A comparison of clinical outcomes associated with dosing metronidazole every 8 hours versus every 12 hours: a systematic review and metaanalysis.

Background: Metronidazole treats obligate anaerobic bacterial and protozoal infections, with an elimination half-life of around 8 hours. The long elimination half-life, the favorable ratio of steady-state serum levels to minimum inhibitory concentration, and the presence of active metabolites have led to the consideration of metronidazole use at 12-hour dosage intervals. This systematic review aimed to compare the clinical outcomes of twice-daily and thrice-daily metronidazole dosing. Methods: Using the PRISMA checklist, we searched five databases to systematically identify all relevant studies published up to June 16, 2023. Results: The final analysis included two published retrospective cohort studies of hospitalized adult patients: a single site study (n = 200) and a multisite study (n = 85) of "good" quality, as measured by the Newcastle-Ottawa scale. The reported baseline characteristics of the 8-hour and 12-hour dosing groups were comparable, and neither study identified significant differences in primary and secondary clinical outcomes. Metaanalysis of the need to escalate antibiotic therapy also showed no statistically significant differences using the Mantel-Haenszel fixed-effect method (95% confidence interval: 47.6% lower to 6.4 times higher risk, P = 0.34) and inverse-variance method (risk ratio: 1.87; 95% confidence interval: 0.52-6.65, P = 0.34). Conclusions: This review suggests that dosing metronidazole every 12 hours is as effective as every-8-hour dosing for hospitalized patients with anaerobic infections. These encouraging findings would benefit from validation by a multicenter randomized controlled trial since there would be many benefits to a 12-hour dosing interval while achieving similar clinical outcomes with traditional dosing. The studies in this systematic review excluded patients with Clostridioides difficile and central nervous system and amebiasis infections, so the findings do not apply to these infection types.

Efficacy and safety of corticosteroids for the treatment of community-acquired pneumonia: A systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: The role of corticosteroids in the treatment of community-acquired pneumonia (CAP) remains uncertain. We conducted an updated meta-analysis to investigate the effectiveness and potential effect modifiers of adjunctive corticosteroids in patients with CAP. METHODS: The protocol of this meta-analysis was registered with PROSPERO (CRD42022354920). We searched MEDLINE, Embase, the Cochrane Library and trial registers from inception till March 2023 to identify randomized controlled trials (RCTs) investigating corticosteroids in adult patients with CAP. Our primary outcome was the risk of all-cause mortality within 30 days after randomization (if not reported at day 30, we extracted the outcome closest to 30 days). Risk ratios (RR) and mean differences (MDs) were pooled under a random-effects model. RESULTS: Fifteen RCTs (n = 3252 patients) were included in this review. Corticosteroids reduced the risk of all-cause mortality in CAP patients (RR: 0.69, 95% CI: 0.53-0.89; high certainty). This significant result was restricted to hydrocortisone therapy and patients with severe CAP. Additionally, younger patients demonstrated a greater reduction in mortality. Corticosteroids reduced the incidence of shock and the need for mechanical ventilation (MV), and decreased the length of hospital and ICU stay (moderate certainty). CONCLUSIONS: Corticosteroids reduce the risk of all-cause mortality, especially in younger patients receiving hydrocortisone, and probably decrease the need for MV, the incidence of shock, and the length of hospital and ICU stay in patients with CAP. Our findings indicate that patients with CAP, especially severe CAP, will benefit from adjunctive corticosteroid therapy.

Gastrointestinal Mucormycosis: A Clinical Review.

Mucormycosis is a devastating fungal infection that is usually seen in immunocompromised hosts. It is caused by fungi of the subphylum Mucoromycotina, order Mucorales, with most cases caused by Mucor, Rhizopus, or Rhizomucor species. It can involve any organ system and can disseminate in severe cases. Lately, there has been an increased number of reports for mucormycosis infection in immunocompetent patients. Gastrointestinal system involvement is rare compared to other organ systems but has been increasingly reported in the literature. Mucormycosis can affect any part of the gastrointestinal tract and lead to different presentations depending on the area of involvement. Due to the paucity of the condition, there has been no specific guidelines on how to treat gastrointestinal mucormycosis. In this review, we discuss the risk factors of gastrointestinal mucormycosis, clinical presentation, approach to diagnosis, and most recent treatment modalities for gastrointestinal mucormycosis.

Association of Non-traditional Indicators of Readers' Engagement With Traditional Dissemination Metrics of COVID-19-Related Research.

INTRODUCTION:  Researchers are increasingly interested in appraising the impact of their research work, which eventually drives public perception. The overall impact of a study can only be gauged if we consider both traditional and non-traditional dissemination patterns. Hence, we preferred to study the association between the non-traditional reader engagement metrics and traditional dissemination metrics in relation to coronavirus disease 2019 (COVID-19)-related research published in five high-impact peer-reviewed medical journals. METHOD:  This observational study was conducted using data sourced from Altmetric, including the Altmetric attention score (AAS), an aggregate score of an article's dissemination. New England Journal of Medicine (NEJM), Lancet Infectious Diseases, Clinical Infectious Diseases (CID), Chest Journal (CHEST), and Journal of the American Medical Association (JAMA) were included in the study based on the prevalence of COVID-19-related original research published in each of them. The number of citations was framed as the reference for traditional metrics. To avoid artificial variance, data were collected on the same day, November 13, 2022. Correlational analyses were performed using the Pearson correlation coefficient using Minitab 17 (Minitab Inc., State College, PA). The relationship between the variables was considered very weak if r<0.3, weak if r: 0.3 to 0.5, moderate if r: 0.5 to 0.7, and strong for r>0.7. RESULTS:  We found a very weak correlation between citations and AAS for Clinical Infectious Diseases, Lancet Infectious Diseases, and CHEST, whereas the correlation was moderate for NEJM and JAMA. The correlation between citations and Twitter mentions was very weak for Clinical Infectious Disease, Lancet Infectious Disease, and CHEST, but it improved for NEJM and JAMA. There was a very weak correlation between citations and news mentions for Clinical Infectious Diseases, Lancet Infectious Diseases, and CHEST. CONCLUSION:  Our study highlights that the traditional indicator, i.e., citation has a very weak to moderate correlation with the AAS and it doesn't capture the entire influence of a research publication. Also, the current method of determining a journal's impact factor doesn't take this disparity into consideration. Hence, there needs to have a more inclusive strategy to define the impact of scientific research on the general population in real-time.

Fluorescein sodium fluorescence: role in stereotactic brain biopsy.

BACKGROUND: Stereotactic brain biopsy for eloquent area brain tumours is associated with complications like hemorrhage due to multiple sampling and increased operative time due to dependence on neuropathologist for frozen section assessment. In order to curb these limitations, we investigated the use of Fluorescein sodium fluorescence in confirming pathological tissue samples in stereotactic brain biopsy of gadolinium-enhancing tumours. METHODS: This prospective observational study included 23 consecutive patients who underwent stereotactic biopsy of gadolinium-contrast-enhancing brain lesions with intravenous fluorescein sodium administration. 93 specimens were obtained and examined for the presence of fluorescence using a microscope with fluorescence visualisation capability. Later the nature of the samples was confirmed on histopathology. The sensitivity and specificity of flourescein sodium fluorescence were calculated based on histopathological confirmation. RESULTS: 58 (62.3%) fluorescent and 35 (37.6%) nonfluorescent samples were obtained. All fluorescent specimens contained diagnostic tissue appropriate for tumor grading. Of 35 nonfluorescent specimens, 12 (34.3%) did not contain tumor, 11 (31.4%) contained minor hypercellularity or gliosis, and 12 (34.3%) contained tumor with a high proportion of necrosis. The sensitivity and specificity for fluorescein fluorescence were 83% and 100%, respectively. CONCLUSIONS: Fluorescein fluorescence is a handy tool to detect the pathological tissue in stereotactic brain biopsy and may improve its diagnostic accuracy and expedite the procedure.

COVID-19 Mortality and Therapeutics in Nebraska and Southwest Iowa during Early Pandemic.

Different pharmacotherapeutics have been introduced, and then stopped or continued, for the treatment of SARS-CoV-2. We evaluated the risks associated with mortality from SARS-CoV-2 infection. METHODS: Data was concurrently or retrospectively captured on COVID-19 hospitalized patients from 6 regional hospitals within the health system. Demographic details, the source of SARS-CoV-2 infection, concomitant disease status, as well as the therapeutic agents used for treating SARS-CoV-2 (e.g., antimicrobials, dexamethasone, convalescent plasma, tocilizumab, and remdesivir) were recorded. Discrete and continuous variables were analyzed using SPSS (ver. 27). Logistic regression identified variables significantly correlated with mortality. RESULTS: 471 patients (admitted from 1 March 2020 through 15 July 2020) were reviewed. Mean (±SD) age and body weight (kg) were 62.5 ± 17.7 years and 86.3 ± 27.1 kg, respectively. Patients were Caucasian (50%), Hispanic (34%), African-American (10%), or Asian (5%). Females accounted for 52% of patients. Therapeutic modalities used for COVID-19 illness included remdesivir (16%), dexamethasone (35%), convalescent plasma (17.8%), and tocilizumab (5.8%). The majority of patients returned home (62%) or were transferred to a skilled nursing facility (23%). The overall mortality from SARS-CoV-2 was 14%. Logistic regression identified variables significantly correlated with mortality. Intubation, receipt of dexamethasone, African-American or Asian ethnicity, and being a patient from a nursing home were significantly associated with mortality (x2 = 86.36 (13) p < 0.0005). CONCLUSIONS: SARS-CoV-2 infected hospitalized patients had significant mortality risk if they were intubated, received dexamethasone, were of African-American or Asian ethnicity, or occupied a nursing home bed prior to hospital admission.

Multifocal Brain Abscesses Due to Streptococcus intermedius.

Brain abscess is a life-threatening illness that occurs when an intracerebral infection leads to cerebritis and subsequent pus formation within a well-vascularized capsule. While streptococci (aerobic, anaerobic, and microaerophilic) are the most common bacteria isolated, its presentation as multifocal brain abscesses is rarely described. In this report, we describe a 43-year-old male patient who presented to the emergency department due to progressive lethargy and low-grade fever of seven days worsening. Upon further evaluation, the patient was found to have multiple brain abscesses secondary to Streptococcus intermedius, confirmed by the culture of stereotactic aspiration of brain collection. This case underlines the importance of considering Streptococcus intermedius as a cause of multifocal brain abscesses.

Challenges in the Management of Gram-Negative Bacterial Infections in Patients With Ventriculoperitoneal Shunt.

Gram-negative bacterial infections of the central nervous system (CNS) have worse clinical outcomes. The most common bacteria include Escherichia Coli, Citrobacter species, Enterobacter species, Serratia species, and Pseudomonas aeruginosa. There are multiple risk factors for CNS infection after shunt insertion, including younger age, obstructive hydrocephalus, shunt revision surgery, and trauma. The clinical presentation of a ventriculoperitoneal (VP) shunt infection includes the signs and symptoms of meningitis to fever with abdominal pain and peritonitis. Apart from cerebrospinal fluid (CSF) analysis, microbiological cultures and radiological studies are key diagnostic tools. Initial empirical intravenous antimicrobial therapy is preferably broad spectrum with appropriate coverage for resistant Gram-negative pathogens and the duration of treatment depends upon pathogenesis, host factors, and clinical response to the therapy. Considering the importance of this disease and associated clinical outcomes, in this review article, we have summarized the epidemiology, clinical features, management, and prevention of Gram-negative VP shunt infections in adults.

Multisystem inflammatory syndrome in adults: A rare sequela of SARS-CoV-2 infection.

Multisystem inflammatory syndrome in adults (MIS-A) came to attention back in June 2020, when the United States Center for Disease Control and Prevention (CDC) received initial reports regarding patients who had presented delayed and multisystem involvement of the disease, with clinical course resembling multisystem inflammatory syndrome in children (MIS-C). This study introduces a case of MIS-A, where the patient presented 3 weeks after initial COVID-19 exposure. His clinical course was consistent with the working definition of MIS-A as specified by the CDC. Aggressive supportive care in the intensive care unit, utilization of advanced heart failure devices, and immunomodulatory therapeutics (high-dose steroids, anakinra, intravenous immunoglobulin) led to clinical recovery. Management of MIS-A is a topic of ongoing research and needs more studies to elaborate on treatment modalities and clinical predictors.

Tumor Occupancy Ratio-An Imaging Characteristic Prognosticating the Surgical Outcome of Benign Intradural Extramedullary Spinal Cord Tumors.

BACKGROUND: Intradural extramedullary (IDEM) spinal cord tumors are two thirds of all spinal tumors. We have prospectively analyzed the importance of the tumor occupancy ratio as a factor for predicting the course of the disease and in prognosticating the surgical outcome in patients with IDEM tumors. METHODS: We prospectively analyzed 44 consecutive cases of IDEM tumors, diagnosed as cervical, thoracic, and lumbar IDEM tumors (excluding conus/cauda equina lesion) by magnetic resonance imaging (MRI), that were operated on at our institution between 2014 and 2016. We measured the tumor occupancy ratio and noted the sagittal and axial location of the tumor in the preoperative MRI and performed the laminectomy and unilateral medial facetectomy. A primary outcome has been noted according to the gait disability score in the preoperative period and in the follow-up period of 1 year. In the statistical analysis, categorical variables were compared using a chi-square test, and an analysis of variance and student t tests were used for the continuous variables. P < .05 was considered statistically significant. RESULTS: The tumor occupancy ratio showed a significant association to the preoperative gait disability score (P < .001) and also predicted that the surgical outcome is much better in patients with tumors with a low tumor occupancy ratio than in patients with tumors with a high occupancy ratio (P < .001). No difference in the tumor occupancy ratio was noted in 2 different pathological tumors, and there was also no difference in the tumor occupancy ratio at different sagittal and axial locations of the tumor. CONCLUSION: Tumor occupancy ratio has shown a significant impact on the preoperative course and also predicts the surgical outcome in patients with IDEM tumors. Hence, it is an important imaging characteristic to prognosticate the outcome in IDEM tumors and should be noted in each case.

The Retrosigmoid Approach: Workhorse for Petroclival Meningioma Surgery.

BACKGROUND: Petroclival meningiomas (PCMs) are technically challenging lesions. We retrospectively analyzed our experience with retrosigmoid approach between 2009 and 2015 in 17 patients with PCM to evaluate changes in management strategy. In this study, we evaluated the possible risk factors and challenges for unfavorable clinical outcomes with retrosigmoid approach. MATERIALS AND METHODS: A total of nine patients (53%) of PCM were treated through the retrosigmoid approach in Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow. The patients received postoperative neurological and radiological follow-up. The primary difficulty in complete resection and outcomes including postoperative neurological deficits were evaluated, and all potential risk factors were assessed. RESULTS: The mean follow-up time was 24 months. The maximum diameter of the tumors ranged from 2.0 cm to 6.8 cm (mean, 3.8 cm). Gross total resection (Simpson Grade II) was achieved in 6 (66%) patients, subtotal resection (Simpson Grade III) in 3 (33%). Two patients (22%) had new neurological deficits or worsening of preexisting deficits. No patient died after surgery. Within the follow-up period, there was no radiographic recurrence in patients with Simpson Grade II excision. Postoperative radiosurgery was administered to three patients who had residual tumors, and no further progression was found in them. CONCLUSIONS: Tumor characteristics played a critical role in identifying postoperative functional status. The retrosigmoid approach is suitable for treatment of majority of PCMs. It offers Simpson Grade II excision if the main part of the tumor is located in the posterior fossa in the cerebellopontine angle and the lower clivus, and only a minor part of the tumor extends to middle fossa or the posterior wall of the cavernous sinus. With incising tentorium or suprameatal extensension middle fossa extension can also be removed. Overall retrosigmoid approach provides a low degree of surgical difficulty and a low complication rate.