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Papazoglou AS, Leite AR, Moysidis DV, Anastasiou V, Daios S, Borges-Canha M, Giannopoulos G, Neves JS, Ziakas A, Giannakoulas G. Serum Prolactin Levels and Mortality in Adults Without Prolactinoma: A Meta-Analysis. J Clin Endocrinol Metab 2024; 109:e1652-e1664. [PMID: 38366650 DOI: 10.1210/clinem/dgae087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 01/17/2024] [Accepted: 02/12/2024] [Indexed: 02/18/2024]
Abstract
CONTEXT Prolactin (PRL) is a highly versatile, multifunctional hormone synthesized and secreted by lactotroph cells of the anterior pituitary. Its metabolic role has been extensively studied even in normoprolactinemic populations. Recently, a wealth of observational data have outlined the potential prognostic value of PRL in various clinical settings. OBJECTIVE This systematic review aims to systematically evaluate and quantitatively synthesize the association between serum PRL levels and risk of mortality in adults without prolactinoma. METHODS A systematic literature search was conducted up to June 10, 2023, to identify studies reporting the association of serum PRL levels with clinical outcomes of adults without prolactinoma. A random-effects meta-analysis was conducted to quantify the adjusted hazard ratios [(a)HRs] for all-cause and cardiovascular death (CVD) during follow-up. RESULTS Twenty-eight studies were deemed eligible reporting the outcomes of adults without prolactinoma, in whom serum PRL levels were measured for risk-stratification. Fourteen studies reported appropriate data for meta-analysis encompassing a total of 23 596 individuals. Each unit of PRL increase was independently associated with increased risk of all-cause (pooled aHR = 1.17 [1.08-1.27]; I2 = 48%) and CV mortality (pooled aHR = 1.54 [1.14-2.09]; I2 = 89%). Individuals belonging to the highest PRL category had significantly higher risk for all-cause (pooled aHR = 1.81 [1.43-2.30]; I2 = 65%) and CV (pooled aHR = 1.59 [1.04-2.42]; I2 = 82%) mortality compared to their lowest-PRL category counterparts. The association between PRL levels and in-hospital death did not reach statistical significance. CONCLUSION PRL levels seem to be an independent predictor for mortality. Further validation is warranted before its role as a risk-stratification tool can be delineated in clinical practice.
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Affiliation(s)
| | - Ana Rita Leite
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário de São João, Alameda Hernâni Monteiro, 4200-319, Porto, Portugal
- Department of Surgery and Physiology, Faculty of Medicine of University of Porto, Unit of Cardiovascular Research and Development-Unic@RISE, Alameda Hernâni Monteiro, 4200-319, Porto, Portugal
| | | | - Vasileios Anastasiou
- First Cardiology Department, AHEPA University Hospital of Thessaloniki, Thessaloniki 54636, Greece
| | - Stylianos Daios
- First Cardiology Department, AHEPA University Hospital of Thessaloniki, Thessaloniki 54636, Greece
| | - Marta Borges-Canha
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário de São João, Alameda Hernâni Monteiro, 4200-319, Porto, Portugal
- Department of Surgery and Physiology, Faculty of Medicine of University of Porto, Unit of Cardiovascular Research and Development-Unic@RISE, Alameda Hernâni Monteiro, 4200-319, Porto, Portugal
| | - Georgios Giannopoulos
- Second Cardiology Department, Ippokrateion University Hospital of Thessaloniki, Thessaloniki 54642, Greece
| | - João Sérgio Neves
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário de São João, Alameda Hernâni Monteiro, 4200-319, Porto, Portugal
- Department of Surgery and Physiology, Faculty of Medicine of University of Porto, Unit of Cardiovascular Research and Development-Unic@RISE, Alameda Hernâni Monteiro, 4200-319, Porto, Portugal
| | - Antonios Ziakas
- First Cardiology Department, AHEPA University Hospital of Thessaloniki, Thessaloniki 54636, Greece
| | - George Giannakoulas
- First Cardiology Department, AHEPA University Hospital of Thessaloniki, Thessaloniki 54636, Greece
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Min SY, Yong HJ, Kim D. Sex or gender differences in treatment outcomes of sepsis and septic shock. Acute Crit Care 2024; 39:207-213. [PMID: 38863351 PMCID: PMC11167424 DOI: 10.4266/acc.2024.00591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 04/12/2024] [Accepted: 04/12/2024] [Indexed: 06/13/2024] Open
Abstract
Gender disparities in intensive care unit (ICU) treatment approaches and outcomes are evident. However, clinicians often pay little attention to the importance of biological sex and sociocultural gender in their treatment courses. Previous studies have reported that differences between sexes or genders can significantly affect the manifestation of diseases, diagnosis, clinicians' treatment decisions, scope of treatment, and treatment outcomes in the intensive care field. In addition, numerous reports have suggested that immunomodulatory effects of sex hormones and differences in gene expression from X chromosomes between genders might play a significant role in treatment outcomes of various diseases. However, results from clinical studies are conflicting. Recently, the need for customized treatment based on physical, physiological, and genetic differences between females and males and sociocultural characteristics of society have been increasingly emphasized. However, interest in and research into this field are remarkably lacking in Asian countries, including South Korea. Through this review, we hope to enhance our awareness of the importance of sex and gender in intensive care treatment and research by briefly summarizing several principal issues, mainly focusing on sex and sex hormone-based outcomes in patients admitted to the ICU with sepsis and septic shock.
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Affiliation(s)
- Seung Yeon Min
- Department of Internal Medicine, Dankook University Hospital, Cheonan, Korea
| | - Ho Jin Yong
- Department of Internal Medicine, Dankook University Hospital, Cheonan, Korea
| | - Dohhyung Kim
- Division of Pulmonary Medicine and Allergy, Department of Internal Medicine, Dankook University Hospital, Dankook University College of Medicine, Cheonan, Korea
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Taylor R, Zhang C, George D, Kotecha S, Abdelghaffar M, Forster T, Santos Rodrigues PD, Reisinger AC, White D, Hamilton F, Watkins WJ, Griffith DM, Ghazal P. Low circulatory levels of total cholesterol, HDL-C and LDL-C are associated with death of patients with sepsis and critical illness: systematic review, meta-analysis, and perspective of observational studies. EBioMedicine 2024; 100:104981. [PMID: 38290288 PMCID: PMC10844818 DOI: 10.1016/j.ebiom.2024.104981] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 01/10/2024] [Accepted: 01/11/2024] [Indexed: 02/01/2024] Open
Abstract
BACKGROUND Mechanistic studies have established a biological role of sterol metabolism in infection and immunity with clinical data linking deranged cholesterol metabolism during sepsis with poorer outcomes. In this systematic review we assess the relationship between biomarkers of cholesterol homeostasis and mortality in critical illness. METHODS We identified articles by searching a total of seven electronic databases from inception to October 2023. Prospective observational cohort studies included those subjects who had systemic cholesterol (Total Cholesterol (TC), HDL-C or LDL-C) levels assessed on the first day of ICU admission and short-term mortality recorded. Meta-analysis and meta-regression were used to evaluate overall mean differences in serum cholesterol levels between survivors and non-survivors. Study quality was assessed using the Newcastle-Ottawa Scale. FINDINGS From 6469 studies identified by searches, 24 studies with 2542 participants were included in meta-analysis. Non-survivors had distinctly lower HDL-C at ICU admission -7.06 mg/dL (95% CI -9.21 to -4.91, p < 0.0001) in comparison with survivors. Corresponding differences were also seen less robustly for TC -21.86 mg/dL (95% CI -31.23 to -12.49, p < 0.0001) and LDL-C -8.79 mg/dL (95% CI, -13.74 to -3.83, p = 0.0005). INTERPRETATION Systemic cholesterol levels (TC, HDL-C and LDL-C) on admission to critical care are inversely related to mortality. This finding is consistent with the notion that inflammatory and metabolic setpoints are coupled, such that the maladaptive-setpoint changes of cholesterol in critical illness are related to underlying inflammatory processes. We highlight the potential of HDL-biomarkers as early predictors of severity of illness and emphasise that future research should consider the metabolic and functional heterogeneity of HDLs. FUNDING EU-ERDF-Welsh Government Ser Cymru programme, BBSRC, and EU-FP7 ClouDx-i project (PG).
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Affiliation(s)
- Rory Taylor
- Deanery of Biomedical Sciences, University of Edinburgh Medical School, Edinburgh, UK.
| | - Chengyuan Zhang
- Department of Anaesthesia, Critical Care and Pain Medicine, NHS Lothian, Edinburgh, UK
| | - Deslit George
- School of Medicine, University of Cardiff, Cardiff, UK
| | - Sarah Kotecha
- Department of Child Health, School of Medicine, University of Cardiff, Cardiff, UK
| | | | | | | | - Alexander C Reisinger
- Department of Internal Medicine, Intensive Care Unit, Medical University of Graz, Graz, Austria
| | - Daniel White
- Project Sepsis, Systems Immunity Research Institute, School of Medicine, University of Cardiff, Cardiff, UK
| | - Fergus Hamilton
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK
| | - W John Watkins
- Dept of Immunity and Infection, School of Medicine, Cardiff University, Cardiff, UK
| | - David M Griffith
- Anaesthesia, Critical Care and Pain, Molecular, Genetics, and Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Peter Ghazal
- Project Sepsis, Systems Immunity Research Institute, School of Medicine, University of Cardiff, Cardiff, UK.
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Shields CA, Wang X, Cornelius DC. Sex differences in cardiovascular response to sepsis. Am J Physiol Cell Physiol 2023; 324:C458-C466. [PMID: 36571442 PMCID: PMC9902216 DOI: 10.1152/ajpcell.00134.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 12/20/2022] [Accepted: 12/20/2022] [Indexed: 12/27/2022]
Abstract
Recently, there has been increased recognition of the importance of sex as a biological factor affecting disease and health. Many preclinical studies have suggested that males may experience a less favorable outcome in response to sepsis than females. The underlying mechanisms for these differences are still largely unknown but are thought to be related to the beneficial effects of estrogen. Furthermore, the immunosuppressive role of testosterone is also thought to contribute to the sex-dependent differences that are present in clinical sepsis. There are still significant knowledge gaps in this field. This mini-review will provide a brief overview of sex-dependent variables in relation to sepsis and the cardiovascular system. Preclinical animal models for sepsis research will also be discussed. The intent of this mini-review is to inspire interest for future considerations of sex-related variables in sepsis that should be addressed to increase our understanding of the underlying mechanisms in sepsis-induced cardiovascular dysfunction for the identification of therapeutic targets and improved sepsis management and treatment.
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Affiliation(s)
- Corbin A Shields
- Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, Mississippi
| | - Xi Wang
- Department of Pharmacology and Toxicology, University of Mississippi Medical Center, Jackson, Mississippi
| | - Denise C Cornelius
- Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, Mississippi
- Department of Pharmacology and Toxicology, University of Mississippi Medical Center, Jackson, Mississippi
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Gokalp C, Ilgen U, Otman E, Dogan F, Bozkurt D, Bacakoglu F, Gurgun C, Ozgen AG, Duman S. Serum estradiol level predicts acute kidney injury in medical intensive care unit patients. Intern Emerg Med 2022; 17:2253-2260. [PMID: 36029396 DOI: 10.1007/s11739-022-03077-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 08/02/2022] [Indexed: 11/30/2022]
Abstract
Previous studies have shown that serum estradiol (E2) levels can predict mortality in intensive care unit patients. Our study investigated the predictive role of admission estradiol level on patient mortality and development of acute kidney injury in medical intensive care unit patients with a wide range of diagnoses. We conducted a prospective cohort study using serum samples from hospitalized patients in medical, cardiac, and pulmonary intensive care units at the Ege University Hospital within 6 months. Serum estradiol levels from 118 adult patients were collected within 48 h of hospitalization. Receiver operating curves and multiple logistic regression analyses were performed to investigate its relationship with acute kidney injury development and mortality. Serum estradiol levels were significantly higher in non-survivor patients than in survivor patients [85 (19-560) pg/mL vs. 32 (3-262) pg/mL, p < 0.001]. Admission estradiol levels were significantly higher in patients with AKI on admission than in patients with chronic kidney disease (p = 0.002) and normal renal function (p = 0.017). Serum E2 levels were higher in patients with renal deterioration during follow-up than patients with stable renal functions [62 (11-560) pg/mL vs. 38 (3-456) pg/mL, p = 0.004]. An admission estradiol level of 52.5 pg/mL predicted follow-up renal deterioration with 63% sensitivity and 74% specificity. A combined (APACHE II-E) score using APACHE II and serum estradiol level predicted overall mortality with 66% sensitivity and 82% specificity. Admission estradiol level is a good marker to predict the development of acute kidney injury and mortality in medical intensive care unit patients.
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Affiliation(s)
- Cenk Gokalp
- Department of Nephrology, Faculty of Medicine, Izmir University of Economics, Medicalpoint Hospital, Imbatli Mahallesi, 35575, Izmir, Turkey.
| | - Ufuk Ilgen
- Department of Rheumatology, Faculty of Medicine, Trakya University, Edirne, Turkey
| | - Eda Otman
- Department of Internal Medicine, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Fulya Dogan
- Department of Internal Medicine, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Devrim Bozkurt
- Department of Internal Medicine, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Feza Bacakoglu
- Department of Pulmonary Diseases, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Cemil Gurgun
- Department of Cardiology, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Ahmet Gokhan Ozgen
- Department of Endocrinology and Metabolism, Faculty of Medicine, Izmir, Turkey
| | - Soner Duman
- Department of Nephrology, Faculty of Medicine, Izmir University of Economics, Medicalpoint Hospital, Imbatli Mahallesi, 35575, Izmir, Turkey
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Lang E, Abdou H, Edwards J, Patel N, Morrison JJ. State-of-the-Art Review: Sex Hormone Therapy in Trauma-Hemorrhage. Shock 2022; 57:317-326. [PMID: 34618728 DOI: 10.1097/shk.0000000000001871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Trauma-hemorrhage is the leading cause of prehospital and early in-hospital deaths, while also significantly contributing to the later development of multisystem organ dysfunction/failure and sepsis. Common and advanced resuscitative methods would potentially demonstrate benefits in the prehospital setting; however, they face a variety of barriers to application and implementation. Thus, a dialogue around a novel adjunct has arisen, sex hormone therapy. Proposed candidates include estradiol and its derivatives, metoclopramide hydrochloride/prolactin, dehydroepiandrosterone, and flutamide; with each having demonstrated a range of salutary effects in several animal model studies. Several retrospective analyses have observed a gender-based dimorphism in mortality following trauma-hemorrhage, thus suggesting that estrogens contribute to this pattern. Trauma-hemorrhage animal models have shown estrogens offer protective effects to the cardiovascular, pulmonary, hepatic, gastrointestinal, and immune systems. Additionally, a series of survival studies utilizing 17α-ethinylestradiol-3-sulfate, a potent, water-soluble synthetic estrogen, have demonstrated a significant survival benefit and beneficial effects on cardiovascular function. This review presents the findings of retrospective clinical studies, preclinical animal studies, and discusses how and why 17α-ethinylestradiol-3-sulfate should be considered for investigation within a prospective clinical trial.
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Affiliation(s)
- Eric Lang
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
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Saini SS, Shrivastav AK, Kumar J, Sundaram V, Mukhopadhyay K, Dutta S, Ray P, Kumar P. Predictors of Mortality in Neonatal Shock: A Retrospective Cohort Study. Shock 2022; 57:199-204. [PMID: 34798634 DOI: 10.1097/shk.0000000000001887] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To study the incidence, clinical profile, and predictors of mortality in neonatal shock. METHODS We enrolled consecutive inborn neonates, who developed shock during hospital stay (between January 1, 2018 to December 31, 2019) at a tertiary-care, research center of northern India. We retrieved the clinical data from our electronic database, case record files, nursing charts, and laboratory investigations from the hospital's Health Information System. Non-survivors were compared with survivors to identify independent predictors of mortality. RESULTS We had 3,271 neonatal admissions during the study period. We recorded 415 episodes of neonatal shock in 392 neonates [incidence 12.0% (95% confidence interval: 10.9%-13.2%)]. Of 415 episodes, 237 (57%) episodes were identified as septic shock, 67 (16%) episodes as cardiogenic shock, and six (1.4%) episodes as obstructive shock. Remaining 105 (25%) episodes were contributed by more than one etiology of shock. There were 242 non-survivors among 392 neonates with shock (case fatality rate: 62%). On univariate analysis, gestational age, birth weight, incidence of hyaline membrane disease, early-onset sepsis, Acinetobacter sepsis, and cardiogenic shock were significantly different between survivors and non-survivors. Female gender and small for gestational age (SGA) neonates showed a trend of significance. On multivariable regression analysis, we found gestational age, SGA neonates, female gender, and Acinetobacter sepsis to have an independent association with mortality. CONCLUSIONS Septic shock was the commonest cause of neonatal shock at our center. Neonatal shock had very high case fatality rate. Gestational age, SGA, female gender, and Acinetobacter sepsis independently predicted mortality in neonatal shock.
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Affiliation(s)
- Shiv Sajan Saini
- Division of Neonatology, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Amit Kumar Shrivastav
- Division of Neonatology, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Jogender Kumar
- Division of Neonatology, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Venkataseshan Sundaram
- Division of Neonatology, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kanya Mukhopadhyay
- Division of Neonatology, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sourabh Dutta
- Division of Neonatology, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pallab Ray
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Praveen Kumar
- Division of Neonatology, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Zettersten E, Jäderling G, Bell M, Larsson E. A cohort study investigating the occurrence of differences in care provided to men and women in an intensive care unit. Sci Rep 2021; 11:23396. [PMID: 34862443 PMCID: PMC8642468 DOI: 10.1038/s41598-021-02815-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 11/16/2021] [Indexed: 12/01/2022] Open
Abstract
It has been reported that there are differences in the care given within the intensive care unit (ICU) between men and women. The aim of this study is to investigate if any differences still exist between men and women regarding the level of intensive care provided, using prespecified intensive care items. This is a retrospective cohort study of 9017 ICU patients admitted to a university hospital between 2006 and 2016. Differences in use of mechanical ventilation, invasive monitoring, vasoactive treatment, inotropic treatment, echocardiography, renal replacement therapy and central venous catheters based on the sex of the patient were analysed using univariate and multivariable logistic regressions. Subgroup analyses were performed on patients diagnosed with sepsis, cardiac arrest and respiratory disease. Approximately one third of the patients were women. Overall, men received more mechanical ventilation, more dialysis and more vasoactive treatment. Among patients admitted with a respiratory disease, men were more likely to receive mechanical ventilation. Furthermore, men were more likely to receive levosimendan if admitted with cardiac arrest. We conclude that differences in the level of intensive care provided to men and women still exist.
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Affiliation(s)
- Erik Zettersten
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Stockholm, Sweden. .,Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden.
| | - Gabriella Jäderling
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Stockholm, Sweden.,Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - Max Bell
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Stockholm, Sweden.,Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - Emma Larsson
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Stockholm, Sweden.,Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
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9
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Zhou X, Zeng N, Liu P, Liu Z, Duan M. Sex Differences in In-hospital Mortality of Patients With Septic Shock: An Observational Study Based on Data Analysis From a Cover Sheet of Medical Records in Beijing. Front Med (Lausanne) 2021; 8:733410. [PMID: 34708054 PMCID: PMC8542919 DOI: 10.3389/fmed.2021.733410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 09/14/2021] [Indexed: 12/02/2022] Open
Abstract
Background: The goal of our study was to evaluate the association of sex and in-hospital mortality in patients with septic shock in Beijing, China. Materials and Methods: We analyzed 3,643 adult patients with septic shock from January 1, 2019, to Dec 31, 2019, in all secondary and tertiary hospitals in Beijing. Study data were retrospectively extracted from the Quality Control Center of Beijing Municipal Health Commission. Results: There were 2,345 (64.37%) male and 1,298 (35.63%) female patients. Compared to male patients, female patients with septic shock had a higher in-hospital mortality rate (55.54 vs. 49.29%, p < 0.01). The median length of hospitalization stay for male patients was 22.71 days, while that for female patients was 19.72 days (p > 0.01). Male patients had a higher prevalence of pulmonary infection (68.8 vs. 31.2%, p < 0.01). The B values of sex in univariate and multivariate logistic regression were −0.251 and −0.312, respectively. Men had a lower likelihood of hospital mortality than women (OR = 0.732, 95% CI = 0.635–0.844, p = 0.000). Conclusions: Female patients with septic shock had a higher risk of dying in the hospital than male patients.
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Affiliation(s)
- Xiao Zhou
- Department of Critical Care Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Na Zeng
- Clinical Epidemiology and EBM Unit, National Clinical Research Center for Digestive Disease, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Pei Liu
- Department of Critical Care Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Zhuang Liu
- Department of Critical Care Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Meili Duan
- Department of Critical Care Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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10
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Zhang MQ, Macala KF, Fox-Robichaud A, Mendelson AA, Lalu MM. Sex- and Gender-Dependent Differences in Clinical and Preclinical Sepsis. Shock 2021; 56:178-187. [PMID: 33399356 DOI: 10.1097/shk.0000000000001717] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT In this mini-review we provide an overview of sex- and gender-dependent issues in both clinical and preclinical sepsis. The increasing recognition for the need to account for sex and gender in biomedical research brings a unique set of challenges and requires researchers to adopt best practices when conducting and communicating sex- and gender-based research. This may be of particular importance in sepsis, given the potential contribution of sex bias in the failures of translational sepsis research in adults and neonates. Clinical evidence of sex-dependent differences in sepsis is equivocal. Since clinical studies are limited to observational data and confounded by a multitude of factors, preclinical studies provide a unique opportunity to investigate sex differences in a controlled, experimental environment. Numerous preclinical studies have suggested that females may experience favorable outcomes in comparison with males. The underlying mechanistic evidence for sex-dependent differences in sepsis and other models of shock (e.g., trauma-hemorrhage) largely centers around the beneficial effects of estrogen. Other mechanisms such as the immunosuppressive role of testosterone and X-linked mosaicism are also thought to contribute to observed sex- and gender-dependent differences in sepsis. Significant knowledge gaps still exist in this field. Future investigations can address these gaps through careful consideration of sex and gender in clinical studies, and the use of clinically accurate preclinical models that reflect sex differences. A better understanding of sex-and gender-dependent differences may serve to increase translational research success.
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Affiliation(s)
- Meng Qi Zhang
- Clinical Epidemiology Program, Blueprint Translational Group, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada K1H 8M5
| | - Kimberly F Macala
- Departments of Critical Care Medicine and Anesthesiology and Pain Medicine, Royal Alexandra Hospital, University of Alberta, Edmonton, AB, Canada
| | - Alison Fox-Robichaud
- Department of Medicine and Thrombosis and Atherosclerosis Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Asher A Mendelson
- Section of Critical Care Medicine, Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Manoj M Lalu
- Clinical Epidemiology Program, Blueprint Translational Group, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, ON, Canada
- Regenerative Medicine Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
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11
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Salonia A, Pontillo M, Capogrosso P, Gregori S, Tassara M, Boeri L, Carenzi C, Abbate C, Cignoli D, Ferrara AM, Cazzaniga W, Rowe I, Ramirez GA, Tresoldi C, Mushtaq J, Locatelli M, Santoleri L, Castagna A, Zangrillo A, De Cobelli F, Tresoldi M, Landoni G, Rovere-Querini P, Ciceri F, Montorsi F. Severely low testosterone in males with COVID-19: A case-control study. Andrology 2021; 9:1043-1052. [PMID: 33635589 PMCID: PMC8013327 DOI: 10.1111/andr.12993] [Citation(s) in RCA: 96] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 02/14/2021] [Accepted: 02/23/2021] [Indexed: 12/16/2022]
Abstract
Background Circulating androgens could have a relevant pathobiological role in clinical outcomes in men with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection (COVID‐19). Objectives We aimed to assess: (a) circulating sex steroids levels in a cohort of 286 symptomatic men with laboratory‐confirmed COVID‐19 at hospital admission compared to a cohort of 281 healthy men; and (b) the association between serum testosterone levels (tT), COVID‐19, and clinical outcomes. Materials and Methods Demographic, clinical, and hormonal values were collected for all patients. Hypogonadism was defined as tT ≤9.2 nmol/l. The Charlson Comorbidity Index (CCI) was used to score health‐significant comorbidities. Severe clinical outcomes were defined as patients either transferred to intensive care unit (ICU) or death. Descriptive statistics and multivariable linear and logistic regression models tested the association between clinical and laboratory variables and tT levels. Univariable and multivariable logistic regression models tested the association between tT and severe clinical outcomes. Results Overall, a significantly lower levels of LH and tT were found in patients with COVID‐19 compared to healthy controls (all p < 0.0001); conversely, healthy controls depicted lower values of circulating E2 (p < 0.001). Testosterone levels suggestive for hypogonadism were observed in 257 (89.8%) patients at hospital admission. In as many as 243 (85%) cases, hypogonadism was secondary. SARS‐CoV‐2 infection status was independently associated with lower tT levels (p < 0.0001) and greater risk of hypogonadism (p < 0.0001), after accounting for age, BMI, CCI, and IL‐6 values. Lower tT levels were associated with higher risk of ICU admission and death outcomes (all p ≤ 0.05), after accounting for clinical and laboratory parameters. Conclusions We unveil an independent association between SARS‐CoV‐2 infection status and secondary hypogonadism already at hospital admission, with lower testosterone levels predicting the most severe clinical outcomes.
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Affiliation(s)
- Andrea Salonia
- Division of Experimental Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy.,University Vita-Salute San Raffaele, Milan, Italy
| | - Marina Pontillo
- Laboratory Medicine Service, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Paolo Capogrosso
- Division of Experimental Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy.,Department of Urology and Andrology, Ospedale di Circolo and Macchi Foundation, Varese, Italy
| | - Silvia Gregori
- San Raffaele Telethon Institute for Gene Therapy (SR-TIGET, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Michela Tassara
- Immunohematology and Transfusion Medicine, IRRCS Ospedale San Raffaele, Milan, Italy
| | - Luca Boeri
- Division of Experimental Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy.,Department of Urology, IRCCS Foundation Ca' Granda, Maggiore Policlinico Hospital, University of Milan, Milan, Italy
| | - Cristina Carenzi
- Division of Experimental Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Costantino Abbate
- Division of Experimental Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Daniele Cignoli
- Division of Experimental Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy.,University Vita-Salute San Raffaele, Milan, Italy
| | - Anna Maria Ferrara
- Division of Experimental Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Walter Cazzaniga
- Division of Experimental Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy.,University Vita-Salute San Raffaele, Milan, Italy
| | - Isaline Rowe
- Division of Experimental Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Giuseppe A Ramirez
- University Vita-Salute San Raffaele, Milan, Italy.,Immunology, Rheumatology, Allergology and Rare Diseases Unit, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Cristina Tresoldi
- Molecular Hematology Unit, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Junaid Mushtaq
- University Vita-Salute San Raffaele, Milan, Italy.,Department of Radiology, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Massimo Locatelli
- Laboratory Medicine Service, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Luca Santoleri
- Immunohematology and Transfusion Medicine, IRRCS Ospedale San Raffaele, Milan, Italy
| | - Antonella Castagna
- University Vita-Salute San Raffaele, Milan, Italy.,Department of Infectious Diseases, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Alberto Zangrillo
- University Vita-Salute San Raffaele, Milan, Italy.,Anesthesia and Intensive Care Department, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Francesco De Cobelli
- University Vita-Salute San Raffaele, Milan, Italy.,Department of Radiology, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Moreno Tresoldi
- General Medicine and Advanced Care Unit, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Giovanni Landoni
- University Vita-Salute San Raffaele, Milan, Italy.,Anesthesia and Intensive Care Department, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Patrizia Rovere-Querini
- University Vita-Salute San Raffaele, Milan, Italy.,Internal Medicine, Diabetes, and Endocrinology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fabio Ciceri
- University Vita-Salute San Raffaele, Milan, Italy.,Hematology and Bone Marrow Transplant Unit, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Francesco Montorsi
- Division of Experimental Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy.,University Vita-Salute San Raffaele, Milan, Italy
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12
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Lin S, He W, Hu Z, Bai L, Zeng M. Sex Differences in Short- and Long-Term Survival Among Critically Ill Patients with Sepsis. Int J Gen Med 2021; 14:613-622. [PMID: 33658834 PMCID: PMC7920582 DOI: 10.2147/ijgm.s294229] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 02/02/2021] [Indexed: 12/29/2022] Open
Abstract
Background Currently, there have been studies showing a correlation between sex differences and prognosis. Nevertheless, the conclusions of clinical studies on sex-based differences are controversial. We aimed to evaluate the effect of sex on the short- and long-term survival of critically ill patients with sepsis. Methods We use the critical care database of the healthcare information mart. Cox models were conducted to determine the relationship of 28-day and 1-year mortality with a different sex. Interaction and stratified analyses were conducted to test whether the effect of sex differed across age and sequential organ failure assessment (SOFA) score subgroups. Results A total of 12,321 patients were enrolled in this study. The Cox regression analysis showed that the 28-day and 1-year mortality rates of female patients were significantly lower than those of male patients by 10% and 8%, respectively (hazard ratio [HR]=0.90, 95% confidence interval [CI] 0.83–0.98, and HR=0.92, 95% CI 0.87–0.97, respectively). The effects of the association between sex and 28-day and 1-year mortality were broadly consistent for age and the SOFA subgroup variables. Only age was observed to have significant interactions in the 1-year mortality (P=0.0177). Compared with male patients, female patients aged <50 years had a long-term survival advantage (HR=0.77, 95% CI 0.62–0.95). In contrast, we did not find sex-based differences in the short- and long-term survival for patients aged ≥50 years. Conclusion In the current retrospective large database review, the 28-day and 1-year mortality were significantly lower in females than in male patients among critically ill patients with sepsis. Notably, there was an interaction between age and sex, and whether female-associated hormones or other contributing factors affect the clinical outcomes of patients with sepsis needs to be further researched.
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Affiliation(s)
- Shan Lin
- Department of Medical Intensive Care Unit, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, People's Republic of China
| | - Wanmei He
- Department of Medical Intensive Care Unit, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, People's Republic of China
| | - Zixuan Hu
- Department of Medical Intensive Care Unit, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, People's Republic of China
| | - Lihong Bai
- Department of Medical Intensive Care Unit, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, People's Republic of China
| | - Mian Zeng
- Department of Medical Intensive Care Unit, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, People's Republic of China
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13
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Kövesdi E, Szabó-Meleg E, Abrahám IM. The Role of Estradiol in Traumatic Brain Injury: Mechanism and Treatment Potential. Int J Mol Sci 2020; 22:E11. [PMID: 33374952 PMCID: PMC7792596 DOI: 10.3390/ijms22010011] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 12/15/2020] [Accepted: 12/18/2020] [Indexed: 01/02/2023] Open
Abstract
Patients surviving traumatic brain injury (TBI) face numerous neurological and neuropsychological problems significantly affecting their quality of life. Extensive studies over the past decades have investigated pharmacological treatment options in different animal models, targeting various pathological consequences of TBI. Sex and gender are known to influence the outcome of TBI in animal models and in patients, respectively. Apart from its well-known effects on reproduction, 17β-estradiol (E2) has a neuroprotective role in brain injury. Hence, in this review, we focus on the effect of E2 in TBI in humans and animals. First, we discuss the clinical classification and pathomechanism of TBI, the research in animal models, and the neuroprotective role of E2. Based on the results of animal studies and clinical trials, we discuss possible E2 targets from early to late events in the pathomechanism of TBI, including neuroinflammation and possible disturbances of the endocrine system. Finally, the potential relevance of selective estrogenic compounds in the treatment of TBI will be discussed.
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Affiliation(s)
- Erzsébet Kövesdi
- Molecular Neuroendocrinology Research Group, Institute of Physiology, Medical School, Center for Neuroscience, Szentágothai Research Center, University of Pécs, H-7624 Pecs, Hungary;
| | - Edina Szabó-Meleg
- Department of Biophysics, Medical School, University of Pécs, H-7624 Pecs, Hungary;
| | - István M. Abrahám
- Molecular Neuroendocrinology Research Group, Institute of Physiology, Medical School, Center for Neuroscience, Szentágothai Research Center, University of Pécs, H-7624 Pecs, Hungary;
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14
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Luethi N, Bailey M, Higgins A, Howe B, Peake S, Delaney A, Bellomo R. Gender differences in mortality and quality of life after septic shock: A post-hoc analysis of the ARISE study. J Crit Care 2019; 55:177-183. [PMID: 31739087 DOI: 10.1016/j.jcrc.2019.11.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 09/28/2019] [Accepted: 11/04/2019] [Indexed: 01/02/2023]
Abstract
PURPOSE To assess the impact of gender and pre-menopausal state on short- and long-term outcomes in patients with septic shock. MATERIAL AND METHODS Cohort study of the Australasian Resuscitation in Sepsis Evaluation (ARISE) trial, an international randomized controlled trial comparing early goal-directed therapy (EGDT) to usual care in patients with early septic shock, conducted between October 2008 and April 2014. The primary exposure in this analysis was legal gender and the secondary exposure was pre-menopausal state defined by chronological age (≤ 50 years). RESULTS 641 (40.3%) of all 1591 ARISE trial participants in the intention-to-treat population were females and overall, 337 (21.2%) (146 females) patients were 50 years of age or younger. After risk-adjustment, we could not identify any survival benefit for female patients at day 90 in the younger (≤50 years) (adjusted Odds Ratio (aOR): 0.91 (0.46-1.89), p = .85) nor in the older (>50 years) age-group (aOR: 1.10 (0.81-1.49), p = .56). Similarly, there was no gender-difference in ICU, hospital, 1-year mortality nor quality of life measures. CONCLUSIONS This post-hoc analysis of a large multi-center trial in early septic shock has shown no short- or long-term survival effect for women overall as well as in the pre-menopausal age-group.
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Affiliation(s)
- Nora Luethi
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Alisa Higgins
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Belinda Howe
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Sandra Peake
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Adelaide, Australia
| | - Anthony Delaney
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, Australia
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Department of Intensive Care, Austin Hospital, Heidelberg, Australia
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15
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Block L, Petzold M, Syrous AN, Lindqvist B, Odenstedt Hergès H, Naredi S. Age, SAPS 3 and female sex are associated with decisions to withdraw or withhold intensive care. Acta Anaesthesiol Scand 2019; 63:1210-1215. [PMID: 31190331 DOI: 10.1111/aas.13411] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 04/05/2019] [Accepted: 05/16/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Intensive care treat critically ill patients. When intensive care is not considered beneficial for the patient, decisions to withdraw or withhold treatments are made. We aimed to identify independent patient variables that increase the odds for receiving a decision to withdraw or withhold intensive care. METHODS Registry study using data from the Swedish Intensive Care Registry (SIR) 2014-2016. Age, condition at admission, including co-morbidities (Simplified Acute Physiology Score version 3, SAPS 3), diagnosis, sex, and decisions on treatment limitations were extracted. Patient data were divided into a full care (FC) group, and a withhold or withdraw (WW) treatment group. RESULTS Of all 97 095 cases, 47.1% were 61-80 years old, 41.9% were women and 58.1% men. 14 996 (15.4%) were allocated to the WW group and 82 149 (84.6%) to the FC group. The WW group, compared with the FC group, was older (P < 0.001), had higher SAPS 3 (P < 0.001) and were predominantly female (P < 0.001). Compared to patients 16-20 years old, patients >81 years old had 11 times higher odds of being allocated to the WW group. Higher SAPS 3 (continuous) increased the odds of being allocated to the WW group by odds ratio [OR] 1.085, (CI 1.084-1.087). Female sex increased the odds of being allocated to the WW group by 18% (1.18; CI 1.13- 1.23). CONCLUSION Older age, higher SAPS 3 at admission and female sex were found to be independent variables that increased the odds to receive a decision to withdraw or withhold intensive care.
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Affiliation(s)
- Linda Block
- Department of Anesthesiology and Intensive Care, Institute of Clinical Sciences Sahlgrenska Academy, University of Gothenburg Gothenburg Sweden
- Department of Anesthesiology and Intensive Care Sahlgrenska University Hospital Gothenburg Sweden
| | - Max Petzold
- Department of Public Health and Community Medicine, Institute of Medicine Sahlgrenska Academy, University of Gothenburg Gothenburg Sweden
| | - Alma Nordenskjöld Syrous
- Department of Anesthesiology and Intensive Care, Institute of Clinical Sciences Sahlgrenska Academy, University of Gothenburg Gothenburg Sweden
- Department of Anesthesiology and Intensive Care Sahlgrenska University Hospital Gothenburg Sweden
| | - Birgitta Lindqvist
- Department of Anesthesiology and Intensive Care Northern Älvsborgs Hospital, Region Västra Götaland Trollhättan Sweden
| | - Helena Odenstedt Hergès
- Department of Anesthesiology and Intensive Care, Institute of Clinical Sciences Sahlgrenska Academy, University of Gothenburg Gothenburg Sweden
- Department of Anesthesiology and Intensive Care Sahlgrenska University Hospital Gothenburg Sweden
| | - Silvana Naredi
- Department of Anesthesiology and Intensive Care, Institute of Clinical Sciences Sahlgrenska Academy, University of Gothenburg Gothenburg Sweden
- Department of Anesthesiology and Intensive Care Sahlgrenska University Hospital Gothenburg Sweden
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16
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Pape M, Giannakópoulos GF, Zuidema WP, de Lange-Klerk ESM, Toor EJ, Edwards MJR, Verhofstad MHJ, Tromp TN, van Lieshout EMM, Bloemers FW, Geeraedts LMG. Is there an association between female gender and outcome in severe trauma? A multi-center analysis in the Netherlands. Scand J Trauma Resusc Emerg Med 2019; 27:16. [PMID: 30760289 PMCID: PMC6373135 DOI: 10.1186/s13049-019-0589-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 01/14/2019] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Little evidence suggest that female gender is associated with a lower risk of mortality in severely injured patients, especially in premenopausal women. Previous clinical studies have shown contradictory results regarding protective effects of gender on outcome after severe trauma. The objective of this study was to determine the association between gender and outcome (mortality and Intensive Care Unit (ICU) admission) among severely injured patients in the Netherlands. METHODS A retrospective multicentre study was performed including all polytrauma patients (Injury Severity Score (ISS) ≥16) admitted to the ED of three level 1 trauma centres, between January 1st, 2006 and December 31st, 2014. Data on age, gender, mechanism of injury, ISS, Abbreviated Injury Scale (AIS), prehospital intubation, Revised Trauma Score (RTS), systolic blood pressure (SBP) and Glasgow Coma Scale (GCS) upon admission at the Emergency Department was collected from three Regional Trauma Registries. To determine whether gender was an independent predictor of mortality and ICU admission, logistic regression analysis was performed. RESULTS Among 6865 trauma patients, male patients had a significantly higher ISS compared to female patients (26.3 ± 10.2 vs 25.3 ± 9.7, P = < 0.0001). Blunt trauma was significantly more common in the female group (95.2% vs 92.3%, P = < 0.0001). Males aged 16- to 44-years had a significant higher in-hospital mortality rate (10.4% vs 13.4%, P = 0.046). ICU admission rate was significantly lower in females (49.3% vs 54.5%, P = < 0.0001). In the overall group, logistic regression did not show gender as an independent predictor for in-hospital mortality (OR 1.020 (95% CI 0.865-1.204), P = 0.811) or mortality within 24 h (OR 1.049 (95% CI 0.829-1.327), P = 0.693). However, male gender was associated with an increased likelihood for ICU admission in the overall group (OR 1.205 (95% CI 1.046-1.388), P = 0.010). CONCLUSION The current study shows that in this population of severely injured patients, female sex is associated with a lower in-hospital mortality rate among those aged 16- to 44-years. Furthermore, female sex is independently associated with an overall decreased likelihood for ICU admission. More research is needed to examine the physiologic background of this protective effect of female sex in severe trauma.
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Affiliation(s)
- M. Pape
- Department of Trauma Surgery, VU University Medical Center, De Boelelaan 1117, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands
| | - G. F. Giannakópoulos
- Department of Trauma Surgery, VU University Medical Center, De Boelelaan 1117, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands
| | - W. P. Zuidema
- Department of Trauma Surgery, VU University Medical Center, De Boelelaan 1117, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands
| | - E. S. M. de Lange-Klerk
- Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, The Netherlands
| | - E. J. Toor
- Trauma Network North-West, VU University Medical Center, Amsterdam, The Netherlands
| | - M. J. R. Edwards
- Department of Trauma Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - M. H. J. Verhofstad
- Department of Trauma Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - T. N. Tromp
- Department of Trauma Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - E. M. M. van Lieshout
- Trauma Research Unit, Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - F. W. Bloemers
- Department of Trauma Surgery, VU University Medical Center, De Boelelaan 1117, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands
| | - L. M. G. Geeraedts
- Department of Trauma Surgery, VU University Medical Center, De Boelelaan 1117, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands
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17
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A Repeated Measures Pilot Comparison of Trajectories of Fluctuating Endogenous Hormones in Young Women with Traumatic Brain Injury, Healthy Controls. Behav Neurol 2019; 2019:7694503. [PMID: 30891100 PMCID: PMC6390250 DOI: 10.1155/2019/7694503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Revised: 11/20/2018] [Accepted: 12/20/2018] [Indexed: 12/20/2022] Open
Abstract
Objective To compare baseline and 72-hour hormone levels in women with traumatic brain injury (TBI) and controls. Setting Hospital emergency department. Participants 21 women ages 18-35 with TBI and 21 controls. Design Repeated measures. Main Measures Serum samples at baseline and 72 hours; immunoassays for estradiol (E2), progesterone (PRO), luteinizing hormone (LH), follicle-stimulating hormone (FSH), and cortisol (CORT); and health history. Results Women with TBI had lower E2 (p = 0.042) and higher CORT (p = 0.028) levels over time. Lower Glasgow Coma Scale (GSC) and OCs were associated with lower FSH (GCS p = 0.021; OCs p = 0.016) and higher CORT (GCS p = 0.001; OCs p = 0.008). Conclusion Acute TBI may suppress E2 and increase CORT in young women. OCs appeared to independently affect CORT and FSH responses. Future work is needed with a larger sample to characterize TBI effects on women's endogenous hormone response to injury and OC use's effects on post-TBI stress response and gonadal function, as well as secondary injury.
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18
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Lusczek ER, Myers C, Popovsky K, Mulier K, Beilman G, Sawyer R. Plasma metabolomics pilot study suggests age and sex-based differences in the metabolic response to traumatic injury. Injury 2018; 49:2178-2185. [PMID: 30266291 DOI: 10.1016/j.injury.2018.09.033] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 09/15/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Age and sex affect outcomes from trauma. Older patients tend to be under-triaged, consume more healthcare resources, and experience worse outcomes relative to younger patients. Sex has also been associated with different outcomes, with women experiencing better outcomes than men. While baseline metabolism differs with both age and sex, no study has examined how these differences affect the response to trauma. We used high-throughput metabolomics to assess metabolic differences associated with blunt trauma according to age and sex. METHODS Metabolic profiles were constructed using nuclear magnetic resonance spectroscopy for trauma patients age 21-40 years (n = 20, 55% male) and >65 years (n = 22, 41% male) from plasma samples obtained on Day 1 and Day 3 of each patient's hospital stay. These were compared to profiles constructed from plasma obtained from healthy controls of the same age (21-40: n = 23, 61% male; 65+: n = 26, 50% male). Differences in metabolic profiles were assessed with partial least squares discriminant analysis. RESULTS Trauma elicits an overwhelming global stress response that includes more subtle differences in metabolism related to age and gender. Significant differences due to normal aging were also identified. Many of the metabolites measured were present in similar levels in healthy controls age 65+ as they were in trauma patients of all ages. Sex-based differences in metabolism were observed in younger trauma patients on Day 3 but not in older patients. CONCLUSIONS Differences in energy metabolism and oxidative stress were implicated in the response to trauma in all patients. Older trauma patients may enter the trauma state with pre-existing oxidative stress and energy deficits that complicate recovery. Sex-based differences in recovery from trauma support the large body of work demonstrating the role of sex in recovery from trauma.
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Affiliation(s)
- Elizabeth R Lusczek
- University of Minnesota Department of Surgery, Minneapolis, MN 55455 United States.
| | - Cole Myers
- University of Minnesota Department of Surgery, Minneapolis, MN 55455 United States.
| | - Kimberly Popovsky
- University of Virginia Department of Surgery, Charlottesville, VA 22903 United States.
| | - Kristine Mulier
- University of Minnesota Department of Surgery, Minneapolis, MN 55455 United States.
| | - Greg Beilman
- University of Minnesota Department of Surgery, Minneapolis, MN 55455 United States.
| | - Robert Sawyer
- Western Michigan University School of Medicine, Department of Surgery, Kalamazoo, MI 49008 United States.
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19
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Rakholia MV, Kumar RG, Oh BM, Ranganathan PR, Berga SL, Kochanek PM, Wagner AK. Systemic Estrone Production and Injury-Induced Sex Hormone Steroidogenesis after Severe Traumatic Brain Injury: A Prognostic Indicator of Traumatic Brain Injury-Related Mortality. J Neurotrauma 2018; 36:1156-1167. [PMID: 29947289 DOI: 10.1089/neu.2018.5782] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Extensive pre-clinical studies suggest that sex steroids are neuroprotective in experimental traumatic brain injury (TBI). However, clinical trials involving sex hormone administration have not shown beneficial results, and our observational cohort studies show systemic estradiol (E2) production to be associated with adverse outcomes. Systemic E2 is produced via aromatization of testosterone (T) or reduction of estrone (E1). E1, also produced via aromatization of androstenedione (Andro) and is a marker of T-independent E2 production. We hypothesized that E1 would be (1) associated with TBI-related mortality, (2) the primary intermediate for E2 production, and (3) associated with adipose tissue-specific aromatase transcription. We assessed 100 subjects with severe TBI and 8 healthy controls. Serum levels were measured on days 0-3 post-TBI for key steroidogenic precursors (progesterone), aromatase pathway intermediates (E1, E2, T, Andro), and the adipose tissue-specific aromatase transcription factors cortisol, tumor necrosis factor-alpha (TNF-α), and interleukin-6 (IL-6). E1 was elevated after TBI versus controls. High E1 was associated with higher progesterone, cortisol, and IL-6 (p < 0.05). Multivariable logistic regression demonstrated that those in the highest E1 tertile had increased odds for mortality (adjusted OR = 5.656, 95% CI = 1.102-29.045, p = 0.038). Structural equation models show that early serum E2 production is largely T independent, occurring predominantly through E1 metabolism. Acute serum E1 functions as a mortality marker for TBI through aromatase-dependent E1 production and T-independent E2 production. Further work should evaluate risk factors for high E2 production and how systemic E2 and its key intermediate E1 contribute to the extracerebral consequences of severe TBI.
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Affiliation(s)
- Milap V Rakholia
- 1 Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh Pennsylvania
| | - Raj G Kumar
- 1 Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh Pennsylvania
| | - Byung-Mo Oh
- 2 Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Prerna R Ranganathan
- 1 Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh Pennsylvania
| | - Sarah L Berga
- 3 Department of Obstetrics and Gynecology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Patrick M Kochanek
- 4 Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh Pennsylvania.,5 Department of Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh Pennsylvania
| | - Amy K Wagner
- 1 Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh Pennsylvania.,5 Department of Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh Pennsylvania.,6 Department of Neuroscience, University of Pittsburgh, Pittsburgh Pennsylvania.,7 Department of Center for Neuroscience, University of Pittsburgh, Pittsburgh Pennsylvania
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20
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Sánchez-Hurtado LA, Lugo-Cob R, Tejeda-Huezo BC, Esquivel-Chávez A, Cano-Oviedo AA, Zamora-Varela S, Gomez-Flores SS, Arvizu-Tachiquin P, Baltazar-Torres JA. Serum Estradiol Level at Intensive Care Unit Admission and Mortality in Critically Ill Patients. Indian J Crit Care Med 2018. [PMID: 29531449 PMCID: PMC5842464 DOI: 10.4103/ijccm.ijccm_395_16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Context: It has been observed that sex hormones may play a role in inflammatory processes and mortality of critically ill patients. Aims: The aim was evaluated the relationship between serum estradiol level at Intensive Care Unit (ICU) admission and mortality of critically ill patients. Settings and Design: This study was a prospective cohort conducted in one mixed ICU. Subjects and Methods: In heterogeneous group of critically ill patients admitted to the ICU, we measured serum estradiol at admission time. Statistical Analysis Used: The discrimination to predict mortality of serum estradiol level was assessed by the receiver-operating curve (ROC) curve and its association with mortality by logistic regression analysis. Results: We included 131 patients, 57.3% of which were male. The serum estradiol level measured at ICU admission was significantly higher in nonsurvivors than in survivors: 116 versus 67.2 pg/mL, respectively (P < 0.0001). The area under the ROC of serum estradiol level to predict mortality was 0.74 (P < 0.0001). Serum estradiol level ≥97.9 pg/mL had sensitivity of 60%, specificity of 90%, positive predictive value of 64%, negative predictive value of 88%, positive likelihood ratio of 6, and negative likelihood ratio of 0.44, for predicting mortality. In multivariate analysis, it had relative risk of 6.47 (P = 0.002) for ICU mortality. Conclusions: The serum estradiol level is elevated in critically ill patients, regardless of gender, especially in those who die. It has good discriminative capacity to predict mortality, and it is an independent risk factor for death in this group of patients.
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Affiliation(s)
- Luis Alejandro Sánchez-Hurtado
- Department of Critical Care Medicine, UMAE Specialties Hospital "Dr. Antonio Fraga Mouret" National Medical Center "La Raza", Mexican Institute of Social Security (IMSS), Mexico City, México.,Department of Critical Care Medicine, Instituto Nacional de Cancerología, SSA, Mexico City, México
| | - Rolando Lugo-Cob
- Department of Critical Care Medicine, UMAE Cardiology Hospital No. 34 Mexican Institute of Social Security (IMSS), Monterrey, Nuevo León, México
| | - Brigette C Tejeda-Huezo
- Department of Critical Care Medicine, UMAE Specialties Hospital "Dr. Antonio Fraga Mouret" National Medical Center "La Raza", Mexican Institute of Social Security (IMSS), Mexico City, México
| | - Alejandro Esquivel-Chávez
- Department of Critical Care Medicine, UMAE Specialties Hospital "Dr. Antonio Fraga Mouret" National Medical Center "La Raza", Mexican Institute of Social Security (IMSS), Mexico City, México
| | - Abraham A Cano-Oviedo
- Department of Critical Care Medicine, UMAE Specialties Hospital "Dr. Antonio Fraga Mouret" National Medical Center "La Raza", Mexican Institute of Social Security (IMSS), Mexico City, México
| | - Sergio Zamora-Varela
- Department of Critical Care Medicine, UMAE Specialties Hospital "Dr. Antonio Fraga Mouret" National Medical Center "La Raza", Mexican Institute of Social Security (IMSS), Mexico City, México
| | - Saira S Gomez-Flores
- Department of Critical Care Medicine, UMAE Specialties Hospital "Dr. Antonio Fraga Mouret" National Medical Center "La Raza", Mexican Institute of Social Security (IMSS), Mexico City, México
| | - Perla Arvizu-Tachiquin
- Department of Critical Care Medicine, UMAE Specialties Hospital "Dr. Antonio Fraga Mouret" National Medical Center "La Raza", Mexican Institute of Social Security (IMSS), Mexico City, México
| | - José A Baltazar-Torres
- Department of Critical Care Medicine, UMAE Specialties Hospital "Dr. Antonio Fraga Mouret" National Medical Center "La Raza", Mexican Institute of Social Security (IMSS), Mexico City, México.,Department of Critical Care Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, México
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21
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Joachim R, Suber F, Kobzik L. Characterising Pre-pubertal Resistance to Death from Endotoxemia. Sci Rep 2017; 7:16541. [PMID: 29185479 PMCID: PMC5707402 DOI: 10.1038/s41598-017-16743-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 11/15/2017] [Indexed: 02/06/2023] Open
Abstract
Sepsis is a common and deadly syndrome in which a dysregulated host response to infection causes organ failure and death. The current lack of treatment options suggests that a new approach to studying sepsis is needed. Pre-pubertal children show a relative resistance to death from severe infections and sepsis. To explore this phenomenon experimentally, we used an endotoxemia model of sepsis in mice. Following intra-peritoneal injection of endotoxin, pre-pubertal mice showed greater survival than post-pubertal mice (76.3% vs. 28.6%), despite exhibiting a similar degree of inflammation after two hours. Age-associated differences in the inflammatory response only became evident at twenty hours, when post-pubertal mice showed prolonged elevation of serum cytokines and differential recruitment of peritoneal immune cells. Mechanistically, prevention of puberty by hormonal blockade or acceleration of puberty by oestrogen treatment led to increased or decreased survival from endotoxemia, respectively. Additionally, the adoptive transfer of pre-pubertal peritoneal cells improved the survival of post-pubertal recipient mice, while post-pubertal peritoneal cells or vehicle did not. These data establish a model for studying childhood resistance to mortality from endotoxemia, demonstrate that oestrogen is responsible for an increased susceptibility to mortality after puberty, and identify peritoneal cells as mediators of pre-pubertal resistance.
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Affiliation(s)
- Rose Joachim
- Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Freeman Suber
- Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Lester Kobzik
- Harvard T. H. Chan School of Public Health, Boston, MA, USA.
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22
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Vaikkakara S, Raj MN, Sachan A, Mohan A, Vengamma B, Rao PVLNS, Mukka A, Sravani C, Reddy AP. Impact of Severity of Illness on the Function of the Hypothalamo-pituitary-gonadal Axis in Postmenopausal Women with Acute Severe Illness: Implications for Predicting Disease Outcome. Indian J Endocrinol Metab 2017; 21:738-744. [PMID: 28989885 PMCID: PMC5628547 DOI: 10.4103/ijem.ijem_398_16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND While elevated levels of estradiol were predictive of mortality in critically ill surgical and trauma patients, their ability to predict outcome in nonsurgical patients has not been studied. We aimed to study the determinants of gonadotropin levels in acutely ill postmenopausal women with nonsurgical disease and the impact of changes in the gonadal axis on the outcome of these patients. METHODS Thirty-five postmenopausal women admitted to medical intensive care with acute severe illness and having a Simplified Acute Physiology Score (SAPS II score) ≥30 (in-hospital mortality rate ≥ 10%) were recruited. On the 5th day of hospitalization, fasting samples were collected at 8.00 am and tested for luteinizing hormone (LH), follicle-stimulating hormone (FSH), estradiol, free triiodothyronine, free thyroxine, thyrotropin, cortisol, prolactin, dehydroepiandrosterone, androstenedione, and sex hormone-binding globulin. Multiple linear regression analysis was performed to identify independent determinants if any of LH and FSH. Receiver operating characteristic (ROC) curves were drawn for different cutoffs of LH, FSH, and estradiol to diagnose mortality and prolonged hospitalization. RESULTS There was an independent negative association between the FSH and the SAPS II score (beta = -0.435; P = 0.014), but not with any of the other tested parameters (estradiol, prolactin, or cortisol). Among components of the SAPS II score, the total leukocyte count (TLC) was negatively associated with serum FSH (beta coefficient = -0.635, P = 0.013). None of these parameters were determinants of LH. On ROC analysis, neither estradiol nor gonadotropins were diagnostic for in-hospital mortality. However, among survivors, low estradiol was diagnostic for prolonged hospital stay (area under the curve = 0.785; P = 0.015). CONCLUSION FSH, but not LH, is negatively associated with the severity of illness, particularly to its inflammatory component (TLC). Low estradiol in survivors was a predictor of prolonged hospital stay.
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Affiliation(s)
- Suresh Vaikkakara
- Department of Endocrinology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
| | - Marella Neelima Raj
- Department of Pharmacy Practice, Sri Venkateswara College of Pharmacy, Chittoor, Nellore, Andhra Pradesh, India
| | - Alok Sachan
- Department of Endocrinology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
| | - Alladi Mohan
- Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
| | - Bhuma Vengamma
- Department of Neurology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
| | - P. V. L. N. Srinivas Rao
- Department of Biochemistry, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
| | - Arun Mukka
- Department of Endocrinology, Yashoda Hospitals, Hyderabad, Telangana, India
| | - Chiruvella Sravani
- Department of Endocrinology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
| | - Amaresh P. Reddy
- Department of Endocrinology, Narayana Medical College and Hospital, Nellore, Andhra Pradesh, India
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Endo S, Shimizu Y, Ikenaga M, Ohta K, Yamada T. Survival benefit of gastrectomy for gastric cancer in patients ≥85 years old: A retrospective propensity score-matched analysis. Surgery 2017; 161:984-994. [DOI: 10.1016/j.surg.2016.10.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 10/04/2016] [Accepted: 10/10/2016] [Indexed: 12/14/2022]
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Raj MN, Suresh V, Mukka A, Reddy A, Sachan A, Mohan A, Vengamma B, Rao PVLNS. Evaluation of activity of hypothalamo-pituitary-gonadal axis in postmenopausal women suffering from severe acute illness. Indian J Med Res 2017; 143:66-71. [PMID: 26997016 PMCID: PMC4822371 DOI: 10.4103/0971-5916.178596] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background & objectives: Postmenopausal women constitute an ideal model for studying the extent of hypothalamo-pituitary gonadal (HPG) axis suppression in critical illness as the gonadotropins are normally high and non-cyclical in them. The objective was to assess the impact of acute severe illness in postmenopausal women on the HPG axis and the activities of the hypothalamo-pituitary-adrenal (HPA), the hypothalamo- pituitary-thyroid (HPT) axes; and levels of serum prolactin, by comparison between critically ill postmenopausal women and otherwise healthy postmenopausal women. Methods: Thirty five consecutive postmenopausal women older than 60 yr admitted to medical intensive care with a Simplified Acute Physiology Score II (SAPS II) more than 30 were included. On day five of their in-hospital stay, blood samples were collected for oestradiol, luteinizing hormone (LH), follicle stimulating hormone (FSH), cortisol, androstenedione, prolactin and thyroid profile. Thirty five apparently healthy postmenopausal women were selected as controls. Results: Levels of LH, FSH, thyrotropin, free thyroxin (fT4) and free tri-iodothyronine (fT3) were lower while oestradiol, cortisol and dehydroepiandrosterone were higher among patients in comparison to healthy controls. Prolactin levels were similar in patients and controls. Among sick patients both FSH and fT4 showed a negative correlation (P<0.05) with the SAPS II score. Interpretation & conclusions: In critically ill postmenopausal women, paradoxically elevated oestrogen levels despite gonadotropin suppression suggests a non-ovarian origin. Prolactin remained unaltered in patients despite their illness, possibly reflecting atrophy of lactotrophs in menopause.
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Affiliation(s)
| | - V Suresh
- Department of Endocrinology, Sri Venkateswara Institute of Medical Sciences, Tirupati, India
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25
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Tsang G, Insel MB, Weis JM, Morgan MAM, Gough MS, Frasier LM, Mack CM, Doolin KP, Graves BT, Apostolakos MJ, Pietropaoli AP. Bioavailable estradiol concentrations are elevated and predict mortality in septic patients: a prospective cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:335. [PMID: 27765072 PMCID: PMC5073735 DOI: 10.1186/s13054-016-1525-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 10/06/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Experimental studies demonstrate beneficial immunological and hemodynamic effects of estradiol in animal models of sepsis. This raises the question whether estradiol contributes to sex differences in the incidence and outcomes of sepsis in humans. Yet, total estradiol levels are elevated in sepsis patients, particularly nonsurvivors. Bioavailable estradiol concentrations have not previously been reported in septic patients. The bioavailable estradiol concentration accounts for aberrations in estradiol carrier protein concentrations that could produce discrepancies between total and bioavailable estradiol levels. We hypothesized that bioavailable estradiol levels are low in septic patients and sepsis nonsurvivors. METHODS We conducted a combined case-control and prospective cohort study. Venous blood samples were obtained from 131 critically ill septic patients in the medical and surgical intensive care units at the University of Rochester Medical Center and 51 control subjects without acute illness. Serum bioavailable estradiol concentrations were calculated using measurements of total estradiol, sex hormone-binding globulin, and albumin. Comparisons were made between patients with severe sepsis and control subjects and between hospital survivors and nonsurvivors. Multivariable logistic regression analysis was also performed. RESULTS Bioavailable estradiol concentrations were significantly higher in sepsis patients than in control subjects (211 [78-675] pM vs. 100 [78-142] pM, p < 0.01) and in sepsis nonsurvivors than in survivors (312 [164-918] pM vs. 167 [70-566] pM, p = 0.04). After adjustment for age and comorbidities, patients with bioavailable estradiol levels above the median value had significantly higher risk of hospital mortality (OR 4.27, 95 % CI 1.65-11.06, p = 0.003). Bioavailable estradiol levels were directly correlated with severity of illness and did not differ between men and women. CONCLUSIONS Contrary to our hypothesis, bioavailable estradiol levels were elevated in sepsis patients, particularly nonsurvivors, and were independently associated with mortality. Whether estradiol's effects are harmful, beneficial, or neutral in septic patients remains unknown, but our findings raise caution about estradiol's therapeutic potential in this setting. Our findings do not provide an explanation for sex-based differences in sepsis incidence and outcomes.
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Affiliation(s)
- Greg Tsang
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY, 14642, USA
| | - Michael B Insel
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY, 14642, USA
| | - Justin M Weis
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY, 14642, USA
| | - Mary Anne M Morgan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY, 14642, USA
| | - Michael S Gough
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY, 14642, USA
| | - Lauren M Frasier
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY, 14642, USA
| | - Cynthia M Mack
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY, 14642, USA
| | - Kathleen P Doolin
- Department of Nursing, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY, 14642, USA
| | - Brian T Graves
- College of Nursing, University of South Florida, MDC22, 12901 Bruce B. Downs Boulevard, Tampa, FL, 33612, USA
| | - Michael J Apostolakos
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY, 14642, USA
| | - Anthony P Pietropaoli
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY, 14642, USA.
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Li G, Cook DJ, Thabane L, Friedrich JO, Crozier TM, Muscedere J, Granton J, Mehta S, Reynolds SC, Lopes RD, Lauzier F, Freitag AP, Levine MAH. Risk factors for mortality in patients admitted to intensive care units with pneumonia. Respir Res 2016; 17:80. [PMID: 27401184 PMCID: PMC4940754 DOI: 10.1186/s12931-016-0397-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Accepted: 07/05/2016] [Indexed: 02/02/2023] Open
Abstract
Background Despite the high mortality in patients with pneumonia admitted to an ICU, data on risk factors for death remain limited. Methods In this secondary analysis of PROTECT (Prophylaxis for Thromboembolism in Critical Care Trial), we focused on the patients admitted to ICU with a primary diagnosis of pneumonia. The primary outcome for this study was 90-day hospital mortality and the secondary outcome was 90-day ICU mortality. Cox regression model was conducted to examine the relationship between baseline and time-dependent variables and hospital and ICU mortality. Results Six hundred sixty seven patients admitted with pneumonia (43.8 % females) were included in our analysis, with a mean age of 60.7 years and mean APACHE II score of 21.3. During follow-up, 111 patients (16.6 %) died in ICU and in total, 149 (22.3 %) died in hospital. Multivariable analysis demonstrated significant independent risk factors for hospital mortality including male sex (hazard ratio (HR) = 1.5, 95 % confidence interval (CI): 1.1 - 2.2, p-value = 0.021), higher APACHE II score (HR = 1.2, 95 % CI: 1.1 - 1.4, p-value < 0.001 for per-5 point increase), chronic heart failure (HR = 2.9, 95 % CI: 1.6 - 5.4, p-value = 0.001), and dialysis (time-dependent effect: HR = 2.7, 95 % CI: 1.3 - 5.7, p-value = 0.008). Higher APACHE II score (HR = 1.2, 95 % CI: 1.1 - 1.4, p-value = 0.002 for per-5 point increase) and chronic heart failure (HR = 2.6, 95 % CI: 1.3 – 5.0, p-value = 0.004) were significantly related to risk of death in the ICU. Conclusion In this study using data from a multicenter thromboprophylaxis trial, we found that male sex, higher APACHE II score on admission, chronic heart failure, and dialysis were independently associated with risk of hospital mortality in patients admitted to ICU with pneumonia. While high illness severity score, presence of a serious comorbidity (heart failure) and need for an advanced life support (dialysis) are not unexpected risk factors of mortality, male sex might necessitate further exploration. More studies are warranted to clarify the effect of these risk factors on survival in critically ill patients admitted to ICU with pneumonia. Trial registration ClinicalTrials.gov Identifier: NCT00182143. Electronic supplementary material The online version of this article (doi:10.1186/s12931-016-0397-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Guowei Li
- Department of Clinical Epidemiology & Biostatistics, McMaster University, 501-25 Charlton Avenue East, Hamilton, ON, L8N 1Y2, Canada. .,St. Joseph's Healthcare Hamilton, McMaster University, 501-25 Charlton Avenue East, Hamilton, ON, L8N 1Y2, Canada.
| | - Deborah J Cook
- Department of Clinical Epidemiology & Biostatistics, McMaster University, 501-25 Charlton Avenue East, Hamilton, ON, L8N 1Y2, Canada.,St. Joseph's Healthcare Hamilton, McMaster University, 501-25 Charlton Avenue East, Hamilton, ON, L8N 1Y2, Canada.,Department of Medicine, McMaster University, Hamilton, ON, Canada.,Interdepartmental Division of Critical Care, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Lehana Thabane
- Department of Clinical Epidemiology & Biostatistics, McMaster University, 501-25 Charlton Avenue East, Hamilton, ON, L8N 1Y2, Canada.,St. Joseph's Healthcare Hamilton, McMaster University, 501-25 Charlton Avenue East, Hamilton, ON, L8N 1Y2, Canada
| | - Jan O Friedrich
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Tim M Crozier
- Intensive Care Unit, Monash Medical Centre, Melbourne, VIC, Australia
| | - John Muscedere
- Department of Critical Care Medicine, Queens University Kingston, Kingston, ON, Canada
| | - John Granton
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,University Health Network, University of Toronto, Toronto, ON, Canada
| | - Sangeeta Mehta
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Steven C Reynolds
- Division of Critical Care, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Francois Lauzier
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec, Canada
| | | | - Mitchell A H Levine
- Department of Medicine, McMaster University, Hamilton, ON, Canada. .,Department of Clinical Epidemiology & Biostatistics, McMaster University, 25 Main St. West, Suite 2000, 20th floor, Hamilton, ON, L8P 1H1, Canada. .,Centre for Evaluation of Medicines, St. Joseph's Healthcare Hamilton, 25 Main St. West, Suite 2000, 20th floor, Hamilton, ON, L8P 1H1, Canada.
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Ranganathan P, Kumar RG, Davis K, McCullough EH, Berga SL, Wagner AK. Longitudinal sex and stress hormone profiles among reproductive age and post-menopausal women after severe TBI: A case series analysis. Brain Inj 2016; 30:452-461. [PMID: 26963638 DOI: 10.3109/02699052.2016.1144081] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PRIMARY OBJECTIVES To describe hormone profiles for pre-/post-menopausal women, to monitor time to resumption of menstruation among pre-menopausal women and to describe cortisol associated LH suppression and phasic variation in other sex hormones over timeMethods and procedures: This study determined amenorrhea duration and characterized acute (days 0-7) and chronic (months 1-6) gonadotropins [luteinizing hormone and follicle stimulating hormone (LH, FSH)], sex hormones (progesterone, estradiol) and stress hormone (cortisol) profiles. Women were pre-menopausal (n = 3) or post-menopausal (n = 3). Among pre-menopausal women, menstrual cycle resolution and phase association (luteal/follicular) was monitored using self-report monthly reproductive history questionnaires. This study compared post-TBI hormone profiles, stratified by menopausal status, to hormone levels from seven controls and described 6- and 12-month outcomes for these women. MAIN OUTCOMES AND RESULTS Consistent with functional hypothalamic amenorrhea (FHA), menstruation resumption among pre-menopausal women occurred when serum cortisol normalized to luteal phase control levels. For post-menopausal women, serum cortisol reductions corresponded with resolution of suppressed LH levels. CONCLUSIONS The stress of TBI results in anovulation and central hypothalamic-pituitary-ovarian (HPG) axis suppression. Future work will examine acute/chronic consequences of post-TBI hypercortisolemia and associated HPG suppression, the temporal association of HPG suppression with other neuroendocrine adaptations and how HPG suppression impacts multidimensional recovery for women with TBI.
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Affiliation(s)
- Prerna Ranganathan
- a Department of Physical Medicine and Rehabilitation , University of Pittsburgh , Pittsburgh , PA , USA
| | - Raj G Kumar
- a Department of Physical Medicine and Rehabilitation , University of Pittsburgh , Pittsburgh , PA , USA
| | - Kendra Davis
- a Department of Physical Medicine and Rehabilitation , University of Pittsburgh , Pittsburgh , PA , USA
| | - Emily H McCullough
- a Department of Physical Medicine and Rehabilitation , University of Pittsburgh , Pittsburgh , PA , USA
| | - Sarah L Berga
- b Department of Obstetrics/Gynecology , Wake Forest University , Winston-Salem , NC , USA
| | - Amy K Wagner
- a Department of Physical Medicine and Rehabilitation , University of Pittsburgh , Pittsburgh , PA , USA.,c University of Pittsburgh, School of Medicine , Pittsburgh , PA , USA.,d Safar Center for Resuscitation Research , University of Pittsburgh , Pittsburgh , PA , USA
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Raheja A, Sinha S, Samson N, Bhoi S, Subramanian A, Sharma P, Sharma BS. Serum biomarkers as predictors of long-term outcome in severe traumatic brain injury: analysis from a randomized placebo-controlled Phase II clinical trial. J Neurosurg 2016; 125:631-41. [PMID: 26722854 DOI: 10.3171/2015.6.jns15674] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE There has been increased interest in the potential importance of biochemical parameters as predictors of outcome in severe traumatic brain injury (sTBI). METHODS Of 107 patients with sTBI (age 18-65 years with a Glasgow Coma Scale score of 4-8 presenting within 8 hours after injury) who were randomized for a placebo-controlled Phase II trial of progesterone with or without hypothermia, the authors serially analyzed serum biomarkers (S100-B, glial fibrillary acidic protein [GFAP], neuron-specific enolase [NSE], tumor necrosis factor-α, interleukin-6 [IL-6], estrogen [Eg], and progesterone [Pg]). This analysis was performed using the sandwich enzyme-linked immunosorbent assay technique at admission and 7 days later for 86 patients, irrespective of assigned group. The long-term predictive values of serum biomarkers for dichotomized Glasgow Outcome Scale (GOS) score, functional independence measure, and survival status at 6 and 12 months were analyzed using an adjusted binary logistic regression model and receiver operating characteristic curve. RESULTS A favorable GOS score (4-5) at 1 year was predicted by higher admission IL-6 (above 108.36 pg/ml; area under the curve [AUC] 0.69, sensitivity 52%, and specificity 78.6%) and Day 7 Pg levels (above 3.15 ng/ml; AUC 0.79, sensitivity 70%, and specificity 92.9%). An unfavorable GOS score (1-3) at 1 year was predicted by higher Day 7 GFAP levels (above 9.50 ng/ml; AUC 0.82, sensitivity 78.6%, and specificity 82.4%). Survivors at 1 year had significantly higher Day 7 Pg levels (above 3.15 ng/ml; AUC 0.78, sensitivity 66.7%, and specificity 90.9%). Nonsurvivors at 1 year had significantly higher Day 7 GFAP serum levels (above 11.14 ng/ml; AUC 0.81, sensitivity 81.8%, and specificity 88.9%) and Day 7 IL-6 serum levels (above 71.26 pg/ml; AUC 0.87, sensitivity 81.8%, and specificity 87%). In multivariate logistic regression analysis, independent predictors of outcome at 1 year were serum levels of Day 7 Pg (favorable GOS-OR 3.24, CI 1.5-7, p = 0.003; and favorable survival-OR 2, CI 1.2-3.5, p = 0.01); admission IL-6 (favorable GOS-OR 1.04, CI 1.00-1.08, p = 0.04); and Day 7 GFAP (unfavorable GOS-OR 0.79, CI 0.65-0.95, p = 0.01; and unfavorable survival-OR 0.80, CI 0.66-0.96, p = 0.01). CONCLUSIONS Serial Pg, GFAP, and IL-6 monitoring could aid in prognosticating outcomes in patients with acute sTBI. A cause and effect relationship or a mere association of these biomarkers to outcome needs to be further studied for better understanding of the pathophysiology of sTBI and for choosing potential therapeutic targets. Clinical trial registration no.: CTRI/2009/091/000893 ( http://www.ctri.nic.in ).
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Affiliation(s)
| | | | | | | | | | - Pushpa Sharma
- Department of Anaesthesiology, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Abstract
The decision to undergo surgery for gastric cancer patients aged ≥85 years should be made carefully. We retrospectively reviewed the prognostic factors of gastrectomy for 64 patients aged ≥85 years who had undergone curative gastrectomy for gastric cancer. The effects of various clinical characteristics and surgical interventions on survival were retrospectively analyzed. Univariate analysis revealed that sex (male/female; P = 0.001), the extent of gastric resection (total/distal; P = 0.028), the extent of lymph node dissection (D2/<D2; P = 0.019), and blood loss (P = 0.005) were significant prognostic factors for overall survival. Multivariate analysis demonstrated that sex was the only independent prognostic factor. For pneumonia-specific survival, sex was also the only prognostic factor by multivariate analysis.Prognoses of males aged ≥85 years after gastrectomy were significantly worse than those of females, as they were more likely to die of pneumonia.
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Parlato M, Cavaillon JM. Host response biomarkers in the diagnosis of sepsis: a general overview. Methods Mol Biol 2015; 1237:149-211. [PMID: 25319788 DOI: 10.1007/978-1-4939-1776-1_15] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Critically ill patients who display a systemic inflammatory response syndrome (SIRS) are prone to develop nosocomial infections. The challenge remains to distinguish as early as possible among SIRS patients those who are developing sepsis. Following a sterile insult, damage-associated molecular patterns (DAMPs) released by damaged tissues and necrotic cells initiate an inflammatory response close to that observed during sepsis. During sepsis, pathogen-associated molecular patterns (PAMPs) trigger the release of host mediators involved in innate immunity and inflammation through identical receptors as DAMPs. In both clinical settings, a compensatory anti-inflammatory response syndrome (CARS) is concomitantly initiated. The exacerbated production of pro- or anti-inflammatory mediators allows their detection in biological fluids and particularly within the bloodstream. Some of these mediators can be used as biomarkers to decipher among the patients those who developed sepsis, and eventually they can be used as prognosis markers. In addition to plasma biomarkers, the analysis of some surface markers on circulating leukocytes or the study of mRNA and miRNA can be helpful. While there is no magic marker, a combination of few biomarkers might offer a high accuracy for diagnosis.
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Affiliation(s)
- Marianna Parlato
- Unit of Cytokines and Inflammation, Institut Pasteur, 28 rue du Dr Roux, 75724, Paris Cedex 15, France
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The early evolving sex hormone environment is associated with significant outcome and inflammatory response differences after injury. J Trauma Acute Care Surg 2015; 78:451-7; discussion 457-8. [PMID: 25710413 DOI: 10.1097/ta.0000000000000550] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Clinical research characterizing the mechanisms responsible for sex-based outcome differences after injury remains conflicting. Currently lacking is an understanding of the early sex hormone milieu of the injured patient and the effects these early hormone differences have on clinical outcomes and the innate immune response following injury. METHODS A prospective cohort study was performed over a 20-month period. Blunt injury patients requiring intensive care unit admission were enrolled. Samples were collected within 6 hours and at 24 hours after injury and were analyzed for total testosterone (TT) and estradiol concentrations. Outcomes of interest included multiple-organ failure (MOF; Marshall Multiple Organ Dysfunction Score [MODScore] > 5), nosocomial infection (NI), mortality, and serial cytokine/chemokine measurements. Multivariate logistic regression was used to determine the independent risks associated with early sex hormone measurements. RESULTS In 288 prospectively enrolled patients, 69% were male, with a median Injury Severity Score (ISS) of 16 (interquartile range 10-21). Elevated TT levels at 6 hours were associated with elevated interleukin 6 levels and cytokine/chemokine measurements (18 of 24 measured). Rising TT levels were significantly associated with more than a fivefold and twofold higher independent risk of MOF and NI, respectively (odds ratio [OR], 5.2; p = 0.02; 95% confidence interval [CI], 1.2-22.3; and OR, 2.1; p = 0.03; 95% CI, 1.02-4.2). At 24 hours, TT levels were no longer associated with poor outcome, while estradiol levels were significantly associated with nearly a fourfold higher independent risk of MOF (OR, 3.9; p = 0.04, 95% CI, 1.05-13). CONCLUSION Early elevations and increasing testosterone levels over initial 24 hours after injury are associated with an exaggerated inflammatory response and a significantly greater risk of MOF and NI. High estrogen levels at 24 hours are independently associated with an increased risk of MOF. The current analysis suggests that an early evolving testosterone to estrogen hormonal environment is associated with a significantly higher independent risk of poor outcome following traumatic injury. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level II.
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32
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Abstract
A body of experimental evidence suggests that the female sex is associated with a lower risk of mortality after trauma-hemorrhage. However, controversy remains regarding the mechanism responsible for these differences and if basic science findings correspond to clinical differences. Racial disparities in trauma outcomes have also been increasingly described. Until now, research on the association between sex and trauma patient outcomes mainly focused on patients in Europe and the United States. Our research attempted to determine whether the female sex is associated with a survival advantage among severely injured Chinese trauma patients. A retrospective analysis of data derived from the Emergency Intensive Care Unit of the Shanghai Sixth People';s Hospital Acute Trauma Center during 2010 to 2013 was performed to characterize differences in sex-based outcomes after severe blunt trauma. The patient study cohort (858 Asian subjects) was then stratified by age and injury severity (using the Injury Severity Score [ISS]). Crude and adjusted odds ratios (ORs) were calculated to evaluate the association between sex and nosocomial infection rate and hospitalized mortality, both overall and by age and ISS category subgroups. Among all trauma patients, females had a significantly lower risk of in-hospital mortality compared with males (OR, 0.41; 95% confidence interval [95% CI], 0.20 - 0.85). This difference was most apparent for patients younger than 50 years (OR, 0.31; 95% CI, 0.12 - 0.82) and the group with ISS scores of 25 or higher (OR, 0.39; 95% CI, 0.17 - 0.91). No differences in the development of nosocomial infections between sexes were seen among the overall patient group and subgroups. This study revealed a statistically significant association between sex and mortality among severe blunt trauma patients, particularly those patients younger than 50 years and with ISSs of 25 or higher. Women had significantly lower mortality than men after severe blunt trauma. These results highlight the important role of sex hormones and sex-based outcome differences after severe traumatic injury in the Chinese population.
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Crago EA, Sherwood PR, Bender C, Balzer J, Ren D, Poloyac SM. Plasma Estrogen Levels Are Associated With Severity of Injury and Outcomes After Aneurysmal Subarachnoid Hemorrhage. Biol Res Nurs 2014; 17:558-66. [PMID: 25548393 DOI: 10.1177/1099800414561632] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Biochemical mediators alter cerebral perfusion and have been implicated in delayed cerebral ischemia (DCI) and poor outcomes after aneurysmal subarachnoid hemorrhage (aSAH). Estrogens (estrone [E1] and estradiol [E2]) are mediators with neuroprotective properties that could play a role in DCI. This study explored associations between plasma estrogen levels and outcomes following aSAH. METHODS Plasma samples from 1-4, 4-6, and 7-10 days after hemorrhage from 99 adult aSAH patients were analyzed for estrogen levels using liquid chromatography tandem mass spectrometry. DCI was operationalized as radiographic/ultrasonic evidence of impaired cerebral blood flow accompanied by neurological deterioration. Outcomes were assessed using the Modified Rankin Scale at 3 and 12 months after hemorrhage. Statistical analysis included correlation, regression, and group-based trajectory. RESULTS Higher E1 and E2 levels were associated with higher Hunt and Hess grade (E1, p = .01; E2, p = .03), the presence of DCI (E1, p = .02; E2, p = .02), and poor 3-month outcomes (E1, p = .002; E2, p = .002). Trajectory analysis identified distinct populations over time for E1 (61% E1 high) and E2 (68% E2 high). Patients in higher trajectory groups had higher Fisher grades (E1, p = .008; E2, p = .01), more frequent DCI (E1, p = .04; E2, p = .08), and worse 3-month outcomes (E1, p = .01; E2, p = .004) than low groups. CONCLUSIONS These results provide the first clinical evidence that plasma E1 and E2 concentrations are associated with severity of injury and outcomes after aSAH.
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Affiliation(s)
| | - Paula R Sherwood
- School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
| | - Catherine Bender
- School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jeffrey Balzer
- School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Dianxu Ren
- School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
| | - Samuel M Poloyac
- School of Pharmaceutical Sciences, University of Pittsburgh, Pittsburgh, PA, USA
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Sethuraman KN, Marcolini EG, McCunn M, Hansoti B, Vaca FE, Napolitano LM. Gender-specific issues in traumatic injury and resuscitation: consensus-based recommendations for future research. Acad Emerg Med 2014; 21:1386-94. [PMID: 25420732 DOI: 10.1111/acem.12536] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Revised: 07/26/2014] [Accepted: 07/29/2014] [Indexed: 02/03/2023]
Abstract
Traumatic injury remains an unacceptably high contributor to morbidity and mortality rates across the United States. Gender-specific research in trauma and emergency resuscitation has become a rising priority. In concert with the 2014 Academic Emergency Medicine consensus conference "Gender-specific Research in Emergency Care: Investigate, Understand, and Translate How Gender Affects Patient Outcomes," a consensus-building group consisting of experts in emergency medicine, critical care, traumatology, anesthesiology, and public health convened to generate research recommendations and priority questions to be answered and thus move the field forward. Nominal group technique was used for the consensus-building process and a combination of face-to-face meetings, monthly conference calls, e-mail discussions, and preconference surveys were used to refine the research questions. The resulting research agenda focuses on opportunities to improve patient outcomes by expanding research in sex- and gender-specific emergency care in the field of traumatic injury and resuscitation.
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Affiliation(s)
- Kinjal N. Sethuraman
- Department of Emergency Medicine and the Division of Hyperbaric Medicine; R Adams Cowley Shock Trauma Center; University of Maryland School of Medicine; Baltimore MD
| | | | - Maureen McCunn
- Department of Anesthesiology; Divisions of Trauma Anesthesiology and Surgical Critical Care; Baltimore MD
| | - Bhakti Hansoti
- Department of Emergency Medicine; Johns Hopkins University; Baltimore MD
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Sex- and diagnosis-dependent differences in mortality and admission cytokine levels among patients admitted for intensive care. Crit Care Med 2014; 42:1110-20. [PMID: 24365862 DOI: 10.1097/ccm.0000000000000139] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To investigate the role of sex on cytokine expression and mortality in critically ill patients. DESIGN A cohort of patients admitted to were enrolled and followed over a 5-year period. SETTING Two university-affiliated hospital surgical and trauma ICUs. PATIENTS Patients 18 years old and older admitted for at least 48 hours to the surgical or trauma ICU. INTERVENTIONS Observation only. MEASUREMENTS AND MAIN RESULTS Major outcomes included admission cytokine levels, prevalence of ICU-acquired infection, and mortality during hospitalization conditioned on trauma status and sex. The final cohort included 2,291 patients (1,407 trauma and 884 nontrauma). The prevalence of ICU-acquired infection was similar for men (46.5%) and women (44.5%). All-cause in-hospital mortality was 12.7% for trauma male patient and 9.1% for trauma female patient (p = 0.065) and 22.9% for nontrauma male patients and 20.6% for nontrauma female patients (p = 0.40). Among trauma patients, logistic regression analysis identified female sex as protective for all-cause mortality (odds ratio, 0.57). Among trauma patients, men had significantly higher admission serum levels of interleukin-2, interleukin-12, interferon-γ, and tumor necrosis factor-α, and among nontrauma patients, men had higher admission levels of interleukin-8 and tumor necrosis factor-α. CONCLUSIONS The relationship between sex and outcomes in critically ill patients is complex and depends on underlying illness. Women appear to be better adapted to survive traumatic events, while sex may be less important in other forms of critical illness. The mechanisms accounting for this gender dimorphism may, in part, involve differential cytokine responses to injury, with men expressing a more robust proinflammatory profile.
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Serum estradiol levels predict survival and acute kidney injury in patients with septic shock--a prospective study. PLoS One 2014; 9:e97967. [PMID: 24904990 PMCID: PMC4048195 DOI: 10.1371/journal.pone.0097967] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 04/26/2014] [Indexed: 01/09/2023] Open
Abstract
Sex hormones have diverse immunomodulatory effects that may be involved in the pathogenesis of sepsis. However, the roles of serum sex hormones in predicting outcomes and the severity of organ dysfunction, especially acute kidney injury (AKI), in septic shock patients remains controversial. We prospectively enrolled 107 clinically diagnosed pneumonia-related septic shock patients and serum sex hormone levels were measured on the day of shock onset. The aim of the present study was to investigate the predictive values of serum sex hormones levels for 28-day mortality and organs dysfunction, especially AKI. Compared with survivors, serum levels of progesterone (p<0.001) and estradiol (p<0.001) were significantly elevated in non-survivors. In multivariate Cox regression analysis, serum level of estradiol >40 pg/mL (p = 0.047) and APACHE II score ≥25 (p = <0.001) were found to be independent predictors of day 28 mortality. Inclusion of estradiol levels further enhanced the ability of APACHE II scores to predict survival in patients with high mortality risk. A serum level of estradiol >40 pg/mL was also an independent predictor of concomitant AKI (p = 0.002) and correlated well with severity of renal dysfunction using RIFLE classification. Elevated serum estradiol levels also predicted the development of new AKI within 28 days of shock onset (p = 0.013). In conclusion, serum estradiol levels appear to have value in predicting 28-day mortality in septic shock patients. Increased serum estradiol levels are associated with higher severity of concomitant AKI and predict development of new AKI.
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Liu SL, Zhang SY, Wang MJ, Jiang H, Yang YX, Chen L. Demethylzeylasteral exhibits dose-dependent inhibitory behaviour towards estradiol glucuronidation. Eur J Drug Metab Pharmacokinet 2014; 39:99-102. [PMID: 23807732 DOI: 10.1007/s13318-013-0147-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Accepted: 06/15/2013] [Indexed: 02/05/2023]
Abstract
The disturbance of estradiol level might induce the occurence of some diseases, including cancer. Estradiol is mainly metabolized through the conjugation reactions, including the sulfation and glucuronidation reactions. The present study tried to evaluate the inhibition of estradiol glucuronidation by the major ingredients of Tripterygium wilfordii Hook F. demethylzeylasteral. Selective ion monitoring at negative ion mode ([M⁺ H⁻] = 447) was employed to monitor the two glucuronides of estradiol. The reaction rate was determined through comparison of peak area of these two glucuronides. Lineweaver-Burk plot and Dixon plot were utilized to determine the inhibition kinetic type, and the inhibition kinetic parameters (K i) were calculated using the second plot. Competitive inhibition of demethylzeylasteral towards the formation of two glucuronides of estradiol was demonstrated, and the K i values were calculated to be 453.3 and 110.9 μM, respectively. All these results will remind us the risk of elevated serum concentrations of estradiol due to the inhibition of estradiol glucuronidation by demethylzeylasteral.
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Affiliation(s)
- Su-Lin Liu
- Intervention Therapy Department, First Affiliated Hospital of Shantou University Medical College, Shantou, China,
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Garringer JA, Niyonkuru C, McCullough EH, Loucks T, Dixon CE, Conley YP, Berga S, Wagner AK. Impact of aromatase genetic variation on hormone levels and global outcome after severe TBI. J Neurotrauma 2013; 30:1415-25. [PMID: 23540392 PMCID: PMC3741419 DOI: 10.1089/neu.2012.2565] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Although experimental traumatic brain injury (TBI) studies support estradiol as a neuroprotectant and potent stimulator of neuroplasticity, clinical studies suggest a negative association between endogenous estradiol profiles and mortality/poor outcomes. However, no studies have evaluated associations with cerebral spinal fluid (CSF) hormone profiles and aromatase gene (cytochrome P450 [CYP]19A1) variability on clinical TBI outcomes. We evaluated 110 adults with severe TBI. Average and daily estradiol, testosterone, and estradiol/testosterone ratios (E2:T) were measured using CSF and serum samples and compared to healthy controls. Eighteen tagging and four functional single-nucleotide polymorphisms (SNPs) for CYP19A1 were genotyped and compared to hormones, acute mortality, and Glasgow Outcome Scale (GOS) scores 6 months post-TBI. TBI subjects had lower CSF estradiol over time versus controls. CSF testosterone was initially high, but declined over time. E2/T ratios were initially low, compared to controls, but rose over time. Higher mean E2/T ratio in bivariate analysis was associated with lower mortality (p=0.019) and better GOS-6 scores (p=0.030). rs2470152 influenced CSF E2/T ratio and also serum and CSF testosterone (p≤0.05 all comparisons). Multiple-risk SNPs rs2470152, rs4646, and rs2470144 were associated with worse GOS-6 scores (p≤0.05, all comparisons), and those with>1 risk SNP variant had a higher risk for poor outcome, compared with those with ≤1 risk variant. TBI results in low CSF estradiol and dynamic CSF testosterone and E2/T ratio. In contrast to clinical serum hormone studies, higher CSF E2/T ratio was associated with better outcome. Further, genetic variation in CYP19A1 influences both hormone dynamics and outcome post-TBI.
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Affiliation(s)
| | - Christian Niyonkuru
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Emily H. McCullough
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Tammy Loucks
- Department of Gynecology and Obstetrics, Emory University, Atlanta, Georgia
| | - C. Edward Dixon
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Yvette P. Conley
- School of Nursing, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sarah Berga
- Department of Obstetrics and Gynecology, Wake forest University, Winston-Salem, North Carolina
| | - Amy K. Wagner
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania
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Lu CW, Liu LC, Hsieh YC, Yang LH, Chen RJ, Hsieh CH. Increased admission serum estradiol level is correlated with high mortality in patients with severe acute pancreatitis. J Gastroenterol 2013; 48:374-81. [PMID: 22825551 DOI: 10.1007/s00535-012-0636-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2012] [Accepted: 06/22/2012] [Indexed: 02/04/2023]
Abstract
BACKGROUND Sexual dimorphism in critical diseases has been documented. Severe acute pancreatitis is a disease with high mortality. We hypothesized that admission sex hormone levels may be used as an early predictor of outcome in these patients. METHODS A prospective cohort of patients with severe acute pancreatitis admitted to the intensive care unit for at least 48 h were enrolled (n = 62). Serum levels of estradiol, progesterone, and testosterone were determined on admission. The association of sex hormone levels and various disease severity scoring systems with patient outcome was analyzed. RESULTS There was no difference in overall mortality between the sexes. However, estradiol was significantly elevated in nonsurvivors (39 vs. 206 pg/mL, p < 0.001). The estradiol level was the best single-variable predictor of mortality (area under the curve 0.97), followed by the sequential organ failure assessment score, the multiple organ dysfunction score, and the acute physiology and chronic health care evaluation II (APACHE II) score. A serum estradiol level of 102 pg/mL was both sensitive and specific to predict mortality. There were no differences between survivors and non-survivors in terms of age, body mass index, or progesterone and testosterone levels. CONCLUSIONS Admission serum estradiol level is a good marker of disease severity and predictor of death in patients with severe acute pancreatitis.
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Affiliation(s)
- Chih-Wei Lu
- Department of Emergency, Nantou Christian Hospital, Nantou, Taiwan, ROC
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Jendeberg AL, Strålin K, Hultgren O. Antimicrobial peptide plasma concentrations in patients with community-acquired pneumonia. ACTA ACUST UNITED AC 2013; 45:432-7. [PMID: 23317166 DOI: 10.3109/00365548.2012.760844] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Community-acquired pneumonia (CAP) is a common and potentially life-threatening infection. Innate immunity is the first line of defence, and antimicrobial peptides (AMPs) produced by white blood cells and at epithelial barriers participate by killing microorganisms and neutralizing bacterial toxins. We wanted to investigate whether concentrations of AMPs (1) are increased in CAP, (2) predict the clinical outcome, and (3) differ depending on the causative microbe. METHODS Plasma concentrations of AMPs were measured using an enzyme-linked immunosorbent assay in 89 patients with CAP, 21 patients with non-respiratory tract infections (non-RTI), and 63 healthy control subjects. RESULTS In subjects with CAP, mean plasma concentrations of secretory leukocyte protease inhibitor (SLPI) and bactericidal/ permeability-increasing protein (BPI) were significantly higher than in healthy control subjects (85 vs 45 ng/ml, p < 0.001 and 48 vs 10 ng/ml, p < 0.001, respectively), but less markedly increased in patients with non-RTI (68 ng/ml, p = 0.06 and 41 ng/ml, p = 0.43). LL-37 and human neutrophil peptides 1-3 (HNP 1-3) levels were not increased in subjects with CAP. Levels of BPI and SLPI did not correlate to severity of disease, and AMP levels did not differ depending on the causative agent. Interestingly, male subjects with CAP displayed increased concentrations of SLPI compared to females. This was not observed in subjects with non-RTI and healthy control subjects. CONCLUSIONS Subjects with CAP showed increased plasma concentrations of SLPI and BPI compared to healthy control subjects. The finding of higher SLPI levels in male subjects with CAP implies that there are sex-dependent immunological differences in SLPI turnover.
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Laughlin GA, Ix JH, Cummins K, Allison MA, Daniels LB. Extremes of an aromatase index predict increased 25-year risk of cardiovascular mortality in older women. Clin Endocrinol (Oxf) 2012; 77:391-8. [PMID: 22066939 PMCID: PMC3298636 DOI: 10.1111/j.1365-2265.2011.04287.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Peripheral conversion of androgens to oestrogens via aromatase is the primary source of oestrogen in postmenopausal women and may play a role in cardiovascular health. DESIGN Prospective. PARTICIPANTS, MEASUREMENTS: The association of an index of aromatase activity (AROM), the serum oestrone-to-androstenedione ratio, with 25-year cardiovascular disease (CVD) mortality was examined in 819 postmenopausal non-oestrogen using women (mean age at baseline = 72). RESULTS Overall, 247 deaths were attributed to CVD. The median AROM value was 60 (95% range 17-129). AROM was positively correlated with age (r = 0·28) and body mass index (BMI) (r = 0·22) (P < 0·001). The age-adjusted risk for CVD mortality was significantly elevated for women in the lowest (HR = 2·01, 95% CI 1·31-3·12) and highest (HR = 1·51, 95%CI 1·02-2·22) quintiles of AROM, compared with the middle quintile. This U-shaped association persisted after additional adjustment for BMI, waist-to-hip ratio, exercise, smoking, alcohol use and traditional CVD risk factor covariates. There was a significant interaction of AROM and BMI (P = 0·001), such that high AROM was associated with a 63% reduction in risk of CVD death for women with low BMI (<22 kg/m(2) ), but with 2·1- to 2·5-fold increased risk in women with mid-range (22-<25 kg/m(2) ) and high (≥25 kg/m(2) ) BMI. Oestradiol did not influence AROM associations and was not independently related to CVD death. CONCLUSIONS These results suggest that aromatase is a novel endocrine factor predictive of CVD mortality among postmenopausal women. If confirmed, additional studies are needed to determine whether extremes of aromatase reflect genetic influences or underlying disease processes.
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Affiliation(s)
- Gail A Laughlin
- Division of Epidemiology, Department of Family and Preventive Medicine, University of California, San Diego, La Jolla, CA 92093, USA.
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Wagner AK, Brett CA, McCullough EH, Niyonkuru C, Loucks TL, Dixon CE, Ricker J, Arenth P, Berga SL. Persistent hypogonadism influences estradiol synthesis, cognition and outcome in males after severe TBI. Brain Inj 2012; 26:1226-42. [DOI: 10.3109/02699052.2012.667594] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Sperry JL, Vodovotz Y, Ferrell RE, Namas R, Chai YM, Feng QM, Jia WP, Forsythe RM, Peitzman AB, Billiar TR. Racial disparities and sex-based outcomes differences after severe injury. J Am Coll Surg 2012; 214:973-80. [PMID: 22521668 DOI: 10.1016/j.jamcollsurg.2012.02.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2011] [Revised: 02/23/2012] [Accepted: 02/23/2012] [Indexed: 12/28/2022]
Abstract
BACKGROUND Controversy exists about the mechanisms responsible for sex-based outcomes differences post-injury. X-chromosome-linked immune response pathway polymorphisms represent a potential mechanism resulting in sex-based outcomes differences post-injury. The prevalence of these variants is known to differ across race. We sought to characterize racial differences and the strength of any sex-based dimorphism post-injury. STUDY DESIGN A retrospective analysis was performed using data derived from the National Trauma Data Bank 7.1 (2002-2006). Blunt-injured adult (older than 15 years) patients, surviving >24 hours and with an Injury Severity Score >16 were analyzed (n = 244,371). Patients were stratified by race (Caucasian, black, Hispanic, Asian) and multivariable regression analysis was used to characterize the risk of mortality and the strength of protection associated with sex (female vs male). RESULTS When stratified by race, multivariable models demonstrated Caucasian females had an 8.5% lower adjusted risk of mortality (odds ratio [OR] = 0.91; 95% CI, 0.88-0.95; p < 0.001) relative to Caucasian males, with no significant association found for Hispanics or blacks. An exaggerated survival benefit was afforded to Asian females relative to Asian males, having a >40% lower adjusted risk of mortality (OR = 0.59; 95% CI, 0.44-78; p < 0.001). Asian males had a >75% higher adjusted risk of mortality relative to non-Asian males (OR = 1.77; 95% CI, 1.5-2.0; p < 0.001), and no significant difference in the mortality risk was found for Asian females relative to non-Asian females. CONCLUSIONS These results suggest that Asian race is associated with sex-based outcomes differences that are exaggerated, resulting from worse outcomes for Asian males. These racial disparities suggest a negative male X-chromosome-linked effect as the mechanism responsible for these sex-based outcomes differences.
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Affiliation(s)
- Jason L Sperry
- Division of General Surgery andTrauma, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA.
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Bastarache JA, Diamond JM, Kawut SM, Lederer DJ, Ware LB, Christie JD. Postoperative estradiol levels associate with development of primary graft dysfunction in lung transplantation patients. ACTA ACUST UNITED AC 2012; 9:154-65. [PMID: 22361838 DOI: 10.1016/j.genm.2012.01.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2011] [Revised: 01/04/2012] [Accepted: 01/18/2012] [Indexed: 01/11/2023]
Abstract
BACKGROUND Primary graft dysfunction (PGD) frequently complicates lung transplantation in the immediate postoperative period. Both female gender and estradiol modulate the body's response to injury and can influence the rate of alveolar fluid clearance. OBJECTIVE We hypothesized that female gender and higher estradiol levels would be associated with a lower risk of PGD after lung transplantation. METHODS We measured plasma estradiol levels preoperatively, 6 hours postoperatively, and 24 hours postoperatively in a cohort of 111 lung transplant recipients at 2 institutions. RESULTS Mean age was 57 years (12.5) and 52% were female. Median postoperative estradiol level was 63.9 pg/mL (interquartile range, 28.8-154.3 pg/mL) in male and 65.1 pg/mL (interquartile range, 28.4-217.2 pg/mL) in female patients. Contrary to our hypothesis, higher estradiol levels at 24 hours were associated with an increased risk of PGD at 72 hours in male patients (P = 0.001). This association was preserved when accounting for other factors known to be associated with PGD. However, there was no relationship between gender and risk of PGD or between estradiol levels and PGD in females. CONCLUSION These findings suggest that there might be different biologic effects of estrogens in males and females, and highlight the importance of considering gender differences in future studies of PGD.
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Affiliation(s)
- Julie A Bastarache
- Division of Allergy, Pulmonary and Critical Care, Vanderbilt University School of Medicine, Nashville, TN 37232-2650, USA.
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Sheth SU, Palange D, Xu DZ, Wei D, Feketeova E, Lu Q, Reino DC, Qin X, Deitch EA. Testosterone depletion or blockade in male rats protects against trauma hemorrhagic shock-induced distant organ injury by limiting gut injury and subsequent production of biologically active mesenteric lymph. ACTA ACUST UNITED AC 2012; 71:1652-8. [PMID: 22182874 DOI: 10.1097/ta.0b013e31823a06ea] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND We tested the hypothesis that testosterone depletion or blockade in male rats protects against trauma hemorrhagic shock-induced distant organ injury by limiting gut injury and subsequent production of biologically active mesenteric lymph. METHODS Male, castrated male, or flutamide-treated rats (25 mg/kg subcutaneously after resuscitation) were subjected to a laparotomy (trauma), mesenteric lymph duct cannulation, and 90 minutes of shock (35 mm Hg) or trauma sham-shock. Mesenteric lymph was collected preshock, during shock, and postshock. Gut injury was determined at 6 hours postshock using ex vivo ileal permeability with fluorescein dextran. Postshock mesenteric lymph was assayed for biological activity in vivo by injection into mice and measuring lung permeability, neutrophil activation, and red blood cell deformability. In vitro neutrophil priming capacity of the lymph was also tested. RESULTS Castrated and flutamide-treated male rats were significantly protected against trauma hemorrhagic shock (T/HS)-induced gut injury when compared with hormonally intact males. Postshock mesenteric lymph from male rats had a higher capacity to induce lung injury, Neutrophil (PMN) activation, and loss of red blood cell deformability when injected into naïve mice when compared with castrated and flutamide-treated males. The increase in gut injury after T/HS in males directly correlated with the in vitro biological activity of mesenteric lymph to prime neutrophils for an increased respiratory burst. CONCLUSIONS After T/HS, gut protective effects can be observed in males after testosterone blockade or depletion. This reduced gut injury contributes to decreased biological activity of mesenteric lymph leading to attenuated systemic inflammation and distant organ injury.
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Affiliation(s)
- Sharvil U Sheth
- Department of Surgery, UMDNJ-New Jersey Medical School, Newark, New Jersey 07103, USA
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Gender and acute respiratory distress syndrome in critically injured adults: a prospective study. ACTA ACUST UNITED AC 2011; 71:878-83; discussion 883-5. [PMID: 21986736 DOI: 10.1097/ta.0b013e31822c0d31] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The acute respiratory distress syndrome (ARDS) is a proinflammatory condition that often complicates trauma and critical illness. Animal studies have shown that both gender and sex hormones play an important role in inflammatory regulation. Human data are scant regarding the role of gender and sex hormones in developing ARDS. Our objective was to describe gender and hormonal differences in patients who develop ARDS in a large cohort of critically injured adults. METHODS A prospective cohort study of adult trauma patients requiring intensive care unit admission for at least 48 hours was performed. Demographic and clinical data were collected prospectively, and sex hormones were assayed at study entry (48 hours). The primary outcome was the development of ARDS. Multivariate logistic regression was used to determine the adjusted odds of death associated with differences in gender. RESULTS Six hundred forty-eight patients met entry criteria, and 180 patients developed ARDS (31%). Women were more likely to develop ARDS (35% vs. 25%, p=0.02). This association remained after adjusting for age, mechanism of injury, injury severity, and blood product transfusion (odds ratio, 1.6; 95% confidence interval: 1.1-2.4; p=0.02). Of patients with ARDS, there was no difference in mortality related to gender (22% mortality in women with ARDS vs. 20% in men; p=not significant). A proinflammatory sex hormone profile (low testosterone and high estradiol) was associated with ARDS in both men and women. CONCLUSION Women are more likely than men to develop ARDS after critical injury. Despite the increased incidence in ARDS, the mortality in patients with ARDS does not differ according to gender. The inflammatory properties of sex hormones may contribute to ARDS, but they do not fully explain observed gender differences.
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Gender dimorphism in the gut: mucosal protection by estrogen stimulation of IgA transcytosis. ACTA ACUST UNITED AC 2011; 71:474-9. [PMID: 21825949 DOI: 10.1097/ta.0b013e318228239d] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Laboratory studies demonstrate gender dimorphism following trauma/hemorrhagic shock (T/HS). These differences have been attributed to estrogen (E2) levels. Maintenance of gut barrier function by E2 following T/HS has been recently described. However, the mechanisms are not clear. The principle humoral defense mechanism of the gut is provided by secretory immunoglobulin IgA. It is transported across intestinal epithelial cells (IEC) by a specific transmembrane protein receptor (polyimmunoglobulin receptor, pIgR). Transport of IgA (transcytosis) may be influenced by a number of factors. We postulated that there may be differences in IgA transcytosis and IEC pIgR expression in response to sex hormones. We studied this in vitro. METHODS Confluent HT-29 IEC monolayers were established in a two-chamber cell culture system. E2 or dihydrotestosterone (DHT) was added for 72 hours; then dimeric IgA (dIgA) was added to the basal chamber (4°C, to obtain maximal pIgR binding of dIgA). Apical media were sampled at intervals and recovery of secretory immunoglobulin IgA quantitated by enzyme-linked immunosorbent assay. PIgR expression in HT-29 cells was quantitated as mean fluorescence intensity using flow cytometry. Monolayer integrity was confirmed by serial measurement of transepithelial electrical resistance. RESULTS IgA transcytosis increased fourfold in 12-hour versus 3-hour culture periods in the control experiments. A similar finding was noted in the DHT experiments on IgA transcytosis. There were dramatic increases in IgA transcytosis across HT-29 cells exposed to E2.This was apparent at both 3- and 12-hour experimental time points and exhibited a dose-response effect. HT-29 cells cocultured with E2 increased pIgR expression in a time- and dose-dependent fashion. The greatest pIgR expression was noted following coculture of HT-29 cells with E2 for 6 days at the 1.0 μmol/L E2 concentration. The integrity of HT-29 monolayers in both the E2 and DHT treatment groups at T = 0 and 72 hours was assessed and showed no significant differences versus control cells. CONCLUSION IgA transcytosis was augmented by E2 in a dose-response fashion. This effect was due to augmented intracellular trafficking of IgA and later partly due to increased pIgR expression. The dose-related effects of E2 on IgA transport confirm the findings in animal studies that improved outcomes in females can be related to the estrus cycle.
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Fraser DR, Dombrovskiy VY, Vogel TR. Infectious complications after vehicular trauma in the United States. Surg Infect (Larchmt) 2011; 12:291-6. [PMID: 21815814 DOI: 10.1089/sur.2010.081] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The purpose of this analysis was to evaluate and define the rates of infectious complications (IC) after vehicular trauma. Secondary goals were to identify the injuries associated with the greatest risk of nosocomial infection and to measure the utilization of hospital resources associated with IC and vehicular trauma. METHODS A secondary analysis of the Nationwide Inpatient Sample (2003-2007) was performed to classify major vehicular trauma injuries utilizing International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) Emergency (E) codes. The post-traumatic IC evaluated were pneumonia, urinary tract infection (UTI), sepsis, and surgical site infection (SSI). All data were analyzed by χ(2) analysis, multivariable logistic regression, and the Cochran-Armitage test for trends. RESULTS A total of 784,037 vehicular trauma patients were identified (462,543 [59.0%] motor vehicle drivers, 142,283 [18.2%] motor vehicle passengers, 98,767 [12.6%] motorcyclists; 6,568 [<1%] motorcycle passengers, and 73,876 [9.4%] pedestrians). Of those sustaining injuries, 44,331 [5.7%] had post-traumatic IC. Pneumonia and UTI were most common after spinal cord injury (SCI), whereas sepsis and SSI were most common after colon injuries. After adjustment by age, sex, and co-morbidities, patients with SCI were 4.4 times as likely (95% confidence interval [CI] 4.20-4.63) and those with cranial injuries were 2.1 times as likely (95% CI 2.06-2.19) to develop IC as patients without these injuries. Secondary infection increased significantly the length of stay and hospital charges in all groups. CONCLUSIONS Patients sustaining vehicular trauma in combination with SCI had the highest rate of IC. Infectious complications increased hospital resource utilization significantly after vehicular trauma. Future root-cause analysis of high-risk groups may decrease complications and hospital utilization.
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Affiliation(s)
- Douglas R Fraser
- The Surgical Outcomes Research Group, Department of Surgery, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick, New Jersey 08903-0019, USA
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Kauffmann RM, Norris PR, Jenkins JM, Dupont WD, Torres RE, Blume JD, Dossett LA, Hranjec T, Sawyer RG, May AK. Trends in estradiol during critical illness are associated with mortality independent of admission estradiol. J Am Coll Surg 2011; 212:703-12; discussion 712-3. [PMID: 21463817 DOI: 10.1016/j.jamcollsurg.2010.12.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2010] [Revised: 12/14/2010] [Accepted: 12/15/2010] [Indexed: 12/25/2022]
Abstract
BACKGROUND We have previously demonstrated that elevated serum estradiol (E(2)) at intensive care unit (ICU) admission is associated with death in the critically ill, regardless of sex. However, little is known about how changes in initial E(2) during the course of care might signal increasing patient acuity or risk of death. We hypothesized that changes from baseline serum E(2) during the course of critical illness are more strongly associated with mortality than a single E(2) level at admission. STUDY DESIGN A prospective cohort of 1,408 critically ill or injured nonpregnant adult patients requiring ICU care for ≥48 hours with admission and subsequent E(2) levels was studied. Demographics, illness severity, and E(2) levels were examined, and the probability of mortality was modeled with multivariate logistic regression. Changes in E(2) were examined by both analysis of variance and logistic regression. RESULTS Overall mortality was 14.1% [95% confidence interval (CI) 12.3% to 16%]. Both admission and subsequent E(2) levels were independently associated with mortality [admission E(2) odds ratio 1.1 (CI 1.0 to 1.2); repeat estradiol odds ratio 1.3 (CI 1.2 to1.4)], with subsequent values being stronger. Changes in E(2) were independently associated with mortality [odds ratio 1.1 (CI 1.0 to 1.16)] and improved regression model performance. The regression model produced an area under the receiver operating characteristic curve of 0.80 (CI 0.77 to 0.83). CONCLUSIONS Although high admission levels of E(2) are associated with mortality, changes from baseline E(2) in critically ill or injured adults are independently associated with mortality. Future studies of E(2) dynamics may yield new indicators of patient acuity and illuminate underlying mechanisms for targeted therapy.
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Affiliation(s)
- Rondi M Kauffmann
- Division of Trauma and Surgical Critical Care, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN 37212, USA
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Wagner AK, McCullough EH, Niyonkuru C, Ozawa H, Loucks TL, Dobos JA, Brett CA, Santarsieri M, Dixon CE, Berga SL, Fabio A. Acute serum hormone levels: characterization and prognosis after severe traumatic brain injury. J Neurotrauma 2011; 28:871-88. [PMID: 21488721 PMCID: PMC3113446 DOI: 10.1089/neu.2010.1586] [Citation(s) in RCA: 117] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Experimental traumatic brain injury (TBI) studies report the neuroprotective effects of female sex steroids on multiple mechanisms of injury, with the clinical assumption that women have hormonally mediated neuroprotection because of the endogenous presence of these hormones. Other literature indicates that testosterone may exacerbate injury. Further, stress hormone abnormalities that accompany critical illness may both amplify or blunt sex steroid levels. To better understand the role of sex steroid exposure in mediating TBI, we 1) characterized temporal profiles of serum gonadal and stress hormones in a population with severe TBI during the acute phases of their injury; and 2) used a biological systems approach to evaluate these hormones as biomarkers predicting global outcome. The study population was 117 adults (28 women; 89 men) with severe TBI. Serum samples (n=536) were collected for 7 days post-TBI for cortisol, progesterone, testosterone, estradiol, luteinizing hormone (LH), and follicle-stimulating hormone (FSH). Hormone data were linked with clinical data, including acute care mortality and Glasgow Outcome Scale (GOS) scores at 6 months. Hormone levels after TBI were compared to those in healthy controls (n=14). Group based trajectory analysis (TRAJ) was used to develop temporal hormone profiles that delineate distinct subpopulations in the cohort. Structural equations models were used to determine inter-relationships between hormones and outcomes within a multivariate model. Compared to controls, acute serum hormone levels were significantly altered after severe TBI. Changes in the post-TBI adrenal response and peripheral aromatization influenced hormone TRAJ profiles and contributed to the abnormalities, including increased estradiol in men and increased testosterone in women. In addition to older age and greater injury severity, increased estradiol and testosterone levels over time were associated with increased mortality and worse global outcome for both men and women. These findings represent a paradigm shift when thinking about the role of sex steroids in neuroprotection clinically after TBI.
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Affiliation(s)
- Amy K Wagner
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania 15213, USA.
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