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Salton F, Confalonieri P, Meduri GU, Mondini L, Trotta L, Barbieri M, Bozzi C, Torregiani C, Lerda S, Bellan M, Confalonieri M, Ruaro B, Tavano S, Pozzan R. Theory and Practice of Glucocorticoids in COVID-19: Getting to the Heart of the Matter-A Critical Review and Viewpoints. Pharmaceuticals (Basel) 2023; 16:924. [PMID: 37513836 PMCID: PMC10385094 DOI: 10.3390/ph16070924] [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: 05/03/2023] [Revised: 06/18/2023] [Accepted: 06/21/2023] [Indexed: 07/30/2023] Open
Abstract
Prolonged, low-dose glucocorticoids (GCs) have shown the highest efficacy among pharmacological and non-pharmacological treatments for COVID-19. Despite the World Health Organization's recommendation against their use at the beginning of the pandemic, GCs at a dose equivalent to dexamethasone 6 mg/day for 10 days are now indicated in all COVID-19 cases who require respiratory support. However, the efficacy of the intervention depends on the timing of initiation, the dose, and other individual factors. Indeed, patients treated with similar GC protocols often experience different outcomes, which do not always correlate with the presence of comorbidities or with the severity of respiratory involvement at baseline. This prompted us to critically review the literature on the rationale, pharmacological principles, and clinical evidence that should guide GC treatment. Based on these data, the best treatment protocol probably involves an initial bolus dose to saturate the glucocorticoid receptors, followed by a continuous infusion to maintain constant plasma levels, and eventually a slow tapering to interruption. Methylprednisolone has shown the highest efficacy among different GC molecules, most likely thanks to its higher ability to penetrate the lung. Decreased tissue sensitivity to glucocorticoids is thought to be the main mechanism accounting for the lower response to the treatment in some individuals. We do not have a readily available test to identify GC resistance; therefore, to address inter-individual variability, future research should aim at investigating clinical, physiological, and laboratory markers to guide a personalized GC treatment approach.
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Affiliation(s)
- Francesco Salton
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University Hospital of Cattinara, University of Trieste, 34149 Trieste, Italy
| | - Paola Confalonieri
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University Hospital of Cattinara, University of Trieste, 34149 Trieste, Italy
| | - Gianfranco Umberto Meduri
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Lucrezia Mondini
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University Hospital of Cattinara, University of Trieste, 34149 Trieste, Italy
| | - Liliana Trotta
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University Hospital of Cattinara, University of Trieste, 34149 Trieste, Italy
| | - Mariangela Barbieri
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University Hospital of Cattinara, University of Trieste, 34149 Trieste, Italy
| | - Chiara Bozzi
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University Hospital of Cattinara, University of Trieste, 34149 Trieste, Italy
| | - Chiara Torregiani
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University Hospital of Cattinara, University of Trieste, 34149 Trieste, Italy
| | - Selene Lerda
- Business School, University of Milano, 20149 Milano, Italy
| | - Mattia Bellan
- Department of Translational Medicine, Università del Piemonte Orientale (UPO), 28100 Novara, Italy
- Center for Autoimmune and Allergic Disease (CAAD), Università del Piemonte Orientale (UPO), 28100 Novara, Italy
- A.O.U. Maggiore della Carità, 28100 Novara, Italy
| | - Marco Confalonieri
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University Hospital of Cattinara, University of Trieste, 34149 Trieste, Italy
| | - Barbara Ruaro
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University Hospital of Cattinara, University of Trieste, 34149 Trieste, Italy
| | - Stefano Tavano
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University Hospital of Cattinara, University of Trieste, 34149 Trieste, Italy
| | - Riccardo Pozzan
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University Hospital of Cattinara, University of Trieste, 34149 Trieste, Italy
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Ilias I, Vassiliou AG, Keskinidou C, Vrettou CS, Orfanos S, Kotanidou A, Dimopoulou I. Changes in Cortisol Secretion and Corticosteroid Receptors in COVID-19 and Non COVID-19 Critically Ill Patients with Sepsis/Septic Shock and Scope for Treatment. Biomedicines 2023; 11:1801. [PMID: 37509441 PMCID: PMC10376106 DOI: 10.3390/biomedicines11071801] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 06/16/2023] [Accepted: 06/22/2023] [Indexed: 07/30/2023] Open
Abstract
Sepsis is associated with dysregulated cortisol secretion, leading to abnormal levels of cortisol in the blood. In the early stages of the condition, cortisol levels are typically elevated due to increased secretion from the adrenal glands. However, as the disease progresses, cortisol levels may decline due to impaired adrenal function, leading to relative adrenal insufficiency. The latter is thought to be caused by a combination of factors, including impaired adrenal function, decreased production of corticotropin-releasing hormone (CRH) and adrenocorticotropic hormone (ACTH) by the hypothalamus and pituitary gland, and increased breakdown of cortisol. The dysregulation of cortisol secretion in sepsis is thought to contribute to the pathophysiology of the disease by impairing the body's ability to mount an appropriate inflammatory response. Given the dysregulation of cortisol secretion and corticosteroid receptors in sepsis, there has been considerable interest in the use of steroids as a treatment. However, clinical trials have yielded mixed results and corticosteroid use in sepsis remains controversial. In this review, we will discuss the changes in cortisol secretion and corticosteroid receptors in critically ill patients with sepsis/septic shock. We will also make special note of COVID-19 patients, who presented a recent challenge for ICU management, and explore the scope for corticosteroid administration in both COVID-19 and non-COVID-19 septic patients.
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Affiliation(s)
- Ioannis Ilias
- Department of Endocrinology, Diabetes and Metabolism, Elena Venizelou Hospital, GR-11521 Athens, Greece
| | - Alice G Vassiliou
- 1st Department of Critical Care Medicine and Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, GR-10676 Athens, Greece
| | - Chrysi Keskinidou
- 1st Department of Critical Care Medicine and Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, GR-10676 Athens, Greece
| | - Charikleia S Vrettou
- 1st Department of Critical Care Medicine and Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, GR-10676 Athens, Greece
| | - Stylianos Orfanos
- 1st Department of Critical Care Medicine and Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, GR-10676 Athens, Greece
| | - Anastasia Kotanidou
- 1st Department of Critical Care Medicine and Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, GR-10676 Athens, Greece
| | - Ioanna Dimopoulou
- 1st Department of Critical Care Medicine and Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, GR-10676 Athens, Greece
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Yu Y, Tang Z, Xie M, Li J, Hang CC, An L, Li C. Glucocorticoid receptor expression in patients with cardiac arrest in the early period after the return of spontaneous circulation: a prospective observational single-centre study. BMJ Open 2022; 12:e060246. [PMID: 36691201 PMCID: PMC9462114 DOI: 10.1136/bmjopen-2021-060246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 08/15/2022] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVES Rapid changes in glucocorticoid (GC) levels and adrenal insufficiency are related to the development of post-cardiac arrest (CA) syndrome. However, GC receptor (GR) expression changes have not been studied. Hence, this study aimed to investigate the association of early changes in GR expression and prognosis and immune response in patients who experienced CA. DESIGN Prospective observational study. SETTING Emergency department. PARTICIPANTS Patients (85) in the early period of return of spontaneous circulation (ROSC) after CA were admitted between October 2018 and October 2019. After a physical examination, age-matched and sex-matched healthy individuals (40) were recruited for the control group. PRIMARY AND SECONDARY OUTCOME MEASURES GR expression and cell counts of circulatory T and B lymphocytes, natural killer cells and regulatory T (Treg) cells were assessed. Plasma total cortisol and adrenocorticotrophic hormone (ACTH) levels were also tested. RESULTS All cell counts were lower, and plasma total cortisol levels were higher (p<0.001) in patients who experienced CA than in the healthy control group. GR expression in Treg cells and CD3+CD4+ T lymphocytes were not significantly different, but the mean fluorescence intensity and GR expression in other cells were lower in patients who experienced CA (p<0.05) than in the healthy control group. ACTH levels were not different. There were no significant differences between survivors and non-survivors. CONCLUSIONS This study revealed that GR expression and cell counts rapidly decreased, whereas plasma total cortisol levels increased in the early period after ROSC among patients who experienced CA. Our findings provide important information about GR level and function, and immunosuppressive status in these patients. Assessing GR expression in patients who experienced CA may help screening for those who are more sensitive to GC therapy.
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Affiliation(s)
- Yanan Yu
- Department of Emergency Medicine, Beijing Chao-Yang Hospital Capital Medical University, Beijing, Beijing, China
| | - Ziren Tang
- Department of Emergency Medicine, Beijing Chao-Yang Hospital Capital Medical University, Beijing, Beijing, China
| | - Miaorong Xie
- Department of Emergency Medicine, Capital Medical University Affiliated Beijing Friendship Hospital, Beijing, Beijing, China
| | - Jiabao Li
- Department of Critical Care, Capital Medical University Affiliated Beijing Friendship Hospital, Beijing, Beijing, China
| | - Chen-Chen Hang
- Department of Emergency Medicine, Beijing Chao-Yang Hospital Capital Medical University, Beijing, Beijing, China
| | - Le An
- Department of Emergency Medicine, Beijing Chao-Yang Hospital Capital Medical University, Beijing, Beijing, China
| | - Chunsheng Li
- Department of Emergency Medicine, Beijing Chao-Yang Hospital Capital Medical University, Beijing, Beijing, China
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Vassiliadi DA, Vassiliou AG, Ilias I, Tsagarakis S, Kotanidou A, Dimopoulou I. Pituitary-Adrenal Responses and Glucocorticoid Receptor Expression in Critically Ill Patients with COVID-19. Int J Mol Sci 2021; 22:11473. [PMID: 34768903 PMCID: PMC8584241 DOI: 10.3390/ijms222111473] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 10/18/2021] [Accepted: 10/21/2021] [Indexed: 12/15/2022] Open
Abstract
The hypothalamus-pituitary-adrenal (HPA) axis was described as the principal component of the stress response 85 years ago, along with the acute-phase reaction, and the defense response at the tissue level. The orchestration of these processes is essential since systemic inflammation is a double-edged sword; whereas inflammation that is timely and of appropriate magnitude is beneficial, exuberant systemic inflammation incites tissue damage with potentially devastating consequences. Apart from its beneficial cardiovascular and metabolic effects, cortisol exerts a significant immunoregulatory role, a major attribute being that it restrains the excessive inflammatory reaction, thereby preventing unwanted tissue damage. In this review, we will discuss the role of the HPA axis in the normal stress response and in critical illness, especially in critically ill patients with coronavirus disease 2019 (COVID-19). Finally, a chapter will be dedicated to the findings from clinical studies in critical illness and COVID-19 on the expression of the mediator of glucocorticoid actions, the glucocorticoid receptor (GCR).
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Affiliation(s)
- Dimitra A. Vassiliadi
- Department of Endocrinology, Diabetes and Metabolism, National Expertise Centre for Rare Endocrine Diseases, Evangelismos Hospital, 106 76 Athens, Greece; (D.A.V.); (S.T.)
| | - Alice G. Vassiliou
- First Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National & Kapodistrian University of Athens, Evangelismos Hospital, 106 76 Athens, Greece; (A.G.V.); (A.K.)
| | - Ioannis Ilias
- Department of Endocrinology, Helena Venizelos Hospital, 115 21 Athens, Greece;
| | - Stylianos Tsagarakis
- Department of Endocrinology, Diabetes and Metabolism, National Expertise Centre for Rare Endocrine Diseases, Evangelismos Hospital, 106 76 Athens, Greece; (D.A.V.); (S.T.)
| | - Anastasia Kotanidou
- First Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National & Kapodistrian University of Athens, Evangelismos Hospital, 106 76 Athens, Greece; (A.G.V.); (A.K.)
| | - Ioanna Dimopoulou
- First Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National & Kapodistrian University of Athens, Evangelismos Hospital, 106 76 Athens, Greece; (A.G.V.); (A.K.)
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Wang J, Zhu CK, Yu JQ, Tan R, Yang PL. Hypoglycemia and mortality in sepsis patients: A systematic review and meta-analysis. Heart Lung 2021; 50:933-940. [PMID: 34433111 DOI: 10.1016/j.hrtlng.2021.07.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 07/09/2021] [Accepted: 07/28/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Hypoglycemia frequently occurs in patients with sepsis. The status of prognosis of sepsis patients varies with the cause of hypoglycemia. OBJECTIVE A meta-analysis was performed to obtain a reliable basis for assessing the severity of disease in sepsis patients. METHODS A search of electronic databases was performed. The random-effects model was employed to calculate the overall odds ratio (OR) and 95% CI. RESULTS Five cohort studies were included. Decreased blood glucose level was associated with an increased risk of death [OR:1.68; 95% CI (1.12-2.53)]. Incidents of mortality were analyzed based on the causative factor of hypoglycemia. Patients with spontaneous hypoglycemia showed a significantly higher mortality rate than the control subjects[OR 1.65; 95% CI (1.20-2.28); p = 0.002]. CONCLUSION In the early stages of sepsis, the occurrence of spontaneous hypoglycemia may be associated with the severity of the disease.
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Affiliation(s)
- Jing Wang
- Graduate school of Dalian Medical University, Dalian, Liaoning, China; Department of Critical Care Medicine, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu, China
| | - Cheng-Kai Zhu
- Department of Gastroenterology, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu, China
| | - Jiang-Quan Yu
- Clinical Medical College, Yangzhou University, Yangzhou, Jiangsu, China; Department of Critical Care Medicine, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu, China.
| | - Rui Tan
- Graduate school of Dalian Medical University, Dalian, Liaoning, China; Department of Critical Care Medicine, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu, China
| | - Peng-Lei Yang
- Graduate school of Dalian Medical University, Dalian, Liaoning, China; Department of Critical Care Medicine, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu, China
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Leukocyte glucocorticoid receptor expression and related transcriptomic gene signatures during early sepsis. Clin Immunol 2020; 223:108660. [PMID: 33352295 DOI: 10.1016/j.clim.2020.108660] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 11/04/2020] [Accepted: 12/17/2020] [Indexed: 11/21/2022]
Abstract
PURPOSE The study aimed to understand the molecular mechanisms that might lead to differences in the glucocorticoid response during sepsis. METHODS Patients diagnosed with sepsis (n = 198) and 40 healthy controls were enrolled. Glucocorticoid receptor (GR) expression in circulating leukocytes and plasma levels of adrenocorticotropic hormone and cortisol on days 1 and 7 were measured in all participants. Expression profiling of 16 genes associated with GR expression in peripheral blood mononuclear cells (PBMCs) in 12 healthy controls and 26 patients with sepsis was performed by PCR. RESULTS Cortisol levels were higher in patients with sepsis than in healthy controls on day 1 after admission and recovered to normal levels by day 7. GR expression was gradually downregulated in leukocyte subsets. Non-survivors showed lower GR and higher cortisol levels than survivors. GRα expression was lower in patients with sepsis than in controls, whereas GRβ showed the opposite trend. MicroRNAs related to GR resistance and suppression were altered in PBMCs during sepsis. CONCLUSION Patients with sepsis showed upregulated plasma cortisol levels along with downregulated GR expression on various leukocyte subtypes, portending poor cortisol response and outcome. Changes in GR-regulatory miRNAs may be responsible for GR low expression.
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Razik SA, Hashem HE, Ahmed WO. New insight of adrenal responses in premature neonates versus full term neonates in critical care setting.. [DOI: 10.1101/2020.07.15.20154849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
BackgroundAdequate adrenocortical function is essential for survival of critically ill neonates. Although most of them display elevated plasma cortisol concentrations, which reflects activation of the hypothalamic pituitary adrenal axis (HPA), yet; adrenocortical insufficiency is seen in septic shock. Objectives: Evaluate the HPA response in critically ill neonates with shock.Methodsthis prospective observational Participant: a total of 60 neonates divided into 3 groups;(A) 30 critical ill neonates with septic shock on inotropic support, (B)15 patients with sepsis with no inotropic support and(C) control group(n=15). Intervention: a single diurnal ACTH reading and two readings for serum cortisol level (diurnal and nocturnal).ResultsGram negative organism was more prevalent among the patients; 53%, 63% in groups A and B respectively. Group A showed Significant statistical hypotension before vasopressor drug administration (p<0.001) as compared to both groups. Group A showed Significant statistical improvement of blood pressure after vasopressor drug administration (p<0.001) as compared to both groups B, C. Serum cortisol was significantly higher in group A(57.21±24.31) and B (48.01±18.27), while it was lower in group C(19.57±16.05). A highly statistically significant rise of serum cortisol level(p=0.000) and ACTH(p=0.000) in group A when was compared to the other two groups.ConclusionThis study introduced a new pattern of serum cortisol response in neonates ranging from very high cortisol level to a near normal values; highlighting a state of glucocorticoid resistance in neonates and relative adrenal insufficiency.
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Meduri GU, Chrousos GP. General Adaptation in Critical Illness: Glucocorticoid Receptor-alpha Master Regulator of Homeostatic Corrections. Front Endocrinol (Lausanne) 2020; 11:161. [PMID: 32390938 PMCID: PMC7189617 DOI: 10.3389/fendo.2020.00161] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 03/09/2020] [Indexed: 12/20/2022] Open
Abstract
In critical illness, homeostatic corrections representing the culmination of hundreds of millions of years of evolution, are modulated by the activated glucocorticoid receptor alpha (GRα) and are associated with an enormous bioenergetic and metabolic cost. Appreciation of how homeostatic corrections work and how they evolved provides a conceptual framework to understand the complex pathobiology of critical illness. Emerging literature place the activated GRα at the center of all phases of disease development and resolution, including activation and re-enforcement of innate immunity, downregulation of pro-inflammatory transcription factors, and restoration of anatomy and function. By the time critically ill patients necessitate vital organ support for survival, they have reached near exhaustion or exhaustion of neuroendocrine homeostatic compensation, cell bio-energetic and adaptation functions, and reserves of vital micronutrients. We review how critical illness-related corticosteroid insufficiency, mitochondrial dysfunction/damage, and hypovitaminosis collectively interact to accelerate an anti-homeostatic active process of natural selection. Importantly, the allostatic overload imposed by these homeostatic corrections impacts negatively on both acute and long-term morbidity and mortality. Since the bioenergetic and metabolic reserves to support homeostatic corrections are time-limited, early interventions should be directed at increasing GRα and mitochondria number and function. Present understanding of the activated GC-GRα's role in immunomodulation and disease resolution should be taken into account when re-evaluating how to administer glucocorticoid treatment and co-interventions to improve cellular responsiveness. The activated GRα interdependence with functional mitochondria and three vitamin reserves (B1, C, and D) provides a rationale for co-interventions that include prolonged glucocorticoid treatment in association with rapid correction of hypovitaminosis.
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Affiliation(s)
- Gianfranco Umberto Meduri
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, United States
- Memphis Veterans Affairs Medical Center, Memphis, TN, United States
| | - George P. Chrousos
- University Research Institute of Maternal and Child Health and Precision Medicine, National and Kapodistrian University of Athens, Medical School, Athens, Greece
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Vassiliou AG, Floros G, Jahaj E, Stamogiannos G, Gennimata S, Vassiliadi DA, Tsagarakis S, Tzanela M, Ilias I, Orfanos SE, Kotanidou A, Dimopoulou I. Decreased glucocorticoid receptor expression during critical illness. Eur J Clin Invest 2019; 49:e13073. [PMID: 30703253 DOI: 10.1111/eci.13073] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 09/27/2018] [Accepted: 01/01/2019] [Indexed: 01/07/2023]
Abstract
INTRODUCTION In critically ill patients, the hypothalamic-pituitary-adrenal axis is activated, resulting in increased serum cortisol concentrations. However, in some patients, especially those with sepsis, cortisol levels are relatively low for the degree of illness severity. Therefore, in the present project, we aim to characterize the time course of glucocorticoid receptor (GCR) alpha and beta expression in peripheral polymorphonuclear cells of critically ill septic or nonseptic patients using real-time PCR. DESIGN A prospective observational study conducted on 32 critically ill adults not receiving steroids, in a university-affiliated, multidisciplinary intensive care unit (ICU). Blood samples were collected for measurement of glucocorticoid receptor expression within 24-48 hours of admission to the ICU and at days 4, 8 and 13 after admission, reflecting the acute and chronic phase of the illness. RESULTS During ICU stay, patients expressed over time reduced levels of both GCR-α and GCR-β mRNA. More specifically, GCR-α mRNA expression was decreased fourfold 4 days after admission (P < 0.0001) and remained low up to 2 weeks after admission (P < 0.001). On the other hand, GCR-β mRNA levels remained stable shortly after admission, but approx. one week after admission, its levels decreased threefold (P < 0.01) and remained reduced up to 2 weeks after admission (P < 0.001). DISCUSSION Our results suggest that critically ill patients have highly variable expression of alpha and beta GCR, and moreover, the levels of both receptors decrease during ICU stay. Taken together, these might explain the differential responsiveness of patients to exogenous steroid administration or to endogenous cortisol secretion.
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Affiliation(s)
- Alice G Vassiliou
- 1st Department of Critical Care Medicine & Pulmonary Services, GP Livanos and M Simou Laboratories, Evangelismos Hospital, Athens Medical School, National & Kapodistrian University of Athens, Athens, Greece
| | - Georgios Floros
- 1st Department of Critical Care Medicine & Pulmonary Services, Evangelismos Hospital, Athens Medical School, National & Kapodistrian University of Athens, Athens, Greece
| | - Edison Jahaj
- 1st Department of Critical Care Medicine & Pulmonary Services, Evangelismos Hospital, Athens Medical School, National & Kapodistrian University of Athens, Athens, Greece
| | - Georgios Stamogiannos
- 1st Department of Critical Care Medicine & Pulmonary Services, Evangelismos Hospital, Athens Medical School, National & Kapodistrian University of Athens, Athens, Greece
| | - Sofianna Gennimata
- 1st Department of Critical Care Medicine & Pulmonary Services, Evangelismos Hospital, Athens Medical School, National & Kapodistrian University of Athens, Athens, Greece
| | - Dimitra A Vassiliadi
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Stylianos Tsagarakis
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Marinella Tzanela
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Ioannis Ilias
- Endocrine Unit, Elena Venizelou Hospital, Athens, Greece
| | - Stylianos E Orfanos
- 1st Department of Critical Care Medicine & Pulmonary Services, GP Livanos and M Simou Laboratories, Evangelismos Hospital, Athens Medical School, National & Kapodistrian University of Athens, Athens, Greece.,1st Department of Critical Care Medicine & Pulmonary Services, Evangelismos Hospital, Athens Medical School, National & Kapodistrian University of Athens, Athens, Greece
| | - Anastasia Kotanidou
- 1st Department of Critical Care Medicine & Pulmonary Services, GP Livanos and M Simou Laboratories, Evangelismos Hospital, Athens Medical School, National & Kapodistrian University of Athens, Athens, Greece.,1st Department of Critical Care Medicine & Pulmonary Services, Evangelismos Hospital, Athens Medical School, National & Kapodistrian University of Athens, Athens, Greece
| | - Ioanna Dimopoulou
- 1st Department of Critical Care Medicine & Pulmonary Services, Evangelismos Hospital, Athens Medical School, National & Kapodistrian University of Athens, Athens, Greece
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Abstract
OBJECTIVE The definition of an adequate adrenal response in critically ill children continues to be controversial. We aimed to evaluate the cortisol levels at baseline and after adrenocorticotropin (ACTH) stimulation and determine their association to clinical outcome of critically ill children. METHODS All children who underwent an ACTH test in the pediatric intensive care unit (PICU) in a tertiary medical center between 2006 and 2013 were included in the study. Data on age, sex, diagnosis, vasoactive-inotropic score, length of pediatric intensive care unit stay, and mortality were obtained. Laboratory variables included hematologic and chemistry data, arterial lactate, and total plasma cortisol levels at baseline and after ACTH stimulation. RESULTS Ninety-nine patients (61 males; median [range] age, 2 [0-204] months) were enrolled. The mortality rate of children with a baseline cortisol level of 600 nmol/L or greater was 36% (12/33 patients) versus 18% (12/66 patients) for children with a baseline cortisol level of less than 600 nmol/L (odds ratio, 2.6 [95% confidence interval, 1-6.6]; P = 0.05). There was a positive correlation between baseline cortisol and lactate levels (r = 0.40, P < 0.0001), vasoactive-inotropic scores (r = 0.24, P = 0.02), and mortality (P = 0.05). There was no correlation between peak cortisol measured at the ACTH test or the delta increment of cortisol from baseline and mortality. CONCLUSIONS A high baseline cortisol level in critically ill children was associated with more severe illness, higher lactate level, and a higher mortality rate. Routine baseline cortisol assessment is recommended to identify patients at high mortality risk.
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Flores S, Cooper DS, Opoka AM, Iliopoulos I, Pluckebaum S, Alder MN, Krallman K, Sahay RD, Fei L, Wong HR. Characterization of the Glucocorticoid Receptor in Children Undergoing Cardiac Surgery. Pediatr Crit Care Med 2018; 19:705-712. [PMID: 29677033 PMCID: PMC6086750 DOI: 10.1097/pcc.0000000000001572] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Postoperative administration of corticosteroids is common practice for managing catecholamine refractory low cardiac output syndrome. Since corticosteroid activity is dependent on the glucocorticoid receptor, we sought to characterize glucocorticoid receptor levels in children undergoing cardiac surgery and examined the association between glucocorticoid receptor levels and cardiovascular dysfunction. DESIGN Prospective observational cohort study. SETTING Large, tertiary pediatric cardiac center. SUBJECTS Children undergoing corrective or palliative cardiac surgery. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A prospective observational cohort study was conducted in 83 children with congenital heart disease. Total glucocorticoid receptor levels were measured in the peripheral WBCs using flow cytometry. In addition, blood samples were collected for total cortisol levels. The primary outcome studied was the time to being inotrope free. An increase in glucocorticoid receptor level from postoperative day 1 to postoperative day 3 was associated with a longer time to being inotrope free (hazard ratio, 0.49 [0.29-0.81]; p = 0.01) in the univariate analysis. This association remained significant after adjusting for age, weight, cardiopulmonary bypass time, cross clamp time, Risk Adjustment for Congenital Heart Surgery-1 score, and postoperative steroid use (hazard ratio, 0.53 [0.29-0.99]; p = 0.05). Postoperative day 3 glucocorticoid receptor level showed a trend to have longer time to being inotrope free (hazard ratio, 0.66 [0.42-1.02]; p = 0.0.06). The cortisol levels minimally increased during the study duration and did not correlate with glucocorticoid receptor levels. CONCLUSIONS Increasing glucocorticoid receptor levels in peripheral WBCs of children undergoing cardiac surgery are associated with a longer time to being inotrope free. Cortisol levels minimally increased during the study duration. These results suggest that exposure to high-dose perioperative corticosteroids may suppress the hypothalamic-pituitary-adrenal axis leading to increase in glucocorticoid receptor levels in response to a low cortisol environment. Further studies are required to better delineate the interplay between glucocorticoid receptor levels, cortisol levels, corticosteroid exposure, and postoperative inotropic requirements.
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Affiliation(s)
- Saul Flores
- Department of Pediatrics, Section of Critical Care Medicine, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, USA
- Department of Pediatrics, Division of Critical Care, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - David S. Cooper
- Department of Pediatrics, The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Amy M. Opoka
- Department of Pediatrics, Division of Critical Care, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Ilias Iliopoulos
- Department of Pediatrics, The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Sarah Pluckebaum
- Department of Pediatrics, The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Matthew N. Alder
- Department of Pediatrics, Division of Critical Care, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Kelli Krallman
- Department of Pediatrics, Division of Critical Care, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Rashmi D. Sahay
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Lin Fei
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Hector R. Wong
- Department of Pediatrics, Division of Critical Care, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
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12
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Looking Under the Lamp Post, But You Dropped Your Keys Down the Street: Glucocorticoid Receptors in WBCs After Heart Surgery? Pediatr Crit Care Med 2018; 19:777-778. [PMID: 30095713 DOI: 10.1097/pcc.0000000000001577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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13
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Menon K, McNally D, Acharya A, O'Hearn K, Choong K, Wong HR, McIntyre L, Lawson M. Random serum free cortisol and total cortisol measurements in pediatric septic shock. J Pediatr Endocrinol Metab 2018; 31:757-762. [PMID: 29953408 DOI: 10.1515/jpem-2018-0027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 04/23/2018] [Indexed: 11/15/2022]
Abstract
Background The aim of the study was to examine the relationship between serum total cortisol (TC) and free cortisol (FC) levels in children with septic shock and the relationship of these levels with baseline illness severity. Methods A sub-study of a randomized controlled trial (RCT) of hydrocortisone vs. placebo in pediatric septic shock conducted in seven academic pediatric intensive care units (PICUs) in Canada on children aged newborn to 17 years. Thirty children with septic shock had serum sent for TC and FC measurement within 6 h of meeting the study eligibility criteria. Results Baseline FC and TC levels were strongly correlated with baseline Pediatric Risk of Mortality (PRISM) score (R2=0.759, p<0.001; R2=0.717, p<0.001) and moderately correlated with admission Vasotropic Inotropic Score (VIS) (R2=0.489, p<0.001; R2=0.316, p<0.001). Serum TC levels were highly correlated with FC levels (R2=0.92, p<0.001) and showed strong agreement (R2=0.98, p<0.001 on a Bland-Altman plot). The ratio of FC to TC moderately correlated with TC levels (R2=0.46, p<0.001) but did not correlate with baseline albumin levels (R2=0.19, p=0.13). Conclusions Random TC and FC levels are strongly correlated, show strong agreement and are reflective of illness severity in children with septic shock. As such, isolated FC measurement does not appear to provide added information relative to TC in acutely ill children with septic shock.
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Affiliation(s)
- Kusum Menon
- Children's Hospital of Eastern Ontario, Department of Pediatrics, 401 Smyth Road, Ottawa, ON K1H 8L1, Canada, Phone: +6137377600 (2538), Fax: +6137384287
| | - Dayre McNally
- Children's Hospital of Eastern Ontario, Department of Pediatrics, Ottawa, ON, Canada
| | - Anand Acharya
- Carleton University, Department of Economics, Ottawa, ON, Canada
| | - Katharine O'Hearn
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Karen Choong
- McMaster Children's Hospital, Department of Pediatrics, Hamilton, ON, Canada
| | - Hector R Wong
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Margaret Lawson
- Children's Hospital of Eastern Ontario, Department of Pediatrics, Ottawa, ON, Canada
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Jenniskens M, Weckx R, Dufour T, Vander Perre S, Pauwels L, Derde S, Téblick A, Güiza F, Van den Berghe G, Langouche L. The Hepatic Glucocorticoid Receptor Is Crucial for Cortisol Homeostasis and Sepsis Survival in Humans and Male Mice. Endocrinology 2018; 159:2790-2802. [PMID: 29788135 DOI: 10.1210/en.2018-00344] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 05/09/2018] [Indexed: 01/15/2023]
Abstract
Sepsis is hallmarked by hypercortisolemia, a stress response essential for survival. This elevation in plasma cortisol is partially brought about by suppressed hepatic cortisol breakdown. We demonstrate that a controlled downregulation of the hepatic glucocorticoid receptor (hepatic GR) is crucial. In a mouse model of fluid-resuscitated, antibiotic-treated abdominal sepsis and in human intensive care unit patients, sepsis reduced hepatic GR expression and signaling but increased (free) plasma cortisol/corticosterone, explained by suppressed cortisol/corticosterone-binding proteins and A-ring reductases. However, further experimental inhibition of hepatic GR with short hairpin RNA (shRNA) in septic mice increased mortality fivefold. Acutely, this further hepatic GR suppression prevented the rise in total corticosterone but further reduced binding proteins, resulting in elevated free corticosterone. After 3 days of shRNA-GR inhibition in sepsis, both total and free corticosterone levels were elevated, now explained by an additional reduction in A-ring reductase expression. Hepatic GR inhibition blunted the hyperglycemic stress response without causing hypoglycemia but also markedly increased circulating and hepatic inflammation markers and caused liver destruction, the severity of which explained increased mortality. In human sepsis, glucocorticoid treatment further suppressed hepatic GR expression, which could directly predispose to worse outcomes. In conclusion, sepsis partially suppressed hepatic GR expression, which appeared crucial to upregulate free cortisol/corticosterone availability. However, further sustained hepatic GR suppression evoked lethal excessive liver and systemic inflammation, independent of systemic cortisol/corticosterone availability.
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Affiliation(s)
- Marc Jenniskens
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Ruben Weckx
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Thomas Dufour
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Sarah Vander Perre
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Lies Pauwels
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Sarah Derde
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Arno Téblick
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Fabian Güiza
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Lies Langouche
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
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15
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Peeters B, Langouche L, Van den Berghe G. Adrenocortical Stress Response during the Course of Critical Illness. Compr Physiol 2017; 8:283-298. [DOI: 10.1002/cphy.c170022] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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16
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American College of Critical Care Medicine Clinical Practice Parameters for Hemodynamic Support of Pediatric and Neonatal Septic Shock. Crit Care Med 2017; 45:1061-1093. [PMID: 28509730 DOI: 10.1097/ccm.0000000000002425] [Citation(s) in RCA: 381] [Impact Index Per Article: 54.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES The American College of Critical Care Medicine provided 2002 and 2007 guidelines for hemodynamic support of newborn and pediatric septic shock. Provide the 2014 update of the 2007 American College of Critical Care Medicine "Clinical Guidelines for Hemodynamic Support of Neonates and Children with Septic Shock." DESIGN Society of Critical Care Medicine members were identified from general solicitation at Society of Critical Care Medicine Educational and Scientific Symposia (2006-2014). The PubMed/Medline/Embase literature (2006-14) was searched by the Society of Critical Care Medicine librarian using the keywords: sepsis, septicemia, septic shock, endotoxemia, persistent pulmonary hypertension, nitric oxide, extracorporeal membrane oxygenation, and American College of Critical Care Medicine guidelines in the newborn and pediatric age groups. MEASUREMENTS AND MAIN RESULTS The 2002 and 2007 guidelines were widely disseminated, translated into Spanish and Portuguese, and incorporated into Society of Critical Care Medicine and American Heart Association/Pediatric Advanced Life Support sanctioned recommendations. The review of new literature highlights two tertiary pediatric centers that implemented quality improvement initiatives to improve early septic shock recognition and first-hour compliance to these guidelines. Improved compliance reduced hospital mortality from 4% to 2%. Analysis of Global Sepsis Initiative data in resource rich developed and developing nations further showed improved hospital mortality with compliance to first-hour and stabilization guideline recommendations. CONCLUSIONS The major new recommendation in the 2014 update is consideration of institution-specific use of 1) a "recognition bundle" containing a trigger tool for rapid identification of patients with septic shock, 2) a "resuscitation and stabilization bundle" to help adherence to best practice principles, and 3) a "performance bundle" to identify and overcome perceived barriers to the pursuit of best practice principles.
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17
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Vardas K, Ilia S, Sertedaki A, Charmandari E, Briassouli E, Goukos D, Apostolou K, Psarra K, Botoula E, Tsagarakis S, Magira E, Routsi C, Stratakis CA, Nanas S, Briassoulis G. Increased glucocorticoid receptor expression in sepsis is related to heat shock proteins, cytokines, and cortisol and is associated with increased mortality. Intensive Care Med Exp 2017; 5:10. [PMID: 28224564 PMCID: PMC5319939 DOI: 10.1186/s40635-017-0123-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 02/09/2017] [Indexed: 01/30/2023] Open
Abstract
Background The purposes of this study are to examine if the human glucocorticoid receptor (hGR) isoform-α mRNA and hGR protein expressions are deficient in the acute phase of sepsis (S) compared to systemic inflammatory response syndrome (SIRS) and healthy subjects (H) and to evaluate if the hGRα and hGR alterations are associated with cortisol changes and if they are related to (1) extracellular and intracellular heat shock proteins (HSP) 72 and 90α; (2) ACTH, prolactin, and interleukins (ILs); and (3) outcome. Methods Patients consecutively admitted to a university hospital intensive care unit (ICU) with S (n = 48) or SIRS (n = 40) were enrolled in the study. Thirty-five H were also included. Total mRNA was isolated from peripheral blood samples and cDNA was prepared. RT-PCR was performed. Intracellular hGR and HSP expression in monocytes and/or neutrophils was evaluated using four-colour flow cytometry. Serum prolactin, ACTH, and cortisol concentrations were also measured. ELISA was used to evaluate serum ILs and extracellular (e) HSPs (eHSP72, eHSP90α). Results hGR protein was higher in S compared to H and SIRS; hGRα mRNA was higher in S compared to H (p < 0.05). In sepsis, hGR protein and eHSP72 were higher among non-survivors compared to survivors (p < 0.05). The hGR MFI and hGRα mRNA fold changes were significantly related to each other (rs = 0.64, p < 0.001). Monocyte hGR protein expression was positively correlated with extracellular and intracellular HSPs, cortisol, and ILs and negatively to organ dysfunction (p < 0.05). HSPs, hGR, and cortisol were able to discriminate sepsis from SIRS (AUROC > 0.85, p < 0.05). In sepsis, monocyte-hGR protein and eHSP72 were strong predictors of mortality (AUROC > 0.95, p < 0.04). Conclusions Acute-phase sepsis is associated with increased hGR expression and cortisol concentrations, possibly implying no need for exogenous steroids. At this stage, hGR is able to predict sepsis and outcome and is related to stress-activated bio-molecules and organ dysfunction.
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Affiliation(s)
- Konstantinos Vardas
- First Critical Care Department, National and Kapodistrian University of Athens, Athens, Greece.,Pediatric Intensive Care Unit, University Hospital, University of Crete, 71500, Heraklion, Crete, Greece
| | - Stavroula Ilia
- Pediatric Intensive Care Unit, University Hospital, University of Crete, 71500, Heraklion, Crete, Greece
| | - Amalia Sertedaki
- Division of Endocrinology, Metabolism and Diabetes, First Department of Pediatrics, 'Aghia Sophia' Children's Hospital and Division of Endocrinology and Metabolism, Biomedical Research Foundation of the Academy of Athens, National and Kapodistrian University of Athens, Athens, Greece
| | - Evangelia Charmandari
- Division of Endocrinology, Metabolism and Diabetes, First Department of Pediatrics, 'Aghia Sophia' Children's Hospital and Division of Endocrinology and Metabolism, Biomedical Research Foundation of the Academy of Athens, National and Kapodistrian University of Athens, Athens, Greece
| | - Efrossini Briassouli
- First Department of Internal Medicine-Propaedeutic, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitris Goukos
- First Department of Internal Medicine-Propaedeutic, National and Kapodistrian University of Athens, Athens, Greece
| | - Kleovoulos Apostolou
- First Critical Care Department, National and Kapodistrian University of Athens, Athens, Greece
| | - Katerina Psarra
- Immunology-Histocompatibility Department, Evangelismos Hospital, Athens, Greece
| | - Efthimia Botoula
- Department of Endocrinology-Diabetes, Evangelismos Hospital, Athens, Greece
| | | | - Eleni Magira
- First Critical Care Department, National and Kapodistrian University of Athens, Athens, Greece
| | - Christina Routsi
- First Critical Care Department, National and Kapodistrian University of Athens, Athens, Greece
| | - Constantine A Stratakis
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health, Bethesda, MD, 20892, USA
| | - Serafim Nanas
- First Critical Care Department, National and Kapodistrian University of Athens, Athens, Greece
| | - George Briassoulis
- Pediatric Intensive Care Unit, University Hospital, University of Crete, 71500, Heraklion, Crete, Greece.
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18
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Boonen E, Van den Berghe G. MECHANISMS IN ENDOCRINOLOGY: New concepts to further unravel adrenal insufficiency during critical illness. Eur J Endocrinol 2016; 175:R1-9. [PMID: 26811405 DOI: 10.1530/eje-15-1098] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Accepted: 01/25/2016] [Indexed: 02/02/2023]
Abstract
The concept of 'relative' adrenal insufficiency during critical illness remains a highly debated disease entity. Several studies have addressed how to diagnose or treat this condition but have often yielded conflicting results, which further fuelled the controversy. The main reason for the controversy is the fact that the pathophysiology is not completely understood. Recently, new insights in the pathophysiology of the hypothalamic-pituitary-adrenal axis response to critical illness were generated. It was revealed that high circulating levels of cortisol during critical illness are explained more by reduced cortisol breakdown than by elevated cortisol production. Cortisol production rate during critical illness is less than doubled during the day but lower than in healthy subjects during the night. High plasma cortisol concentrations due to reduced breakdown in turn reduce plasma ACTH concentrations via feedback inhibition, which with time may lead to an understimulation and hereby a dysfunction of the adrenal cortex. This could explain the high incidence of adrenal insufficiency in the prolonged phase of critical illness. These novel insights have created a new framework for the diagnosis and treatment of adrenal failure during critical illness that has redirected future research.
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Affiliation(s)
- Eva Boonen
- Clinical Division and Laboratory of Intensive Care MedicineDepartment of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, B-3000 Leuven, Belgium
| | - Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care MedicineDepartment of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, B-3000 Leuven, Belgium
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19
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Bergquist M, Huss F, Hästbacka J, Lindholm C, Martijn C, Rylander C, Hedenstierna G, Fredén F. Glucocorticoid receptor expression and binding capacity in patients with burn injury. Acta Anaesthesiol Scand 2016; 60:213-21. [PMID: 26338204 DOI: 10.1111/aas.12604] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 05/25/2015] [Accepted: 06/25/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND Burn injuries are associated with strong inflammation and risk of secondary sepsis which both may affect the function of the glucocorticoid receptor (GR). The aim of this study was to determine GR expression and binding capacity in leucocytes from patients admitted to a tertiary burn center. METHODS Blood was sampled from 13 patients on admission and days 7, 14 and 21, and once from 16 healthy subjects. Patients were grouped according to the extent of burn and to any sepsis on day 7. Expression and binding capacity of GR were determined as arbitrary units using flow cytometry. RESULTS GR expression and binding capacity were increased compared to healthy subjects in most circulating leucocyte subsets on admission irrespective of burn size. Patients with sepsis on day 7 displayed increased GR expression in T lymphocytes (51.8%, P < 0.01) compared to admission. There was a negative correlation between GR binding capacity in neutrophils and burn size after 14 days (P < 0.05). CONCLUSIONS GR expression and binding capacity are increased in most types of circulating leucocytes of severely burned patients on their admission to specialized burn care. If sepsis is present after 1 week, it is associated with higher GR expression in T lymphocytes and NK cells.
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Affiliation(s)
- M. Bergquist
- Department of Medical Sciences, Clinical Physiology; Uppsala University; Uppsala Sweden
- Department of Rheumatology and Inflammation Research; Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
| | - F. Huss
- Uppsala Burn Center; Uppsala University Hospital; Uppsala Sweden
- Department of Surgical Sciences, Plastic Surgery; Uppsala University; Uppsala Sweden
| | - J. Hästbacka
- Department of Anaesthesia and Intensive Care Medicine; Helsinki University Central Hospital; Helsinki Finland
| | - C. Lindholm
- Department of Rheumatology and Inflammation Research; Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
| | - C. Martijn
- Department of Chemistry; Biomedical Center; Uppsala University; Uppsala Sweden
| | - C. Rylander
- Department of Anaesthesia and Intensive Care; Sahlgrenska University Hospital; Gothenburg Sweden
| | - G. Hedenstierna
- Department of Medical Sciences, Clinical Physiology; Uppsala University; Uppsala Sweden
| | - F. Fredén
- Uppsala Burn Center; Uppsala University Hospital; Uppsala Sweden
- Department of Surgical Sciences, Anaesthesiology and Intensive Care; Uppsala University; Uppsala Sweden
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20
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Boonen E, Bornstein SR, Van den Berghe G. New insights into the controversy of adrenal function during critical illness. Lancet Diabetes Endocrinol 2015; 3:805-15. [PMID: 26071883 DOI: 10.1016/s2213-8587(15)00224-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 10/17/2014] [Accepted: 10/17/2014] [Indexed: 12/18/2022]
Abstract
Critical illness represents a life-threatening disorder necessitating recruitment of defence mechanisms for survival. Herein, the hypothalamic-pituitary-adrenal axis is essential. However, the relevance of a relative insufficiency of the hypothalamic-pituitary-adrenal axis in critical illness, which is diagnosed by a suppressed cortisol response to exogenous adrenocorticotropic hormone (ACTH) irrespective of the plasma cortisol concentration, is controversial. Findings from several studies have provided insights that clarify at least part of this controversy. Rather than an activated hypothalamic-pituitary-adrenal axis, ACTH-independent regulators have been reported to contribute to increased cortisol availability during critical illness. One of these regulators is reduced cortisol breakdown, mediated by suppressed expression and activity of cortisol metabolising enzymes in the liver and kidneys. This downstream mechanism increases concentrations of plasma cortisol, but the ensuing feedback-inhibited ACTH release, when sustained for more than 1 week, has been shown to negatively affect adrenocortical integrity and function. Reduced adrenocortical ACTH signalling could explain reduced cortisol responses to exogenous ACTH. Whether such reduced cortisol responses in the presence of raised plasma (free) cortisol identifies adrenal failure needing treatment is unlikely. Additionally, reduced cortisol breakdown affects the optimum dose of hydrocortisone treatment during critical illness. Identification of patients with an insufficient hypothalamic-pituitary-adrenal axis response and the optimum treatment for this disorder clearly need more well designed preclinical and clinical studies.
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Affiliation(s)
- Eva Boonen
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven University, Leuven, Belgium
| | - Stefan R Bornstein
- Department of Medicine III, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany; Diabetes and Nutritional Sciences, Rayne Institute, Denmark Hill Campus, King's College London, London, UK
| | - Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven University, Leuven, Belgium.
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21
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Abstract
OBJECTIVES To characterize glucocorticoid receptor expression in peripheral WBCs of critically ill children using flow cytometry. DESIGN Prospective observational cohort. SETTING A university-affiliated, tertiary PICU. PATIENTS Fifty-two critically ill children. INTERVENTIONS Samples collected for measurement of glucocorticoid receptor expression and parallel cortisol levels. MEASUREMENTS AND MAIN RESULTS Subjects with cardiovascular failure had significantly lower glucocorticoid receptor expression both in CD4 lymphocytes (mean fluorescence intensity, 522 [354-787] vs 830 [511-1,219]; p = 0.036) and CD8 lymphocytes (mean fluorescence intensity, 686 [350-835] vs 946 [558-1,511]; p = 0.019) compared with subjects without cardiovascular failure. Subjects in the upper 50th percentile of Pediatric Risk of Mortality III scores and organ failure also had significantly lower glucocorticoid receptor expression in CD4 and CD8 lymphocytes. There was no linear correlation between cortisol concentrations and glucocorticoid receptor expression. CONCLUSIONS Our study suggests that patients with shock and increased severity of illness have lower glucocorticoid receptor expression in CD4 and CD8 lymphocytes. Glucocorticoid receptor expression does not correlate well with cortisol levels. Future studies could focus on studying glucocorticoid receptor expression variability and isoform distribution in the pediatric critically ill population as well as on different strategies to optimize glucocorticoid response.
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22
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Balbão VMP, Costa MMA, Castro M, Carlotti APCP. Evaluation of adrenal function in critically ill children. Clin Endocrinol (Oxf) 2014; 81:559-65. [PMID: 24588209 DOI: 10.1111/cen.12444] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Revised: 01/03/2014] [Accepted: 02/25/2014] [Indexed: 12/15/2022]
Abstract
OBJECTIVE There is no consensus on adequate adrenal response to critical illness. We aimed to evaluate adrenal function in critically ill children and its association with clinical outcome. We hypothesized that salivary cortisol would be a more appropriate tool to evaluate adrenal function in critically ill children. METHODS This was a prospective cohort study. The concentrations of serum total and salivary cortisol were measured in 34 critically ill children before and after stimulation with 250 μg adrenocorticotropic hormone (ACTH), and values were compared to a control group of healthy children (n = 15). Association between outcome and adrenal insufficiency defined by an increment in serum cortisol ≤250 nm (9 μg/dl) post-ACTH was assessed. RESULTS Serum total and salivary cortisol concentrations pre- and post-ACTH were significantly higher in patients, and they were correlated at baseline (r = 0·67; P < 0·0001) and after ACTH (r = 0·41; P = 0·02). The incidence of adrenal insufficiency was 32·3%. This group had higher Paediatric Risk of Mortality III score (P = 0·04) but Paediatric Logistic Organ Dysfunction and vasoactive inotropic scores, duration of mechanical ventilation and length of paediatric intensive care unit and hospital stay were not significantly different compared with those with an increment >250 nm (9 μg/dl) post-ACTH. An inverse correlation between salivary cortisol post-ACTH and vasoactive inotropic score (r = -0·56; P = 0·0008) was observed. A salivary cortisol concentration post-ACTH of ≤226 nm (8·2 μg/dl) had a sensitivity of 79% and a specificity of 62% to discriminate need for vasoactive or inotropic support (area under receiver operating characteristic (ROC) curve 0·74). CONCLUSION Adrenal insufficiency defined by the 'delta criterion' was not associated with outcome. A post-ACTH salivary cortisol of ≤226 nm (8·2 μg/dl) may be suggestive of an insufficient adrenal response to critical illness.
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Affiliation(s)
- Viviane M P Balbão
- Department of Paediatrics, Division of Paediatric Critical Care, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
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23
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Levy-Shraga Y, Pinhas-Hamiel O. Critical illness-related corticosteroid insufficiency in children. Horm Res Paediatr 2014; 80:309-17. [PMID: 24217117 DOI: 10.1159/000354759] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Accepted: 07/31/2013] [Indexed: 02/05/2023] Open
Abstract
Adequate adrenocortical function is essential for survival in critical illness. Most critically ill patients display elevated plasma cortisol concentrations, which reflects activation of the hypothalamic-pituitary-adrenal axis and is considered to be a homeostatic adaptation. However, many critically ill patients have 'relative' or 'functional' adrenal insufficiency, which is characterized by an inadequate production of cortisol in relation to an increased demand during periods of severe stress. Recently, the term 'critical illness-related corticosteroid insufficiency' (CIRCI) was coined. CIRCI occurs as a result of a decrease in adrenal steroid production or tissue resistance to glucocorticoids. An international task force of the American College of Critical Care Medicine issued recommendations for the diagnosis and management of this condition in adult patients. We review the prevalence, diagnosis, and therapeutic approach to adrenal insufficiency in critically ill children. We found a lack of consensus within the pediatric field as to the optimal approach to CIRCI, and call for an international task force to establish unified guidelines.
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Affiliation(s)
- Yael Levy-Shraga
- Pediatric Endocrine and Diabetes Unit, Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Israel
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24
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Boonen E, Van den Berghe G. Cortisol metabolism in critical illness: implications for clinical care. Curr Opin Endocrinol Diabetes Obes 2014; 21:185-92. [PMID: 24722172 DOI: 10.1097/med.0000000000000066] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Critical illness is uniformly characterized by elevated plasma cortisol concentrations, traditionally attributed exclusively to increased cortisol production driven by an activated hypothalamic pituitary adrenal axis. However, as plasma adrenocorticotropic hormone (ACTH) concentrations are often not elevated or even low during critical illness, alternative mechanisms must contribute. RECENT FINDINGS Recent investigations revealed that plasma clearance of cortisol is markedly reduced during critical illness, explained by suppressed expression and activity of the main cortisol metabolizing enzymes in liver and kidney. Furthermore, unlike previously inferred, cortisol production rate in critically ill patients was only moderately increased to less than double that of matched healthy subjects. In the face of low-plasma ACTH concentrations, these data suggest that other factors drive hypercortisolism during critical illness, which may suppress ACTH by feedback inhibition. These new insights add to the limitations of the current diagnostic tools to identify patients at risk of failing adrenal function during critical illness. They also urge to investigate the impact of lower hydrocortisone doses than those hitherto used. SUMMARY Recent novel insights reshape the current understanding of the hormonal stress response to critical illness and further underline the need for more studies to unravel the pathophysiology of adrenal (dys)functioning during critical illness.
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Affiliation(s)
- Eva Boonen
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
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25
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Boonen E, Van den Berghe G. Endocrine responses to critical illness: novel insights and therapeutic implications. J Clin Endocrinol Metab 2014; 99:1569-82. [PMID: 24517153 DOI: 10.1210/jc.2013-4115] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
CONTEXT Critical illness, an extreme form of severe physical stress, is characterized by important endocrine and metabolic changes. Due to critical care medicine, survival from previously lethal conditions has become possible, but many patients now enter a chronic phase of critical illness. The role of the endocrine and metabolic responses to acute and prolonged critical illness in mediating or hampering recovery remains highly debated. EVIDENCE ACQUISITION The recent literature on changes within the hypothalamic-pituitary-thyroid axis and the hypothalamic-pituitary-adrenal axis and on hyperglycemia in relation to recovery from critical illness was critically appraised and interpreted against previous insights. Possible therapeutic implications of the novel insights were analyzed. Specific remaining questions were formulated. EVIDENCE SYNTHESIS In recent years, important novel insights in the pathophysiology and the consequences of some of these endocrine responses to acute and chronic critical illness were generated. Acute endocrine adaptations are directed toward providing energy and substrates for the vital fight-or-flight response in a context of exogenous substrate deprivation. Distinct endocrine and metabolic alterations characterize the chronic phase of critical illness, which seems to be no longer solely beneficial and could hamper recovery and rehabilitation. CONCLUSIONS Important novel insights reshape the current view on endocrine and metabolic responses to critical illness and further clarify underlying pathways. Although many issues remain unresolved, some therapeutic implications were already identified. More work is required to find better treatments, and the optimal timing for such treatments, to further prevent protracted critical illness, to enhance recovery thereof, and to optimize rehabilitation.
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Affiliation(s)
- Eva Boonen
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, B-3000 Leuven, Belgium
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Bhatia R, Muraskas J, Janusek LW, Mathews H. Measurement of the glucocorticoid receptor: relevance to the diagnosis of critical illness-related corticosteroid insufficiency in children. J Crit Care 2014; 29:691.e1-5. [PMID: 24747037 DOI: 10.1016/j.jcrc.2014.02.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Revised: 02/19/2014] [Accepted: 02/20/2014] [Indexed: 01/01/2023]
Abstract
Diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in children continues to remain difficult and controversial in that no consensus for either exists among pediatric critical care physicians. Critical illness-related corticosteroid insufficiency is defined as a corticosteroid response that is inadequate for the severity of the illness experienced by the patient. Critical illness-related corticosteroid insufficiency manifests as an insufficient corticosteroid mediated down-regulation of proinflammatory cytokines, due to either corticosteroid tissue resistance and/or inadequate circulating levels of cortisol. The tissue resistance is likely due to alterations in the functionality of the intracellular receptor for corticosteroids, the glucocorticoid receptor (GR). This article details the role of the GR during critical illness with a focus upon the measurement of the GR, as a potentially important means by which to clinically assess the level of corticosteroid tissue-resistant in patients suspected of CIRCI. Measurement of the GR may be particularly useful as a means by which to determine the judicious administration of steroids, maximizing their therapeutic potential, whereas minimizing the morbidity that can be associated with their use.
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Affiliation(s)
- Rahul Bhatia
- Division of Pediatric Critical Care, Department of Pediatrics, Loyola University Medical Center, Stritch School of Medicine, Maywood, IL.
| | - Jonathan Muraskas
- Division of Neonatology and Perinatal Medicine, Department of Pediatrics, Loyola University Medical Center, Stritch School of Medicine, Maywood, IL
| | - Linda Witek Janusek
- Department of Health Promotion, Health Science Division, Loyola University of Chicago, Niehoff School of Nursing, Maywood, IL
| | - Herbert Mathews
- Department of Microbiology and Immunology, Health Science Division, Loyola University of Chicago, Stritch School of Medicine, Maywood, IL
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