Excessive use of antibiotics is a significant public health concern with several severe implications for the development of Antibiotic Resistance and its impact on Gut Microbiota. C-reactive Protein (CRP) is non-specific, acute-phase reactant whose levels increase in response to infection or inflammation due bacterial and viral etiologies. Many studies have explored the role of CRP as a point-of-care tool to assist in decision-making and improve the efficiency of antibiotic prescribing practices among healthcare professionals in primary care settings. The main benefit of POC CRP testing is its ease of use, providing results within 2 to 3 minutes from a simple finger prick, which is optimal for an outpatient clinic. While several studies demonstrate reductions in antibiotic use with POC CRP testing, there are many controversies around those need to be resolved, including the cutoff values of CRP for antibiotic prescription, whether CRP can differentiate bacterial and viral etiologies, and whether a single CRP level can reflect the disease state. Future research needs to focus on developing uniform guidelines for interpreting CRP levels and evaluating whether serial CRP measurements, physician training, especially in primary care and rural settings, to reduce overprescribing. Ultimately, while POC CRP testing can support antibiotic stewardship, its utility must be carefully balanced with sound clinical judgment.

Background: The role of glycopyrrolate and other pharmacological drying agents is well established for secretion management in specific populations such as patients living with cerebral palsy or requiring palliative care. Whilst drying agents are used for weaning tracheostomised patients with an acute neurological condition, clinical decision–making pathways have not been well described. To examine the clinical practice of tracheostomy weaning and use of pharmacological drying agents in an acute neurological population admitted to a tertiary hospital. Methods: A retrospective cohort analysis between 2014 to 2019 of all patients tracheostomised after a neurological event. Data were extracted from medical records to obtain patient demographic details, history of presenting condition and weaning plans. Results: A total of 116 patients with a neurological diagnosis required a tracheostomy, of whom 20 patients were using at least one pharmacological drying agent during tracheostomy weaning process. Nine patients still required drying agents on discharge from hospital. Conclusion Patients who required drying agents in their tracheostomy wean demonstrated a trend towards a longer duration of tracheostomy and a longer length of stay than those who did not. Clinicians need to complete patient–centred objective measures regarding swallowing function and saliva management when considering if a drying agent will be required.

Hydrocephalus, characterized by abnormal cerebrospinal fluid (CSF) accumulation, is commonly treated with ventriculoperitoneal shunting (VPS). Despite its efficacy, VPS is prone to complications, with distal catheter occlusion being a frequent cause of shunt malfunction. This study presents our experience using laparoscopy to manage distal catheter malfunctions in two VPS patients. Postoperative outcomes demonstrated symptom resolution and normalization of imaging parameters without complications. Our findings suggest that laparoscopy is a minimally invasive, effective, and cost-efficient alternative for addressing distal shunt malfunctions, complementing current neurosurgical practices. Additionally, we review the literature on the use of endoscopy and laparoscopy in VPS management and propose an applicable protocol.

Background: External ventricular drain (EVD) placement is one of the most commonly used interventions in life-saving neurosurgical care. EVDs are often used to treat traumatic brain injuries, infection, primary and secondary hydrocephalus, and intracranial space occupying lesions, such as tumors, cysts, and ischemic/hemorrhagic strokes. EVDs have been proven to reduce mortality but are often associated with complications that can affect patient outcomes. Our study investigates the patient outcomes associated with emergent EVD placement in a patient population with no prior history of neurosurgery. Methods: A retrospective chart review was performed on all patients 18+ requiring emergent EVD placement from January 2016 to December 2022 at Allegheny General Hospital in Pittsburgh, PA. Exclusion criteria included intra-operative EVD placements and patients with any prior neurosurgical history. 223 patient charts were analyzed for outcomes of independent ambulation capability, length of hospital stay, subsequent neurosurgical intervention, and final patient disposition. Subsequent neurosurgical interventions were stratified into six subcategories: EVD removal only, subsequent EVD placement, ventriculoperitoneal shunt (VPS) placement, endoscopic third ventriculostomy (ETV), craniotomy, and other. Patient disposition included home, inpatient rehab, skilled nursing facility, long-term acute care, hospice, and expiration. Results: Our study demonstrated that only 10% of patients were able to ambulate independently at discharge, 24% of patients required shunt placement, 20% of patients expired in hospital and the average length of hospital stay was 20 days. Conclusions Despite there being immense research demonstrating the efficacy and safety of EVDs, there is limited literature for clinicians and patients together to demonstrate the clinical gravity of EVD placement. Our study accurately delineates the clinical patient outcomes associated with EVD placement on neuro-surgically naive patients.

Angiogram-negative subarachnoid hemorrhage (SAH) represents a diagnostic challenge because rebleeding risk persists despite negative initial angiography. We report a rare case of a 65-year-old man presenting with diffuse SAH on initial CT but with negative CTA and transfemoral cerebral angiography (TFCA). Serial follow-up CT scans demonstrated gradual resolution of subarachnoid blood except for persistent prepontine cisternal hemorrhage. On hospital day 7, repeat TFCA revealed a bilobulated pseudoaneurysm arising from a midbasilar perforator artery. The lesion was treated using a modified stent-assisted coiling technique involving partial coil deployment, achieving complete angiographic obliteration with parent artery preservation. Post-procedural diffusion-weighted MRI demonstrated a left pontine infarction, but the patient achieved meaningful functional recovery and returned to work at the 3-month follow-up. This case underscores the necessity of repeat angiography in diffuse angiogram-negative SAH and highlights tailored endovascular strategies for fragile basilar perforator pseudoaneurysm.

Streptococcus gordonii is an oral commensal viridans streptococcus that rarely causes invasive infections such as lung abscess or intracranial empyema. The sequential presentation of concomitant pulmonary and cranial abscesses by this organism is extremely uncommon. A 70-year-old man presented with progressive dyspnea and fever. Chest CT demonstrated a 14.4 × 6.8cm mass like lung lesion consistent with a lung abscess. Percutaneous drainage yielded Streptococcus gordoniii. On hospital day 5 following drainage, patient presented with scalp swelling and headache. Brain MRI revealed a subgaleal abscess with an epidural empyema. Emergent craniectomy and debridement were performed, and cultures again grew Streptococcus gordonii. This case is a rare but clinically significant pattern of sequential presentation of concomitant pulmonary and cranial abscesses caused by Streptococcus gordonii, emphasizing the need for dental evaluation, meticulous inpatient monitoring, and early neuroimaging when viridans streptococci are revealed from deep infections.

Hemorrhagic moyamoya disease (MMD) often manifests with pure intraventricular hemorrhage (IVH) or intracerebral hemorrhage (ICH) with IVH, causing increased intracranial pressure (ICP) and neurological decline. Although intraventricular injection of recombinant tissue plasminogen activator (rt-PA) has been proven safe, its safety in MMD is uncertain. We introduce a case of rescue intraventricular rt-PA injection for an ICP crisis caused by IVH in MMD. A patient with MMD presented with acute ICH with IVH. Bilateral external ventricular drains (EVD) were placed, but the both EVD lost patency immediately due to an intraventricular clot. The next day, due to increased ICP, we injected rt-PA into the right EVD catheter to facilitate intraventricular drainage and reduce clot burden. After injection, IVH volume and ICP decreased significantly without rebleeding, leading to gradual neurological improvement. Intraventricular rt-PA effectively reduced ICP and IVH burden without rebleeding in hemorrhagic MMD, warranting further safety studies.

Studies have suggested that patients with severe head injury, in addition to Glasgow Coma Scale (GCS), reveal high D-dimer levels which are independently associated with increased mortality. In the present review, we analyzed the literature where studies have reported the role of D-dimers as a potential biomarker in stratification and early identification of patients with TBI who are at risk of clinical deterioration, where early intervention can improve overall outcomes. After scrutinizing 246 articles, which were narrowed down to 38 (16 prospective, 9 retrospective, 2 RCTs, 2 case-control, 1 cross-sectional study). All these studies included 7,589 patients, in whom D-dimer was measured at different timings and in different ways. Most studies demonstrated significant changes that could be utilized for prognostication. However, we also observed instances where no significant changes were found. Unfortunately, direct comparisons were hindered by variations in the methods used to measure D-dimer across different outcomes. Limitations included the lack of a substantial number of RCTs, heterogeneity of available data, and the difficulty in summarization of specific cutoff points for D-dimer. Future studies, especially RCTs, should measure D-dimer levels at different times from injury for an accurate assessment of its correlation with outcomes.

Malignant hyperthermia (MH) is a rare, potentially fatal genetic disorder characterized by an unexplained elevation of expired carbon dioxide despite increased minute ventilation, muscle rigidity, and rhabdomyolysis, hyperthermia, tachycardia, acidosis, and hyperkalemia. It can be triggered by many pharmacological agents such as potent inhalation agents (halothane/ isoflurane/ sevoflurane/ desflurane), the depolarizing muscle relaxant (succinylcholine), and extreme physiological conditions such as vigorous exercise and working excessively in a hot and dry environment. Prompt and early recognition of the condition and rapid initiation of treatment measures are necessary to salvage the patient. Since MH is commonly encountered in the operating room or early postoperative period, anesthetists and surgeons need to keep themselves updated regarding the same. This review article aims to summarize our understanding of MH's pathophysiology, current diagnostics, management, and treatment strategies, along with a brief review of literature of published cases in Indian Subcontinent.

Background: There is a shortage of data on brain tumor patients admitted in to intensive care unit (ICU) from developing countries. We aimed to assess the clinical course and 30-day mortality with factors affecting the mortality of brain tumor patients who were admitted to medical ICU. Methods: This study was a single-centre retrospective observational cohort study and was conducted in a medical ICU of a tertiary care center in India. We included 42 patients admitted in to the medical oncology ICU over 3 years. Data regarding demographics, baseline characteristics, clinical and laboratory data, need for organ support, and 30-day mortality were collected. Factors associated with increased mortality in these patients were determined. Results: Overall 30-day mortality was 30.95%. The most common indication for ICU admission was altered sensorium (57.1%) followed by sepsis (23.8%). Age [odds ratio, OR: 0.843 (95% confidence interval, CI: 0.721–0.986)], and need for invasive mechanical ventilator (IMV) support [OR: 484.62 (95% CI: 2.707–8676.02)] or vasopressor support [OR: 523.83 (95% CI: 2.12– 3,023.13)] were directly associated with 30-day mortality. Severity indices such as Sequential Organ Failure Assessment (SOFA) score, SAPS II (Simplified Acute Physiology Score II), and Acute physiology and chronic health evaluation II (APACHE II), APACHE III and APACHE IV scores were higher in non-survivors than survivors. Conclusion Advancing age and need for IMV or vasopressor support may be associated with worse prognosis in brain tumor patients admitted in to ICU. A scoring system could be used along with clinical judgement to triage brain tumor patients for ICU admission.