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Dominguez JF, Sursal T, Kazim SF, Ng C, Vazquez S, DAS A, Naftchi A, Spirollari E, Elkun Y, Gatzoflias S, Ampie L, Feldstein E, Uddin A, Damodara N, Hanft SJ, Gandhi CD, Bowers CA. Frailty is a risk factor for intracranial abscess and is associated with longer length of stay: a retrospective single institution case-control study. J Neurosurg Sci 2024; 68:422-427. [PMID: 35416458 DOI: 10.23736/s0390-5616.22.05720-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Intracranial abscess (IA) causes significant morbidity and mortality. The impact of baseline frailty status on post-operative outcomes of IA patients remains largely unknown. The present study evaluated if frailty status can be used to prognosticate outcomes in IA patients. METHODS We retrospectively reviewed all IA patients undergoing craniotomy at our institution from 2011 to 2018 (N.=18). These IA patients were age and gender matched with patients undergoing craniotomy for intracranial tumor (IT), an internal control for comparison. Demographic and clinical data were collected to measure frailty, using the modified frailty index-11 (mFI-11) and pre-operative American Society of Anesthesiologists Physical Status Classification System (ASA). Post-operative complications were measured by the Clavien-Dindo Grade (CDG). RESULTS No significant difference in mFI-11 or ASA score was observed between the IA and IT groups (P=0.058 and P=0.131, respectively). IA patients had significantly higher CDG as compared with the control IT patients (P<0.001). There was a trend towards increasing LOS in the IA group as compared to the IT group (P=0.053). Increasing mFI and ASA were significant predictors of LOS by multiple linear regression in the IA group (P=0.006 and P=0.001, respectively), but not in the control IT group. Neither mFI-11 nor ASA were found to be predictors for CDG in either group. Within this case-control group of patients, we found an increase for odds of having IA with increasing mFI (OR=1.838, 95% CI: 1.016-3.362, P=0.044). CONCLUSIONS Frail IA patients tend to have more severe postoperative complications. The mFI-11 seems to predict increased resource utilization in the form of LOS. This study provides the initial retrospective data of another neurosurgical pathology where frailty leads to significantly worse outcomes. We also found that mFI may serve as a potential risk factor for severe disease.
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Affiliation(s)
- Jose F Dominguez
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA -
| | - Tolga Sursal
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Syed F Kazim
- Department of Neurosurgery, University of New Mexico, Albuquerque, NM, USA
| | | | | | - Ankita DAS
- New York Medical College, Valhalla, NY, USA
| | | | | | | | | | - Leonel Ampie
- Department of Neurosurgery, University of Virginia-National Institute of Health, Bethesda, MD, USA
| | - Eric Feldstein
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Anaz Uddin
- New York Medical College, Valhalla, NY, USA
| | - Nitesh Damodara
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Simon J Hanft
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Christian A Bowers
- Department of Neurosurgery, University of New Mexico, Albuquerque, NM, USA
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2
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Bodilsen J, D'Alessandris QG, Humphreys H, Iro MA, Klein M, Last K, Montesinos IL, Pagliano P, Sipahi OR, San-Juan R, Tattevin P, Thurnher M, de J Treviño-Rangel R, Brouwer MC. European society of Clinical Microbiology and Infectious Diseases guidelines on diagnosis and treatment of brain abscess in children and adults. Clin Microbiol Infect 2024; 30:66-89. [PMID: 37648062 DOI: 10.1016/j.cmi.2023.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 08/16/2023] [Accepted: 08/17/2023] [Indexed: 09/01/2023]
Abstract
SCOPE These European Society of Clinical Microbiology and Infectious Diseases guidelines are intended for clinicians involved in diagnosis and treatment of brain abscess in children and adults. METHODS Key questions were developed, and a systematic review was carried out of all studies published since 1 January 1996, using the search terms 'brain abscess' OR 'cerebral abscess' as Mesh terms or text in electronic databases of PubMed, Embase, and the Cochrane registry. The search was updated on 29 September 2022. Exclusion criteria were a sample size <10 patients or publication in non-English language. Extracted data was summarized as narrative reviews and tables. Meta-analysis was carried out using a random effects model and heterogeneity was examined by I2 tests as well as funnel and Galbraith plots. Risk of bias was assessed using Risk Of Bias in Non-randomised Studies - of Interventions (ROBINS-I) (observational studies) and Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) (diagnostic studies). The Grading of Recommendations Assessment, Development and Evaluation approach was applied to classify strength of recommendations (strong or conditional) and quality of evidence (high, moderate, low, or very low). QUESTIONS ADDRESSED BY THE GUIDELINES AND RECOMMENDATIONS Magnetic resonance imaging is recommended for diagnosis of brain abscess (strong and high). Antimicrobials may be withheld until aspiration or excision of brain abscess in patients without severe disease if neurosurgery can be carried out within reasonable time, preferably within 24 hours (conditional and low). Molecular-based diagnostics are recommended, if available, in patients with negative cultures (conditional and moderate). Aspiration or excision of brain abscess is recommended whenever feasible, except for cases with toxoplasmosis (strong and low). Recommended empirical antimicrobial treatment for community-acquired brain abscess in immuno-competent individuals is a 3rd-generation cephalosporin and metronidazole (strong and moderate) with the addition of trimethoprim-sulfamethoxazole and voriconazole in patients with severe immuno-compromise (conditional and low). Recommended empirical treatment of post-neurosurgical brain abscess is a carbapenem combined with vancomycin or linezolid (conditional and low). The recommended duration of antimicrobial treatment is 6-8 weeks (conditional and low). No recommendation is offered for early transition to oral antimicrobials because of a lack of data, and oral consolidation treatment after ≥6 weeks of intravenous antimicrobials is not routinely recommended (conditional and very low). Adjunctive glucocorticoid treatment is recommended for treatment of severe symptoms because of perifocal oedema or impending herniation (strong and low). Primary prophylaxis with antiepileptics is not recommended (conditional and very low). Research needs are addressed.
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Affiliation(s)
- Jacob Bodilsen
- Department of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark; European Society of Clinical Microbiology and Infectious Diseases, Study Group for Infections of the Brain (ESGIB), Basel, Switzerland.
| | - Quintino Giorgio D'Alessandris
- Department of Neurosurgery, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy; Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Hilary Humphreys
- Department of Clinical Microbiology, Royal College of Surgeons in Ireland University of Medicine and Health Sciences, Dublin, Ireland
| | - Mildred A Iro
- Department of Paediatric Infectious diseases and Immunology, The Royal London Children's Hospital, Barts Health NHS Trust, London, UK
| | - Matthias Klein
- European Society of Clinical Microbiology and Infectious Diseases, Study Group for Infections of the Brain (ESGIB), Basel, Switzerland; Department of Neurology, Hospital of the Ludwig-Maximilians University, Munich, Germany; Emergency Department, Hospital of the Ludwig-Maximilians University, Munich, Germany
| | - Katharina Last
- European Society of Clinical Microbiology and Infectious Diseases, Study Group for Infections of the Brain (ESGIB), Basel, Switzerland; Institute for Hygiene and Public Health, University Hospital Bonn, Bonn, Germany
| | - Inmaculada López Montesinos
- Infectious Disease Service, Hospital del Mar, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain; CIBERINFEC ISCIII, CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | - Pasquale Pagliano
- European Society of Clinical Microbiology and Infectious Diseases, Study Group for Infections of the Brain (ESGIB), Basel, Switzerland; Department of Medicine, Surgery and Dentistry, Scuola Medica Salernitana, Unit of Infectious Diseases, University of Salerno, Baronissi, Italy; UOC Clinica Infettivologica AOU San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Oğuz Reşat Sipahi
- European Society of Clinical Microbiology and Infectious Diseases, Study Group for Infections of the Brain (ESGIB), Basel, Switzerland; Faculty of Medicine, Department of Infectious Diseases and Clinical Microbiology, Ege University, Bornova, Izmir, Turkey; Infectious Diseases Department, Bahrain Oncology Center, King Hamad University Hospital, Muharraq, Bahrain
| | - Rafael San-Juan
- CIBERINFEC ISCIII, CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain; Unit of Infectious Diseases, 12 de Octubre University Hospital, Madrid, Spain; European Society of Clinical Microbiology and Infectious Diseases, Study Group for Infections in Compromised Hosts (ESGICH), Basel, Switzerland
| | - Pierre Tattevin
- European Society of Clinical Microbiology and Infectious Diseases, Study Group for Infections of the Brain (ESGIB), Basel, Switzerland; Department of Infectious Diseases and Intensive Care Unit, Pontchaillou University Hospital, Rennes, France
| | - Majda Thurnher
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Rogelio de J Treviño-Rangel
- Faculty of Medicine, Department of Microbiology, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, Mexico; European Society of Clinical Microbiology and Infectious Diseases, Fungal Infection Study Group (EFISG), Basel, Switzerland; European Society of Clinical Microbiology and Infectious Diseases, Study Group for Antimicrobial Stewardship (ESGAP), Basel, Switzerland; European Society of Clinical Microbiology and Infectious Diseases, Study Group for Genomic and Molecular Diagnostics (ESGMD), Basel, Switzerland
| | - Matthijs C Brouwer
- European Society of Clinical Microbiology and Infectious Diseases, Study Group for Infections of the Brain (ESGIB), Basel, Switzerland; Department of Neurology, Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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3
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Dahlberg D, Holm S, Sagen EML, Michelsen AE, Stensland M, de Souza GA, Müller EG, Connelly JP, Revheim ME, Halvorsen B, Hassel B. Bacterial Brain Abscesses Expand Despite Effective Antibiotic Treatment: A Process Powered by Osmosis Due to Neutrophil Cell Death. Neurosurgery 2023; 94:00006123-990000000-00996. [PMID: 38084989 PMCID: PMC10990409 DOI: 10.1227/neu.0000000000002792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 10/22/2023] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND AND OBJECTIVES A bacterial brain abscess is an emergency and should be drained of pus within 24 hours of diagnosis, as recently recommended. In this cross-sectional study, we investigated whether delaying pus drainage entails brain abscess expansion and what the underlying mechanism might be. METHODS Repeated brain MRI of 47 patients who did not undergo immediate pus drainage, pus osmolarity measurements, immunocytochemistry, proteomics, and 18F-fluorodeoxyglucose positron emission tomography. RESULTS Time from first to last MRI before neurosurgery was 1 to 14 days. Abscesses expanded in all but 2 patients: The median average increase was 23% per day (range 0%-176%). Abscesses expanded during antibiotic therapy and even if the pus did not contain viable bacteria. In a separate patient cohort, we found that brain abscess pus tended to be hyperosmolar (median value 360 mOsm; range 266-497; n = 14; normal cerebrospinal fluid osmolarity is ∼290 mOsm). Hyperosmolarity would draw water into the abscess cavity, causing abscess expansion in a ballooning manner through increased pressure in the abscess cavity. A mechanism likely underlying pus hyperosmolarity was the recruitment of neutrophils to the abscess cavity with ensuing neutrophil cell death and decomposition of neutrophil proteins and other macromolecules to osmolytes: Pus analysis showed the presence of neutrophil proteins (protein-arginine deiminases, citrullinated histone, myeloperoxidase, elastase, cathelicidin). Previous studies have shown very high levels of osmolytes (ammonia, amino acids) in brain abscess pus. 18F-fluorodeoxyglucose positron emission tomography showed focal neocortical hypometabolism 1 to 8 years after brain abscess, indicating long-lasting damage to brain tissue. CONCLUSION Brain abscesses expand despite effective antibiotic treatment. Furthermore, brain abscesses cause lasting damage to surrounding brain tissue. These findings support drainage of brain abscesses within 24 hours of diagnosis.
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Affiliation(s)
- Daniel Dahlberg
- Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
| | - Sverre Holm
- Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway
| | - Ellen Margaret Lund Sagen
- Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Annika Elisabet Michelsen
- Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Maria Stensland
- Institute of Immunology and Centre for Immune Regulation, Oslo University Hospital, Oslo, Norway
| | - Gustavo Antonio de Souza
- Institute of Immunology and Centre for Immune Regulation, Oslo University Hospital, Oslo, Norway
- Department of Biochemistry, Universidade Federal Do Rio Grande Do Norte, Natal, Brazil
| | - Ebba Gløersen Müller
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Division of Radiology and Nuclear Medicine, Department of Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | - James Patrick Connelly
- Division of Radiology and Nuclear Medicine, Department of Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | - Mona-Elisabeth Revheim
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Division of Radiology and Nuclear Medicine, Department of Nuclear Medicine, Oslo University Hospital, Oslo, Norway
- The Intervention Centre, Oslo University Hospital, Oslo, Norway
| | - Bente Halvorsen
- Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Bjørnar Hassel
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Neurohabilitation, Oslo University Hospital, Oslo, Norway
- Norwegian Defence Research Establishment (FFI), Kjeller, Norway
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4
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Ngo TM, Okabe A, Nguyen KB, Tong A, Chang J, Lui F. Cryptogenic Pontine Abscess Treated With Stereotactic Aspiration: A Case Report. Cureus 2023; 15:e41463. [PMID: 37546074 PMCID: PMC10404128 DOI: 10.7759/cureus.41463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2023] [Indexed: 08/08/2023] Open
Abstract
Brainstem abscesses are localized collections of pus or infected material within the brainstem, which can cause inflammation, tissue damage, and compression of adjacent structures. This can lead to a variety of symptoms, including headache, fever, and focal neurological deficits, among many others. Brainstem abscesses are potentially life-threatening and considered to be rare, and pontine abscesses are even rarer. Both are often caused by the spread of infection from nearby structures like the middle ear, sinuses, and mastoid air cells, but they can also result from distant infectious sites that have spread to the bloodstream. Ambiguous clinical presentation can delay appropriate care and lead to poorer outcomes. We present a rare case of pontine abscess in a 54-year-old male with both undetermined causal origins and unclear infectious signs, namely, the lack of fever, fatigue, and chills. We will discuss the etiologies, diagnosis, and treatment of cryptogenic brainstem lesions in this case report.
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Affiliation(s)
- Taylor M Ngo
- Neurology, California Northstate University College of Medicine, Elk Grove, USA
| | - Anna Okabe
- Neurology, California Northstate University College of Medicine, Elk Grove, USA
| | - Kailey B Nguyen
- Neurology, California Northstate University College of Medicine, Elk Grove, USA
| | - Anhtho Tong
- Neurology, California Northstate University College of Medicine, Elk Grove, USA
| | - Jason Chang
- Neurology, Kaiser Permanente South Sacramento Medical Center, Sacramento, USA
| | - Forshing Lui
- Clinical Sciences, California Northstate University College of Medicine, Elk Grove, USA
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5
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Balak N. Choice of surgical procedure in the treatment of brain abscess. Br J Neurosurg 2023; 37:121. [PMID: 34821178 DOI: 10.1080/02688697.2021.2007216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Naci Balak
- MD, IFAANS, Department of Neurosurgery, Göztepe Education and Research Hospital, Istanbul Medeniyet University, Istanbul, Turkey
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6
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Lannon M, Trivedi A, Martyniuk A, Farrokhyar F, Sharma S. Surgical aspiration versus excision for intraparenchymal abscess: a systematic review and Meta-analysis. Br J Neurosurg 2022; 36:743-749. [PMID: 36062586 DOI: 10.1080/02688697.2022.2118231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Brain abscesses are associated with considerable morbidity and mortality, requiring timely intervention to achieve favourable outcomes. With the advent of high-resolution computed tomography (CT) imaging, mortality following both aspiration and excision of brain abscesses has improved markedly. As a result, there has been a marked shift in neurosurgical practice with aspiration eclipsing excision as the favoured first-line modality for most abscesses. However, this trend lacks sufficient supporting evidence, and this systematic review and meta-analysis seeks to compare aspiration and excision in the treatment of brain abscess. Twenty-seven studies were included in the systematic review, and seven comparative papers in meta-analysis. Aspiration was the chosen technique for 67.5% of patients. Baseline characteristics from the studies included only in the systematic review demonstrated that abscesses treated by aspiration were typically larger and in a deeper location than those excised. In the meta-analysis, we initially found no significant difference in mortality, re-operation rate, or functional outcome between the two treatment modalities. However, sensitivity analysis revealed that excision results in lower re-operation rate. On average, the included studies were of poor quality with average Methodological Index for Non-Randomized Studies (MINORS) scores of 10.3/16 and 14.43/24 for non-comparative and comparative papers respectively. Our study demonstrates that excision may offer improved re-operation rate as compared to aspiration for those abscesses where there is no prior clinical indication for either modality. However, no differences were found with respect to mortality or functional outcome. Evidence from the literature was deemed low quality, emphasizing the need for further investigation in this field, specifically in the form of large, well-controlled, comparative trials.
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Affiliation(s)
- Melissa Lannon
- Division of Neurosurgery, McMaster University, Hamilton, Canada
| | - Arunchala Trivedi
- Michael G DeGroote School of Medicine, McMaster University, Hamilton, Canada
| | | | - Forough Farrokhyar
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
| | - Sunjay Sharma
- Division of Neurosurgery, McMaster University, Hamilton, Canada
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7
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Yoon J, O'Bryan CM, Maclachlan L, Redmond M. Intracranial infected collections and epidemiology in the top end, Northern Territory, Australia. A 10-year case series. ANZ J Surg 2021; 91:2793-2799. [PMID: 34580966 DOI: 10.1111/ans.17202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 08/28/2021] [Accepted: 08/29/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The incidence of intracranial infected collections (IIC) ranges between 0.4 and 1.2/100 000 persons per year. There is anecdotal evidence that residents in Top End of the Northern Territory are at a greater risk of infections with protracted clinical presentations. To our knowledge, there is no study to date to explore IIC in the Top End. METHODS Retrospective observational analysis of IIC in the Top End, Northern Territory, Australia from 2009 to 2019. International classification of disease code G06 was used to identify cases diagnosed at Royal Darwin, Gove District and Katherine Hospital with no restriction of age or gender. RESULTS A total of 51 cases were identified. This equated to an incidence of 2.9 (95% CI 2.2-3.8) in 100 000 PPY. When separated into Indigenous and non-Indigenous populations, the respective incidences were 8.65 (95% CI 6.2-12.1) and 1.1 (95% CI 0.7-1.9) in 100 000 PPY. The Indigenous population was at a significantly higher risk of IIC compared with non-Indigenous Australians with a relative risk of 7.3 (P < 0.0001 95% CI 4.0-13.3). The most common aetiology was otogenic infections with all cases being identified in the Indigenous population. Comparison of other clinical parameters between the two populations were not statistically significant. CONCLUSIONS Within the limitations of a retrospective study, the incidence of IICs is higher in the Top End than reported elsewhere in the literature. This is particularly true for the Indigenous population.
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Affiliation(s)
- Joseph Yoon
- Kenneth G Jamieson Department of Neurosurgery, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Neurosurgery Department, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Claire Maree O'Bryan
- College of Medicine and Public Health, Flinders University, Darwin, Northern Territory, Australia
| | - Liam Maclachlan
- Kenneth G Jamieson Department of Neurosurgery, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
| | - Michael Redmond
- Kenneth G Jamieson Department of Neurosurgery, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Neurosurgery Department, Royal Darwin Hospital, Darwin, Northern Territory, Australia
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8
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Hassel B, De Souza GA, Stensland ME, Ivanovic J, Voie Ø, Dahlberg D. The proteome of pus from human brain abscesses: host-derived neurotoxic proteins and the cell-type diversity of CNS pus. J Neurosurg 2018; 129:829-837. [DOI: 10.3171/2017.4.jns17284] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVEWhat determines the extent of tissue destruction during brain abscess formation is not known. Pyogenic brain infections cause destruction of brain tissue that greatly exceeds the area occupied by microbes, as seen in experimental studies, pointing to cytotoxic factors other than microbes in pus. This study examined whether brain abscess pus contains cytotoxic proteins that might explain the extent of tissue destruction.METHODSPus proteins from 20 human brain abscesses and, for comparison, 7 subdural empyemas were analyzed by proteomics mass spectrometry. Tissue destruction was determined from brain abscess volumes as measured by MRI.RESULTSBrain abscess volume correlated with extracellular pus levels of antibacterial proteins from neutrophils and macrophages: myeloperoxidase (r = 0.64), azurocidin (r = 0.61), lactotransferrin (r = 0.57), and cathelicidin (r = 0.52) (p values 0.002–0.018), suggesting an association between leukocytic activity and tissue damage. In contrast, perfringolysin O, a cytotoxic protein from Streptococcus intermedius that was detected in 16 patients, did not correlate with abscess volume (r = 0.12, p = 0.66). The median number of proteins identified in each pus sample was 870 (range 643–1094). Antibiotic or steroid treatment prior to pus evacuation did not reduce the number or levels of pus proteins. Some of the identified proteins have well-known neurotoxic effects, e.g., eosinophil cationic protein and nonsecretory ribonuclease (also known as eosinophil-derived neurotoxin). The cellular response to brain infection was highly complex, as reflected by the presence of proteins that were specific for neutrophils, eosinophils, macrophages, platelets, fibroblasts, or mast cells in addition to plasma and erythrocytic proteins. Other proteins (neurofilaments, myelin basic protein, and glial fibrillary acidic protein) were specific for brain cells and reflected damage to neurons, oligodendrocytes, and astrocytes, respectively. Pus from subdural empyemas had significantly higher levels of plasma proteins and lower levels of leukocytic proteins than pus from intracerebral abscesses, suggesting greater turnover of the extracellular fluid of empyemas and washout of pus constituents.CONCLUSIONSBrain abscess pus contains leukocytic proteins that are neurotoxic and likely participate actively in the excessive tissue destruction inherent in brain abscess formation. These findings underscore the importance of rapid evacuation of brain abscess pus.
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Affiliation(s)
- Bjørnar Hassel
- 1Department of Complex Neurology and Neurohabilitation,
- 2Norwegian Defence Research Establishment (FFI), Kjeller, Norway; and
| | - Gustavo Antonio De Souza
- 3Institute of Immunology and Centre for Immune Regulation, and
- 4The Brain Institute, Universidade Federal do Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil
| | | | - Jugoslav Ivanovic
- 5Department of Neurosurgery, Oslo University Hospital, University of Oslo
| | - Øyvind Voie
- 2Norwegian Defence Research Establishment (FFI), Kjeller, Norway; and
| | - Daniel Dahlberg
- 5Department of Neurosurgery, Oslo University Hospital, University of Oslo
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9
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Widdrington JD, Bond H, Schwab U, Price DA, Schmid ML, McCarron B, Chadwick DR, Narayanan M, Williams J, Ong E. Pyogenic brain abscess and subdural empyema: presentation, management, and factors predicting outcome. Infection 2018; 46:785-792. [PMID: 30054798 DOI: 10.1007/s15010-018-1182-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 07/24/2018] [Indexed: 12/15/2022]
Abstract
PURPOSE To describe the presentation and management of bacterial brain abscess and subdural empyema in adults treated at two tertiary centers. In addition, to identify factors that may predict a poor clinical outcome. METHODS A retrospective analysis of data obtained from clinical records was performed, followed by multivariate regression analysis of patient and treatment-related factors. RESULTS 113 patients were included with a median age of 53 years and a male preponderance. At presentation symptoms were variable, 28% had a focal neurological deficit, and 39% had a reduced Glasgow coma scale (GCS). Brain abscesses most frequently affected the frontal, temporal, and parietal lobes while 36% had a subdural empyema. An underlying cause was identified in 76%; a contiguous ear or sinus infection (43%), recent surgery or trauma (18%) and haematogenous spread (15%). A microbiological diagnosis was confirmed in 86%, with streptococci, staphylococci, and anaerobes most frequently isolated. Treatment involved complex, prolonged antibiotic therapy (> 6 weeks in 84%) combined with neurosurgical drainage (91%) and source control surgery (34%). Mortality was 5% with 31% suffering long-term disability and 64% achieving a good clinical outcome. A reduced GCS, focal neurological deficit, and seizures at presentation were independently associated with an unfavorable clinical outcome (death or disability). CONCLUSIONS Complex surgical and antimicrobial treatment achieves a good outcome in the majority of patients with bacterial brain abscess and subdural empyema. Factors present at diagnosis can help to predict those likely to suffer adverse outcomes. Research to determine optimal surgical and antibiotic management would be valuable.
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Affiliation(s)
- John D Widdrington
- Department of Infection and Tropical Medicine, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK. .,Centre for Clinical Infection, James Cook University Hospital, Marton Road, Middlesbrough, TS4 3BW, UK.
| | - Helena Bond
- Department of Infection and Tropical Medicine, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK.,Centre for Clinical Infection, James Cook University Hospital, Marton Road, Middlesbrough, TS4 3BW, UK
| | - Ulrich Schwab
- Department of Infection and Tropical Medicine, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK
| | - D Ashley Price
- Department of Infection and Tropical Medicine, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK
| | - Matthias L Schmid
- Department of Infection and Tropical Medicine, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK
| | - Brendan McCarron
- Centre for Clinical Infection, James Cook University Hospital, Marton Road, Middlesbrough, TS4 3BW, UK
| | - David R Chadwick
- Centre for Clinical Infection, James Cook University Hospital, Marton Road, Middlesbrough, TS4 3BW, UK
| | - Manjusha Narayanan
- Department of Microbiology, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK
| | - John Williams
- Centre for Clinical Infection, James Cook University Hospital, Marton Road, Middlesbrough, TS4 3BW, UK
| | - Edmund Ong
- Department of Infection and Tropical Medicine, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK
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10
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Bodilsen J, Brouwer MC, Nielsen H, Van De Beek D. Anti-infective treatment of brain abscess. Expert Rev Anti Infect Ther 2018; 16:565-578. [PMID: 29909695 DOI: 10.1080/14787210.2018.1489722] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Brain abscess is an uncommon and potentially life-threatening infection of the CNS that can be caused by a range of different pathogens including bacteria, fungi, and parasites. A multidisciplinary approach is important and anti-infective treatment remains crucial. Here, we review anti-infective treatment of brain abscess. Areas covered: We used the terms '(Brain abscess[ti] AND (antibiotic* OR treatment)) NOT case report'), to conduct a search in the PubMed. Additional papers were identified by cross-reference checking and by browsing textbooks of infectious diseases and neurology. COMMENTARY Empiric treatment of bacterial brain abscess consists of cefotaxime and metronidazole with the addition of vancomycin if meticilline-resistant Staphylococcus aureus is suspected. For severely immuno-suppressed patients, for example transplant recipients, voriconazole and trimethoprim-sulfamethoxazole or sulfadiazine should be added. Increased knowledge of the pharmacokinetic profile of anti-infective treatments may help to improve the treatment of brain abscess. Future studies should address efficacy and safety of continuous abscess drainage, mode of anti-infective administration (continuous vs. bolus), and anti-infective treatments in immuno-suppressed patients.
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Affiliation(s)
- Jacob Bodilsen
- a Departments of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark (JB, HN) and Neurology, Amsterdam Neuroscience , Academic Medical Centre, Amsterdam , The Netherlands (MCB, DvdB)
| | - Matthijs C Brouwer
- a Departments of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark (JB, HN) and Neurology, Amsterdam Neuroscience , Academic Medical Centre, Amsterdam , The Netherlands (MCB, DvdB)
| | - Henrik Nielsen
- a Departments of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark (JB, HN) and Neurology, Amsterdam Neuroscience , Academic Medical Centre, Amsterdam , The Netherlands (MCB, DvdB)
| | - Diederik Van De Beek
- a Departments of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark (JB, HN) and Neurology, Amsterdam Neuroscience , Academic Medical Centre, Amsterdam , The Netherlands (MCB, DvdB)
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Yu X, Liu R, Wang Y, Zhao H, Chen J, Zhang J, Hu C. CONSORT: May stereotactic intracavity administration of antibiotics shorten the course of systemic antibiotic therapy for brain abscesses? Medicine (Baltimore) 2017; 96:e6359. [PMID: 28538360 PMCID: PMC5457840 DOI: 10.1097/md.0000000000006359] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Despite advances in surgical techniques in the management of the brain abscess, continuous systemic long-term antibiotics are necessary and crucial. This study was designed to evaluate the effect of intracavity administration of high-dose antibiotics on the course of antibiotic therapy. METHODS Between 2003 and 2013, 55 patients with bacterial brain abscesses (83 abscesses) were treated with stereotactic aspiration and intracavity injection of high-dose antibiotics combined with a short course systemic antibiotic therapy. Antibiotics of one-eighth daily systemic dosage were injected into the abscess cavity after stereotactic aspiration and intravenous antibiotics were given in all patients for 3 to 4 weeks. The results of the group treated with stereotactic aspiration and intracavity injection of antibiotic solution were compared to the results of our previous patients treated by stereotactic aspiration only. RESULTS Thirty-nine males and 16 females (age ranging from 1.5 to 76 years; mean age 38.7 years) were included in this study. During the follow-up (mean 26.2 months, ranging from 6 to 72 months), all the abscesses subsided with no recurrence. No adverse effects related to topical use of antibiotics occurred. At the end of follow-up, 38 patients had good outcomes, 11 had mild neurological deficits, 3 had moderate deficits, 1 was in vegetative state, and 2 died of accidents not related to brain abscesses. Compared with conventional stereotactic aspiration and drainage, intracavity injection of antibiotics shorted the course of consecutive systemic intravenous antibiotics by average 10.8 days without an increase of the recurrence rate of abscesses. CONCLUSIONS Our results indicate that topical application of antibiotics into the brain abscess cavity helps to reduce the length of systemic antibiotic therapy, decreases the abscess recurrence rate, avoids the side effects of long-term high dose antibiotics, shortens the hospitalization and reduces treatment costs.
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Bourne EL, Dimou J. Invasive central nervous system aspergillosis in a patient with Crohn’s disease after treatment with infliximab and corticosteroids. J Clin Neurosci 2016; 30:163-164. [DOI: 10.1016/j.jocn.2016.02.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 01/30/2016] [Accepted: 02/14/2016] [Indexed: 01/18/2023]
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Yoganathan S, Chakrabarty B, Gulati S, Kumar A, Kumar A, Singh M, Xess I. Candida tropicalis brain abscess in a neonate: An emerging nosocomial menace. Ann Indian Acad Neurol 2014; 17:448-50. [PMID: 25506171 PMCID: PMC4251023 DOI: 10.4103/0972-2327.144036] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Revised: 03/05/2014] [Accepted: 04/29/2014] [Indexed: 11/18/2022] Open
Abstract
Fungi are a relatively uncommon cause of brain abscess in neonates and early infancy. They are usually associated with predisposing factors like prematurity, low birth weight, use of broad-spectrum antibiotics, and prolonged stay in the intensive care unit. Candida tropicalis (C. tropicalis) is rapidly emerging as a nosocomial threat in the neonatal intensive care settings. This case report describes a neonate with C. tropicalis brain abscess who was diagnosed early and managed aggressively with a favorable outcome. Inadvertent use of intravenous antibiotics can have serious complications such as invasive fungal infection. Correct microbiological diagnosis is the key to successful treatment of deep-seated pyogenic infection. Fungal etiology should always be studied in relevant clinical settings.
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Affiliation(s)
- Sangeetha Yoganathan
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | | | - Sheffali Gulati
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Ajay Kumar
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Atin Kumar
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Manmohan Singh
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Immaculata Xess
- Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India
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Tissue is Not the Issue. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2014. [DOI: 10.1097/ipc.0b013e31828bbb9a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Helweg-Larsen J, Astradsson A, Richhall H, Erdal J, Laursen A, Brennum J. Pyogenic brain abscess, a 15 year survey. BMC Infect Dis 2012. [PMID: 23193986 PMCID: PMC3536615 DOI: 10.1186/1471-2334-12-332] [Citation(s) in RCA: 115] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Background Brain abscess is a potentially fatal disease. This study assesses clinical aspects of brain abscess in a large hospital cohort. Methods Retrospective review of adult patients with pyogenic brain abscess at Rigshospitalet University Hospital, Denmark between 1994 and 2009. Prognostic factors associated with Glasgow Outcome Score (GOS) (death, severe disability or vegetative state) were assessed by logistic regression. Results 102 patients were included. On admission, only 20% of patients had a triad of fever, headache and nausea, 39% had no fever, 26% had normal CRP and 49% had no leucocytosis. Median delay from symptom onset to antibiotic treatment was 7 days (range 0–97 days). Source of infection was contiguous in 36%, haematogenous in 28%, surgical or traumatic in 9% and unknown in 27% of cases. Abscess location did not accurately predict the portal of entry. 67% were treated by burr hole aspiration, 20% by craniotomy and 13% by antibiotics alone. Median duration of antibiotic treatment was 62 days. No cases of recurrent abscess were observed. At discharge 23% had GOS ≤3. The 1-, 3- and 12-month mortality was 11%, 17% and 19%. Adverse outcome was associated with a low GCS at admission, presence of comorbidities and intraventricular rupture of abscess. Conclusions The clinical signs of brain abscess are unspecific, many patients presented without clear signs of infection and diagnosis and treatment were often delayed. Decreased GCS, presence of comorbidities and intraventricular rupture of brain abscess were associated with poor outcome. Brain abscess remains associated with considerable morbidity and mortality.
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Affiliation(s)
- Jannik Helweg-Larsen
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Denmark.
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Saito N, Hida A, Koide Y, Ooka T, Ichikawa Y, Shimizu J, Mukasa A, Nakatomi H, Hatakeyama S, Hayashi T, Tsuji S. Culture-negative brain abscess with Streptococcus intermedius infection with diagnosis established by direct nucleotide sequence analysis of the 16s ribosomal RNA gene. Intern Med 2012; 51:211-6. [PMID: 22246493 DOI: 10.2169/internalmedicine.51.6419] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 70-year-old woman developed a headache for a month followed by right upper limb weakness. CT scan and MRI showed multiple ring-enhancing lesions. An intracerebral aspiration of an abscess was performed, but culture results were negative. The nucleotide sequence analysis of the 16S rRNA gene from the specimens identified Streptococcus intermedius. Given this result, S. intermedius was cultured by enrichment culture, and its sensitivities to antibiotics were determined. The patient exhibited complete remission. Thus, 16S rRNA gene analysis was highly useful not only for pathogen identification with negative culture results but also for the appropriate selection of antibiotics.
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Affiliation(s)
- Naoko Saito
- Department of Neurology, Graduate School of Medicine, The University of Tokyo, Japan
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Leong SC, Waugh LK, Sinha A, De S. Clinical outcomes of sinogenic intracranial suppuration: the Alder Hey experience. Ann Otol Rhinol Laryngol 2011; 120:320-5. [PMID: 21675588 DOI: 10.1177/000348941112000507] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The aim of this study was to present a series of cases of sinogenic intracranial suppuration in a pediatric tertiary referral center and to review the long-term outcomes of the patients. METHODS We performed a retrospective review of the hospital database and the patient case notes. RESULTS Over 10 years, 14 patients were identified. The clinical presentations at the time of admission tended to include headache, vomiting, pyrexia, limb weakness, and decreased level of consciousness, in decreasing order of frequency. Sinonasal symptoms such as discharge and obstruction were only present in 36% and 21% of cases, respectively. The most common intracranial complication was subdural empyema in the frontal lobe region. The mortality rate was 21% (3 of 14). The remaining 11 patients remained alive at latest follow-up. The average follow-up period after hospital discharge was 19 months (median, 15 months; range, 6 to 64 months). No significant complications were noted in 4 patients, who had returned to normal daily activities at 6 months of follow-up. A significant proportion of patients who survived have some form of neurologic sequelae, although 64% of cases became asymptomatic in the 12 months following hospital discharge. CONCLUSIONS The significant risk of morbidity and mortality of this disease requires a multidisciplinary approach that is best delivered at a tertiary referral center.
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Affiliation(s)
- Samuel Chee Leong
- Department of Otorhinolaryngology, Alder Hey Children's National Health Service Foundation Trust, Liverpool, England. United Kingdom
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O'Loughlin E, Smithies WJ, Corcoran TB. Out-of-Hours Surgery – a Snapshot in Time. Anaesth Intensive Care 2010; 38:1059-63. [DOI: 10.1177/0310057x1003800616] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Anaesthesia in Australia is amongst the safest in the world. This record of safety is under threat from increasing pressures to operate at times of poor human performance, particularly late at night. Our institution has a policy mandating the prioritisation of surgery based on clinical need while minimising the risks associated with after-hours surgery. The policy states that “only Category 1 (urgent, needing immediate surgery) and Category 2 cases which cannot wait until the morning should be done between 2230 and 0800”. From 5 March 2007 we performed an eight-week prospective audit of all cases where surgery occurred in this time period. The anaesthetic senior registrar on duty recorded the clinical priority of the case. There were 95 cases commenced between 2230 and 0800 hours during the audit period, of which 28 (30%) were in clear breach of this policy, in some cases delaying urgent surgery. The potential implications of such breaches are significant in the context of worse outcomes for patients undergoing surgery in the after-hours period. When non-urgent cases occupy resources, the capacity of the system to deal with the truly urgent case is significantly impaired. Adequate ‘in-hours’ resourcing, capacity and appropriate scheduling may be key to maintaining the excellent safety record of anaesthesia. A large study prospectively examining morbidity, error and outcomes of after-hours operating would serve to further elucidate the risk benefit ratio of after-hours operating.
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Affiliation(s)
- E. O'Loughlin
- Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
- Clinical Senior Lecturer, School of Medicine and Pharmacology, University of Western Australia
| | - W. J. Smithies
- Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
- Specialist Anaesthetist
| | - T. B. Corcoran
- Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
- Clinical Associate Professor, School of Medicine and Pharmacology, University of Western Australia, Director of Research
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Hamann GF, Dieterich M. [Report of the 2nd NeuroUpdate from the MedUpdate series in Wiesbaden]. DER NERVENARZT 2010; 81:998-1002. [PMID: 20617428 DOI: 10.1007/s00115-010-3037-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Affiliation(s)
- G F Hamann
- Neurologischen Klinik der Dr. Horst Schmidt Klinik GmbH Wiesbaden, Wiesbaden, Deutschland.
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