International Guidelines For Management Research Articles

Potential and challenges for an integrated management of tuberculosis, diabetes mellitus, and hypertension: A scoping review protocol.

In many low- and middle-income countries (LMICs), the epidemiological transition is characterized by an increased burden of non-communicable diseases (NCDs) and the persistent challenge of infectious diseases. The transmission of tuberculosis, one of the leading infectious diseases, can be halted through active screening of risk groups and early case findings. Studies have reported comorbidities between tuberculosis (TB) and NCDs, which necessitates the development of an integrated disease management model. This scoping review discusses the possibilities and problems of integration in managing TB and NCDs, with a particular emphasis on diabetic mellitus (DM) and hypertension screening and control. We will conduct this review following Arksey and O'Malley's framework for scoping review. We will use key terms related to integrated management, i.e., screening, diagnosis, treatment, and care, of TB, DM, and hypertension in PubMed, Scopus Database, and ScienceDirect for research published from January 2005 to July 2021. This review will also consider grey literature, including unpublished literature and international disease management guidelines on TB, DM, and hypertension from WHO or other health professional organization. We will export the search results to citation manager software (EndNote). We will remove duplicates and apply the inclusion and exclusion criteria to identify the set of papers for the review. After screening the titles and abstract, two authors will independently review the full text of selected studies and extract the data. We will synthesize all selected studies qualitatively and the results will be discussed with the experts. The results will be used as the basis of the development of a guideline for integrated TB, DM, and hypertension management.

A comparison of psychological characteristics in people with knee osteoarthritis from Japan and Australia: A cross-sectional study.

The aim of this study was to investigate differences in psychological characteristics between people with knee osteoarthritis (OA) from Japan and Australia. Sixty-two adults from Japan and 168 adults from Australia aged over 50 years with knee pain were included. Japanese data were collected from patients with knee OA diagnosed by medical doctors. Australian data were baseline data from a randomized controlled trial. Participants were not exercising regularly or receiving physiotherapy at the time. Psychological characteristics evaluated were depressive symptoms, fear of movement, and pain catastrophizing. These psychological characteristics were compared between the Japanese and Australian cohorts by calculating 95% confidence intervals (CIs) for difference of the mean. To test for equivalence, an equivalence margin was set at 0.5 standard deviations (SD) of the mean, where these SDs were based on the Australian data. When the 95%CI for the difference of the mean value lay entirely within the range of equivalence margin (i.e. between -0.5 and 0.5 times the Australian SD), the outcome was considered equivalent. There were no differences between the groups from Japan and Australia for depressive symptoms and the two groups were considered equivalent. There was no difference between groups for fear of movement, however the criteria for equivalence was not met. People from Japan with knee OA had higher scores for pain catastrophizing than people from Australia. The findings should be confirmed in other samples of people with knee OA from Japan and Australia due to the limitations of the participant recruitment strategy in this study. However, our findings suggest there may be a greater need to consider pain catastrophizing and build pain self-efficacy when managing Japanese people with knee OA. Implementation of international clinical practice guidelines for OA management may require different strategies in different countries due to different psychological profiles.

IMPLEMENTATION OF A OSTEOARTHRITIS MANAGEMENT PROGRAM IN THE UNITED STATES

Purpose: Osteoarthritis (OA) is a chronic and disabling condition affecting morbidity and mortality. Despite its high prevalence and the availability of international management guidelines, nearly half of patients do not receive recommended treatments. OA Management Programs (OAMPs) are an alternative care model to reduce barriers and enhance the receipt of evidence-based care. This study was designed to evaluate the fidelity and feasibility of an OAMP in a United States academic medical center and understand its patients' baseline characteristics.

Barrett's esophagus: Review of natural history and comparative efficacy of endoscopic and surgical therapies.

Barrett's esophagus (BE) is the precursor to esophageal adenocarcinoma (EAC). Progression to cancer typically occurs in a stepwise fashion through worsening dysplasia and ultimately, invasive neoplasia. Established EAC with deep involvement of the esophageal wall and/or metastatic disease is invariably associated with poor long-term survival rates. This guides the rationale of surveillance of Barrett’s in an attempt to treat lesions at an earlier, and potentially curative stage. The last two decades have seen a paradigm shift in management of Barrett’s with rapid expansion in the role of endoscopic eradication therapy (EET) for management of dysplastic and early neoplastic BE, and there have been substantial changes to international consensus guidelines for management of early BE based on evolving evidence. This review aims to assist the physician in the therapeutic decision-making process with patients by comprehensive review and summary of literature surrounding natural history of Barrett’s by histological stage, and the effectiveness of interventions in attenuating the risk posed by its natural history. Key findings were as follows. Non-dysplastic Barrett’s is associated with extremely low risk of progression, and interventions cannot be justified. The annual risk of cancer progression in low grade dysplasia is between 1%-3%; EET can be offered though evidence for its benefit remains confined to highly select settings. High-grade dysplasia progresses to cancer in 5%-10% per year; EET is similarly effective to and less morbid than surgery and should be routinely performed for this indication. Risk of nodal metastases in intramucosal cancer is 2%-4%, which is comparable to operative mortality rate, so EET is usually preferred. Submucosal cancer is associated with nodal metastases in 14%-41% hence surgery remains standard of care, except for select situations.

Surviving sepsis campaign: International guidelines for management of sepsis and septic shock in adults 2021 - endorsement by the Scandinavian society of anaesthesiology and intensive care medicine.

The Clinical Practice Committee of the Scandinavian Society of Anaesthesiology and Intensive Care Medicine endorses the clinical practice guideline Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. The guideline serves as a useful bedside decision aid for clinicians managing adults with suspected and confirmed septic shock and sepsis‐associated organ dysfunction.

The role of sodium-glucose co-transporter (SGLT)-2 inhibitors in heart failure management and implications for the kidneys.

Sodium-glucose co-transporter (SGLT)-2 inhibitors were initially developed for management of type 2 diabetes but have been shown to offer improved outcomes in heart failure, a condition in which concomitant chronic kidney disease (CKD) is common. Randomised controlled trials initially demonstrated prognostic cardiovascular and renal benefits of SGLT2 inhibitors in high cardiovascular risk individuals with type 2 diabetes particularly in relation to heart failure. Improved outcomes have been replicated in cohorts with established heart failure and/or CKD and appear to extend in those without diabetes. Several specific agents have been considered, with evidence of a class effect, and dapagliflozin and empagliflozin are now incorporated into major international cardiovascular guidelines for management of heart failure with reduced ejection fraction. Beyond glucose lowering effects the mechanisms mediating SGLT2 inhibitors favourable actions are not fully elucidated. Haemodynamic alterations, natriuresis, osmotic diuresis, and weight loss likely contribute to improved outcomes, along with an enhanced cardiometabolic profile. The functional drop in estimated glomerular filtration rate (eGFR) which accompanies SGLT2 inhibitor initiation, before eGFR stabilisation, is likely central in the observed renal benefits. In this review we discuss in detail the evidence for SGLT2 inhibitors in heart failure, particularly with regard to kidney health.

Nutraceuticals for Dyslipidaemia and Glucometabolic Diseases: What the Guidelines Tell Us (and Do Not Tell, Yet).

Background: The use of nutraceutical products and functional foods in the cardiovascular and metabolic field is rising in several countries. Preparation and implementation of guidelines are pivotal for translating research-derived knowledge and evidence-based medicine to the clinical practice. Based on these considerations, the aim of this paper is to explore if and how nutraceutical products are discussed by the most recent international guidelines related to cardio-metabolic diseases (dyslipidaemia, obesity, type 2 diabetes mellitus (T2DM) and cardiovascular disease (CVD) prevention). Some, but not all, guidelines for dyslipidaemia mention nutraceutical products as potential useful options for the treatment of mild dyslipidaemia, but also indicate the low level of evidence associated to their effects on hard endpoints (myocardial infarction, stroke, CVD-related death). In the most recent guidelines on obesity, it is mentioned that no safe and effective dietary supplement nor nutraceutical product is available for the management of weight loss in this condition, and more high-quality studies are necessary in this field. The examined guidelines for T2DM do not mention any specific nutraceutical approach to this disease, nor to milder forms, such as insulin resistance and pre-diabetes. Conclusions: The focus on nutraceutical products in the main international guidelines for cardio-metabolic disease management remains limited. Since robust scientific evidence is the background of useful and effective guidelines, the implementation of high-quality clinical research is strongly needed in the field of nutraceutical products for cardio-metabolic diseases.

Реамберин у комплексі оптимізації та диференціації стратегії інтенсивної терапії вторинних гнійних менінгоенцефалітів

Стаття присвячена питанням покращання діагностики, застосування методик оцінки тяжкості стану хворих при надходженні у відділення інтенсивної терапії, у динаміці спостереження за ними, оптимізації інтенсивної терапії (ІТ) вторинного гнійного менінгоенцефаліту (ВГМЕ). Загальна схема відбору пацієнтів, їх рандомізації, включення в дослідження й аналіз можуть бути подані в такий спосіб. Пацієнти з підтвердженим ВГМЕ методом рандомізації з урахуванням тяжкості стану та варіанту ІТ були розподілені на 2 групи. У I групу увійшли 22 пацієнти, котрим проводилася базисна ІТ із позицій доказової медицини відповідно до міжнародних рекомендацій Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septiс shock 2012, що доповнювалася включенням дексаметазону. У II групу увійшов 21 пацієнт, у яких ІТ, що проводилась у I групі, доповнювалась в/в введенням розчину реамберин. На початку дослідження не виявлено вірогідних відмінностей між групами за статтю, віком, локалізацією септичного вогнища, частотою реєстрації 4 ознак синдрому системної запальної відповіді, позитивних результатів бактеріологічних посівів ліквору та матеріалів із первинного вогнища, тобто вибірки були порівняними за цими ознаками. У цей же час серед пацієнтів II групи було в 2,8 раза більше хворих із рівнем свідомості «сопор» або «кома I ступеня» (76,2 % проти 27,2 %; р < 0,001). Несприятливий прогноз (центральний перфузійний тиск < 50 мм рт.ст.) при надходженні до стаціонару мали 22,7 % хворих із I групи і 28,6 % — із II (р > 0,60). Незважаючи на початково більш тяжкий стан хворих із ВГМЕ в II групі, додавання до базисної терапії в/в введення розчину реамберин сприяло тому, що санація ліквору в II групі проходила більш плавно, без вторинного сплеску цитозу, характерного для I групи на 5-ту добу дослідження. Установлено, що в I групі С-реактивний білок у лікворі зникав до 3-ї доби дослідження, з’являвся на 5-ту добу і був відсутнім до 7-ї доби дослідження. У II групі наявність С-реактивного білка було зафіксовано лише на початку і 1-шу добу дослідження, що свідчить про більш стійкий характер відновлення функціонального стану гематоенцефалічного бар’єра в II групі, без вторинного (повторного) його прориву. Оцінка ефективності ІТ на 28-му добу дослідження показала, що відмічалось зменшення когнітивних дисфункцій у I групі на 28,4 %, у II — на 37,7 %; органних дисфункцій у I групі — з 76,3 до 43,8 %; у II — з 88,7 до 36,9 %. Показники істинної летальності становили 27,27 і 23,81 % (р > 0,90) відповідно. Зниження прогнозованої летальності в I групі становило 4,73 %, у II — 16,19 %.

Вплив основних положень «Міжнародних настанов з інтенсивної терапії тяжкого сепсису і септичного шоку — 2012» на тлі локальної внутрішньопросвітної реоксигенації перфтораном на перебіг септичного процесу і вираженість енцефалопатії в структурі поліорганно

У роботі проведено аналіз результатів впливу ключових питань діагностики та інтенсивної терапії сепсису, що базуються на положеннях «Міжнародних настанов з інтенсивної терапії тяжкого сепсису і септичного шоку — 2012», доповнених локальною внутрішньопросвітною реоксигенацією перфтораном, на перебіг септичного процесу і вираженість енцефалопатії в структурі поліорганної недостатності. Висновки базувалися на підставі динаміки кількісних характеристик фізіологічного патерну CI-DO2-VO2; pH інтрамукозного; шкал GCS, APACHE II, SOFA; показників синдрому системної запальної відповіді, концентрації цитокінів (TNFα, IL-1, ­IL-4, IFNα), імуноглобулінів (IgA, IgM, IgG). Відновлення показників фізіологічного патерну DO2-VO2 до наднормальних значень до 3-ї доби сприяло поліпшенню загальної та регіональної оксигенації; швидкому оборотному розвитку церебральної недостатності: кількість балів становила 13,83 і коливалась клінічно між помірним оглушенням і ясною свідомістю; реєструвалась відсутність проявів SIRS; вірогідному зниженню концентрацій прозапальних цитокінів і відновленню їх рівноваги з протизапальним IL-4. Відсутність фази повторного погіршення стану хворих асоціювалася з обмеженням гострого медіатозу, подальшим регресом проявів гастроінтестинальної недостатності. Запобігання шлунково-кишковим кровотечам свідчить про прискорення репаративної регенерації ентероцитів під впливом перфторану. Початково передбачувана летальність за сумою балів шкали APACHE II становила 51 %, істинна летальність — 25 %, локальна реоксигенація перфтораном призвела до зниження летальності на 26 %.

Вплив основних положень Міжнародного керівництва з інтенсивної терапії тяжкого сепсису та септичного шоку — 2012 із додатковою ентеропротекцією на перебіг септичного процесу і вираженість енцефалопатії в структурі поліорганної недостатності

У статті проведено аналіз результатів впливу ключових положень Міжнародного керівництва з інтенсивної терапії тяжкого сепсису та септичного шоку — 2012, доповнених ентеропротекцією, на перебіг септичного процесу і вираженість енцефалопатії в структурі поліорганної недостатності. Заключення аналізу базувалося на підставі динаміки кількісних характеристик фізіологічного патерну CI-DO2-VO2; рН інтрамукозного, шкал GCS, APACHE II, SOFA; показників синдрому системної запальної відповіді; концентрації цитокінів (TNF-α, IL-1, IL-4, IFN-α); імуноглобулінів (IgA, IgM, IgG). Незважаючи на відновлення загальної оксигенації в умовах супранормальних значень DO2-VO2, на 3-тю — 5-ту добу відмічали чотири критерії SIRS, що розцінювалося як імовірність ризику уповільненої регресії синдрому запальної відповіді в подальшому. Сказане вище знайшло своє підтвердження в клінічному показнику лейкоцитів на 7-му добу — 15,18 • 109/л і незрілих форм — 11,88 %. Бали за шкалами APACHE II і SOFA, знизившись порівняно з такими на 5-ту добу, «застигли» на цьому рівні на 7-му добу. Неврологічна симптоматика на 7-му добу оцінювалася як сопор — 10,88 бала. Максимально високі концентрації прозапальних цитокінів на 5-ту — 7-му добу можна пояснити їх реперфузійним походженням після відновлення спланхнічного кровообігу. При цьому позитивним було перевищення IL-4 на 7-му добу свого рівня на 5-ту добу на 77,42 %. Використання сорбентів виявилося неефективним за наявності гострих ерозій і виразок шлунково-кишкового тракту для регенерації ентероцитів і запобігання шлунково-кишковим кровотечам навіть у поєднанні з інгібіторами протонної помпи. Початково передбачувана летальність за сумою балів шкали APACHE II становила 51 %, справжня летальність — 35,5 %, тобто застосування ентеросорбенту призвело до зниження летальності на 15,5 %.

Currently Available Inhaled Therapies in Asthma and Advances in Drug Delivery and Devices.

Medications delivered in the inhaled form remains the cornerstone of medical management of asthma. There have been considerable advances in the development of inhaled medications and devices over the past several decades. Clinicians also have access to regularly updated international guidelines for management of asthma. Despite this, a substantial proportion of children with asthma continue to have persistent poor asthma control and considerable morbidity even in well-resourced settings. The wide selection of medications and devices may complicate clinical decision making. The ideal inhaler would be one that the patient can and will use as advised. One cannot overemphasize the importance of medication adherence and a correct inhaler technique in achieving optimal asthma control. Clinicians who manage children with asthma should have a good understanding of inhaled medications and devices commercially available for the management of asthma and this would help them select the right medication and device for the right patient. This review aims to provide an overview of physiologic basis of inhaler therapy, commonly used inhaled therapies, and the advances in the field of inhaler devices including emerging technologies.

Update on Existing Care Models for Chronic Kidney Disease in Low- and Middle-Income Countries: A Systematic Review.

Background:Approximately 78% of chronic kidney disease (CKD) cases reside in low- and middle-income countries (LMICs). However, little is known about the care models for CKD in LMICs.Objective:Our objective was to update a prior systematic review on CKD care models in LMICs and summarize information on multidisciplinary care and management of CKD complications.Design:We searched MEDLINE, EMBASE, and Global Health databases in September 2020, for papers published between January 1, 2017, and September 14, 2020. We used a combination of search terms, which were different iterations of CKD, care models, and LMICs. The World Bank definition (2019) was used to identify LMICs.Setting:Our review included studies published in LMICs across 4 continents: Africa, Asia, North America (Mexico), and Europe (Ukraine). The study settings included tertiary hospitals (n = 6), multidisciplinary clinics (n = 1), primary health centers (n = 2), referral centers (n = 2), district hospitals (n = 1), teaching hospitals (n = 1), regional hospital (n = 1), and an urban medical center (n = 1).Patients:Eighteen studies met inclusion criteria, and encompassed 4679 patients, of which 4665 were adults. Only 9 studies reported mean eGFR which ranged from 7 to 45.90 ml/min/1.73 m2.Measurements:We retrieved the following details about CKD care: funding, urban or rural location, types of health care staff, and type of care provided, as defined by Kidney Disease Improving Global Outcomes (KDIGO) guidelines for CKD care.Methods:We included studies which met the following criteria: (1) population was largely adults, defined as age 18 years and older; (2) most of the study population had CKD, and not end-stage kidney disease (ESKD); (3) population resided in an LMIC as defined by the World Bank; (4) manuscript described in some detail a clinical care model for CKD; (5) manuscript was in either English or French. Animal studies, case reports, comments, and editorials were excluded.Results:Eighteen studies (24 care models with 4665 patients) met inclusion criteria. Out of 24 care models, 20 involved interdisciplinary health care teams. Twenty models incorporated international guidelines for CKD management. However, conservative kidney management (management of kidney failure without dialysis or renal transplant) was in a minority of models (11 of 24). Although there were similarities between all the clinical care models, there was variation in services provided and in funding arrangement; the latter ranged from comprehensive government funding (eg, Sri Lanka, Thailand), to out-of-pocket payments (eg, Benin, Togo).Limitations:These include (1) lack of detail on CKD care in many of the studies, (2) small number of included studies, (3) using a different definition of care model from the original Stanifer et al paper, and (4) using the KDIGO Guidelines as the standard for defining a CKD care model.Conclusions:Most of the CKD models of care include the key elements of CKD care. However, access to such care depends on the funding mechanism available. In addition, few models included conservative kidney management, which should be a priority for future investment.Trial registration:Not applicable.

P063 Consensus-based recommendations for treat to target management of immunoglobulin A vasculitis

Abstract Background IgAvasculitis (IgAV) is the commonest cause of vasculitis in childhood. It is characterized by small vessel vasculitis of the skin, gastrointestinal tract, kidneys, joints, and, rarely, the lungs and the central nervous system. There is paucity of international guidelines for management of IgA V. the Objective is to develop guidelines specific for Egyptian children with IgA vasculitis. Method This study was carried out to achieve an Egyptian expert consensus on a treat-to-target management strategy for IgA vasculitis using Delphi technique. The preliminary scientific committee identified a total of 16 key clinical questions according to the Patient/Population, Intervention, Comparison, and Outcomes (PICO) approach. Delphi process was implemented (2-rounds) to reach a consensus. Results An online questionnaire were sent to expert panel (n = 26) who participated in the two rounds. At the end of round 2, a total of 20 recommendation items, categorized into 2 sections were obtained. Agreement with the recommendations (rank 7–9) ranged from 91.7–100%. Consensus was reached (i.e. ≥75% of respondents strongly agreed or agreed) on the wording of all the 20 clinical standards identified by the scientific committee. Algorithms for the management have been suggested. Conclusion This was an expert, consensus recommendations for the diagnosis and treatment of IgA V and IgA V nephritis, based on best available evidence and expert opinion.

Successful Use of Plasma Exchange Preceding RBC Exchange in Sickle Cell Disease Hyperhemolytic Crisis with Hepatic Sequestration: A Case Report

IntroductionHyperhemolytic crisis is an uncommon complication of SCD that may cause multiorgan failure and lead to significant mortality. There are no current national or international guidelines for management of hyperhemolytic crisis and associated complications. There have been limited number of case reports and series that demonstrated utility of plasma exchange in the patients with multiorgan failure resulting from hemolysis complications (Zaidi GZ et al.,2020). We are presenting the case where hyperhemolytic crisis was complicated by hepatic sequestration and acute liver failure, that was dramatically reversed by 2 plasma exchange treatments followed by RBC exchange.Case reportWe present a case of a 35-year-old African American male with SCD and beta thalassemia trait with frequent hospitalizations for sickle cell pain crisis. He presented with pain typical for his acute pain crises and was admitted for intravenous hydration and pain control. The next morning, lab work showed bicytopenia with a drop in hemoglobin from 10.5 to 5.8 g/dL and platelets (PLT) from 100 to 22 X10E3/uL. Lactate dehydrogenase (LDH) increased from 434 to 2848 U/L, haptoglobin was 36 mg/dL, but disseminated intravascular coagulation (DIC) and Heparin-induced Thrombocytopenia (HIT) antibody panel were negative. The blood urea nitrogen (BUN) creatinine (Cr) ratio was also elevated (30.6) suggesting renal damage as well. He was transferred to the intensive care unit and started on Intravenous Immunoglobulin (IVIG) 0.4 grams/kilogram daily for 5 days and methylprednisolone 500 mg daily for 2 days followed by a prednisone taper. Liver enzymes continued to trend upward with AST of 19,866 U/L and ALT of 3,675 U/L on day 3 of hospitalization. Ultrasound of abdomen demonstrated mild splenomegaly with a spleen measuring 13.3 cm. The clinical presentation and hepatocellular pattern of injury was consistent with hepatic sequestration crisis. Despite receiving 1 unit of platelet 3 units of pRBC, there was little improvement and apheresis service was consulted. Plasma exchange was initiated for 2 procedures on consecutive days followed by RBC exchange with rapid improvement in clinical status and laboratory findings with a reduction of LDH (1304), AST (129), ALT (204), Hgb (8.0), PLT (41), BUN/Cr (20.0). He was discharged on day 7 at baseline status.DiscussionAlthough the mechanism of development of hyperhemolysis in SCD is not fully understood, the hemolysis leads to release of free hemoglobin (Hb) and free heme that activate neutrophils, and vascular endothelial cells via TLR-4. This ultimately leads to inflammatory, coagulative, and cytotoxic damages and decreased nitric oxide (NO) bioavailability which further contributes to SCD complications such as pulmonary and systemic vasculopathy, pain crisis and acute chest syndrome and multi organ failure (Louie JE et al., 2018). This provides a rationale for plasma exchange - removal of free heme from the patient plasma and replenishing exhausted haptoglobin and hemopexin reserves from donor plasma.Hemolytic crisis causing visceral organ damage is relatively rare. There are no current guidelines for management of such patients. In 1996 Betrosian et al. discussed the first case of liver failure in a SCD with vasa-occlusive crisis treated with RBC and plasma transfusions (Betrosian A et al., 1996). Since then, there have been case reports/series of plasma exchange/plasma transfusions in SCD with multi organ failure (Geigel EJ et al., 1997, Louie JE et al., 2018) but reports about use of plasma exchange in SCD patients with hepatic sequestration have not been identified by our literature review.Our case demonstrates that plasma exchange in hyperhemolysis and hepatic sequestration is: •Safe•Leads to quick and significant improvement in hemolysis laboratory values.•Results in quick and durable reversal of hepatic sequestration and associated liver failure.•Adds plasma exchange as therapeutic apheresis modality in addition to previously accepted RBC exchange.•Provides data about priority of plasma exchange over RBC exchange in this clinical situation. DisclosuresNo relevant conflicts of interest to declare.

Насколько целесообразно применение иммуноглобулинов при сепсисе и септическом шоке?

Авторы Surviving Sepsis Campaign: International Guidelines for Managementof Sepsisand Septic Shock: 2016 (Sepsis-3) не рекомендуют применять внутривенный иммуноглобулин при сепсисе и септическом шоке (слабая рекомендация, низкое качество доказательств). В качестве подтверждения приводится рандомизированное контролируемое исследование по применению внутривенных иммуноглобулинов при сепсисе и септическом шоке, итогом которого явилось уменьшение количества койко-дней в отделении интенсивной терапии (ОИТ), часов проведения механической вентиляции легких, более быстрая нормализация количества лейкоцитов. Однако летальность в контрольной группе изменялась недостоверно. Цель обзора: на основании анализа данных литературы выявить предикторы целесообразности назначения иммуноглобулинов при сепсисе и септическом шоке. В плане анализа литературных источников наше внимание привлекают японские рекомендации по диагностике и интенсивной терапии сепсиса, опубликованные в 2014 году, в которых представлены ответы на следующие вопросы: 1) каковы показания для введения иммуноглобулинов; 2) на каком этапе развития сепсиса вводят иммуноглобулины; 3) в каких дозах и на какой срок назначают введение иммуноглобулинов; 4) на что следует обратить внимание при выборе препаратов иммуноглобулинов. Далее в обзоре приводятся данные литературы по сопоставлению эффектов применения иммуноглобулинов при сепсисе в зависимости от суточной дозировки, динамики уровней прокальцитонина, С-реактивного белка, молочной кислоты, интерлейкина-6, баллов по шкале SOFA (Hamano N. et al., 2013; Kusunoki M. et al., 2017). Согласно данным I. Martin-Loeches et al. (2017), низкие концентрации эндогенных иммуноглобулинов (IgG < 407 мг/дл; IgA < 219 мг/дл; IgM < 43 мг/дл) у септических пациентов ОИТ с ≤ 8 баллов по SOFA являются предикторами для назначения IVIG.

Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock 2021, interpretation and expectation

The Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock 2021 (2021 guidelines) was recently released. The guidelines summarized the evidences from literatures up to July 2019, and composed by 6 parts as "screening and early treatment", "infection", "hemodynamic management", "ventilation", "additional therapies" and "long-term outcomes and goals of care" with a total of 93 items and 99 recommendations. Compared with the 2016 guidelines (96 recommendations), although the total number of recommendations in the 2021 guidelines is similar, the number of "strong recommendations (recommend)" in 2021 guidelines has dropped significantly, as the number of "weak recommendations (suggest)" has increased significantly, and the level of the quality of evidence on which the recommendations are based has been significantly lowered. Furthermore, 2021 guidelines have also markedly deleted or simplified the recommendations regarding infection prevention, acute respiratory distress syndrome (ARDS) treatment, nutritional support and so on. While, the most obvious improvement appears in the segment of "long-term outcomes and goals of care", in which the patients and their families could get help in term of determining their physical rehabilitation and discharge follow-up plans and formulating exact goals of care. 2021 guidelines did not adopt new and emerging therapies or treatments, such as metagenomic next-generation sequencing (mNGS), diaphragm protective ventilation, timing of initiating renal replacement therapy for acute kidney injury, early mobility, endotoxin adsorption, tranexamic acid, E-medicine and telemedicine, big data and artificial intelligence and other new therapies. Collectively, it may suggest the 2021 guidelines tend to be conservative and simplified rather than fairly optimized and logicalized, which may arouse controversy in the future and affect clinician compliance.

WHO global antimicrobial resistance surveillance for Neisseria gonorrhoeae 2017–18: a retrospective observational study

Gonorrhoea and antimicrobial resistance (AMR) in Neisseria gonorrhoeae are major health concerns globally. Increased global surveillance of gonococcal AMR is essential. We aimed to describe the 2017-18 data from WHO's global gonococcal AMR surveillance, and to discuss priorities essential for the effective management and control of gonorrhoea. We did a retrospective observational study of the AMR data of gonococcal isolates reported to WHO by 73 countries in 2017-18. WHO recommends that each country collects at least 100 gonococcal isolates per year, and that quantitative methods to determine the minimum inhibitory concentration of antimicrobials, interpreted by internationally standardised resistance breakpoints, are used. In 2017-18, 73 countries provided AMR data for one or more drug. Decreased susceptibility or resistance to ceftriaxone was reported by 21 (31%) of 68 reporting countries and to cefixime by 24 (47%) of 51 reporting countries. Resistance to azithromycin was reported by 51 (84%) of 61 reporting countries and to ciprofloxacin by all 70 (100%) reporting countries. The annual proportion of decreased susceptibility or resistance across countries was 0-21% to ceftriaxone and 0-22% to cefixime, and that of resistance was 0-60% to azithromycin and 0-100% to ciprofloxacin. The number of countries reporting gonococcal AMR and resistant isolates, and the number of examined isolates, have increased since 2015-16. Surveillance remains scarce in central America and the Caribbean and eastern Europe, and in the WHO African, Eastern Mediterranean, and South-East Asian regions. In many countries, ciprofloxacin resistance was exceedingly high, azithromycin resistance was increasing, and decreased susceptibility or resistance to ceftriaxone and cefixime continued to emerge. WHO's global surveillance of gonococcal AMR needs to expand internationally to provide imperative data for national and international management guidelines and public health policies. Improved prevention, early diagnosis, treatment of index patients and partners, enhanced surveillance (eg, infection, AMR, treatment failures, and antimicrobial use or misuse), and increased knowledge on antimicrobial selection, stewardship, and pharmacokinetics or pharmacodynamics are essential. The development of rapid, accurate, and affordable point-of-care gonococcal diagnostic tests, new antimicrobials, and gonococcal vaccines is imperative. None.

Maternal-focused interventions to improve infant growth and nutritional status in low-middle income countries: A systematic review of reviews.

BackgroundSmall and nutritionally at-risk infants under 6 months (<6m) are a vulnerable group at increased risk of mortality, morbidity, poor growth and sub-optimal development. Current national and international (World Health Organization) management guidelines focus mainly on infants’ needs, yet growing evidence suggests that maternal factors also influence infant outcomes. We aimed to inform future guidelines by exploring the impacts of maternal-focused interventions on infant feeding and growth.MethodsWe conducted a systematic review of reviews published since 2008 (PROSPERO, register number CRD 42019141724). We explored five databases and a wide variety of maternal-focused interventions based in low- and middle-income countries. Infant outcomes of interest included anthropometric status, birthweight, infant mortality, breastfeeding and complementary feeding practices. Given heterogenous interventions, we present a narrative synthesis of the extracted data.ResultsWe included a total of 55 systematic reviews. Numerous maternal interventions were effective in improving infant growth or feeding outcomes. These included breastfeeding promotion, education, support and counselling interventions. Maternal mental health, while under-researched, showed potential to positively impact infant growth. There was also some evidence for a positive impact of: women’s empowerment, m-health technologies, conditional cash transfers, water, sanitation and hygiene and agricultural interventions. Effectiveness was increased when implemented as part of a multi-sectoral program. Antenatal supplementation with macronutrient, multiple micronutrients, Vitamin D, zinc, iron folic acid and possibly calcium, iodine and B12 in deficient women, improved birth outcomes. In contrast, evidence for postnatal supplementation was limited as was evidence directly focusing on small and nutritionally at-risk infants; most reviews focused on the prevention of growth faltering.ConclusionOur findings suggest sufficient evidence to justify greater inclusion of mothers in more holistic packages of care for small and nutritionally at-risk infants aged <6m. Context specific approaches are likely needed to support mother-infant dyads and ensure infants survive and thrive.

Management of the Phanom-Surin Archaeological Site in Thailand: Concept, Policies and Practices

The Phanom-Surin (PNS) archaeological site contains the remains of a sewn-plank vessel that is dated to the 9th century CE and discovered in Thailand’s mangrove swamp. As the only accessible sewn-plank vessel archaeology in the world, it provides research opportunities and potential for collaboration between heritage stakeholders. Preservation of the site within its context is crucial. Throughout this article, I will explain the importance of the PNS site management and its context based on my experience. The fuller understanding of the PNS site relies much on the information to be extracted from the materials and contexts. This article therefore encourages the preservation and management of the site within the original context. There are several relevant international guidelines for heritage and environmental management, such as the World Heritage Operational Guidelines, the Annex of the UNESCO (United Nations Educational, Scientific and Cultural Organization) 2001 Convention and the technical Ramsar Convention, all of which can help develop domestic framework and practices. This article aims to draw public and government attention towards the PNS site, and discusses concepts, policies and practices relating to the site.

Diagnostic performance of acr-tirads in differentiating benign from malignant thyroid nodules in patients undergoing fine-needle aspiration biopsy: Comparative study based on five international guidelines for management of thyroid nodules

Background: The purpose of this study was to retrospectively analyze the diagnostic performance of different international guidelines to detect benign from malignant nodules using fine-needle aspiration biopsy as a reference test. Methods: This study is a multi-institution, IRB-approved, retrospective study conducted from 2016 to 2020 that evaluated 200 consecutive biopsied thyroid nodules. The nodules were reclassified according to American College of Radiology Thyroid Imaging and Reporting Data System (ACR-TIRADS), Kwak-TIRADS (K-TIRADS), Korean Society of Thyroid Radiology (KSThR), European Thyroid Imaging and Reporting Data System (EU-TIRADS), and American Thyroid Association (ATA) guidelines. A Chi-squared test and receiver operating curve (ROC) with 95% confidence intervals and P-value < 0.05 were performed to calculate sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), false negative and unnecessary biopsy rate. The unnecessary biopsy rate was defined as the percentage of benign nodules among total biopsy-required nodules. Results: A total of 200 patients were included in this study. Patients aged from 23 to 74 years including 36 males and 164 females. The female/male ratio was 4.5:1. Female predominance was seen among most of the age groups. The cohort showed 26 (13%) malignant nodules and 174 (87%) benign nodules. A solid component was observed in the majority of malignant nodules (61.6%, P = 0.0376) and mixed component was observed in the majority of benign nodules (51.7%, P = 0.0376). There was no statistically significant difference in differentiating benign from malignant nodule with the echogenicity or orientation of the nodule. The statistically significant features of a benign nodule were spongiform appearance, no echogenic foci or comet tail and absence of peripheral halo (P < 0.03). The statistically significant features of a malignant nodule were a solid, peripheral halo, peripheral or punctate echogenic foci, microcalcification, and macrocalcification (P < 0.001). The ACR-TIRADS showed the highest specificity (40.23% (95% confidence interval (CI) 32 - 47)), PPV (18.75 (95% CI 0.12 - 0.26)), NPV (97.22 (95% CI 0.90 - 0.99)) and area under the curve (AUC) (0.6627 (95% CI 0.59 - 0.72)). This was closely followed by ATA which demonstrated the PPV of 17.39 (95% CI 0.11 - 0.24), NPV of 96.77 (95% CI 0.89 - 0.99) and AUC of 0.6340 (95% CI 0.57 - 0.69). The K-TIRADS has the highest sensitivity (96.15% (95% CI 80 - 99)). Lowest unnecessary biopsy rates were found with ACR-TIRADS (104 (52%) (P = 0.0013)) and KSThR guidelines (114 (57%) (P = 0.0059)) and highest with K-TIRADS (160 (80%) (P = 0.4482)). Conclusion: We found that diagnostic performance of ACR and ATA guidelines is higher and is a practical method for assessing thyroid nodules in routine practice. Both these guidelines can avoid unnecessary biopsies in a significant proportion of benign thyroid lesions. ACR-TIRADS is also very specific in identifying malignant lesions. The increased sensitivity of K-TIRADS is likely due to their lower size threshold. J Endocrinol Metab. 2021;11(3-4):69-75 doi: https://doi.org/10.14740/jem735