Recommendations for sepsis management in resource-limited settings

PURPOSE: To provide clinicians practicing in resource-limited settings with a framework to improve the diagnosis and treatment of pediatric and adult patients with sepsis. METHODS: The medical literature on sepsis management was reviewed. Specific attention was paid to identify clinical evidence on sepsis management from resource-limited settings. RESULTS: Recommendations are grouped into acute and post-acute interventions. Acute interventions include liberal fluid resuscitation to achieve adequate tissue perfusion, normal heart rate and arterial blood pressure, use of epinephrine or dopamine for inadequate tissue perfusion despite fluid resuscitation, frequent measurement of arterial blood pressure in hemodynamically unstable patients, administration of hydrocortisone or prednisolone to patients requiring catecholamines, oxygen administration to achieve an oxygen saturation >90%, semi-recumbent and/or lateral position, non-invasive ventilation for increased work of breathing or hypoxemia despite oxygen therapy, timely administration of adequate antimicrobials, thorough clinical investigation for infectious source identification, fluid/tissue sampling and microbiological work-up, removal, drainage or debridement of the infectious source. Post-acute interventions include regular re-assessment of antimicrobial therapy, administration of antimicrobials for an adequate but not prolonged duration, avoidance of hypoglycemia, pharmacological or mechanical deep vein thrombosis prophylaxis, resumption of oral food intake after resuscitation and regaining of consciousness, careful use of opioids and sedatives, early mobilization, and active weaning of invasive support. Specific considerations for malaria, puerperal sepsis and HIV/AIDS patients with sepsis are included. CONCLUSION: Only scarce evidence exists for the management of pediatric and adult sepsis in resource-limited settings. The presented recommendations may help to improve sepsis management in middle- and low-income countries

Translational Science Research: Towards Better Health

Even though it is considered a 21st century term, translational research has been present for much longer. Idea of translating experimental discovery to its’ clinical application and use is old as research itself. However, it is the understanding of missing links between the basic science research and clinical research that emerged in the past decade and mobilized scientific and clinical communities and organizations worldwide. Hence term, translational research, which represents an “enterprise of harnessing knowledge from basic sciences to produce new drugs, devices, and treatment options for patients” (1). It has been also characterized as “effective translation of the new knowledge, mechanisms, and techniques generated by advances in basic science research into new approaches for prevention, diagnosis, and treatment of disease, which is essential for improving health” (2). This translation is a complex process and involves more than one step for transfer of research knowledge. At least 3 such roadblocks have been identified (Figure 1) ; T1 translation: “The transfer of new understandings of disease mechanisms gained in the laboratory into the development of new methods for diagnosis, therapy, and prevention and their first testing in humans”, T2 translation: “The translation of results from clinical studies into everyday clinical practice and health decision making”, and T3 translation: “Practice-based research, which is often necessary before distilled knowledge (e.g., systematic reviews, guidelines) can be implemented in practice” (3-5). The international research community rapidly recognized importance for promotion of translational research and made it their priority(5). In the USA, National Institutes of Health, (NIH) expects to fund 60 translational research centers with a budget of $500 million per year by 2012 (6). Besides academic centers, foundations, industry, disease-related organizations, and individual hospitals and health systems have also established translational research programs and at least 2 journals (Translational Medicine and the Journal of Translational Medicine) are devoted to the topic. In Europe, translational research has become a centerpiece of the European Commission’s €6 billion budget for health related research, and the United Kingdom has invested £450 million over 5 years to establish translational research centers (7). In this issue of Bosnian Journal of Basic Medical Sciences, members of medical section of Bosnian and Herzegovinian-American Academy of Arts and Sciences (BHAAAS), contributed their own work and expertise to bridge the gap between basic and clinical research, between inventing the treatments and getting them used in practice, and laid down foundations for future collaborative development of translational research in Bosnia and Herzegovina, as well as in the region (8). At the first glance of this issue’s table of content, a reader will easily notice the variety and breadth of topics and themes, from medical informatics and genetics, to hematology and oncology, pulmonary and critical care medicine, orthopedics, trauma surgery and neurosurgery. However, all of the articles share common ideas of translation of knowledge, from bench to bedside and back, and individualized approach to medicine, which are the true hallmarks of the 21st century medicine. Deeper under the surface and titles, there lies our common privilege and honor to be part of a broader mission of BHAAAS: to connect with our fellow physicians and scientists, and to build bridges of cooperation with our homeland, to promote the spirit of intellectual diversity and free exchange of ideas with the strong belief that this knowledge sharing will promote betterment of health in Bosnia and Herzegovin

Adjuvant Inhaled Corticosteroids in Community-Acquired Pneumonia: A Review Article

Community-acquired pneumonia is still a major cause of morbidity and mortality worldwide. Since the inflammatory response induced by the immune system is often a major contributor to the lung injury, it becomes reasonable to assess the potential benefit of anti-inflammatory agents in treating community-acquired pneumonia. The role of corticosteroids as adjunct anti-inflammatory agents in treating community-acquired pneumonia is still controversial. Several studies have assessed the benefit of their use in patients with community-acquired pneumonia. In most of those studies, the route of corticosteroids administration was systemic. The aim of this article is to provide a concise review of the role of corticosteroids in treating community-acquired pneumonia when administered via inhalational route, with the potential benefit of avoiding systemic side effects of corticosteroids while exerting the same anti-inflammatory effects on the lungs. Conclusion: the use of inhaled corticosteroids may be of benefit in certain patient subsets with community-acquired pneumonia. Further randomized controlled trials are needed for better determination of such patient subsets

Acute Respiratory Distress Syndrome: Insights Gained from Clinical and Translational Research

Acute lung injury and its more severe form acute respiratory distress syndrome (ARDS) are characterized by diffuse impairment of alveolocapillary membrane in the settings of different predisposing conditions such as sepsis, trauma and shock. Many intrahospital exposures, including aspiration, delayed resuscitation, high tidal volume mechanical ventilation and non critical use of transfusions may contribute or worsen ARDS. Therapy is targeted to treatment of predisposing condition, life supportive measures and prevention of nosocomial complications. Rigorous adherence to lung-protective mechanical ventilation is critical to prevent ventilator induced lung injury and decrease mortality. Although survival of ARDS patients has improved in the last decades ARDS mortality rates are still high and survivors encounter significant physical and psychological impairment

Association of Inhaled Corticosteroids with Incident Pneumonia and Mortality in COPD Patients; Systematic Review and Meta-Analysis

<div><p></p><p><i>Background:</i> Inhaled corticosteroids are commonly prescribed for patients with severe COPD. They have been associated with increased risk of pneumonia but not with increased pneumonia-associated or overall mortality. <i>Methods:</i> To further examine the effects of inhaled corticosteroids on pneumonia incidence, and mortality in COPD patients, we searched for potentially relevant articles in PubMed, Medline, CENTRAL, EMBASE, Scopus, Web of Science and manufacturers' web clinical trial registries from 1994 to February 4, 2014. Additionally, we checked the included and excluded studies' bibliographies. We subsequently performed systematic review and meta-analysis of included randomized controlled trials and observational studies on the topic. <i>Results:</i> We identified 38 studies: 29 randomized controlled trials and nine observational studies. The estimated unadjusted risk of pneumonia was increased in randomized trials: RR 1.61; 95% CI 1.35–1.93, <i>p</i> < 0.001; as well as in observational studies: OR 1.89; 95% CI 1.39–2.58, <i>p</i> < 0·001. Six randomized trials and seven observational studies were useful in estimating unadjusted risk of pneumonia ­case-fatality: RR 0.91; 95% CI 0.52–1.59, <i>p</i> = 0.74; and OR 0.72; 95% CI 0.59–0.88, <i>p</i> = 0.001, respectively. Twenty-nine randomized trials and six observational studies allowed estimation of unadjusted risk of overall mortality: RR 0.95; 95% CI 0.85–1.05, <i>p</i> = 0.31; and OR 0.79; 95% CI 0.65–0.97, <i>p</i> = 0.02, respectively. <i>Conclusions:</i> Despite a substantial and significant increase in unadjusted risk of pneumonia associated with inhaled corticosteroid use, pneumonia fatality and overall mortality were found not to be increased in randomized controlled trials and were decreased in observational studies.</p></div