COVID-19 Outcome

COVID-19 Outcome

The possible risk factors that lead to death in critical inpatients with coronavirus disease 2019 (COVID-19) are not yet fully understood.

Old age (>70 years), neutrophiliaC-reactive protein greater than 100 mg/L and lactate dehydrogenase over 300 U/L are high-risk factors for mortality in critical patients with COVID-19Sinus tachycardia and ventricular arrhythmia are independent ECG risk factors for mortality from COVID-19 1).

While the disease itself is often mild, approximately 11% of cases require acute medical care, and this cohort quickly overwhelmed healthcare systems around the world 2).

In anticipation of such a demand, hospitals in many countries quickly stopped all nonurgent visits, procedures, and surgeries, freeing up beds, equipment, and workforce 3)


The mortality rate for COVID-19 is not as high (approximately 2-3%), but its rapid propagation has resulted in the activation of protocols to stop its spread. 4).

A total of 174 consecutive patients confirmed with COVID-19 were studied. Demographic data, medical history, symptoms and signs, laboratory findings, chest computed tomography (CT) as well we treatment measures were collected and analyzed.

Guo et al. found that COVID-19 patients without other comorbidities but with diabetes (n=24) were at higher risk of severe pneumonia, the release of tissue injury-related enzymes, excessive uncontrolled inflammation responses and hypercoagulable state associated with dysregulation of glucose metabolism. Furthermore, serum levels of inflammation-related biomarkers such as IL-6, C-reactive protein, serum ferritin, and coagulation index, D-dimer, were significantly higher (p< 0.01) in diabetic patients compared with those without, suggesting that patients with diabetes are more susceptible to an inflammatory storm eventually leading to rapid deterioration of COVID-19.

Data support the notion that diabetes should be considered as a risk factor for a rapid progression and bad prognosis of COVID-19. More intensive attention should be paid to patients with diabetes, in case of rapid deterioration 5).


see Racism and discrimination in COVID-19 responses 6).


1)

Li L, Zhang S, He B, Chen X, Wang S, Zhao Q. Risk factors and electrocardiogram characteristics for mortality in critical inpatients with COVID-19. Clin Cardiol. 2020 Oct 22. doi: 10.1002/clc.23492. Epub ahead of print. PMID: 33094522.
2)

Remuzzi A, Remuzzi G. COVID-19 and Italy: what next? Lancet. 2020;395(10231):P1225-P1228.
3)

Wong J, Goh QY, Tan Z, et al. Preparing for a COVID-19 pandemic: a review of operating room outbreak response measures in a large tertiary hospital in Singapore. Can J Anaesth. 2020;395:497.
4)

Palacios Cruz M, Santos E, Velázquez Cervantes MA, León Juárez M. COVID-19, a worldwide public health emergency. Rev Clin Esp. 2020 Mar 20. pii: S0014-2565(20)30092-8. doi: 10.1016/j.rce.2020.03.001. [Epub ahead of print] Review. English, Spanish. PubMed PMID: 32204922.
5)

Guo W, Li M, Dong Y, Zhou H, Zhang Z, Tian C, Qin R, Wang H, Shen Y, Du K, Zhao L, Fan H, Luo S, Hu D. Diabetes is a risk factor for the progression and prognosis of COVID-19. Diabetes Metab Res Rev. 2020 Mar 31:e3319. doi: 10.1002/dmrr.3319. [Epub ahead of print] PubMed PMID: 32233013.
6)

Devakumar D, Shannon G, Bhopal SS, Abubakar I. Racism and discrimination in COVID-19 responses. Lancet. 2020 Apr 1. pii: S0140-6736(20)30792-3. doi: 10.1016/S0140-6736(20)30792-3. [Epub ahead of print] PubMed PMID: 32246915.

COVID-19 Pandemic

COVID-19 Pandemic

On 30 December 2019, a report of a cluster of pneumonia of unknown etiology was published on ProMED-mail, possibly related to contact with a seafood market in WuhanChina 1).

Hospitals in the region held an emergency symposium, and support from federal agencies is reportedly helping to determine the source of infection and causative organism. The seafood market has since been closed, but purportedly sold a variety of live animal species. On 5 January 2019, the World Health Organization (WHO) published a document outlining their request for more information from Chinese public health authorities and detailed 44 patients had ‘pneumonia of unknown etiology’, with 121 close contacts under surveillance (www.who.int/csr/don/05-january-2020-pneumonia-of-unkown-cause-china/en/). The WHO reported that 11 patients were severely ill, and many affected individuals had contact with the Huanan Seafood market. Some patients were reported to have feverdyspnea and pulmonary infiltrates on chest radiography 2).

It was declared a public health emergency of international concern on Jan 30, 2020, by WHO 3).

By early January, terms like “the new coronavirus” and “Wuhan coronavirus” were in common use. On February 11, 2020, a taxonomic designation “severe acute respiratory syndrome coronavirus 2” (SARS-CoV-2) became the official means to refer to the virus strain, that was previously termed as 2019-nCoV and Wuhan coronavirus. Within a few hours on the same day, the WHO officially renamed the disease as COVID-19.

The infection spread quickly and was declared a pandemic by the World Health Organization (WHO) on March 11, 2019 4).

By March 30, more than 782 365 confirmed cases were reported and a third of the world population were living in confinement to try to contain the virus 5).

Epidemiology

COVID-19 Epidemiology

Etiology

COVID-19 has high homology to other pathogenic coronaviruses, such as those originating from bat-related zoonosis (SARS-CoV), which caused approximately 646 deaths in China at the start of the decade.

The COVID-19 generally had a high reproductive number, a long incubation period, a short serial interval and a low case fatality rate (much higher in patients with comorbidities) than SARS and MERS. Clinical presentation and pathology of COVID-19 greatly resembled SARS and MERS, with less upper respiratory and gastrointestinal symptoms, and more exudative lesions in post-mortems. Potential treatments included remdesivir, chloroquine, tocilizumab, convalescent plasma and vaccine immunization (when possible) 6).

Transmission

COVID-19 Transmission.

COVID-19 virus genome

The complete genome of SARS-CoV-2 from Wuhan, China was submitted on January 17, 2020 in the National Center for Biotechnology 7) (NCBI) database, with ID NC_045512. The genome of SARS-CoV-2 is a 29,903 bp single-stranded RNA (ss-RNA) coronavirus. It has now been shown that the virus causing COVID-19 is a SARS-like coronavirus that had previously been reported in bats in China.

COVID-19 and central nervous system

COVID-19 and central nervous system.

Essential care of critical illness

Essential care of critical illness must not be forgotten in the COVID-19 pandemic 8).

COVID-19 for neurologists

COVID-19 for neurologists.

COVID-19 for Neurosurgeons

see COVID-19 for neurosurgeons.

COVID-19 in Spinal Disorders

Effects of the COVID-19 Pandemic on the Management of Spinal Disorders.

COVID-19 for Vascular surgeons

see COVID-19 for Vascular surgeons.

COVID-19 for Dermatologists

COVID-19 for Dermatologists.

COVID-19 for Gastroenterologists

COVID-19 for Gastroenterologists

COVID-19 for Pediatricians

COVID-19 for Pediatricians

COVID-19 for Psychiatrists

COVID-19 for Psychiatrists.

COVID-19 for Oncologists

COVID-19 for Oncologists.

COVID-19 for Otolaryngologists

COVID-19 for Otolaryngologists.

COVID-19 for Cardiologists

COVID-19 for Cardiologists.

COVID-19 for Gynecologists

COVID-19 for Gynecologists.

Diagnosis

COVID-19 Diagnosis.

Treatment

COVID-19 Treatment.

Palliative Care

COVID-19 Palliative Care.

Prevention

COVID-19 Prevention.

Operating room preparation for COVID-19

see Operating room preparation for COVID-19.

Telemedicine in the COVID-19 era

see Telemedicine in the COVID-19 era.

Outcome

COVID-19 Outcome.

Case reports

2019 novel coronavirus infection in a three-month-old baby 9).


3 cases of SARS-CoV-2 infected children diagnosed from February 3 to February 17, 2020 in Tianjin, China. All of these three cases experienced mild illness and recovered soon after treatment, with the nucleic acid of throat swab turning negative within 14, 11, 7 days after diagnosis respectively. However, after been discharged, all the three cases were tested SARS-CoV-2 positive in the stool samples within 10 days, in spite of their remained negative nucleic acid in throat swab specimens. Therefore, it is necessary to be aware of the possibility of fecal-oral transmission of SARS-CoV-2 infection, especially for children cases 10).


Lv et al. reported the dynamic change process of target genes by RT-PCR testing of SARS-Cov-2 during the course of a COVID-19 patient: from successive negative results to successive single positive nucleocapsid gene, to two positive target genes (orf1ab and nucleocapsid) by RT-PCR testing of SARS-Cov-2, and describe the diagnosis, clinical course, and management of the case. In this case, negative results of RT-PCR testing was not excluded to diagnose a suspected COVID-19 patient, clinical signs and symptoms, other laboratory findings, and chest CT images should be taken into account for the absence of enough positive evidence. This case highlights the importance of successive sampling and testing SARS-Cov-2 by RT-PCR as well as the increased value of single positive target gene from pending to positive in two specimens to diagnose laboratory-confirmed COVID-19 11).

Literature

see COVID-19 Literature

References

1)

Zhu N, Zhang D, Wang W, et al. A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med. 2020;382(8):727-733.
2)

Bogoch II, Watts A, Thomas-Bachli A, Huber C, Kraemer MUG, Khan K. Pneumonia of unknown aetiology in Wuhan, China: potential for international spread via commercial air travel. J Travel Med. 2020 Mar 13;27(2). pii: taaa008. doi: 10.1093/jtm/taaa008. PubMed PMID: 31943059; PubMed Central PMCID: PMC7107534.
3)

WHO. Statement on the second meeting of the International Health Regulations (2005) Emergency Committee regarding the outbreak of novel coronavirus (2019-nCoV). Jan 30, 2020. https://www.who.int/newsroom/detail/30-01-2020-statement-on-thesecond-meeting-of-the-international-healthregulations-(2005)-emergency-committeeregarding-the-outbreak-of-novel-coronavirus- (2019-ncov) (accessed Feb 1, 2020).
4)

World Health Organization. WHO Director-General’s Opening Remarks at the Media Briefing on COVID-19—11 March 2020. World Health Organization. https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarksat-the-media-briefing– on-covid-19–11-march-2020. Accessed March 30, 2020
5)

Center for Systems Science and Engineering, Johns Hopkins Coronavirus Resource Center. COVID-19 Dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University, March 2020. https://coronavirus.jhu.edu/map.html. Accessed March 30, 2020
6)

Xie M, Chen Q. Insight into 2019 novel coronavirus – an updated intrim review and lessons from SARS-CoV and MERS-CoV. Int J Infect Dis. 2020 Apr 1. pii: S1201-9712(20)30204-6. doi: 10.1016/j.ijid.2020.03.071. [Epub ahead of print] Review. PubMed PMID: 32247050.
7)

Wuhan seafood market pneumonia virus isolate Wuhan-Hu-1, complete genome. Nucleotide, National Center for Biotechnology Information (NCBI), National Library of Medicine (US), National Center for Biotechnology Information, Bethesda, MD, https://www. ncbi.nlm.nih.gov/nuccore/1798174254 (accessed on 2020-02-28).
8)

Baker T, Schell CO, Petersen DB, Sawe H, Khalid K, Mndolo S, Rylance J, McAuley DF, Roy N, Marshall J, Wallis L, Molyneux E. Essential care of critical illness must not be forgotten in the COVID-19 pandemic. Lancet. 2020 Apr 1. pii: S0140-6736(20)30793-5. doi: 10.1016/S0140-6736(20)30793-5. [Epub ahead of print] PubMed PMID: 32246914.
9)

Zhang YH, Lin DJ, Xiao MF, Wang JC, Wei Y, Lei ZX, Zeng ZQ, Li L, Li HA, Xiang W. [2019 novel coronavirus infection in a three-month-old baby]. Zhonghua Er Ke Za Zhi. 2020 Mar 2;58(3):182-184. doi: 10.3760/cma.j.issn.0578-1310.2020.03.004. Chinese. PubMed PMID: 32135587.
10)

Zhang T, Cui X, Zhao X, Wang J, Zheng J, Zheng G, Guo W, Cai C, He S, Xu Y. Detectable SARS-CoV-2 Viral RNA in Feces of Three Children during Recovery Period of COVID-19 Pneumonia. J Med Virol. 2020 Mar 29. doi: 10.1002/jmv.25795. [Epub ahead of print] PubMed PMID: 32222992.
11)

Lv DF, Ying QM, Weng YS, Shen CB, Chu JG, Kong JP, Sun DH, Gao X, Weng XB, Chen XQ. Dynamic change process of target genes by RT-PCR testing of SARS-Cov-2 during the course of a Coronavirus Disease 2019 patient. Clin Chim Acta. 2020 Mar 27. pii: S0009-8981(20)30134-0. doi: 10.1016/j.cca.2020.03.032. [Epub ahead of print] PubMed PMID: 32229107.

Subgaleal abscess

Subgaleal abscess

Subgaleal abscesses and skull osteomyelitis are rarely encountered today.

The subgaleal space is the between the galea aponeurotica and periosteum of the cranial bones, subgaleal abscess may result from hematogenous infection or contiguous spread, and the diagnosis may not be initially obvious. The predominant organism isolated from post-traumatic and post-surgical scalp infections is Staphylococcus aureus.

Diagnosis and management will be guided by head CT scan, management of subgaleal abscess should focus on effective intravenous antibiotic therapy, immediate surgical drainage of abscess and debridement of necrotic tissue.

Subgaleal abscess is a rare complication, imaging can prevent serious complications. Negative pressure wound therapy is an invaluable tool for closure of the wounds 1).

Etiology

Reports of these entities usually describe an underlying pathology such as trauma or puncture wounds which account for direct inoculation or contiguous spread of microorganisms.

Acute bacterial sinusitis 2) Surgical correction of craniosynostosis 3)

Treatment

Although the diagnosis and management of a secondary subgaleal abscess may be straightforward, the same cannot be said for a primary or de novo subgaleal abscess 4).

Case series

Goodman SJ, Cahan L, Chow AW. Subgaleal abscess: a preventable complication of scalp trauma. West J Med. 1977 Aug;127(2):169-72. PubMed PMID: 898950; PubMed Central PMCID: PMC1237748.

Case reports

A case of extensive subgaleal abscess that presented as an infected scalp sebaceous cyst, in male diabetic patient, its management and the role of vaccum assisted closure (V.A.C.) dressing which was never described in such atypical presentation 5)


Spontaneous subgaleal abscess associated with lung adenocarcinoma: first description of this unusual association 6).


Spontaneous skull osteomyelitis with subgaleal abscess due to Kocuria rosea 7).


A 47-year-old immunosuppressed woman presented with fever, altered level of consciousness, dysphasia, and a left occipital subgaleal fluctuant mass after acupuncture for headaches in the same area. Imaging demonstrated subgaleal and epidural collection localized in the left occipital region. She underwent urgent surgical evacuation of both collections. Cultures from intraoperative specimens grew Streptococcus anginosus. The patient started targeted antibiotic treatment leading to complete recovery.

This is the first report of intracranial abscess after acupuncture. Given the worldwide application of this alternative treatment, physicians, acupuncturists, and the general public should be aware of the possibility of this rare but serious complication 8).


A case of a 64-year-old Sri Lankan Sinhalese man with prolonged fever and constitutional symptoms with a neglected swelling over the back of the scalp who was found to have an abscess in the subgaleal space of the scalp during surgical drainage. Burkholderia pseudomallei was isolated in pus culture, and melioidosis serology was highly positive. The patient was treated with ceftazidime for 2 weeks, followed by co-trimoxazole for another 3 months. He made a complete clinical recovery with normalization of inflammatory markers. This is the first case of subgaleal abscess following melioidosis infection reported in the literature.

Abscesses in anatomically unusual locations should raise suspicion for melioidosis infection, particularly among patients with risk factors such as diabetes mellitus 9).


A case of an infected SGH in an 8-month-old following closed skull fracture. The patient presented with scalp swelling 1 day after falling 3 feet. Initial evaluation found a nondisplaced skull fracture on computed tomography. She was discharged following an uneventful 23-hour observation. Three days later, she developed symptoms concerning for a viral upper respiratory tract infection and received symptomatic treatment. Nine days after injury, she returned with continued fevers, irritability, and significant increase in scalp swelling. Magnetic resonance imaging showed a subgaleal abscess with osteomyelitis. Needle aspiration revealed an infected hematoma with cultures positive for Streptococcus pneumoniae, treated with intravenous ampicillin. Purulent drainage from an enlarging necrotic needle aspiration site required subsequent surgical debridement of the subgaleal abscess with drain placement. She recovered well following surgery and intravenous antibiotics. Physicians should be aware that SGH carries a risk of serious morbidity and mortality. SGH can serve as a nidus for infection, typically from skin barrier breakdown or, as in this case, hematogenous spread. Early recognition, appropriate antibiotic therapy, and surgical debridement are critical in treating infected SGH 10).


Chang et al. reported an infected SGH with abscess formation as a complication of early-onset Escherichia coli sepsis in a term neonate. The patient was discovered to have SGH soon after birth. Early-onset E. coli sepsis developed on Day 3 of life. The SGH became infected, with abscess formation 1 week later. The infected SGH was probably due to direct hematogenous spreading of sepsis. The patient was successfully treated without complications. Clinicians should be aware that SGH is a potential site of infection and infection may be caused either by direct hematogenous extension or from traumatic scalp lesions. Appropriate antibiotic treatment and surgical debridement are necessary when an infected SGH occurs 11).


Chou et al. reported on an elderly female who suffered from forehead carbuncle with intractable headache, later confirmed as having subgaleal abscess. Physicians should pay special attention to elderly and immune-compromised patients with carbuncles located in the middle of the face, especially when accompanied by intractable headache, to avoid poor outcome 12).


A 14-year-old boy with a rare combination of periorbital cellulitis, subgaleal abscess and superior sagittal sinus thrombosis following a late presentation of unilateral frontal sinusitis.

Following multiple surgical procedures, and antimicrobial and anticoagulation therapy, the patient made a full recovery.

Serious sinusitis complications still occur and can do so in unusual combinations with minimal clinical signs. Systemic anticoagulation therapy is considered safe practice in the management of cerebral venous sinus thrombosis and may reduce morbidity and mortality 13).


A 5-year-old child presented to the emergency department with a three-week history of fever associated with drowsiness and left parietal headache, and a week’s history of swelling on the left frontoparietal soft tissue. He had suffered a penetrating scalp injury four month ago. On physical examination, there was a tender swelling with purulent stream on the lateral half of his scalp. His vital signs are within normal limits. Plain X-ray of the skull showed a lytic lesion on the left frontoparietal bone. A cranial computed tomography (CT) scan demonstrated a large subgaleal abscess at the left frontoparietal region. SBO possesses a high morbidity and mortality; therefore, prompt diagnosis and appropriate treatment are mandatory to prevent further complications and to reduce morbidity and mortality significantly 14).


A case of bacterial meningitis, subgaleal, subdural, and epidural empyema due to Pasteurella multocida by a rabbit licking that resulted in neurological complications and a prolonged recovery period 15).


A preterm infant who developed scalp abscess and E. coli sepsis following a scalp electrode. Onyeama et al. recommend a careful examination of babies with a history of fetal electrode monitoring as this could be a nidus for local and generalised infection 16).


A 12-year-old girl presented with a swollen right eye with three days of pain and a diffused swollen frontal region and head lasting for one day. On the computed tomography with contrast, diffused collection was detected in the subgaleal regions and subperiosteal of the right orbita. It was observed that she had bilateral maxillary, ethmoidal, and frontal sinusitis and an infected bilateral middle concha bullosa in the right side. No symptoms of intracranial complication and osteomyelitis in the frontal or other calvarial bones were determined. This case presentation is thought to be the first one in literature that is an acute sinusitis without an intracranial complication and osteomyelitis, but with a diffused subgaleal abscess resulting from a subperiosteal abscess 17).

References

1) , 5)

Nabri M, Alharbi M, Al-Sayyid A, Alabdrabalrasol K, Hassan K, Al-Jehani H. Sub-galeal abscess: A rare sequel of an infected scalp sebaceous cyst. Int J Surg Case Rep. 2020 Sep 24;76:30-32. doi: 10.1016/j.ijscr.2020.09.063. Epub ahead of print. PMID: 33010610.
2)

Stokken J, Gupta A, Krakovitz P, Anne S. Rhinosinusitis in children: a comparison of patients requiring surgery for acute complications versus chronic disease. Am J Otolaryngol. 2014 Sep-Oct;35(5):641-6. doi: 10.1016/j.amjoto.2014.05.008. Epub 2014 Jun 5. PubMed PMID: 25069389.
3)

Zakhary GM, Montes DM, Woerner JE, Notarianni C, Ghali GE. Surgical correction of craniosynostosis. A review of 100 cases. J Craniomaxillofac Surg. 2014 Dec;42(8):1684-91. doi: 10.1016/j.jcms.2014.05.014. Epub 2014 Jun 4. PubMed PMID: 24969768.
4)

Schaefer J, Clein L, Conly J. De novo subgaleal abscess. Can J Infect Dis. 1992 Jan;3(1):30-2. PubMed PMID: 22451760; PubMed Central PMCID: PMC3307424.
6)

Umana GE, Scalia G, Fagone S, Strano G, Tranchina MG, Raudino G, Cicero S. Spontaneous subgaleal abscess associated with lung adenocarcinoma: first description of this unusual association. World Neurosurg. 2019 Aug 7. pii: S1878-8750(19)32149-7. doi: 10.1016/j.wneu.2019.07.233. [Epub ahead of print] PubMed PMID: 31400523.
7)

Rangnekar RD, Jamaluddin MA, Raja K, Abraham M. Spontaneous skull osteomyelitis with subgaleal abscess due to Kocuria rosea. Neurol India. 2019 May-Jun;67(3):915-918. doi: 10.4103/0028-3886.263238. PubMed PMID: 31347589.
8)

Priola SM, Moghaddamjou A, Ku JC, Taslimi S, Yang VXD. Acupuncture-Induced Cranial Epidural Abscess: Case Report and Review of the Literature. World Neurosurg. 2019 Feb 8. pii: S1878-8750(19)30300-6. doi: 10.1016/j.wneu.2019.01.189. [Epub ahead of print] PubMed PMID: 30743042.
9)

Dalugama C, Tennegedara A, Gawarammana IB. De novo subgaleal abscess – a rare presentation of melioidosis: a case report. J Med Case Rep. 2018 Apr 30;12(1):115. doi: 10.1186/s13256-018-1643-x. PubMed PMID: 29706135; PubMed Central PMCID: PMC5925829.
10)

Barry J, Fridley J, Sayama C, Lam S. Infected Subgaleal Hematoma Following Blunt Head Trauma in a Child: Case Report and Review of the Literature. Pediatr Neurosurg. 2015;50(4):223-8. doi: 10.1159/000433442. Epub 2015 Jun 13. Review. PubMed PMID: 26088299.
11)

Chang HY, Cheng KS, Liu YP, Hung HF, Fu HW. Neonatal infected subgaleal hematoma: an unusual complication of early-onset E. coli sepsis. Pediatr Neonatol. 2015 Apr;56(2):126-8. doi: 10.1016/j.pedneo.2013.03.003. Epub 2013 Apr 13. PubMed PMID: 23597516.
12)

Chou PY, Chen YC, Huang P. Forehead carbuncle with intractable headache. Neuropsychiatr Dis Treat. 2015 Mar 20;11:793-5. doi: 10.2147/NDT.S79349. eCollection 2015. PubMed PMID: 25848276; PubMed Central PMCID: PMC4376302.
13)

Jones H, Trinidade A, Jaberoo MC, Lyons M. Periorbital cellulitis, subgaleal abscess and superior sagittal sinus thrombosis: a rare combination of complications arising from unilateral frontal sinusitis. J Laryngol Otol. 2012 Dec;126(12):1281-3. doi: 10.1017/S0022215112002228. Epub 2012 Oct 1. PubMed PMID: 23020898.
14)

Sayhan MB, Kavalci C, Sogüt O, Sezenler E. Skull base osteomyelitis in the emergency department: a case report. Emerg Med Int. 2011;2011:947327. doi: 10.1155/2011/947327. Epub 2011 May 29. PubMed PMID: 22046552; PubMed Central PMCID: PMC3200088.
15)

Per H, Kumandaş S, Gümüş H, Oztürk MK, Coşkun A. Meningitis and subgaleal, subdural, epidural empyema due to Pasteurella multocida. J Emerg Med. 2010 Jul;39(1):35-8. doi: 10.1016/j.jemermed.2008.04.008. Epub 2008 May 16. PubMed PMID: 18486411.
16)

Onyeama CO, Srinivasan H, Lotke M, Vickers DL. Subgaleal abscess and E. coli septicemia following scalp electrode in a preterm newborn: a case report. J Matern Fetal Neonatal Med. 2009 Dec;22(12):1201-3. doi: 10.3109/14767050903042553. PubMed PMID: 19916718.
17)

Celik H, Islam A, Felek SA, Yüksel D. A very rare complication of acute sinusitis: subgaleal abscess. Kulak Burun Bogaz Ihtis Derg. 2009 May-Jun;19(3):155-8. PubMed PMID: 19857195.
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