Stephen V. Tornabene

Immune cell recruitment following acoustic trauma.

Acoustic trauma induces cochlear inflammation. We hypothesized that chemokines are involved in the recruitment of leukocytes as part of a wound healing response. The cochleas of NIH-Swiss mice, exposed to octave-band noise (8-16 kHz, at 118 dB) for 2h, were examined after the termination of exposure. Leukocytes were identified immunohistochemically with antibodies to CD45 and F4/80. Gene array analysis followed by RT-PCR was performed on cochlear tissue to identify up-regulation of chemokine and adhesion molecule mRNA. The expression of the adhesion molecule ICAM-1 was also investigated immunohistochemically. Few CD45- or F4/80-positive leukocytes were observed in the non-exposed cochlea. Following acoustic trauma however, the number of CD45-positive cells was dramatically increased especially after 2 and 4 days, after which time the numbers decreased. F4/80-positive cells also increased in number over the course of a week. Gene array analysis indicated increased expression of monocyte chemoattractant protein 5 (MCP-5), monocyte chemoattractant protein 1 (MCP-1), macrophage inflammatory protein-1beta (MIP-1beta) and ICAM-1. RT-PCR, performed using primers for the individual mRNA sequences, confirmed the increased expression of MCP-1, MCP-5, MIP-1beta, and ICAM-1 relative to non-exposed mice. In the normal cochlea, ICAM-1 immunohistochemical expression was observed in venules, spiral ligament fibrocytes and in endosteal cells of the scala tympani. Expression increased to include more of the spiral ligament and endosteal cells after acoustic trauma. A cochlear inflammatory response is initiated in response to acoustic trauma and involves the recruitment of circulating leukocytes to the inner ear.

Paramedic Self-Reported Medication Errors

Background. Continuing quality improvement (CQI) reviews reflect that medication administration errors occur in the prehospital setting. These include errors involving dose, medication, route, concentration, andtreatment. Methods. A survey was given to paramedics in San Diego County. The survey tool was established on the basis of previous literature reviews andquestions developed with previous CQI data. Results. A total of 352 surveys were returned, with the paramedics reporting a mean of 8.5 years of field experience. They work an average of 11.0 shifts/month with an average of 25.4 hours and6.7 calls/shift. Thirty-two (9.1%) responding paramedics reported committing a medication error in the last 12 months. Types of errors included dose-related errors (63%), protocol errors (33%), wrong route errors (21%), andwrong medication errors (4%). Issues identified in contributing to the errors include failure to triple check, infrequent use of the medication, dosage calculation error, andincorrect dosage given. Fatigue, training, andequipment setup of the drug box were not listed as any of the contributing factors. The majority of these errors were self-reported to their CQI representative (79.1%), with 8.3% being reported by the base hospital radio nurse, 8.3% found upon chart review, and4.2% noted by paramedic during call but never reported. Conclusions. Nine percent of paramedics responding to an anonymous survey report medication errors in the last 12 months, with 4% of these errors never having been reported in the CQI process. Additional safeguards must continue to be implemented to decrease the incidence of medication errors.

Evaluating the Use and Timing of Opioids for the Treatment of Migraine Headaches in the Emergency Department

The objective of this study was to evaluate the throughput times of patients administered opioids for the treatment of migraine headaches in the frequent emergency department (ED) visitor. A retrospective review of ED patient records was conducted. Repeat patients were significantly more likely to receive opioids as a treatment, receive multiple doses of opioids, and receive opioids as the initial pharmacological treatment compared to non-repeaters. Patients administered opioids, regardless of repeater status, had significantly longer ED stays; 142 min (95% confidence interval [CI] 124-160) vs. 111 min (95% CI 93-129), respectively, p = 0.015. Patients given multiple doses of opioids had significantly longer ED stays than patients given a single dose of an opioid; 191 min (95% CI 156-225) vs. 125 min (95% CI 101-149), respectively, p = 0.003. Delayed administration of opioids did not result in longer ED stays in those patients eventually treated with opioids. Administration of opioids for migraine headache may result in longer ED stays when compared with non-opioid migraine treatments. Judicious use of opioids as a treatment for migraine headaches is recommended.

Gradenigo's Syndrome

The syndrome of constant otorrhea, headache, and diplopia, which is attributed to inflammation of the petrous apex, is known as Gradenigos syndrome. It is often the result of chronic otitis media with long-standing purulent otorrhea. It has traditionally been treated surgically, but recent advances in imaging, allied with improved antibiotic treatment, have allowed for consideration of non-surgical management of these cases. A 60-year-old woman presented to the emergency department with 7 days of right-sided headache, facial pain, and diplopia. She awoke with the headache and facial pain 7 days earlier. She was without any preceding infectious symptoms including ear pain, sinus congestion, sore throat, and cough, and she denied fevers and chills. Examination demonstrated a right eye lateral gaze palsy and reproducible diplopia. Computed tomography studies demonstrated the possibility of fluid in the petrous apex of the temporal bone. A follow-up magnetic resonance imaging study confirmed a moderate amount of fluid in the right petrous apex consistent with Gradenigos syndrome. Imaging with computed tomography and magnetic resonance is an important tool in the evaluation of petrous apex lesions. Gradenigos syndrome is a rare condition that does not always present with the classical triad of otorrhea, headache, and diplopia. Appropriate management requires antibiotic treatment and possible surgical intervention.

Cerebellopontine angle cyst compressing the vagus nerve: case report.

OBJECTIVEThe cerebellopontine angle (CPA) is a rare location for an arachnoid cyst. We describe a patient with a CPA arachnoid cyst who presented with hoarseness (unilateral vocal cord paralysis) and dysphagia secondary to isolated compression of the vagus nerve. This rare presentation of a CPA arachnoid cyst has not been reported previously. CLINICAL PRESENTATIONThe patient described is a 50-year-old man who experienced a precipitous onset of hoarseness and dsyphagia. An otolaryngological evaluation revealed right-sided vocal cord paralysis. Brain magnetic resonance images displayed a cystic mass at the right CPA and anterior displacement of the vagus nerve. INTERVENTIONThe patient underwent retrosigmoidal craniectomy with cyst fenestration, which was well tolerated. Intraoperatively, Cranial Nerve X was found splayed over the cyst and was consequently decompressed. CONCLUSIONPostoperatively, the patients dysphagia completely resolved. However, the results of a laryngeal electromyocardiogram revealed minimal evidence of recovery in the affected vocal fold, and the patient continued to suffer from dysphonia. Although CPA arachnoid cysts are rare, they should be considered when a patient presents with an isolated cranial nerve palsy. Treatment options include cyst fenestration and cranial nerve decompression.