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Huang X, Sun Y, Wu A, Zhang XY. Prevalence and clinical profile of abnormal glucose in first-episode and drug-naïve patients with major depressive disorder with comorbid abnormal thyroid function: a large-scale cross-sectional study. BMC Psychiatry 2023; 23:362. [PMID: 37226146 DOI: 10.1186/s12888-023-04842-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 05/04/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND The associated factors of abnormal glucose in patients with major depressive disorder (MDD) with comorbid abnormal thyroid function (ATF) remain unclear. To the best of our knowledge, this is the first study with a large sample size that examines the risk factors of abnormal glucose in first-episode drug-naïve (FEDN) MDD patients comorbid with ATF and includes clinical correlates and thyroid hormone levels. METHODS A total of 1718 FEDN MDD patients were recruited. The Hamilton Depression Scale (HAMD), Hamilton Anxiety Scale (HAMA), and Positive and Negative Syndrome Scale (PANSS) positive subscale were used to evaluate the symptoms of patients. Fasting blood glucose concentration and thyroid hormone levels were measured. RESULTS The prevalence of abnormal glucose in MDD patients with comorbid ATF was 47.3%, which was 4.25 times higher than that in MDD patients without ATF (17.4%). Compared to those ATF patients without abnormal glucose, ATF patients with abnormal glucose scored higher on HAMD, HAMA and PANSS positive subscale, had a higher rate of suicide attempts, severe anxiety and psychotic symptoms, and had higher levels of thyroid-stimulating hormone (TSH), and thyroid peroxidases antibody (TPOAb) which were also correlated with abnormal glucose in MDD patients comorbid ATF (all P < 0.05). The combination of HAMD score and TSH could differentiate abnormal glucose from ATF. Further, TSH was independence-related with the concentration of fasting blood glucose in MDD patients with comorbid ATF. CONCLUSION Our results demonstrate a high prevalence of abnormal glucose in MDD patients with comorbid ATF. Some clinical and thyroid function-related variables may be associated with abnormal glucose in MDD patients with comorbid ATF.
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Affiliation(s)
- Xiao Huang
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Workers' Stadium South Road, Beijing, Chaoyang, 100020, China
| | - Yuan Sun
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Workers' Stadium South Road, Beijing, Chaoyang, 100020, China
| | - Anshi Wu
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, No. 8 Workers' Stadium South Road, Beijing, Chaoyang, 100020, China
| | - Xiang-Yang Zhang
- CAS Key Laboratory of Mental Health, Institute of Psychology, Beijing, China.
- Department of Psychology, University of Chinese Academy of Sciences, Beijing, China.
- Key Laboratory of Mental Health, Institute of Psychology, Chinese Academy of Sciences, 16 Lincui Rd, Beijing, 100101, China.
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Besci T, Besci Ö, Arslan G, Ilgaz H, Prencuva P, Özdemir G, Abacı A, Demir K. Biochemical indicators of euthyroid sick syndrome in critically ill children. J Pediatr Endocrinol Metab 2022; 35:1285-1292. [PMID: 36106490 DOI: 10.1515/jpem-2022-0232] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 08/29/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES This study aimed to determine the prevalence and predictors of euthyroid sick syndrome (ESS) in pediatric intensive care, and to establish a link between thyroid function tests and mortality. METHODS Between January 2015 and March 2020, children admitted to our pediatric intensive care unit (PICU) and tested for free triiodothyronine (fT3), free thyroxine (fT4), and thyrotropin (TSH) levels were included. Patients with decreased fT3, with normal or decreased fT4, and normal or decreased TSH levels were assigned to the ESS group. The association between biochemical indicators and ESS, as well as the relationship between fT3 and mortality, were examined. RESULTS A total of 141 (36%) of 386 children included to study were classified in the ESS group. The ESS group had a higher rate of 28-day mortality (12 [8.5%] vs. 9 [3.7%]). Blood urea nitrogen (BUN), albumin, platelet, lactate, and pediatric index of mortality 3 [PIM3 (%)] were significantly associated with ESS (odds ratios in order: 1.024, 0.422, 0.729, 1.208, 1.013). Multivariate regression analysis showed that BUN, albumin, platelet, and lactate were independently associated with ESS progression. The area under curve (AUC [95%CI]) for fT3 was 0.644 (0.555-0.789) to detect mortality. Children with a fT3 level lower than 2.31 pg/mL had significantly higher 28-day mortality (log rank test, p=0.001). CONCLUSIONS Our study identified BUN, albumin, lactate, and platelet count as independent risk factors for ESS progression in children. Furthermore, our findings indicated a correlation between fT3 and mortality, which makes fT3 an ideal candidate to be included in mortality indices.
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Affiliation(s)
- Tolga Besci
- Department of Pediatric Critical Care, Dokuz Eylul University, Izmir, Turkey
- Department of Pediatric Critical Care, Buca Seyfi Demirsoy Research and Training Hospital, Izmir, Turkey
| | - Özge Besci
- Department of Pediatric Endocrinology, Dokuz Eylul University, Izmir, Turkey
| | - Gazi Arslan
- Department of Pediatric Critical Care, Dokuz Eylul University, Izmir, Turkey
| | - Hande Ilgaz
- Department of Pediatrics, Dokuz Eylul University, Izmir, Turkey
| | - Pınar Prencuva
- Department of Pediatrics, Dokuz Eylul University, Izmir, Turkey
| | - Göktuğ Özdemir
- Department of Pediatric Critical Care, Dokuz Eylul University, Izmir, Turkey
| | - Ayhan Abacı
- Department of Pediatric Endocrinology, Dokuz Eylul University, Izmir, Turkey
| | - Korcan Demir
- Department of Pediatric Endocrinology, Dokuz Eylul University, Izmir, Turkey
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Joosten K, Verbruggen S. PN Administration in Critically Ill Children in Different Phases of the Stress Response. Nutrients 2022; 14:nu14091819. [PMID: 35565787 PMCID: PMC9104104 DOI: 10.3390/nu14091819] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/13/2022] [Accepted: 04/18/2022] [Indexed: 01/22/2023] Open
Abstract
Nutritional support is an important part of the treatment of critical ill children and the phase of disease has to be taken into account. The metabolic stress response during acute critical illness is characterized by severe catabolism. So far, there is no evidence that the acute catabolic state can be prevented with nutritional support. The Pediatric ’Early versus Late Parenteral Nutrition’ (PEPaNIC) trial showed that withholding supplemental parenteral nutrition (PN) during the first week in critically ill children, when enteral nutrition was not sufficient, prevented infections and shortened the stay in the pediatric intensive care unit (PICU) and the hospital. A follow-up performed 2 and 4 years later showed that withholding parenteral nutrition (PN) also improved several domains of the neurocognitive outcome of the children. Current international guidelines recommend considering withholding parenteral macronutrients during the first week of pediatric critical illness, while providing micronutrients. These guidelines also recommend upper and lower levels of intake of macronutrients and micronutrients if PN is administered.
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Veldscholte K, Cramer ABG, Joosten KFM, Verbruggen SCAT. Intermittent fasting in paediatric critical illness: The properties and potential beneficial effects of an overnight fast in the PICU. Clin Nutr 2021; 40:5122-5132. [PMID: 34461586 DOI: 10.1016/j.clnu.2021.07.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/21/2021] [Accepted: 07/26/2021] [Indexed: 12/30/2022]
Abstract
Although evidence for the superiority of continuous feeding over intermittent feeding is lacking, in most paediatric intensive care units (PICU) artificial feeding is administered continuously for 24 h per day. Until now, studies in PICU on intermittent feeding have primarily focused on surrogate endpoints such as nutritional intake and gastro-intestinal complaints and none have studied the effects of an extended fasting period. Intermittent fasting has been proven to have many health benefits in both animal and human studies. The observed beneficial effects are based on multiple metabolic and endocrine changes that are presumed crucial in critical illness as well. One key element is the transition to ketone body metabolism, which, among others, contributes to the stimulation of several cellular pathways involved in stress resistance (neuro)plasticity and mitochondrial biogenesis, and might help preserve brain function. Secondly, the fasting state stimulates the activation of autophagy, a process that is crucial for cellular function and integrity. Of the different intermittent fasting strategies investigated, time-restricted feeding with a daily extended fasting period appears most feasible in the PICU. Moreover, planning the fasting period overnight could help maintain the circadian rhythm. Although not investigated, such an overnight intermittent fasting strategy might improve the metabolic profile, feeding tolerance and perhaps even have beneficial effects on tissue repair, reperfusion injury, muscle weakness, and the immune response. Future studies should investigate practical implications in critically ill children and the optimal duration of the fasting periods, which might be affected by the severity of illness and by age.
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Affiliation(s)
- Karlien Veldscholte
- Intensive Care Unit, Department of Paediatrics and Paediatric Surgery, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Arnout B G Cramer
- Intensive Care Unit, Department of Paediatrics and Paediatric Surgery, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Koen F M Joosten
- Intensive Care Unit, Department of Paediatrics and Paediatric Surgery, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Sascha C A T Verbruggen
- Intensive Care Unit, Department of Paediatrics and Paediatric Surgery, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, the Netherlands.
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Abstract
The non-thyroidal illness syndrome (NTIS) was first reported in the 1970s as a remarkable ensemble of changes in serum TH (TH) concentrations occurring in probably any severe illness. Ever since, NTIS has remained an intriguing phenomenon not only because of the robustness of the decrease in serum triiodothyronine (T3), but also by its clear correlation with morbidity and mortality. In recent years, it has become clear that (parenteral) feeding in patients with critical illness should be taken into account as a major determinant not only of NTIS but also of clinical outcome. Moreover, both experimental animal and clinical studies have shown that tissue TH concentrations during NTIS do not necessarily reflect serum low TH concentrations and may decrease, remain unaltered, or even increase according to the organ and type of illness studied. These differential changes now have a solid basis in molecular studies on organ-specific TH transporters, receptors and deiodinases. Finally, the role of inflammatory pathways in these non-systemic changes has begun to be clarified. A fascinating role for TH metabolism in innate immune cells, including neutrophils and monocytes/macrophages, was reported in recent years, but there is no evidence at this early stage that this may be a determinant of susceptibility to infections. Although endocrinologists have been tempted to correct NTIS by TH supplementation, there is at present insufficient evidence that this is beneficial. Thus, there is a clear need for adequately powered randomized clinical trials (RCT) with clinically relevant endpoints to fill this knowledge gap.
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Affiliation(s)
- E Fliers
- Department of Endocrinology and Metabolism, Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - A Boelen
- Endocrine Laboratory, Department of Clinical Chemistry, Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam UMC, University of Amsterdam, 1105 AZ, Amsterdam, The Netherlands
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Langouche L, Jacobs A, Van den Berghe G. Nonthyroidal Illness Syndrome Across the Ages. J Endocr Soc 2019; 3:2313-2325. [PMID: 31745528 PMCID: PMC6853682 DOI: 10.1210/js.2019-00325] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 09/17/2019] [Indexed: 02/07/2023] Open
Abstract
In conditions of acute illness, patients present with reduced plasma T3 concentrations without a concomitant rise in TSH. In contrast, plasma concentrations of the inactive hormone rT3 increase, whereas plasma concentrations of T4 remain low-normal. This constellation of changes, referred to as nonthyroidal illness syndrome (NTIS), is present across all ages, from preterm neonates and over-term critically ill infants and children to critically ill adults. Although the severity of illness strongly correlates with the severity of the NTIS phenotype, the causality of this association remains debated, and pathophysiological mechanisms remain incompletely understood. In the acute phase of illness, NTIS appears to be caused predominantly by an increased peripheral inactivation of thyroid hormones, in which reduced nutritional intake plays a role. Current evidence suggests that these acute peripheral changes are part of a beneficial adaptation of the body to reduce expenditure of energy and to activate the innate immune response, which is important for survival. In contrast, in more severely ill and prolonged critically ill patients, an additional central suppression of the thyroid hormone axis alters and further aggravates the NTIS phenotype. Recent studies suggest that this central suppression may not be adaptive. Whether treatment of this central component of NTIS in prolonged critically ill patients, with the use of hypothalamic releasing factors, improves outcome remains to be investigated in large randomized control trials.
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Affiliation(s)
- Lies Langouche
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven University Hospital, Leuven, Belgium
| | - An Jacobs
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven University Hospital, Leuven, Belgium
| | - Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven University Hospital, Leuven, Belgium
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Abstract
PURPOSE OF REVIEW This review summarizes recent literature on nonthyroidal illness syndrome (NTI) and outcome of pediatric critical illness, to provide insight in pathophysiology and therapeutic implications. RECENT FINDINGS NTI is typically characterized by lowered triiodothyronine levels without compensatory TSH rise. Although NTI severity is associated with poor outcome of pediatric critical illness, it remains unclear whether this association reflects an adaptive protective response or contributes to poor outcome. Recently, two metabolic interventions that improved outcome also altered NTI in critically ill children. These studies shed new light on the topic, as the results suggested that the peripheral NTI component, with inactivation of thyroid hormone, may represent a beneficial adaptation, whereas the central component, with suppressed TSH-driven thyroid hormone secretion, may be maladaptive. There is currently insufficient evidence for treatment of NTI in children. However, the recent findings raised the hypothesis that reactivation of the central NTI component could offer benefit, which should be tested in RCTs. SUMMARY NTI in critically ill children can be modified by metabolic interventions. The peripheral, but not the central, component of NTI may be a beneficial adaptive response. These findings open perspectives for the development of novel strategies to improve outcome of critical illness in children.
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Affiliation(s)
- An Jacobs
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven University Hospital, Leuven, Belgium
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Jacobs A, Derese I, Vander Perre S, van Puffelen E, Verstraete S, Pauwels L, Verbruggen S, Wouters P, Langouche L, Garcia Guerra G, Joosten K, Vanhorebeek I, Van den Berghe G. Non-Thyroidal Illness Syndrome in Critically Ill Children: Prognostic Value and Impact of Nutritional Management. Thyroid 2019; 29:480-492. [PMID: 30760183 PMCID: PMC6457888 DOI: 10.1089/thy.2018.0420] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Non-thyroidal illness (NTI), which occurs with fasting and in response to illness, is characterized by thyroid hormone inactivation with low triiodothyronine (T3) and high reverse T3 (rT3), followed by suppressed thyrotropin (TSH). Withholding supplemental parenteral nutrition early in pediatric critical illness (late-PN), thus accepting low/no macronutrient intake up to day 8 in the pediatric intensive care unit (PICU), accelerated recovery compared to initiating supplemental parenteral nutrition early (early-PN). Whether NTI is harmful or beneficial in pediatric critical illness and how it is affected by a macronutrient deficit remains unclear. This study investigated the prognostic value of NTI, the impact of late-PN on NTI, and whether such impact explains or counteracts the outcome benefit of late-PN in critically ill children. METHODS This preplanned secondary analysis of the Early versus Late Parenteral Nutrition in the Pediatric Intensive Care Unit randomized controlled trial quantified serum TSH, total thyroxine (T4), T3, and rT3 concentrations in 982 patients upon PICU admission versus 64 matched healthy children and in 772 propensity score-matched early-PN and late-PN patients upon admission and at day 3 or last PICU day for shorter PICU stay. Associations between thyroid hormone concentrations upon admission and outcome, as well as impact of late-PN on NTI in relation with outcome, were assessed with univariable analyses and multivariable logistic regression, linear regression, or Cox proportional hazard analysis, adjusted for baseline risk factors. RESULTS Upon PICU admission, critically ill children revealed lower TSH, T4, T3, and T3/rT3 and higher rT3 than healthy children (p < 0.0001). A more pronounced NTI upon admission, with low T4, T3, and T3/rT3 and high rT3 was associated with higher mortality and morbidity. Late-PN further reduced T4, T3, and T3/rT3 and increased rT3 (p ≤ 0.001). Statistically, the further lowering of T4 by late-PN reduced the outcome benefit (p < 0.0001), whereas the further lowering of T3/rT3 explained part of the outcome benefit of late-PN (p ≤ 0.004). This effect was greater for infants than for older children. CONCLUSION In critically ill children, the peripheral inactivation of thyroid hormone, characterized by a decrease in T3/rT3, which is further accentuated by low/no macronutrient intake, appears beneficial. In contrast, the central component of NTI attributable to suppressed TSH, evidenced by the decrease in T4, seems to be a harmful response to critical illness. Whether treating the central component with TSH releasing hormone infusion in the PICU is beneficial requires further investigation.
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Affiliation(s)
- An Jacobs
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven University Hospital, Leuven, Belgium
| | - Inge Derese
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven University Hospital, Leuven, Belgium
| | - Sarah Vander Perre
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven University Hospital, Leuven, Belgium
| | - Esther van Puffelen
- Intensive Care, Department of Pediatrics and Pediatric Surgery, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Sören Verstraete
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven University Hospital, Leuven, Belgium
| | - Lies Pauwels
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven University Hospital, Leuven, Belgium
| | - Sascha Verbruggen
- Intensive Care, Department of Pediatrics and Pediatric Surgery, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Pieter Wouters
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven University Hospital, Leuven, Belgium
| | - Lies Langouche
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven University Hospital, Leuven, Belgium
| | - Gonzalo Garcia Guerra
- Department of Pediatrics, Intensive Care Unit, University of Alberta, Stollery Children's Hospital, Edmonton, Canada
| | - Koen Joosten
- Intensive Care, Department of Pediatrics and Pediatric Surgery, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Ilse Vanhorebeek
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven University Hospital, Leuven, Belgium
| | - Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven University Hospital, Leuven, Belgium
- Address correspondence to: Greet Van den Berghe, MD, Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, Leuven 3000, Belgium
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Tight glycemic control in critically ill pediatric patients: a meta-analysis and systematic review of randomized controlled trials. Pediatr Res 2018; 84:22-27. [PMID: 29795449 DOI: 10.1038/s41390-018-0002-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 11/02/2017] [Accepted: 11/19/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND There still are controversies in the impact of tight glycemic control (TGC) in critically ill children. The aim of this study was to assess the benefits and risks of TGC compared with conventional glycemic control (CGC) in critically ill pediatric patients admitted to the pediatric intensive care unit (PICU) by using data retrieved from randomized controlled trials (RCTs). METHOD EMBASE, CNKI, PubMed, and the Cochrane Database were searched for RCTs comparing TGC with CGC in critically ill children in PICU. RESULT The meta-analysis included five RCTs representing 3933 patients and compared TGC with CGC. Our result revealed that TGC did not reduce the 30-day mortality rates (OR 0.99, 95% CI 0.74-1.32, P = 0.95) and was not associated with decreasing health care-associated infections (OR 0.80, 95% CI 0.64-1.00, P = 0.05) compared with CGC, but significantly increased the incidence of hypoglycemia (OR 6.37, 95% CI 4.41-9.21, P < 0.001). CONCLUSION Tight glycemic control was not associated with reducing the 30-day mortality rates and acquired infections compared with CGC in critically ill children. Significant increase of the incidence of hypoglycemia was revealed in TGC group. The conclusion should be interpreted with caution for the methodological heterogeneity among trials.
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Zhao Y, Wu Y, Xiang B. Tight glycemic control in critically ill pediatric patients: a meta-analysis and systematic review of randomized controlled trials. Pediatr Res 2018; 83:930-935. [PMID: 29244792 DOI: 10.1038/pr.2017.310] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 11/19/2017] [Indexed: 02/05/2023]
Abstract
BackgroundThere still are controversies in the impact of tight glycemic control (TGC) in critically ill children. The aim of this study was to assess the benefits and risks of TGC compared with conventional glycemic control (CGC) in critically ill pediatric patients admitted to the pediatric intensive care unit (PICU) by using the data retrieved from randomized controlled trials (RCTs).MethodsEMBASE, CNKI, PubMed, and the Cochrane Database were searched for RCTs comparing TGC with CGC in critically ill children in PICU.ResultsThe meta-analysis included 5 RCTs representing 3,933 patients that compared TGC with CGC. Our result revealed that TGC did not reduce 30-day mortality rates (odds ratio (OR) 0.99, 95% confidence interval (CI) 0.74-1.32, P=0.95) and was not associated with decreasing health care-associated infections (OR 0.80, 95% CI 0.64-1.00, P=0.05) compared with CGC, but significantly increased the incidence of hypoglycemia (OR 6.37, 95% CI 4.41-9.21, P<0.001).ConclusionTight glycemic control was not associated with reducing 30-day mortality rates and acquired infections compared with CGC in critically ill children. Significant increase of incidence of hypoglycemia was revealed in TGC group. The conclusion should be interpreted with caution for the methodological heterogeneity among trials.
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Affiliation(s)
- Yiyang Zhao
- Department of Pediatric Surgery, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Yang Wu
- Department of Pediatric Surgery, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Bo Xiang
- Department of Pediatric Surgery, Sichuan University West China Hospital, Chengdu, Sichuan, China
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11
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Abstract
PURPOSE OF REVIEW We discuss key studies that have set the scene for the debate on the efficacy and safety of tight glycemic control in critically ill patients, highlighting important differences among them, and describe the ensuing search towards strategies for safer glucose control. RECENT FINDINGS Differences in level of glycemic control, glucose measurement and insulin administration, expertise, and nutritional management may explain the divergent outcomes of the landmark studies on tight glycemic control in critical illness. Regarding strategies towards safer glucose control, several computerized algorithms have shown promise, but lack validation in adequately powered outcome studies. Real-time continuous glucose monitoring and closed loop blood glucose control systems are not up to the task yet due to technical challenges, though recent advances are promising. Alternatives for insulin have only been investigated in small feasibility studies. Severe hyperglycemia in critically ill patients generally is not tolerated anymore, but the optimal blood glucose target may depend on the specific patient and logistic context.
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Affiliation(s)
- Ilse Vanhorebeek
- Clinical Division and Laboratory of Intensive Care Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium.
| | - Jan Gunst
- Clinical Division and Laboratory of Intensive Care Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
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Van den Berghe G. On the Neuroendocrinopathy of Critical Illness. Perspectives for Feeding and Novel Treatments. Am J Respir Crit Care Med 2016; 194:1337-1348. [DOI: 10.1164/rccm.201607-1516ci] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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13
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Abstract
PURPOSE OF REVIEW This article describes the current best available evidence on optimal nutrition in the paediatric intensive care based on different levels of outcome, which can be divided in surrogate and hard clinical outcome parameters. RECENT FINDINGS Undernutrition is associated with increased morbidity and mortality, whereas in specific cohorts of critically ill children, such as those with burn injury, obesity is associated with more complications, longer length of stay, and decreased likelihood of survival. There is a relation with adequacy of delivery of enteral nutrition and the amount of protein on length of hospital stay, neurological status, and mortality. Studies relating organ function, other than skin healing after thermal injury, with the nutritional status are scarce. There is also a scarcity of data concerning long-term follow-up and health economics. SUMMARY Until now, there are no randomized controlled trials which have investigated a causal relation between different feeding regimens on the nutritional status and short and long-term outcome. As a result current optimal nutritional strategies are based on small trials with surrogate outcome parameters. Prospective randomized studies are needed with nutritional and/or metabolic interventions to come to an optimal feeding strategy for critically ill children.
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Affiliation(s)
- Koen Joosten
- ErasmusMC-Sophia Children's Hospital, Department of Paediatric Intensive Care, Dr Molewaterplein 60, 3015 GJ Rotterdam, The Netherlands
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Sakai H, Nagao H, Sakurai M, Okumura T, Nagai Y, Shikuma J, Ito R, Imazu T, Miwa T, Odawara M. Correlation between Serum Levels of 3,3',5'-Triiodothyronine and Thyroid Hormones Measured by Liquid Chromatography-Tandem Mass Spectrometry and Immunoassay. PLoS One 2015; 10:e0138864. [PMID: 26426328 PMCID: PMC4591014 DOI: 10.1371/journal.pone.0138864] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Accepted: 09/06/2015] [Indexed: 12/26/2022] Open
Abstract
Objective For measuring serum 3,3′,5′-triiodothyronine (rT3) levels, radioimmunoassay (RIA) has traditionally been used owing to the lack of other reliable methods; however, it has recently become difficult to perform. Meanwhile, liquid chromatography-tandem mass spectrometry (LC-MS/MS) has recently been attracting attention as a novel alternative method in clinical chemistry. To the best of our knowledge, there are no studies to date comparing results of the quantification of human serum rT3 between LC-MS/MS and RIA. We therefore examined the feasibility of LC-MS/MS as a novel alternative method for measuring serum rT3, thyroxine (T4), and 3,5,3′-triiodothyronine (T3) levels. Methods Assay validation was performed by LC-MS/MS using quality control samples of rT3, T4, and T3 at 4 various concentrations which were prepared from reference compounds. Serum samples of 50 outpatients in our department were quantified both by LC-MS/MS and conventional immunoassay for rT3, T4, and T3. Correlation coefficients between the 2 measurement methods were statistically analyzed respectively. Results Matrix effects were not observed with our method. Intra-day and inter-day precisions were less than 10.8% and 9.6% for each analyte at each quality control level, respectively. Intra-day and inter-day accuracies were between 96.2% and 110%, and between 98.3% and 108.6%, respectively. The lower limit of quantification was 0.05 ng/mL. Strong correlations were observed between the 2 measurement methods (correlation coefficient, T4: 0.976, p < 0.001; T3: 0.912, p < 0.001; rT3: 0.928, p < 0.001). Conclusions Our LC-MS/MS system requires no manual cleanup operation, and the process after application of a sample is fully automated; furthermore, it was found to be highly sensitive, and superior in both precision and accuracy. The correlation between the 2 methods over a wide range of concentrations was strong. LC-MS/MS is therefore expected to become a useful tool for clinical diagnosis and research.
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Affiliation(s)
- Hiroyuki Sakai
- Department of Diabetes, Endocrinology and Metabolism, Tokyo Medical University, Tokyo, Japan
- * E-mail:
| | - Hidenori Nagao
- Pharmacokinetics Research Department of ASKA Pharmaceutical Co., Ltd., Kawasaki, Kanagawa, Japan
| | - Mamoru Sakurai
- Department of Diabetes, Endocrinology and Metabolism, Tokyo Medical University, Tokyo, Japan
| | - Takako Okumura
- Department of Diabetes, Endocrinology and Metabolism, Tokyo Medical University, Tokyo, Japan
| | - Yoshiyuki Nagai
- Department of Diabetes, Endocrinology and Metabolism, Tokyo Medical University, Tokyo, Japan
| | - Junpei Shikuma
- Department of Diabetes, Endocrinology and Metabolism, Tokyo Medical University, Tokyo, Japan
| | - Rokuro Ito
- Department of Diabetes, Endocrinology and Metabolism, Tokyo Medical University, Tokyo, Japan
| | - Tetsuya Imazu
- Pharmacokinetics Research Department of ASKA Pharmaceutical Co., Ltd., Kawasaki, Kanagawa, Japan
| | - Takashi Miwa
- Department of Diabetes, Endocrinology and Metabolism, Tokyo Medical University, Tokyo, Japan
| | - Masato Odawara
- Department of Diabetes, Endocrinology and Metabolism, Tokyo Medical University, Tokyo, Japan
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16
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Fliers E, Bianco AC, Langouche L, Boelen A. Thyroid function in critically ill patients. Lancet Diabetes Endocrinol 2015; 3:816-25. [PMID: 26071885 PMCID: PMC4979220 DOI: 10.1016/s2213-8587(15)00225-9] [Citation(s) in RCA: 228] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Revised: 01/14/2015] [Accepted: 01/19/2015] [Indexed: 12/20/2022]
Abstract
Patients in the intensive care unit (ICU) typically present with decreased concentrations of plasma tri-iodothyronine, low thyroxine, and normal range or slightly decreased concentration of thyroid-stimulating hormone. This ensemble of changes is collectively known as non-thyroidal illness syndrome (NTIS). The extent of NTIS is associated with prognosis, but no proof exists for causality of this association. Initially, NTIS is a consequence of the acute phase response to systemic illness and macronutrient restriction, which might be beneficial. Pathogenesis of NTIS in long-term critical illness is more complex and includes suppression of hypothalamic thyrotropin-releasing hormone, accounting for persistently reduced secretion of thyroid-stimulating hormone despite low plasma thyroid hormone. In some cases distinguishing between NTIS and severe hypothyroidism, which is a rare primary cause for admission to the ICU, can be difficult. Infusion of hypothalamic-releasing factors can reactivate the thyroid axis in patients with NTIS, inducing an anabolic response. Whether this approach has a clinical benefit in terms of outcome is unknown. In this Series paper, we discuss diagnostic aspects, pathogenesis, and implications of NTIS as well as its distinction from severe, primary thyroid disorders in patients in the ICU.
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Affiliation(s)
- Eric Fliers
- Department of Endocrinology and Metabolism, Academic Medical Centre, University of Amsterdam, AZ, Amsterdam, Netherlands
| | - Antonio C Bianco
- Division of Endocrinology and Metabolism, Rush University Medical Center, Chicago, IL, USA
| | - Lies Langouche
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, University of Leuven, Leuven, Belgium
| | - Anita Boelen
- Department of Endocrinology and Metabolism, Academic Medical Centre, University of Amsterdam, AZ, Amsterdam, Netherlands.
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Langouche L, Vander Perre S, Marques M, Boelen A, Wouters PJ, Casaer MP, Van den Berghe G. Impact of early nutrient restriction during critical illness on the nonthyroidal illness syndrome and its relation with outcome: a randomized, controlled clinical study. J Clin Endocrinol Metab 2013; 98:1006-13. [PMID: 23348400 DOI: 10.1210/jc.2012-2809] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Both critical illness and fasting induce low circulating thyroid hormone levels in the absence of a rise in TSH, a constellation-labeled nonthyroidal illness syndrome (NTI). The contribution of restricted nutrition during critical illness in the pathophysiology of NTI remains unclear. OBJECTIVE The objective of the study was to investigate the impact of nutrient restriction early during critical illness on the NTI, in relation to outcome. DESIGN AND PATIENTS A preplanned subanalysis in a group of intensive care unit (ICU) patients admitted after complicated surgery and for whom enteral nutrition was contraindicated (n = 280) of a randomized controlled trial, which compared tolerating pronounced nutritional deficit for 1 week in the ICU [late parenteral nutrition (PN)] with early initiation of parenteral nutrition (early PN). MEASUREMENTS Circulating TSH, total T4, T3, rT3, and leptin levels were quantified upon admission and on ICU day 3 or the last day when patients were discharged earlier. After correction for baseline risk factors, the role of these changes from baseline in explaining the outcome benefit of late PN was assessed with the multivariable Cox proportional hazard analysis. RESULTS Late PN reduced complications and accelerated recovery. Circulating levels of TSH, total T4, T3, the T3 to rT3 ratio, and leptin levels were all further reduced by late PN. The further lowering of T4 appeared to reduce the outcome benefit of late PN, whereas the further reduction of T3 to rT3 ratio appeared to statistically explain part of the outcome benefit. CONCLUSIONS Tolerating nutrient restriction early during critical illness, shown to accelerate recovery, further aggravated the NTI. The statistical analyses suggested that the more pronounced peripheral inactivation of the thyroid hormone with nutrient restriction during critical illness could be a beneficial adaptation, whereas the lowering of T4 could be deleterious.
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Affiliation(s)
- Lies Langouche
- Clinical Department and Laboratory of Intensive Care Medicine, Division Cellular and Molecular Medicine, University of Leuven (KU Leuven), B-3000 Leuven, Belgium.
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