Delayed hyperbaric treatment of cerebral air embolism: report of a case.

A 23-year-old woman with Eisenmenger's complex had a cerebral air embolism with resultant severe neurologic impairment while undergoing phlebotomy for secondary polycythemia. She was treated with hyperbaric therapy 29 hours after the original accident with almost complete recovery of neurologic function.

Animal models of osteomyelitis.

Clinical research involving osteomyelitis is difficult because of the multiple variables found in the disease process. In order to evaluate osteomyelitis critically, a more precise staging system is needed, along with reproducible animal models for each of the clinical stages. The current animal models for osteomyelitis include the rabbit models of Norden and Andriole, the rat model of Zak, and the dog models of Fitzgerald and Deysine. Although each animal model of osteomyelitis has certain advantages and limitations, they have provided us with a clearer understanding of this disease process and what forms of treatment may prove satisfactory.

Cefmenoxime therapy in bacterial osteomyelitis.

Cefmenoxime, a new parenteral beta-lactamase-resistant cephalosporin, was evaluated for safety and efficacy in 15 patients (10 male and five female) with acute (1 patient) and chronic (14 patients) osteomyelitis. Diagnosis was made by culture of the surgical biopsy specimen. Osteomyelitis was treated with 8 to 12 g of cefmenoxime per day (mean 9.1 g) for 42 to 66 days (mean 47.3). Staphylococcus aureus was the most frequently isolated organism. Minimum inhibitory concentrations (MICs) of cefmenoxime were determined and all pathogens were inhibited by 12.5 micrograms/ml or less, except for Enterobacter cloacae and Acinetobacter species, both of which had an MIC of 25.0 micrograms/ml. All patients had at least one surgical debridement. Of the 15 patients, 10 (67 percent) had the osteomyelitis "arrested." These patients have been followed up five to 14 months after completion of cefmenoxime therapy. Toxicity studies indicated mild elevations in serum glutamic oxalacetic transaminase and serum glutamic pyruvic transaminase in two patients. Cefmenoxime appears to be a safe and effective antibiotic in the treatment of osteomyelitis.

Indium-111 chloride imaging in chronic osteomyelitis.

Sixty-eight patients with clinically suspected chronic osteomyelitis were studied with [111In]chloride. Fifty-four images were categorized as true positive; seven were categorized as true negative. There were four false-positive studies, two of which were associated with healing cancellous bone grafts. There were three false-negative studies in patients previously treated with long-term antibiotic therapy. Images in eight noninfected healing fractures 3 to 8 mo old were normal. Three patients with infected total hip prostheses had positive images. Two patients with loose prostheses had negative images. This study shows that [111In]chloride imaging is an accurate way to localize chronic osteomyelitis and may overcome some of the disadvantages of [67Ga]citrate such as localization in noninfected healing fractures and in some loose [67Ga]citrate such as localization in noninfected healing fractures and in some loose prostheses.

Indium-111 chloride imaging in the detection of infected prostheses.

Thirty-three patients with painful joint prostheses and a suspicion of infection were imaged with [111In]chloride. A final diagnosis was established by culture in 19. Of these, 12 were categorized as true positives and three as true negatives. There were two false-positive studies, occurring in patients with knee prostheses. In both, the culture was obtained by aspiration. Two false negatives were in patients with hip prostheses, one of whom had been on long-term antibiotic suppressive therapy. The sensitivity was 86%, specificity 60%, and accuracy 79%. Seventeen of the proven cases had bone imaging prior to [111In]chloride imaging. All 17 static images were positive and were not helpful in differentiating loosening from infection. Using increased uptake on the blood-pool image as a criteria for infection, the sensitivity was 89%, but the specificity was 0. Adding flow studies made little difference in interpreting the blood-pool images. This study shows that [111In]chloride accurate in evaluating infection in prosthesis than bone imaging.

Skeletal scintigraphy with technetium-99m-tetraphenyl porphyrin sulfonate for the detection and determination of osteomyelitis in an animal model.

UNLABELLED: This article explores the accumulation of 99mTc-tetraphenyl porphyrin sulfonate (TPPS4) at inflammatory sites, especially osteomyelitis, and compares the results with 111In Cl3 and 111In-WBC in an animal model. METHODS: Osteomyelitis was induced in 12 New Zealand white rabbits by injecting staphylococcus aureus in the left tibia. Three weeks later, radiographs confirmed the disease. Two hours later, after injection of 74 MBq 99mTc-TPPS4, scintiphotos of the lower extremities were acquired and repeat scintiphotos were obtained 24 hr after injection of 5.55 MBq 111In Cl3. After these studies, 24- and 48-hr scintiphotos of the lower extremities were acquired after injecting 5.55 MBq 111In-labeled WBC. RESULTS: The left tibia averaged three times the uptake with 99mTc-TPPS4 compared with right tibia; with 111In Cl3 and 111In WBC the ratios are two times. These three radiopharmaceuticals reveal positive images, but the image quality using 99mTc-TPPS4 is better, as would be expected from the more favorable physical characteristics of 99mTc and the higher uptake. CONCLUSION: The traditional combination of three-phase bone and 67Ga-citrate scintigraphy can be replaced by a single injection of 99mTc-TPPS4 with imaging as early as 2 hr. Finally, the use 99mTc-TPPS4 should result in a substantial reduction in radiopharmaceutical cost.

A practical guide to the diagnosis and management of bone and joint infections.

Infectious arthritis arises from haematogenous spread of organisms through the synovial membrane or from the direct extension of a contiguous infection. The diagnosis rests on the isolation of the pathogen(s) from joint fluid obtained by aspiration or from debridement. Synovial fluid analysis and Gram stains provide clues to the aetiology. The treatment of septic arthritis includes appropriate antimicrobial therapy and joint drainage. Bone infections are currently classified by the Waldvogel or Cierny-Mader classification. Cierny-Mader staging allows stratification and development of comprehensive treatment guidelines for each stage. Osteomyelitis therapy emphasises early diagnosis and aggressive treatment. Radiographs and bone cultures are the mainstays of diagnosis. Radionuclide scans, computerised tomography or magnetic resonance imaging may be obtained when the diagnosis of osteomyelitis is equivocal or to help gauge the extent of the infection. Medical therapy includes improving any host deficiencies, initial antibiotic selection and antibiotic modification based on culture results. Surgical treatment involves debridement of necrotic bone and tissue, obtaining appropriate cultures, managing dead space and, when necessary, obtaining bone stability.

Hyperbaric oxygen as adjunctive therapy for osteomyelitis.

Mechanistically, hyperbaric oxygen (HBO) appears useful for the treatment of osteomyelitis. HBO increases the oxygen tension in infected tissue, including bone. An adequate oxygen tension is necessary for oxygen-dependent killing of organisms by the polymorphonuclear leukocytes and for fibroblast activity leading to angiogenesis and wound healing. HBO has a direct bacteriocidal or bacteriostatic effect on anaerobic organisms. In addition, HBO augments the killing of Pseudomonas aeruginosa by the aminoglycoside--tobramycin. At the University of Texas Medical Branch at Galveston, adjunctive HBO is used for the Cierny Mader stage 3B and 4B osteomyelitis.

Cefotaxime treatment in patients with osteomyelitis and septic arthritis: a multicenter study.

The effectiveness of parenteral cefotaxime in the treatment of adults with acute septic arthritis or acute or chronic osteomyelitis was evaluated in a multicenter trial. The drug was given to 47 patients admitted to the University of Texas Medical Branch Hospitals or Hahnemann Medical College and Hospital (UT-H study) and to 40 patients in other medical centers using an identical protocol. In the UT-H study, cefotaxime was effective in 15 of 16 patients (94%) with acute osteomyelitis, in 24 of 27 patients (89%) with chronic osteomyelitis, and in four of four patients (100%) with acute septic arthritis. In the multicenter study, the success rates were as follows: acute osteomyelitis, six of six (100%); chronic osteomyelitis, 14 of 19 (74%); and septic arthritis, 12 of 15 (80%). The antibiotic was well tolerated in most patients. The most serious side effect was significant neutropenia, which occurred in three patients. Cefotaxime appears to be a clinically useful, broad-spectrum antibiotic for bone and joint infections.

Comparative evaluation of the diffusion of tobramycin and cefotaxime out of antibiotic-impregnated polymethylmethacrylate beads.

Both tobramycin and cefotaxime diffuse from antibiotic-impregnated polymethylmethacrylate (PMMA) beads in quantities sufficient to inhibit the growth of bacteria on agar lawns or in broth cultures over a 28-day period. Extraction of antibiotic from tobramycin or cefotaxime-impregnated PMMA beads revealed that substantial amounts of both antibiotics remained within the beads despite 28 days of diffusion. Diffusion of antibiotic from the PMMA beads during the initial 3-5 days is much greater than occurs for the remainder of the 4-week period. The results of the study suggest that perhaps tobramycin of cefotaxime-impregnated PMMA beads would produce local levels of antibiotic high enough to sterilize a given dead space for a period of 28 days.

Antibiotic beads in the management of surgical infections.

Polymethyl methacrylate antibiotic beads have been used successfully in the treatment of surgical infections. Presented are their mechanism of action, their use in experimental and clinical settings, and their complications.

Bone and joint infections in the elderly: practical treatment guidelines.

Two types of haematogenous osteomyelitis that are seen in the elderly are vertebral and long bone osteomyelitis. Osteomyelitis secondary to contiguous foci of infection can occur in older adults without vascular insufficiency (secondary to pressure ulcers) or with vascular insufficiency due to diabetes mellitus or peripheral vascular disease from atherosclerosis. Most cases of osteomyelitis can be reasonably treated with adequate drainage, thorough debridement, obliteration of dead space, wound protection, and antimicrobial therapy. Patients are initially given a broad spectrum antimicrobial that is changed to specific antimicrobial therapy based on meticulous bone cultures taken at debridement surgery or from deep bone biopsies. Surgical management is often required in the treatment of osteomyelitis and includes adequate drainage, extensive debridement of all necrotic tissue, obliteration of dead spaces, stabilisation, adequate soft tissue coverage, and restoration of an effective blood supply. Bone repair and bone mineral density may be significantly retarded and may be corrected by eliminating risk factors, supplementing the diet with calcium, bisphosphonates, and/or vitamin D, and treating with testosterone and/or estrogen when deficient. Sodium fluoride treatment and anabolic steroids may be used as alternatives. Septic arthritis is a medical emergency, and prompt recognition and rapid and aggressive treatment are critical to ensuring a good prognosis. The treatment of septic arthritis includes appropriate antimicrobial therapy and joint drainage. Adverse effects of prescribed antibacterials occur more often in the elderly patient than in young adults. The physician can help to minimise the incidence of adverse effects and improve outcomes by being aware of the principles of clinical pharmacology, the characteristics of specific drugs, and the special physical, psychological and social needs of older patients.

Oral ciprofloxacin compared with standard parenteral antibiotic therapy for chronic osteomyelitis in adults.

A group of fourteen patients who had chronic osteomyelitis and were treated with oral ciprofloxacin was compared with a group of twelve patients of similar age who had chronic osteomyelitis and received standard parenteral antibiotic therapy consisting of nafcillin, clindamycin, and gentamicin, singly or in combination. The osteomyelitis was arrested at the end of therapy and on follow-up examination of eleven patients in the first group and ten in the second group. The average duration of antibiotic therapy (thirty-eight days) and follow-up (approximately thirty months) were about the same for both groups. Oral administration of ciprofloxacin was as effective and safe as parenteral therapy for the treatment of osteomyelitis in these adults.

Short-term tympanostomy in conjunction with hyperbaric oxygen therapy.

OBJECTIVE: To determine the most effective method of short-term middle ear aeration in patients unable to tolerate hyperbaric oxygen (HBO) therapy. STUDY DESIGN: Prospective study comparing two methods of short-term tympanostomy in each patient. METHODS: Seventeen adult patients were referred for management of barotitis and inability to tolerate hyperbaric oxygen therapy (HBO). Each patient underwent CO2 laser tympanostomy on the right ear and tympanostomy with T-tube placement in the left ear. The tube was removed on completion of HBO. Patients were asked to rate pain and their satisfaction with each method of tympanostomy using a visual analog scale. Otorrhea, persistent perforation, recurrent barotitis, hearing loss, and otalgia occurring during the study period were documented. RESULTS: Laser tympanostomy was associated with a significantly lower incidence of otorrhea but was attended by recurrent barotitis in four of 16 patients. Laser tympanostomy was perceived as being less painful and was rated higher in overall satisfaction. CONCLUSIONS: Laser tympanostomy is an effective method for management of barotitis in patients unable to tolerate HBO. Otorrhea is significantly reduced, although a risk of recurrent barotitis exists if the laser perforation closes prior to completion of HBO. Both methods of short-term tympanostomy reduce complications when compared with a retrospective cohort.

The effect of hyperbaric oxygen therapy of oral mucosal carcinoma.

Hyperbaric oxygen is sometimes used in the course of treatment in head and neck cancer patient. This study was undertaken to investigate the effect of hyperbaric oxygen on oral cavity carcinogenesis in an animal model. Dimethylbenzanthracene was applied three times weekly to induce oral squamous cell cancers. The group that received simultaneous hyperbaric oxygen had fewer tumors, but the tumors were larger than the dimethylbenzanthracene-only group. We concluded that hyperbaric oxygen has a tumor-suppressive effect during the induction phase of oral carcinoma and appears to have a stimulatory effect during the proliferative phase of carcinoma in this animal model.

Rhinocerebral mucormycosis with cerebral extension successfully treated with adjunctive hyperbaric oxygen therapy.

Rhinocerebral mucormycosis is a devastating fungal disease with a high mortality rate. Extensive surgical débridement and amphotericin B are currently the mainstays of therapy. When cerebral extension of the fungus occurs, the disease is almost invariably fatal. Two patients with rhinocerebral mucormycosis had progression of their infection to brain abscesses despite aggressive débridement surgery and amphotericin B therapy. Both patients showed marked clinical improvement with the addition of adjunctive hyperbaric oxygen therapy. Both patients remained free of their disease 21 months after hospital discharge.

Complications of tympanostomy tubes inserted for facilitation of hyperbaric oxygen therapy.

OBJECTIVE: To document the incidence of complications occurring secondary to placement of tympanostomy tubes in patients undergoing hyperbaric oxygen therapy. DESIGN: Retrospective chart review. SETTING: Tertiary referral center. PATIENTS: Forty-five patients referred to the Department of Otolaryngology for inability to tolerate hyperbaric oxygen therapy between January 1, 1990, and December 31, 1995. INTERVENTIONS: All patients underwent bilateral myringotomy and tube placement. OUTCOME MEASURES: Charts were reviewed for complications of tube placement, including otorrhea, otalgia, hearing loss, persistent perforations, and tinnitus. RESULTS: Seventeen (38%) of 45 patients experienced complications, with most having more than 1. Most complications occurred after conclusion of hyperbaric oxygen therapy. Otorrhea was most common, occurring in 13 patients (29%). Persistent tympanic membrane perforations occurred in 7 patients (16%). CONCLUSIONS: The rate of complications is higher than reported for placement of tympanostomy tubes in other patient populations. Coexisting illness, such as diabetes mellitus, may contribute to the development of complications in patients undergoing hyperbaric oxygen therapy. Alternative methods of tympanostomy, with emphasis on shorter duration of intubation, should be considered in this patient population.

Osteomyelitis of the mandible.

The presenting characteristics and clinical courses of 60 patients with mandibular bone infections are described. Fifteen of the patients had posttraumatic osteomyelitis, 13 had odontogenic osteomyelitis, and 28 had osteoradionecrosis. Most infections (93%) were polymicrobial, and anaerobes played an important role. Types of surgical procedures and use of adjunctive hyperbaric oxygen are described. There were minimal differences in presentation or response to treatment between these four different groups. A clinical staging system for mandibular bone infections is proposed and results of treatment are retrospectively analyzed by stage. The results support the concept that initial treatment planning can be safely and successfully based on the stage of the disease.

Adjuvant hyperbaric oxygen in malignant external otitis.

Necrotizing invasive pseudomonal infection of the external auditory canal (malignant external otitis) is an uncommon but important disorder in the elderly. The high morbidity, and even mortality, of this disorder has been reduced by the early and intensive use of combination antipseudomonal antibiotics. However, in severely immunocompromised patients or in infection involving the base of the skull, multiple cranial nerves, or the meninges, conventional therapy has been prolonged, intensive, and relatively ineffective. We treated 16 patients with malignant external otitis with adjuvant hyperbaric oxygen therapy. In six patients, infection was in advanced stages, infections were recurrences after previous treatment, and repeated treatment with antipseudomonal antibiotics had failed. All 16 cases responded promptly when a 30-day course of hyperbaric oxygen was added to the antibiotic regimen, and all patients remained free of infection or neurologic deficit during 1 to 4 years of follow-up. No complications of this treatment modality were noted. Hyperbaric oxygen therapy reverses tissue hypoxia, which enhances phagocytic killing of aerobic microorganisms, and stimulates neomicroangiogenesis. In addition, hyperbaric oxygen augments the action of aminoglycoside antibiotics. Adjuvant hyperbaric oxygen therapy should be considered in advanced or recurrent cases of malignant external otitis.

Hematogenous pyogenic spinal infections and their surgical management.

STUDY DESIGN: Mainly a retrospective study of 101 cases of pyogenic spinal infection, excluding postoperative infections. Data were obtained through medical record review, imaging examination, and patient follow-up evaluation. SUMMARY OF BACKGROUND DATA: Hematogenous pyogenic spinal infection has been described variously as spondylodiscitis, discitis, vertebral osteomyelitis, and epidural abscess. Recommended treatment options have included conservative methods (antibiotics and bracing) and surgical intervention. However, a comprehensive classification that would aid in diagnosis, treatment planning, and prognosis has not yet been devised. OBJECTIVES: To analyze the bacteriology, pathologic entities, complications, and results of treatment options for pyogenic spinal infection. METHOD: All patients received plain radiographs, gadolinium-enhanced magnetic resonance imaging scans, and bone/gallium radionuclide studies. All patients had tissue biopsies. Bacteriology, hematology, and predisposing factors were analyzed. All patients received intravenous and oral antibiotics. A total of 58 patients underwent surgery. Patient outcomes were correlated with clinical status, with treatment method and, where applicable, with location and nature of epidural compression. Statistical analyses were performed. RESULTS: Spondylodiscitis occurred most commonly with primary epidural abscess, spondylitis, discitis, and pyogenic facet arthropathy, all occurring rarely. Staphylococcus aureus was the main organism. Infection elsewhere was the most common predisposing factor. Leukocyte counts were elevated in 42.6% of spondylodiscitis cases. The erythrocyte sedimentation rate was elevated in all cases of epidural abscess. There were 35 cases of epidural abscess (frank abscess, 29; granulation tissue, 6). Epidural abscess complicating spondylodiscitis occurred most often in the cervical spine, followed by thoracic and lumbar areas. The rate of paraplegia or paraparesis also was highest in cervical and thoracic regions. There were no cases of quadriplegia. All patients with either epidural granulation tissue or paraparesis recovered completely after surgical decompression. Only 18% of patients with frank epidural abscess and 23% of patients with paralysis recovered completely after surgical decompression. Patients with spondylodiscitis who were treated nonsurgically reported residual back pain more often (64%) than patients treated surgically (26.3%). CONCLUSIONS: Pyogenic spinal infection can be thought of as a spectrum of disease comprising spondylitis, discitis, spondylodiscitis, pyogenic facet arthropathy, and epidural abscess. Spondylodiscitis is more prone to develop epidural abscesses in the cervical spine (90%) than the thoracic (33.3%) or lumbar (23.6%) areas. Thecal sac neurocompression has a greater chance of causing neurologic deficit in the thoracic spine (81.8%). Treatment of neurologic deficit caused by epidural abscess is prompt surgical decompression, with or without fusion. Patients with frank abscess had less favorable outcomes than those with granulation tissue, and paraplegia responded to treatment more poorly than paraparesis. Surgery was preferable to nonsurgical treatment for improving back pain.