From Toothpick to Intraparenychmal Otogenic Pneumocephalus: A Case Report.

BACKGROUND: Intracranial pneumocephalus, the accumulation of air, occurs most frequently from trauma, tumor, cranial surgeries, or infection. Intraparenchymal otogenic pneumocephalus is a rare but well-documented development. We describe a patient who developed pneumocephalus in the context of eardrum perforation secondary to toothpick use for ear wax. CASE DESCRIPTION: An 86-year-old female presented to the emergency room with a 1-day history of dysarthria and a few days of cough and sneezing. History revealed she had recently been advised to avoid Q-Tips to clean her ears and instead was using toothpicks. She denied otalgia or otorrhea and had no signs of infection near the ear. On otoscopic examination, the right tympanic membrane was perforated. On head computed tomography, she was found to have a large right temporal pneumocephalus extending from the petrous bone. Magnetic resonance imaging of the brain revealed a defect in the right tegmen. She was started on empiric antibiotics and subsequently taken to the operating room for craniotomy and repair of bony and dural defects. CONCLUSIONS: Otogenic pneumocephalus is a rare occurrence. This is the first reported case of pneumocephalus related to self-induced middle ear trauma with a toothpick that ultimately required craniotomy for repair.

Reliability of the validated clinical diagnosis of pneumonia on validated outcomes after intracranial hemorrhage.

PURPOSE: Reducing the incidence of hospital-acquired pneumonia (PNU) is important but depends on accurate assessment. We sought to determine the interrater reliability of diagnosis of PNU and its impact on resource utilization and functional outcomes in a high-risk population. MATERIALS AND METHODS: Patients admitted in 2007 with intracranial hemorrhage were prospectively identified. Pneumonia was prospectively diagnosed by Centers for Disease Control criteria by a neurointensivist and infection control. An independent retrospective determination was made by a fellow, an infectious disease attending physician, and a pulmonologist after review of the electronic medical records and radiographs. Interrater reliability was analyzed with κ statistics. One and 3-month outcomes were measured with the modified Rankin scale. RESULTS: Of 103 patients, the incidence of PNU ranged from 5% to 25%. Interrater reliability was poor (median κ = 0.30 [0.19-0.42]; P < .001). Any ascertainment of PNU was associated with longer intensive care unit length of stay, more fever and ventilator dependence, and worse functional outcomes. CONCLUSIONS: Pneumonia had poor interrater reliability despite highly trained reviewers and validated criteria. Although the clinical assessment of PNU is difficult, it was associated with greater resource use and worse outcomes. Diagnosis of clinical PNU may be suboptimal for measuring quality of intensive care.

Prospective, randomized trial of higher goal hemoglobin after subarachnoid hemorrhage.

BACKGROUND AND PURPOSE: In patients with subarachnoid hemorrhage (SAH), higher hemoglobin (HGB) has been associated with better outcomes, but packed red blood cell (PRBC) transfusions with worse outcomes. We performed a prospective pilot trial of goal HGB after SAH. METHODS: Forty-four patients with SAH and high risk for vasospasm were randomized to goal HGB concentration of at least 10 or 11.5 g/dl. We obtained blinded clinical outcomes at 14 days (NIH Stroke Scale and modified Rankin Scale, mRS), 28 days (mRS), and 3 months (mRS), and blinded interpretation of brain MRI for cerebral infarction at 14 days. This trial is registered at www.stroketrials.org. RESULTS: Forty-four patients were randomized. Patients with goal HGB 11.5 g/dl received more PRBC units per transfusion [1 (1-2) vs. 1 (1-1), P < 0.001] and more total PRBC units [3 (2-4) vs. 2 (1-3), P = 0.045]. Prospectively defined safety endpoints were not different between groups. HGB concentration was different between study groups from day 4 onwards. The number of cerebral infarctions on MRI (6 of 20 vs. 9 of 22), NIH Stroke Scale scores at 14 days [1 (0-9.75) vs. 2 (0-16)], and rates of independence on the mRS at 14 days (65% vs. 44%) and 28 days (80% vs. 67%) were similar, but favored higher goal HGB (P > 0.1 for all). CONCLUSIONS: Higher goal hemoglobin in patients with SAH seems to be safe and feasible. A phase III trial of goal HGB after SAH is warranted.

Low-grade gliomas: management issues.

Low-grade gliomas are relatively rare tumors. The optimal management of these tumors remains to be defined and has some controversies associated with it. In this review, we present the data that is available to date and some of the issues that exist in treating these tumors.

Are "accidental" gun deaths as rare as they seem? A comparison of medical examiner manner of death coding with an intent-based classification approach.

OBJECTIVES: Unintentional firearm death is often considered a nearly negligible proportion of overall gun death. These rates are based on medical examiner (ME) and coroner death classifications, which affect derived epidemiologic data and subsequent prevention measures. The aim of this study was to compare the proportion of pediatric unintentional gun deaths in Miami-Dade County based on manner of death coding by the ME with an intent-based classification of child gun deaths. METHODS: ME and police records for all pediatric firearm fatalities in Miami-Dade County from 1994 to 1998 were reviewed. The ME's assignment of manner of death as homicide, suicide, or accident was compared with an intent-based classification of intentional homicide, intentional suicide, and unintentional firearm death based on expressed or implied evidence of intent to harm. RESULTS: There were 123 pediatric firearm deaths in Miami-Dade County from 1994 to 1998. A significant difference between ME coding and the intent-based classification was found for homicide (94 vs 78) but not for suicide. A significant difference was also found between the ME's coding for "accident" and the investigator's classification of "unintentional" firearm death (4 vs 26). CONCLUSIONS: The incidence of unintentional pediatric firearm deaths is significantly underreported by the Miami-Dade County ME when the classification of "accidental" firearm death is used. Reviewing the manner of death classification criteria or establishing an intent code on official death documentation is recommended. Furthermore, clinicians should be aware that the true incidence of unintentional gun death may be higher than that reported as accidental.