study was to evaluate the incidence and severity of IAIs in patients suffering from spinal fractures with or without SCI. METHODS: A retrospective cohort study using the Israeli National Trauma Registry was conducted. Patients with thoracic, lumbar and thoracolumbar fractures resulting from blunt mechanisms of injury from January 1, 1997 to December 31, 2018 were examined, comparing the incidence, severity and mortality of IAIs in patients with or without SCI. The collected variables included age, gender, mechanism of injury, incidence and severity of the concomitant IAIs and pelvic fractures, abbreviated injury scale, injury severity score, and mortality. Statistical analysis was performed using GraphPad InStat ® Version 3.10, with Chi-square test for independence and two sided Fisher's exact probability test. RESULTS: Review of the Israeli National Trauma Database revealed a total of 16,878 patients with spinal fractures. Combined thoracic and lumbar fractures were observed in 1272 patients (7.5%), isolated thoracic fractures in 4967 patients (29.4%) and isolated lumbar fractures in 10,639 patients (63.0%). The incidence of concomitant SCI was found in 4.95% (63/1272), 7.65% (380/4967) and 2.50% (266/10639) of these patients, respectively. The overall mortality was 2.5%, proving higher among isolated thoracic fracture patient than among isolated lumbar fracture counterparts (11.3% vs. 4.6%, p < 0.001). Isolated thoracic fractures with SCI were significantly more likely to die than non-SCI counterparts (8.2% vs. 3.1%, p < 0.001). There were no differences in the incidence of IAIs between patients with or without SCI following thoracolumbar fractures overall or in isolated thoracic fractures; although isolated lumbar fractures patients with SCI were more likely to have renal (3.4% vs. 1.6%, p = 0.02) or bowel injuries (2.3% vs. 1.0%, p = 0.04) than the non-SCI counterparts. CONCLUSION: SCI in the setting of thoracolumbar fracture does not appear to be a marker for associated IAI. However, in a subset of isolated lumbar fractures, SCI patient is associated with increased risks for renal and bowel injury.

Validating the Hebrew version of the Person-Centered Care of Older People with Cognitive Impairment in Acute Care scale.

AIM: To validate the Hebrew version of the Person-Centered Care of Older People with Cognitive Impairment in the Acute Care scale. BACKGROUND: The Person-Centered Care of Older People with Cognitive Impairment in Acute Care scale is a reliable and valid measure to assess the extent to which person-centred care among people with dementia is adopted in the acute care setting. METHODS: A cross-sectional study using a self-reporting structured questionnaire was conducted with 678 professionals (69% nurses, 26% physicians, 5% other health care professionals) in five hospitals across Israel. RESULTS: Similar to other languages, best results were obtained using 14 of the 15 items included in the original scale. Confirmatory factor analysis indicated the appropriateness of a three-factor structure for the Hebrew version of the scale. Cronbach's alpha scores for these factors were moderate to good. CONCLUSIONS: The Hebrew version of the scale is a reliable and valid tool for assessing hospital professionals' perceptions of person-centred care. IMPLICATIONS FOR NURSING MANAGEMENT: A new language validated version of the scale will allow nurse managers to learn from multiple countries' experience while conducting international comparisons. Such developments will improve and expand the implementation of the person-centred care among people with dementia in hospital settings.

Potential resuscitative endovascular balloon occlusion of aorta candidates: defining the potential need using the National Trauma Registry.

BACKGROUND: Most of the trauma patients who die in the first 24 h from arrival to the hospital do so as a result of haemorrhagic shock. Resuscitative endovascular balloon occlusion of the aorta (REBOA) facilitates expedient proximal aortic control, potentially bridging a needed gap for partial or non-responders to traditional resuscitation en route to emergent definitive haemostasis. This resuscitation tool continues to evolve and has recently achieved some consensus defined indications for its use. The aim of this study is designed to examine the potential utility of REBOA among trauma victims who die within 24 h of arrival. METHODS: Data of all trauma patients who died in the first 24 h, from 2012 to 2017 were extracted from the National Trauma Registry in the Gertner Institute for Epidemiology and Health Policy Research. Patients who died in the first half an hour, and those with neck and thorax injuries were excluded. Demographics, clinical and injury data were collected. RESULTS: Overall, 129 patients were included; 74% male and 26% female with the mean age of 46.4 years. A total of 76% suffered blunt trauma and 24% penetrating trauma. Mean survival time was 5.87 h. The cause of death was major abdominal organ injury in 47.2%, injury to major abdominal vessel in 23.3% and pelvic fractures in 21.7%. A total of 69 patients (53.5%) ultimately required delayed resuscitative thoracotomy in the operation room. CONCLUSION: Registry data suggest that there is a subset of patients presenting to modern trauma centres who might benefit from REBOA in order to avoid death.

[CONTRIBUTION OF CONVENTIONAL CHEST/ABDOMINAL PLAIN FILMS FOR THE DECISION-MAKING PROCESS IN PATIENTS WITH PREVIOUS ABDOMINAL SURGERIES, WHO HAVE SUSPECTED GASTROINTESTINAL PERFORATION].

INTRODUCTION: Gastrointestinal perforation is a well-known phenomenon among patients presented to emergency rooms. Common causes for perforation are gastric and duodenal ulcers, colon tumors and trauma. Some patients are operated on immediately due to the clear clinical picture of acute abdomen. The most accurate imaging is the abdominal CT scan. Conventional X-rays remain the first choice in the case of GI tract perforations. Our clinical observation is that in many cases X-ray studies are not sufficient for the decision-making process in patients with previous abdominal surgeries. AIMS: The purpose of this study was to evaluate the impact of X-rays on the decision-making process in patients with previous abdominal surgery. METHODS: A retrospective evaluation was conducted of chest/abdominal X-rays, computed tomography findings and the surgeries reports of patients admitted due to GI perforation. RESULTS: The study population of 69 patients was divided into two groups. In group 1: patients without previous abdominal surgery, X-rays of 27 patients (69.2%) were found positive for free air. In group 2: patients with previous abdominal surgeries, 16 patients demonstrated free air on chest/abdominal X-rays. The sensitivity in group 2 (53.3%) was found significantly lower compared to group 1 (69.2 %). The difference between the groups was not statistically significant; 19 of 30 (63.3%) patients with previous abdominal operations needed abdominal CT scan before final surgical decision in comparison to 38.5% of the patients without previous abdominal operations. CONCLUSIONS: Based on these results we recommend not routinely performing X-rays in patients with previous abdominal surgery. Urgent computed tomography should be the first imaging modality. DISCUSSION: In patients with previous abdominal surgeries, free air is visible only in half the patients in routine X-ray imaging. A significant number of those patients needed abdominal CT scan. Our study demonstrated that chest and abdominal plain radiography films are insufficient for the decision-making process in patients with previous abdominal operations. A multi-center prospective study is required in order to validate our findings.

[HIGH VOLTAGE ELECTRIC INJURY: MECHANISM OF INJURY, CLINICAL FEATURES AND INITIAL EVALUATION.]

INTRODUCTION: Electrical injury is an infrequent but potentially devastating form of multisystem injury associated with high morbidity and mortality. Despite significant improvement in injury prevention and implementation of safety protocols at work places, electrical injury accounts for more than 500 deaths per year in the United States with a mortality rate of 10-30%. Electrical injuries are traditionally divided into low-voltage electric power injuries (less than 1,000V) and high-voltage )more than 1,000V). In contrast with other types of trauma, high voltage injuries present some rather unique problems that require a high index of suspicion and awareness of all possible manifestations. Electrical injury should be viewed and managed as a multisystem injury, since there is virtually no organ that is protected against it. The most essential concept of successful management of patients who sustain high voltage injury is that there is no relationship between skin burn, vital organs involvement and severity of injuries. This review aims to provide a comprehensive overview of reported high voltage electrical injury manifestations in an attempt to gain a better understanding of the distribution of morbidity and clinical features of the injury. We tried to encompass most of the reported cases of high voltage electrical injuries in order to give the readers a general view of the spectrum of injuries that can be encountered in victims suffering high voltage current, aiming to increase the awareness of emergency care and trauma teams to this rare but dangerous and potentially fatal type of injury.

Femoral versus Multiple Nerve Blocks for Analgesia after Total Knee Arthroplasty.

BACKGROUND: The PROSPECT (Procedure-Specific Postoperative Pain Management) Group recommended a single injection femoral nerve block in 2008 as a guideline for analgesia after total knee arthroplasty. Other authors have recommended the addition of sciatic and obturator nerve blocks. The lateral femoral cutaneous nerve is also involved in pain syndrome following total knee arthroplasty. We hypothesized that preoperative blocking of all four nerves would offer superior analgesia to femoral nerve block alone. METHODS: This is a prospective, randomized, controlled, and observer-blinded clinical study. A total of 107 patients were randomly assigned to one of three groups: a femoral nerve block group, a multiple nerve block group, and a control group. All patients were treated postoperatively using patient-controlled intravenous analgesia with morphine. Pain intensity at rest, during flexion and extension, and morphine consumption were compared between groups over three days. RESULTS: A total of 90 patients completed the study protocol. Patients who received multiple nerve blocks experienced superior analgesia and had reduced morphine consumption during the postoperative period compared to the other two groups. Pain intensity during flexion was significantly lower in the "blocks" groups versus the control group. Morphine consumption was significantly higher in the control group. CONCLUSIONS: Pain relief after total knee arthroplasty immediately after surgery and on the first postoperative day was significantly superior in patients who received multiple blocks preoperatively, with morphine consumption significantly lower during this period. A preoperative femoral nerve block alone produced partial and insufficient analgesia immediately after surgery and on the first postoperative day. (Clinical trial registration number (NIH): NCT01303120).

Transversus Abdominis Plane Versus Ilioinguinal and Iliohypogastric Nerve Blocks for Analgesia Following Open Inguinal Herniorrhaphy.

OBJECTIVES: We hypothesized that preoperative (pre-op) ultrasound (US)-guided posterior transversus abdominis plane block (TAP) and US-guided ilioinguinal and iliohypogastric nerve block (ILI+IHG) will produce a comparable analgesia after Lichtenstein patch tension-free method of open inguinal hernia repair in adult men. The genital branch of the genitofemoral nerve will be blocked separately. METHODS: This is a prospective, randomized, controlled, and observer-blinded clinical study. A total of 166 adult men were randomly assigned to one of three groups: a pre-op TAP group, a pre-op ILI+IHG group, and a control group. An intraoperative block of the genital branch of the genitofemoral nerve was performed in all patients in all three groups, followed by postoperative patient-controlled intravenous analgesia with morphine. The pain intensity and morphine consumption immediately after surgery and during the 24 hours after surgery were compared between the groups. RESULTS: A total of 149 patients completed the study protocol. The intensity of pain immediately after surgery and morphine consumption were similar in the two "block" groups; however, they were significantly decreased compared with the control group. During the 24 hours after surgery, morphine consumption in the ILI+IHG group decreased compared with the TAP group, as well as in each "block" group versus the control group. Twenty-four hours after surgery, all evaluated parameters were similar. CONCLUSION: Ultrasound-guided ILI+IHG provided better pain control than US-guided posterior TAP following the Lichtenstein patch tension-free method of open inguinal hernia repair in men during 24 hours after surgery. (ClinicalTrials.gov number: NCT01429480.).

Real time cerebral perfusion monitoring in acute trauma patients: a preliminary study.

BACKGROUND: Management of traumatic brain injury is focused on preventing secondary damage. Early recognition of brain ischaemia may improve the final outcome of the trauma victim. The primary aim of this study was to examine the correlation between peripheral oxygen pulse oximetry and brain oxygen saturation measured by a near infrared oximetry device. A second aim was to evaluate the influence of different factors such as fluid and blood administration on brain tissue oxygenation. METHODS: This was a prospective pilot study. Mechanically ventilated trauma patients admitted to the trauma unit had cerebral-somatic oxygen saturation monitoring. Oximeter readings (rSO2) were prospectively collected and compared with concurrent values for peripheral pulse oximetry (SO2). Data were recorded every 15 min and during interventions such as administration of a fluid bolus and blood administration. All interventions were based on accepted clinical parameters. RESULTS: Thirty-three patients were enrolled. A total of 210 simultaneous measurements of rSO2 and pulse oximetry values were performed. There was correlation between these two parameters in only one third of patients. Twenty-seven events of possible brain ischemia, defined as rSO2 values less than 50 or a decrease of more than 20% from the baseline, were observed. In 68 (77.2%) of these measurements there was no decrease of peripheral SO2. Significant increases in rSO2 were observed only during administration of fluid boluses. CONCLUSIONS: A cerebral oxygenation monitoring device may recognize the possible events of brain ischaemia which are not reflected by pulse oximetry. Fluid administration was the only factor found to improve brain saturation.

Nurse willingness to report for work in the event of an earthquake in Israel.

AIM: To examine variables affecting nurse willingness to report for work in the event of an earthquake in Israel and whether this can be predicted through the Theory of Self-Efficacy. BACKGROUND: The nursing profession has a major role in preparing for earthquakes. Nurse willingness to report to work in the event of an earthquake has never before been examined. METHOD: Self-administered questionnaires were distributed among a convenience sample of 400 nurses and nursing students in Israel during January-April 2012. RESULTS: High willingness to report to work in the event of an earthquake was declared by 57% of respondents. High perceived self-efficacy, level of knowledge and experience predict willingness to report to work in the event of an earthquake. Multidisciplinary collaboration and support was also cited as a meaningful factor. CONCLUSION: Perceived self-efficacy, level of knowledge, experience and the support of a multidisciplinary staff affect nurse willingness to report to work in the event of an earthquake. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse managers can identify factors that increase nurse willingness to report to work in the event of an earthquake and consequently develop strategies for more efficient management of their nursing workforce.

Advanced rescue techniques: lessons learned from the collapse of a building in Nairobi, Kenya.

This paper examines the collapse of a five-storey building in Nairobi, Kenya, on 23 January 2006. It draws on reports from local authorities and on debriefings by Israel's Home Front Command (HFC), including information on injury distribution, rescue techniques, and the mode of operation. Most of the 117 people found under the structure were evacuated on the first day to a public hospital, which was overwhelmed by the incident. HFC forces arrived 23 hours after the disaster. At that stage, two people were still buried under the building and special techniques (tunnelling and scalping) were required to secure their evacuation. The two people quickly recovered after a short stay in hospital. Local technology is the preferred option during such events because time is crucial. International cooperation is required when this technology is not available. All of the hospitals in the disaster area, including private facilities, should participate in treating casualties.

Acute parotitis as a complication of fine-needle aspiration in Warthin's tumor. A unique finding of a 3-year experience with parotid tumor aspiration.

OBJECTIVE/HYPOTHESIS: Fine needle aspiration (FNA) is an accurate, cost-effective tool for the study of salivary gland lesions. Although complications are extremely rare, salivary gland FNA can lead to hemorrhage, facial nerve injury, and cellulitis at the needle puncture site. Some studies suggest that FNA can cause infarction or metaplastic transformation of benign Warthin's tumors. We review our recent experience with FNA of the parotid gland, focusing on possible complications and pitfalls. STUDY DESIGN AND SETTING: The medical records of all patients who underwent FNA of the parotid gland from 2000 to 2002 in the Department of Otolaryngology-Head and Neck Surgery of a major tertiary-care referral center were reviewed. Cytological results were compared to the histological diagnosis and complications were recorded. RESULTS: Of the 256 lesions aspirated, 99 patients (39%), were cytologically diagnosed as benign tumors, including 31 (12%) Warthin's tumors, of which 16/17 resected and confirmed histologically. Five patients with Warthin's tumor had post-FNA parotitis and were treated accordingly. CONCLUSIONS: The combination of cystic spaces surrounded by oncocytic cells and a poor blood supply makes the tumor susceptible to infarction and inflammation. Our findings indicate that FNA is a strong and reliable tool in the investigation of the salivary glands. Nevertheless, when Warthin's tumor is clinically suspected on the basis of its location (tail of the parotid gland), cystic texture, patient sex (male) and age, one should consider parotitis as a possible complication. EBM RATING: C-4.

Acute mastoiditis and osteomyelitis of the temporal bone.

OBJECTIVE: Acute mastoiditis becomes clinically significant when infection spreads through the periosteum and induces periosteitis. This study describes an atypical complication of acute mastoiditis: osteomyelitis of the temporal bone. PATIENTS AND METHODS: The study sample included all patients admitted for acute mastoiditis between September 2001 and December 2003 who had symptoms, signs and imaging findings of osteomyelitis of the temporal bone beyond the mastoid area. The files were reviewed for diagnosis, work-up, radiographic findings and treatment. RESULTS: The study group included 6 of the 120 patients treated for acute mastoiditis. In four children (66%), the diagnoses of acute otitis media and acute mastoiditis were made simultaneously at admission. Ear cultures yielded coagulase-positive Staphylococcus in three patients, Bacteroides in two, multiple organisms in two, S. pneumoniae in one, and no growth in two. Complications were suspected if there was a lack of improvement in symptoms and signs, or in cases of skin involvement over the temporal bone beyond the area of the mastoid in accordance with imaging findings. Computerized tomography demonstrated temporal bone absorption beyond the mastoid area (squama and/or petrous bones) in all children, suspected sinus vein thrombosis in two, and suspected epidural abscess in one. All children were treated with at least cortical mastoidectomy and insertion of ventilation tubes. Revision mastoidectomy was performed in three children in whom no improvement was noted and imaging suggested other complications. CONCLUSION: The present study describes an unusual complication of acute mastoiditis-osteomyelitis of the temporal bone beyond the mastoid framework. The disorder is characterized by a failure to respond both locally and systemically to accepted medical and surgical therapy, persistent fever and high levels of inflammatory markers, and computerized tomography findings of temporal bone destruction. Treatment includes broad-spectrum antibiotics and at least cortical mastoidectomy. Prognosis is good.

Preoperative evaluation of patients with parathyroid adenoma: role of high-resolution ultrasonography.

BACKGROUND: Unilateral parathyroid exploration with adenoma removal and identification of a normal parathyroid gland is a controversial surgical approach to the treatment of primary hyperparathyroidism. The aim of this study was to evaluate the ability of high-resolution ultrasonography to localize adenomas preoperatively and to assess the effect of such localization on operative time. METHODS: One hundred twenty consecutive previously non-operated patients with primary hyperparathyroidism underwent ultrasonography before surgery, which consisted of unilateral neck exploration. The procedure was changed to bilateral exploration when justified by the surgical findings. RESULTS: The sensitivity and positive predictive value of the ultrasonographic examinations were 89% and 98%, respectively. These results were obtained regardless of the size of the adenoma. No significant difference was found in the presence of thyroid multinodular disease (p =.2). A positive sonographic examination decreased the operative time to an average of 59 minutes. The average size of the adenomas was 19 mm (range, 4-55 mm). A positive and highly statistically significant correlation was found between adenoma size and both preoperative calcium level (p =.01) and parathyroid hormone level (p =.0001). CONCLUSIONS: In experienced hands, high-resolution ultrasonography can be a cost-effective means of localizing parathyroid adenomas when unilateral neck exploration is considered the acceptable surgical approach.