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Kovacevic M, Adam VN, Causevic S. Triiodothyronine hormone supplementation therapy in septic shock patients with euthyroid sick syndrome: two pilot, placebo-controlled, randomized trials. Anaesth Crit Care Pain Med 2024; 43:101336. [PMID: 38061681 DOI: 10.1016/j.accpm.2023.101336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 11/29/2023] [Accepted: 11/30/2023] [Indexed: 01/18/2024]
Abstract
BACKGROUND To assess 28-day survival in two pilot groups of septic shock patients with euthyroid sick syndrome (ESS) supplemented with triiodothyronine (T3). METHODS A total of 95 septic shock patients with ESS were divided according to values of the thyroid hormones into low T3 and low T3T4 groups. Among 48 patients with low T3, 24 (50%) were randomized to T3 for 4 days and 24 (50%) to placebo. Among 47 patients with low T3T4, 24 (51%) were randomized to T3 for 4 days and 23 (49%) to placebo. The analysis included 28-day survival as the primary outcome and laboratory with hemodynamics as the secondary outcomes. Laboratory data were analyzed on the day of admission (T0), on the first (T1), third (T2) and seventh day (T3) with hemodynamics analyzed for the first four days. RESULTS In the low T3 population, 18 (75%) patients receiving T3 died at day 28 compared with 8 (33.3%) patients receiving placebo (p = 0.004). In the low T3T4 population, 6 (25%) patients receiving T3 died in ICU compared with 12 (52.1%) patients receiving placebo (p = 0.039). Oral T3 treatment increased mean arterial pressure values at day 1, day 3 and day 7 in the low T3T4 population, (p = 0.015, =0.005 and =0.042 respectively), and had no significant effect on these values in the low T3 population. CONCLUSION T3 supplementation was associated with a low 28-day mortality rate in patients with low T3T4 but with increased mortality in patients with low T3 ESS. These results suggest caution before initiating thyroid supplementation in septic patients. REGISTRATION ClinTrials.gov (NCT05270798).
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Affiliation(s)
- Mirza Kovacevic
- Department of Anesthesiology, Resuscitation and Intensive Care, Cantonal Hospital, Zenica, Bosnia and Herzegovina; Faculty of Medicine, Zenica, Bosnia and Herzegovina.
| | - Visnja Nesek Adam
- University Department of Anesthesiology, Resuscitation and Intensive Care, Clinical Hospital Sveti Duh, Zagreb, Croatia; Faculty of Medicine, Osijek, Croatia; Faculty of Dental Medicine and Health, University of Josip Juraj Strossmayer, Osijek, Croatia.
| | - Senada Causevic
- Department of Anesthesiology, Resuscitation and Intensive Care, Cantonal Hospital, Zenica, Bosnia and Herzegovina; Faculty of Medicine, Zenica, Bosnia and Herzegovina.
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Deana C, Gunst J, De Rosa S, Umbrello M, Danielis M, Biasucci DG, Piani T, Cotoia A, Molfino A, Vetrugno L. Bioimpedance-assessed muscle wasting and its relation to nutritional intake during the first week of ICU: a pre-planned secondary analysis of Nutriti Study. Ann Intensive Care 2024; 14:29. [PMID: 38367198 PMCID: PMC10874356 DOI: 10.1186/s13613-024-01262-w] [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: 11/25/2023] [Accepted: 02/12/2024] [Indexed: 02/19/2024] Open
Abstract
BACKGROUND Muscle mass evaluation in ICU is crucial since its loss is related with long term complications, including physical impairment. However, quantifying muscle wasting with available bedside tools (ultrasound and bioimpedance analysis) must be more primarily understood. Bioimpedance analysis (BIA) provides estimates of muscle mass and phase angle (PA). The primary aim of this study was to evaluate muscle mass changes with bioimpedance analysis during the first 7 days after ICU admission. Secondary aims searched for correlations between muscular loss and caloric and protein debt. METHODS Patients with an expected ICU-stay ≥ 72 h and the need for artificial nutritional support were evaluated for study inclusion. BIA evaluation of muscle mass and phase angle were performed at ICU admission and after 7 days. Considering the difference between ideal caloric and protein targets, with adequate nutritional macronutrients delivered, we calculated the caloric and protein debt. We analyzed the potential correlation between caloric and protein debt and changes in muscle mass and phase angle. RESULTS 72 patients from September 1st to October 30th, 2019 and from August 1st to October 30th, 2021 were included in the final statistical analysis. Median age was 68 [59-77] years, mainly men (72%) admitted due to respiratory failure (25%), and requiring invasive mechanical ventilation for 7 [4-10] days. Median ICU stay was 8 [6-12] days. Bioimpedance data at ICU admission and after 7 days showed that MM and PA resulted significantly reduced after 7 days of critically illness, 34.3 kg vs 30.6 kg (p < 0.0001) and 4.90° vs 4.35° (p = 0.0004) respectively. Mean muscle loss was 3.84 ± 6.7 kg, accounting for 8.4% [1-14] MM reduction. Correlation between caloric debt (r = 0.14, p = 0.13) and protein debt (r = 0.18, p = 0.13) with change in MM was absent. Similarly, no correlation was found between caloric debt (r = -0.057, p = 0.631) and protein debt (r = -0.095, p = 0.424) with changes in PA. CONCLUSIONS bioimpedance analysis demonstrated that muscle mass and phase angle were significantly lower after 7 days in ICU. The total amount of calories and proteins does not correlate with changes in muscle mass and phase angle.
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Affiliation(s)
- Cristian Deana
- Anesthesia and Intensive Care 1, Department of Anesthesia and Intensive Care, Health Integrated Agency of Friuli Centrale, Piazzale S. M. Della Misericordia 15, 33100, Udine, Italy.
| | - Jan Gunst
- Laboratory of Intensive-Care Medicine, Department of Cellular and Molecular Medicine, Louvain, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Louvain, Belgium
| | - Silvia De Rosa
- Centre for Medical Sciences - CISMed, University of Trento, Trento, Italy
- Anesthesia and Intensive Care, Santa Chiara Regional Hospital, APSS Trento, Trento, Italy
| | - Michele Umbrello
- Department of Intensive Care and Anaesthesia, ASST Ovest Milanese, Legnano Hospital, Milan, Italy
| | - Matteo Danielis
- Laboratory of Studies and Evidence Based Nursing, Department of Cardiac, Vascular Sciences and Public Health, University of Padua, ThoracicPadua, Italy
| | - Daniele Guerino Biasucci
- Department of Clinical Science and Translational Medicine, 'Tor Vergata' University of Rome, Rome, Italy
| | - Tommaso Piani
- Health Professions Staff, Health Integrated Agency of Friuli Centrale, Udine, Italy
| | - Antonella Cotoia
- Department of Medical and Surgical Sciences, Anesthesia and Intensive Care Unit, Policlinico Riuniti Foggia, University of Foggia, Foggia, Italy
| | - Alessio Molfino
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Luigi Vetrugno
- Department of Medical, Oral and Biotechnological Sciences, University of Chieti-Pescara, Chieti, Italy
- Department of Anesthesiology, Critical Care Medicine and Emergency, SS. Annunziata Hospital, Chieti, Italy
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Zabuliene L, Kubiliute I, Urbonas M, Jancoriene L, Urboniene J, Ilias I. Hyperglycaemia and Its Prognostic Value in Patients with COVID-19 Admitted to the Hospital in Lithuania. Biomedicines 2023; 12:55. [PMID: 38255162 PMCID: PMC10813648 DOI: 10.3390/biomedicines12010055] [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: 11/02/2023] [Revised: 12/06/2023] [Accepted: 12/19/2023] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Increased blood glucose levels atadmission are frequently observed in COVID-19 patients, even in those without pre-existing diabetes. Hyperglycaemia is associated with an increased incidence of severe COVID-19 infection. The aim of this study was to evaluate the association between hyperglycaemia at admission with the need for invasive mechanical ventilation (IMV) and in-hospital mortality in patients without diabetes who were hospitalized for COVID-19 infection. MATERIALS AND METHODS This retrospective observational study was conducted at Vilnius University Hospital Santaros Clinics, Lithuania with adult patients who tested positive for severe acute respiratory syndrome coronavirus 2 SARS-CoV-2 and were hospitalized between March 2020 and May 2021. Depersonalized data were retrieved from electronic medical records. Based on blood glucose levels on the day of admission, patients without diabetes were divided into 4 groups: patients with hypoglycaemia (blood glucose below 4.0 mmol/L), patients with normoglycaemia (blood glucose between ≥4.0 mmol/L and <6.1 mmol/L), patients with mild hyperglycaemia (blood glucose between ≥6.1 mmol/L and <7.8 mmol/L), and patients with intermittent hyperglycaemia (blood glucose levels ≥7.8 mmol/L and <11.1 mmol/L). A multivariable binary logistic regression model was created to determine the association between hyperglycaemia and the need for IMV. Survival analysis was performed to assess the effect of hyperglycaemia on outcome within 30 days of hospitalization. RESULTS Among 1945 patients without diabetes at admission, 1078 (55.4%) had normal glucose levels, 651 (33.5%) had mild hyperglycaemia, 196 (10.1%) had intermittent hyperglycaemia, and 20 (1.0%) had hypoglycaemia. The oddsratio (OR) for IMV in patients with intermittent hyperglycaemia was 4.82 (95% CI 2.70-8.61, p < 0.001), and the OR was 2.00 (95% CI 1.21-3.31, p = 0.007) in those with mild hyperglycaemia compared to patients presenting normal glucose levels. The hazardratio (HR) for 30-day in-hospital mortality in patients with mild hyperglycaemia was 1.62 (95% CI 1.10-2.39, p = 0.015), while the HR was 3.04 (95% CI 2.01-4.60, p < 0.001) in patients with intermittent hyperglycaemia compared to those with normoglycaemia at admission. CONCLUSIONS In COVID-19 patients without pre-existing diabetes, the presence of hyperglycaemia at admission is indicative of COVID-19-induced alterations in glucose metabolism and stress hyperglycaemia. Hyperglycaemia at admission in COVID-19 patients without diabetes is associated with an increased risk of invasive mechanical ventilation and in-hospital mortality. This finding highlights the importance for clinicians to carefully consider and select optimal support and treatment strategies for these patients. Further studies on the long-term consequences of hyperglycaemia in this specific population are warranted.
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Affiliation(s)
- Lina Zabuliene
- Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, 03101 Vilnius, Lithuania;
| | - Ieva Kubiliute
- Clinic of Infectious Diseases and Dermatovenerology, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, 08661 Vilnius, Lithuania; (I.K.); (L.J.)
| | - Mykolas Urbonas
- Faculty of Medicine, Vilnius University, 03101 Vilnius, Lithuania
| | - Ligita Jancoriene
- Clinic of Infectious Diseases and Dermatovenerology, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, 08661 Vilnius, Lithuania; (I.K.); (L.J.)
| | - Jurgita Urboniene
- Center of Infectious Diseases, Vilnius University Hospital Santaros Klinikos, 08661 Vilnius, Lithuania;
| | - Ioannis Ilias
- Department of Endocrinology, Diabetes and Metabolism, Elena Venizelou Hospital, 11521 Athens, Greece
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Saha D, Chattopadhyay S, Dutta SS, Roy AK. Critically ill patients: Histopathological evidence of thyroid dysfunction. J Crit Care 2023; 78:154384. [PMID: 37499381 DOI: 10.1016/j.jcrc.2023.154384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 07/16/2023] [Accepted: 07/17/2023] [Indexed: 07/29/2023]
Abstract
PURPOSE Critical illness is characterized by severe biphasic physical and metabolic stress as result of systemic inflammatory response syndrome and/or multiple organ dysfunction syndrome, and is frequently associated with non-thyroidal illness. Purpose of this study is to better understand the cytomorphological basis of NTI by performing histopathological examinations of thyroid gland on autopsies of patients who died from critical illness. METHODS Histopathological examination of thyroid gland of 58 critically ill patients was performed in our hospital. The cases included 24 cases of burn injury, 24 cases of traumatic brain injury, and 10 cases of cerebral stroke. Thyroid samples obtained during autopsy were preserved in formol saline and stained with hematoxylin and eosin. The sections were visualized under light microscopy. RESULTS Out of 58 cases examined, 21 patients showed normal thyroid findings, and rest of the cases had unusual thyroid findings in the histopathological study. The principal finding was distortion of thyroid follicular architecture. Other findings include mononuclear cell infiltration, clumping of thyroglobulin, and exhaustion of thyroid follicles. CONCLUSION Critical illness produces metabolically damaging effects on thyroid gland, which functionally corresponds to a state of low T3 syndrome. These changes are more pronounced in BI and cerebral stroke than in TBI.
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Affiliation(s)
- Dipti Saha
- Nilratan Sircar Medical College and Hospital, 138 Acharya Jagadish Chandra Bose Road, Kolkata, West Bengal 700014, India.
| | - Saurabh Chattopadhyay
- Department of Forensic Medicine and Toxicology, Nilratan Sircar Medical College and Hospital, 138 Acharya Jagadish Chandra Bose Road, Kolkata, West Bengal 700014, India
| | - Sayak Sovan Dutta
- Department of Forensic Medicine and Toxicology, Nilratan Sircar Medical College and Hospital, 138 Acharya Jagadish Chandra Bose Road, Kolkata, West Bengal 700014, India
| | - Anup Kumar Roy
- Department of Pathology, Nilratan Sircar Medical College and Hospital, 138 Acharya Jagadish Chandra Bose Road, Kolkata, West Bengal 700014, India
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Langouche L, Téblick A, Gunst J, Van den Berghe G. The Hypothalamus-pituitary-adrenocortical Response to Critical Illness: A Concept in Need of Revision. Endocr Rev 2023; 44:1096-1106. [PMID: 37409973 PMCID: PMC10638597 DOI: 10.1210/endrev/bnad021] [Citation(s) in RCA: 1] [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] [Received: 10/27/2022] [Revised: 06/06/2023] [Accepted: 07/03/2023] [Indexed: 07/07/2023]
Abstract
Based on insights obtained during the past decade, the classical concept of an activated hypothalamus-pituitary-adrenocortical axis in response to critical illness is in need of revision. After a brief central hypothalamus-pituitary-adrenocortical axis activation, the vital maintenance of increased systemic cortisol availability and action in response to critical illness is predominantly driven by peripheral adaptations rather than by an ongoing centrally activated several-fold increased production and secretion of cortisol. Besides the known reduction of cortisol-binding proteins that increases free cortisol, these peripheral responses comprise suppressed cortisol metabolism in liver and kidney, prolonging cortisol half-life, and local alterations in expression of 11βHSD1, glucocorticoid receptor-α (GRα), and FK506 binding protein 5 (FKBP51) that appear to titrate increased GRα action in vital organs and tissues while reducing GRα action in neutrophils, possibly preventing immune-suppressive off-target effects of increased systemic cortisol availability. Peripherally increased cortisol exerts negative feed-back inhibition at the pituitary level impairing processing of pro-opiomelanocortin into ACTH, thereby reducing ACTH-driven cortisol secretion, whereas ongoing central activation results in increased circulating pro-opiomelanocortin. These alterations seem adaptive and beneficial for the host in the short term. However, as a consequence, patients with prolonged critical illness who require intensive care for weeks or longer may develop a form of central adrenal insufficiency. The new findings supersede earlier concepts such as "relative," as opposed to "absolute," adrenal insufficiency and generalized systemic glucocorticoid resistance in the critically ill. The findings also question the scientific basis for broad implementation of stress dose hydrocortisone treatment of patients suffering from acute septic shock solely based on assumption of cortisol insufficiency.
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Affiliation(s)
- Lies Langouche
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, B-3000 Leuven, Belgium
| | - Arno Téblick
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, B-3000 Leuven, Belgium
| | - Jan Gunst
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, B-3000 Leuven, Belgium
| | - Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, B-3000 Leuven, Belgium
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Does stress hyperglycemia in diabetic and non-diabetic acute ischemic stroke patients predict unfavorable outcomes following endovascular treatment? Neurol Sci 2023; 44:1695-1702. [PMID: 36652040 DOI: 10.1007/s10072-023-06625-y] [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: 12/11/2022] [Accepted: 01/12/2023] [Indexed: 01/19/2023]
Abstract
BACKGROUND Hyperglycemia in hospitalized patients is related to increased morbidity and mortality, we determine if stress hyperglycemia, as assessed by the stress hyperglycemia ratio (SHR) index, increases the risk of adverse events in diabetic and non-diabetic AIS (acute ischemic stroke) patients following EVT (endovascular treatment). METHODS We retrospectively analyzed data of 209 patients who achieved complete recanalization. SHR was defined as [FPG (mmol/L)/HbA1c (%)]. This study comprised 130 non-diabetic AIS patients and 79 people with diabetes, and they were categorized into three different groups based on SHR (Q1-Q3) tertiles. The primary outcome was futile recanalization, characterized as a 3-month modified Rankin scale score (mRS) of 3-6. Multivariable logistic regression analyses were utilized to calculate the relationship between stress hyperglycemia and poor outcomes. RESULTS Non-diabetic patients showed statistically significant differences in the proportion of 3-month all-cause mortality (14.6% for Q1, 63.0% for Q2, 74.4% for Q3, p<0.001) and futile recanalization (2.4% for Q1, 19.6% for Q2, 37.2% for Q3, p<0.001) between the three groups. After adjusting for potential confounders, we found that the highest SHR tertile remained an independent risk factor of futile recanalization (OR 18.13, 95% CI 3.38-97.38, p = 0.001) and 3-month all-cause mortality (OR 15.9, 95% CI 1.46-173.26, p = 0.023) among non-diabetic patients. As demonstrated by restricted cubic splines, the SHR reference was 1.12. CONCLUSIONS Severe stress hyperglycemia independently increased the odds of futile recanalization and 3-month all-cause mortality in AIS patients receiving EVT but without diabetes.
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Razvi S, Duntas L, Biondi B. Editorial: Treatment of subclinical thyroid dysfunction in patients with comorbidities. Front Endocrinol (Lausanne) 2023; 14:1141612. [PMID: 36742407 PMCID: PMC9896362 DOI: 10.3389/fendo.2023.1141612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 01/16/2023] [Indexed: 01/21/2023] Open
Affiliation(s)
- Salman Razvi
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
- *Correspondence: Salman Razvi,
| | - Leonidas Duntas
- Evgenideion Hospital, Unit of Endocrinology, Metabolism and Diabetes, University of Athens, Athens, Greece
| | - Bernadette Biondi
- Department of Clinical Medicine and Surgery, Federico II University of Naples, Naples, Italy
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Guan B, Luo J, Huang X, Tian F, Sun S, Ma Y, Yu Y, Liu R, Cao J, Fan L. Association between thyroid hormone levels and frailty in the community-dwelling oldest-old: a cross-sectional study. Chin Med J (Engl) 2022; 135:1962-1968. [PMID: 36378137 PMCID: PMC9746773 DOI: 10.1097/cm9.0000000000002208] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Changes in thyroid hormone levels are commonly recognized characters among the elderly, which were reported to potentially influence incident frailty. Therefore, we examined the cross-sectional associations of thyroid hormones (THs) with frailty as well as the five components characterizing frailty (fatigue, resistance, ambulation, number of illnesses, and loss of weight) among the oldest-old. METHODS Four hundred and eighty-seven community-dwelling oldest-old from a local community in Haidian District, Beijing, participated in our recruitment campaign between April 2019 and May 2020. The primary outcomes were a definitive diagnosis of frailty according to the FRAIL scale (Fatigue, Resistance, Ambulation, Illnesses, Loss of weight) and a positive score for each frailty subdomain. Demographic information (age, sex, marital status, and educational status), comorbidities, and details on the participants' lifestyles were recorded. Serum THs including free triiodothyronin (fT3), triiodothyronine (T3), free thyroxine (fT4), and thyroxine (T4) and thyroid stimulating hormone (TSH) levels were also measured at the beginning of our study. Logistic regressions were conducted to screen for potential risk factors for frailty and its subdomains. RESULTS Among the total 487 subjects at enrollment, 60 (12.23%) of them were diagnosed with subclinical hypothyroidism and 110 (22.59%) of the total population scored positive for frailty. Logistic regression analyses adjusted for all potential confounders, showed that frailty was significantly associated with the serum TSH concentration (odds ratio [OR]: 1.06), fT3 concentration (OR: 0.54), and subclinical hypothyroidism score (OR: 2.18). The association between fT4 and frailty was absent in our observational study. The fT3/fT4 ratio characterizing peripheral hormone conversion was also tested to be correlated with frailty. CONCLUSION Subclinical hypothyroidism, higher TSH level, lower fT3 level, and decreased fT3/fT4 ratio were all associated with frailty assessed by the FRAIL scale among the community-dwelling oldest-old, suggesting a relevant role of thyroid function in aging. Future longitudinal studies are warranted to determine the casual relationship between thyroid dysfunction and frailty in the oldest-old.
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Affiliation(s)
- Bo Guan
- Geriatric Cardiology Department of the Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese People's Liberation Army General Hospital, Beijing 100089, China
- Medical School of People's Liberation Army General Hospital, Beijing 100089, China
| | - Jiakun Luo
- Geriatric Cardiology Department of the Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese People's Liberation Army General Hospital, Beijing 100089, China
- Medical School of People's Liberation Army General Hospital, Beijing 100089, China
| | - Xin Huang
- Geriatric Cardiology Department of the Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese People's Liberation Army General Hospital, Beijing 100089, China
- Medical School of People's Liberation Army General Hospital, Beijing 100089, China
| | - Fan Tian
- Geriatric Cardiology Department of the Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese People's Liberation Army General Hospital, Beijing 100089, China
- Medical School of People's Liberation Army General Hospital, Beijing 100089, China
| | - Shasha Sun
- Geriatric Cardiology Department of the Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese People's Liberation Army General Hospital, Beijing 100089, China
- Medical School of People's Liberation Army General Hospital, Beijing 100089, China
| | - Yufei Ma
- Geriatric Cardiology Department of the Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese People's Liberation Army General Hospital, Beijing 100089, China
- Medical School of People's Liberation Army General Hospital, Beijing 100089, China
| | - Yan Yu
- Geriatric Cardiology Department of the Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese People's Liberation Army General Hospital, Beijing 100089, China
- Medical School of People's Liberation Army General Hospital, Beijing 100089, China
| | - Ruihan Liu
- Geriatric Cardiology Department of the Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese People's Liberation Army General Hospital, Beijing 100089, China
- Medical School of People's Liberation Army General Hospital, Beijing 100089, China
| | - Jian Cao
- Geriatric Cardiology Department of the Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese People's Liberation Army General Hospital, Beijing 100089, China
| | - Li Fan
- Geriatric Cardiology Department of the Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese People's Liberation Army General Hospital, Beijing 100089, China
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Téblick A, Gunst J, Van den Berghe G. Critical Illness-induced Corticosteroid Insufficiency: What It Is Not and What It Could Be. J Clin Endocrinol Metab 2022; 107:2057-2064. [PMID: 35358303 PMCID: PMC9202732 DOI: 10.1210/clinem/dgac201] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Indexed: 01/07/2023]
Abstract
Critical illnesses are hallmarked by increased systemic cortisol availability, a vital part of the stress response. Acute stress may trigger a life-threatening adrenal crisis when a disease of the hypothalamic-pituitary-adrenal (HPA) axis is present and not adequately treated with stress doses of hydrocortisone. Stress doses of hydrocortisone are also used to reduce high vasopressor need in patients suffering from septic shock, in the absence of adrenal insufficiency. Research performed over the last 10 years focusing on the HPA axis during critical illness has led to the insight that neither of these conditions can be labeled "critical illness-induced corticosteroid insufficiency" or CIRCI. Instead, these data suggested using the term CIRCI for a condition that may develop in prolonged critically ill patients. Indeed, when patients remain dependent on vital organ support for weeks, they are at risk of acquiring central adrenal insufficiency. The sustained increase in systemic glucocorticoid availability, mainly brought about by suppressed circulating cortisol-binding proteins and suppressed hepatic/renal cortisol metabolism, exerts negative feedback inhibition at the hypothalamus/pituitary, while high levels of other glucocorticoid receptor ligands, such as bile acids, and drugs, such as opioids, may further suppress adrenocorticotropic hormone (ACTH) secretion. The adrenal cortex, depleted from ACTH-mediated trophic signaling for weeks, may become structurally and functionally impaired, resulting in insufficient cortisol production. Such a central HPA axis suppression may be maladaptive by contributing to lingering vasopressor need and encephalopathy, hence preventing recovery. Here, we review this concept of CIRCI and we advise on how to recognize and treat this poorly understood condition.
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Affiliation(s)
- Arno Téblick
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven University, B-3000 Leuven, Belgium
| | - Jan Gunst
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven University, B-3000 Leuven, Belgium
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Stanculescu D, Bergquist J. Perspective: Drawing on Findings From Critical Illness to Explain Myalgic Encephalomyelitis/Chronic Fatigue Syndrome. Front Med (Lausanne) 2022; 9:818728. [PMID: 35345768 PMCID: PMC8957276 DOI: 10.3389/fmed.2022.818728] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 02/11/2022] [Indexed: 12/15/2022] Open
Abstract
We propose an initial explanation for how myalgic encephalomyelitis / chronic fatigue syndrome (ME/CFS) could originate and perpetuate by drawing on findings from critical illness research. Specifically, we combine emerging findings regarding (a) hypoperfusion and endotheliopathy, and (b) intestinal injury in these illnesses with our previously published hypothesis about the role of (c) pituitary suppression, and (d) low thyroid hormone function associated with redox imbalance in ME/CFS. Moreover, we describe interlinkages between these pathophysiological mechanisms as well as “vicious cycles” involving cytokines and inflammation that may contribute to explain the chronic nature of these illnesses. This paper summarizes and expands on our previous publications about the relevance of findings from critical illness for ME/CFS. New knowledge on diagnostics, prognostics and treatment strategies could be gained through active collaboration between critical illness and ME/CFS researchers, which could lead to improved outcomes for both conditions.
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Affiliation(s)
| | - Jonas Bergquist
- Division of Analytical Chemistry and Neurochemistry, Department of Chemistry - Biomedical Center, Uppsala University, Uppsala, Sweden.,The Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) Collaborative Research Centre at Uppsala University, Uppsala, Sweden
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11
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Yang X, Zhang R, Jin T, Zhu P, Yao L, Li L, Cai W, Mukherjee R, Du D, Fu X, Xue J, Martina R, Liu T, Pendharkar S, Phillips AR, Singh VK, Sutton R, Windsor JA, Deng L, Xia Q, Huang W. Stress Hyperglycemia Is Independently Associated with Persistent Organ Failure in Acute Pancreatitis. Dig Dis Sci 2022; 67:1879-1889. [PMID: 33939149 PMCID: PMC9142444 DOI: 10.1007/s10620-021-06982-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 03/30/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND/AIMS Stress hyperglycemia is common in critical illness but it has not been clearly studied in patients with acute pancreatitis (AP). This study aimed to investigate the specific blood glucose (BG) level that defines stress hyperglycemia and to determine the impact of stress hyperglycemia on clinical outcomes in AP patients. METHODS AP patients admitted ≤ 48 h after abdominal pain onset were retrospectively analyzed. Patients were stratified by pre-existing diabetes and stress hyperglycemia was defined using stratified BG levels for non-diabetes and diabetes with clinical outcomes compared. RESULTS There were 967 non-diabetic and 114 diabetic (10.5%) patients met the inclusion criteria and the clinical outcomes between these two groups were not significantly different. In non-diabetes, the cut-off BG level of ≥ 180 mg/dl was selected to define stress hyperglycemia with an 8.8-fold higher odds ratio for persistent organ failure (POF) (95% CI 5.4-14.3; P < 0.001). For diabetes, ≥ 300 mg/dl was selected with a 7.5-fold higher odds ratio for POF (95% CI 1.7-34.3; P = 0.009). In multivariable logistic regression, stress hyperglycemia was independently associated with POF, acute necrotic collection, major infection and mortality. The combination of BG and systemic inflammatory response syndrome (SIRS) score in predicting POF was better than SIRS or Glasgow score alone. CONCLUSIONS This study identifies a cut-off BG level of ≥ 180 mg/dl and ≥ 300 mg/dl was optimal to define stress hyperglycemia for non-diabetic and diabetic AP patients, respectively. There was a significant relationship between stress hyperglycemia and adverse clinical outcomes.
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Affiliation(s)
- Xinmin Yang
- Department and Laboratory of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, No. 37 Wannan Guoxue Alley, Chengdu, 610041 Sichuan Province China
| | - Ruwen Zhang
- Department and Laboratory of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, No. 37 Wannan Guoxue Alley, Chengdu, 610041 Sichuan Province China
| | - Tao Jin
- Department and Laboratory of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, No. 37 Wannan Guoxue Alley, Chengdu, 610041 Sichuan Province China
| | - Ping Zhu
- Department and Laboratory of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, No. 37 Wannan Guoxue Alley, Chengdu, 610041 Sichuan Province China
| | - Linbo Yao
- Department and Laboratory of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, No. 37 Wannan Guoxue Alley, Chengdu, 610041 Sichuan Province China
| | - Lan Li
- Department and Laboratory of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, No. 37 Wannan Guoxue Alley, Chengdu, 610041 Sichuan Province China
| | - Wenhao Cai
- Department and Laboratory of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, No. 37 Wannan Guoxue Alley, Chengdu, 610041 Sichuan Province China ,Liverpool Pancreatitis Research Group, Liverpool University Hospitals NHS Foundation Trust and Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Rajarshi Mukherjee
- Liverpool Pancreatitis Research Group, Liverpool University Hospitals NHS Foundation Trust and Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Dan Du
- West China-Washington Mitochondria and Metabolism Center, West China Hospital, Sichuan University, Chengdu, China
| | - Xianghui Fu
- Division of Endocrinology and Metabolism, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu, China
| | - Jing Xue
- State Key Laboratory of Oncogenes and Related Genes, Stem Cell Research Center, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Reynaldo Martina
- Biostatistics and Clinical Trials, Department of Oncology, University of Cambridge, Cambridge, UK
| | - Tingting Liu
- Department and Laboratory of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, No. 37 Wannan Guoxue Alley, Chengdu, 610041 Sichuan Province China
| | - Sayali Pendharkar
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Anthony R. Phillips
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand ,Applied Surgery and Metabolism Laboratory, School of Biological Sciences, University of Auckland, Auckland, New Zealand
| | - Vikesh K. Singh
- Pancreatitis Center, Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, USA
| | - Robert Sutton
- Liverpool Pancreatitis Research Group, Liverpool University Hospitals NHS Foundation Trust and Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - John A. Windsor
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Lihui Deng
- Department and Laboratory of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, No. 37 Wannan Guoxue Alley, Chengdu, 610041 Sichuan Province China
| | - Qing Xia
- Department and Laboratory of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, No. 37 Wannan Guoxue Alley, Chengdu, 610041 Sichuan Province China
| | - Wei Huang
- Department and Laboratory of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital, Sichuan University, No. 37 Wannan Guoxue Alley, Chengdu, 610041 Sichuan Province China
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12
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Zheng J, Cui Z, Shi N, Tian S, Chen T, Zhong X, Qiu K, Zhang J, Zeng T, Chen L, Li H. Suppression of the hypothalamic-pituitary-thyroid axis is associated with the severity of prognosis in hospitalized patients with COVID-19. BMC Endocr Disord 2021; 21:228. [PMID: 34781943 PMCID: PMC8591433 DOI: 10.1186/s12902-021-00896-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 11/02/2021] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND The outbreak of severe acute respiratory syndrome novel coronavirus 2 (SARS-CoV-2) has spread rapidly worldwide. SARS-CoV-2 has been found to cause multiple organ damage; however, little attention has been paid to the damage to the endocrine system caused by this virus, and the subsequent impact on prognosis. This may be the first research on the hypothalamic-pituitary-thyroid (HPT) axis and prognosis in coronavirus disease 2019 (COVID-19). METHODS In this retrospective observational study, 235 patients were admitted to the hospital with laboratory-confirmed SARS-CoV-2 infection from 22 January to 17 March 2020. Clinical characteristics, laboratory findings, and treatments were obtained from electronic medical records with standard data collection forms and compared among patients with different thyroid function status. RESULTS Among 235 patients, 17 (7.23%) had subclinical hypothyroidism, 11 (4.68%) severe non-thyroidal illness syndrome (NTIS), and 23 (9.79%) mild to moderate NTIS. Composite endpoint events of each group, including mortality, admission to the ICU, and using IMV were observed. Compared with normal thyroid function, the hazard ratios (HRs) of composite endpoint events for mild to moderate NTIS, severe NTIS, subclinical hypothyroidism were 27.3 (95% confidence interval [CI] 7.07-105.7), 23.1 (95% CI 5.75-92.8), and 4.04 (95% CI 0.69-23.8) respectively. The multivariate-adjusted HRs for acute cardiac injury among patients with NTF, subclinical hypothyroidism, severe NTIS, and mild to moderate NTIS were 1.00, 1.68 (95% CI 0.56-5.05), 4.68 (95% CI 1.76-12.4), and 2.63 (95% CI 1.09-6.36) respectively. CONCLUSIONS Our study shows that the suppression of the HPT axis could be a common complication in COVID-19 patients and an indicator of the severity of prognosis. Among the three different types of thyroid dysfunction with COVID-19, mild to moderate NTIS and severe NTIS have a higher risk of severe outcomes compared with subclinical hypothyroidism.
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Affiliation(s)
- Juan Zheng
- Department of Endocrinology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Hubei provincial Clinical Research Center for Diabetes and Metabolic Disorders, Wuhan, China
| | - Zhenhai Cui
- Department of Endocrinology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Hubei provincial Clinical Research Center for Diabetes and Metabolic Disorders, Wuhan, China
| | - Ningjie Shi
- Department of Endocrinology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Hubei provincial Clinical Research Center for Diabetes and Metabolic Disorders, Wuhan, China
| | - Shenghua Tian
- Department of Endocrinology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Hubei provincial Clinical Research Center for Diabetes and Metabolic Disorders, Wuhan, China
| | - Ting Chen
- Department of Endocrinology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Hubei provincial Clinical Research Center for Diabetes and Metabolic Disorders, Wuhan, China
| | - Xueyu Zhong
- Department of Endocrinology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Hubei provincial Clinical Research Center for Diabetes and Metabolic Disorders, Wuhan, China
| | - Kangli Qiu
- Department of Endocrinology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Hubei provincial Clinical Research Center for Diabetes and Metabolic Disorders, Wuhan, China
| | - Jiaoyue Zhang
- Department of Endocrinology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Hubei provincial Clinical Research Center for Diabetes and Metabolic Disorders, Wuhan, China
| | - Tianshu Zeng
- Department of Endocrinology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
- Hubei provincial Clinical Research Center for Diabetes and Metabolic Disorders, Wuhan, China.
| | - Lulu Chen
- Department of Endocrinology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
- Hubei provincial Clinical Research Center for Diabetes and Metabolic Disorders, Wuhan, China.
| | - Huiqing Li
- Department of Endocrinology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
- Hubei provincial Clinical Research Center for Diabetes and Metabolic Disorders, Wuhan, China.
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13
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The Multiple Organ Dysfunction Syndrome: Syndrome, Metaphor, and Unsolved Clinical Challenge. Crit Care Med 2021; 49:1402-1413. [PMID: 34259449 DOI: 10.1097/ccm.0000000000005139] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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14
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García Martínez MA, Martínez de Lagrán Zurbano I, García de Lorenzo Y Mateos A. Recommendations for specialized nutritional-metabolic treatment of the critical patient: Metabolic response to stress. Metabolism and Nutrition Working Group of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC). Med Intensiva 2021; 44 Suppl 1:15-18. [PMID: 32532405 DOI: 10.1016/j.medin.2019.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 11/14/2019] [Accepted: 12/09/2019] [Indexed: 10/24/2022]
Affiliation(s)
- M A García Martínez
- Servicio de Medicina Intensiva, Hospital Universitario de Torrevieja, Alicante, España.
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15
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Wasyluk W, Wasyluk M, Zwolak A. Sepsis as a Pan-Endocrine Illness-Endocrine Disorders in Septic Patients. J Clin Med 2021; 10:jcm10102075. [PMID: 34066289 PMCID: PMC8152097 DOI: 10.3390/jcm10102075] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 05/11/2021] [Accepted: 05/12/2021] [Indexed: 12/18/2022] Open
Abstract
Sepsis is defined as "life-threatening organ dysfunction caused by a dysregulated host response to infection". One of the elements of dysregulated host response is an endocrine system disorder. Changes in its functioning in the course of sepsis affect almost all hormonal axes. In sepsis, a function disturbance of the hypothalamic-pituitary-adrenal axis has been described, in the range of which the most important seems to be hypercortisolemia in the acute phase. Imbalance in the hypothalamic-pituitary-thyroid axis is also described. The most typical manifestation is a triiodothyronine concentration decrease and reverse triiodothyronine concentration increase. In the somatotropic axis, a change in the secretion pattern of growth hormone and peripheral resistance to this hormone has been described. In the hypothalamic-pituitary-gonadal axis, the reduction in testosterone concentration in men and the stress-induced "hypothalamic amenorrhea" in women have been described. Catecholamine and β-adrenergic stimulation disorders have also been reported. Disorders in the endocrine system are part of the "dysregulated host response to infection". They may also affect other components of this dysregulated response, such as metabolism. Hormonal changes occurring in the course of sepsis require further research, not only in order to explore their potential significance in therapy, but also due to their promising prognostic value.
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Affiliation(s)
- Weronika Wasyluk
- Chair of Internal Medicine and Department of Internal Medicine in Nursing, Faculty of Health Sciences, Medical University of Lublin, 20-093 Lublin, Poland;
- Doctoral School, Medical University of Lublin, 20-093 Lublin, Poland
- Correspondence:
| | - Martyna Wasyluk
- Student’s Scientific Association at Chair of Internal Medicine and Department of Internal Medicine in Nursing, Faculty of Health Sciences, Medical University of Lublin, 20-093 Lublin, Poland;
| | - Agnieszka Zwolak
- Chair of Internal Medicine and Department of Internal Medicine in Nursing, Faculty of Health Sciences, Medical University of Lublin, 20-093 Lublin, Poland;
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16
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Stanculescu D, Larsson L, Bergquist J. Theory: Treatments for Prolonged ICU Patients May Provide New Therapeutic Avenues for Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS). Front Med (Lausanne) 2021; 8:672370. [PMID: 34026797 PMCID: PMC8137963 DOI: 10.3389/fmed.2021.672370] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 04/01/2021] [Indexed: 12/20/2022] Open
Abstract
We here provide an overview of treatment trials for prolonged intensive care unit (ICU) patients and theorize about their relevance for potential treatment of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). Specifically, these treatment trials generally target: (a) the correction of suppressed endocrine axes, notably through a "reactivation" of the pituitary gland's pulsatile secretion of tropic hormones, or (b) the interruption of the "vicious circle" between inflammation, oxidative and nitrosative stress (O&NS), and low thyroid hormone function. There are significant parallels in the treatment trials for prolonged critical illness and ME/CFS; this is consistent with the hypothesis of an overlap in the mechanisms that prevent recovery in both conditions. Early successes in the simultaneous reactivation of pulsatile pituitary secretions in ICU patients-and the resulting positive metabolic effects-could indicate an avenue for treating ME/CFS. The therapeutic effects of thyroid hormones-including in mitigating O&NS and inflammation and in stimulating the adreno-cortical axis-also merit further studies. Collaborative research projects should further investigate the lessons from treatment trials for prolonged critical illness for solving ME/CFS.
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Affiliation(s)
| | - Lars Larsson
- Basic and Clinical Muscle Biology, Department of Physiology and Pharmacology, Karolinska Institute, Solna, Sweden
| | - Jonas Bergquist
- Analytical Chemistry and Neurochemistry, Department of Chemistry–Biomedical Center, Uppsala University, Uppsala, Sweden
- The Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) Collaborative Research Centre at Uppsala University, Uppsala, Sweden
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17
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Campos FA, Archie EA, Gesquiere LR, Tung J, Altmann J, Alberts SC. Glucocorticoid exposure predicts survival in female baboons. SCIENCE ADVANCES 2021; 7:7/17/eabf6759. [PMID: 33883141 PMCID: PMC8059933 DOI: 10.1126/sciadv.abf6759] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 03/02/2021] [Indexed: 05/29/2023]
Abstract
Are differences in hypothalamic-pituitary-adrenal (HPA) axis activation across the adult life span linked to differences in survival? This question has been the subject of considerable debate. We analyze the link between survival and fecal glucocorticoid (GC) measures in a wild primate population, leveraging an unusually extensive longitudinal dataset of 14,173 GC measurements from 242 adult female baboons over 1634 female years. We document a powerful link between GCs and survival: Females with relatively high current GCs or high lifelong cumulative GCs face an elevated risk of death. A hypothetical female who maintained GCs in the top 90% for her age across adulthood would be expected to lose 5.4 years of life relative to a female who maintained GCs in the bottom 10% for her age. Hence, differences among individuals in HPA axis activity provide valuable prognostic information about disparities in life span.
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Affiliation(s)
- Fernando A Campos
- Department of Anthropology, University of Texas at San Antonio, San Antonio, TX 78249-1644, USA.
- Department of Biology, Duke University, Durham, NC 27708, USA
| | - Elizabeth A Archie
- Department of Biological Sciences, University of Notre Dame, Notre Dame, IN, 46556, USA
| | | | - Jenny Tung
- Department of Biology, Duke University, Durham, NC 27708, USA
- Population Research Institute, Duke University, Durham, NC 27708, USA
- Department of Evolutionary Anthropology, Duke University, Durham, NC 27708, USA
- Canadian Institute for Advanced Research, 661 University Ave., Suite 505, Toronto, ON M5G 1M1, Canada
| | - Jeanne Altmann
- Department of Ecology and Evolutionary Biology, Princeton University, Princeton, NJ 08544, USA
| | - Susan C Alberts
- Department of Biology, Duke University, Durham, NC 27708, USA
- Population Research Institute, Duke University, Durham, NC 27708, USA
- Department of Evolutionary Anthropology, Duke University, Durham, NC 27708, USA
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18
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Mamtani M, Athavale AM, Abraham M, Vernik J, Amarah AR, Ruiz JP, Joshi AJ, Itteera M, Zhukovski SD, Madaiah RP, White BC, Hart P, Kulkarni H. Association of hyperglycaemia with hospital mortality in nondiabetic COVID-19 patients: A cohort study. DIABETES & METABOLISM 2021; 47:101254. [PMID: 33781926 PMCID: PMC7994287 DOI: 10.1016/j.diabet.2021.101254] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 02/26/2021] [Accepted: 03/16/2021] [Indexed: 01/08/2023]
Abstract
Objective Diabetes is a known risk factor for mortality in Coronavirus disease 2019 (COVID-19) patients. Our objective was to identify prevalence of hyperglycaemia in COVID-19 patients with and without prior diabetes and quantify its association with COVID-19 disease course. Research design and methods This observational cohort study included all consecutive COVID-19 patients admitted to John H Stroger Jr. Hospital, Chicago, IL from March 15, 2020 to May 3, 2020 and followed till May 15, 2020. The primary outcome was hospital mortality, and the studied predictor was hyperglycaemia [any blood glucose ≥7.78 mmol/L (140 mg/dL) during hospitalization]. Results Of the 403 COVID-19 patients studied, 51 (12.7%) died; 335 (83.1%) were discharged while 17 (4%) were still in hospital. Hyperglycaemia occurred in 228 (56.6%) patients; 83 of these hyperglycaemic patients (36.4%) had no prior history of diabetes. Compared to the reference group no-diabetes/no-hyperglycaemia patients the no-diabetes/hyperglycaemia patients showed higher mortality [1.8% versus 20.5%, adjusted odds ratio 21.94 (95% confidence interval 4.04–119.0), P < 0.001]; improved prediction of death (P = 0.01) and faster progression to death (P < 0.01). Hyperglycaemia within the first 24 and 48 h was also significantly associated with mortality (odds ratio 2.15 and 3.31, respectively). Conclusions Hyperglycaemia without prior diabetes was common (20.6% of hospitalized COVID-19 patients) and was associated with an increased risk of and faster progression to death. Development of hyperglycaemia in COVID-19 patients who do not have diabetes is an early indicator of progressive disease.
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Affiliation(s)
- M Mamtani
- M&H Research, LLC, San Antonio, Texas, USA
| | - A M Athavale
- Division of Nephrology, Department of Medicine, Cook County Health, Chicago, Illinois, USA
| | - M Abraham
- Division of Nephrology, Department of Medicine, Cook County Health, Chicago, Illinois, USA
| | - J Vernik
- Division of Nephrology, Department of Medicine, Cook County Health, Chicago, Illinois, USA
| | - A R Amarah
- Division of Nephrology, Department of Medicine, Cook County Health, Chicago, Illinois, USA
| | - J P Ruiz
- Division of Nephrology, Department of Medicine, Cook County Health, Chicago, Illinois, USA
| | - A J Joshi
- Division of Nephrology, Department of Medicine, Cook County Health, Chicago, Illinois, USA
| | - M Itteera
- Division of Nephrology, Department of Medicine, Cook County Health, Chicago, Illinois, USA
| | | | - R P Madaiah
- Cerner Corporation, Kansas City, Missouri, USA
| | - B C White
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - P Hart
- Division of Nephrology, Department of Medicine, Cook County Health, Chicago, Illinois, USA
| | - H Kulkarni
- M&H Research, LLC, San Antonio, Texas, USA.
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19
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Neiman DJ, Bruyette DS, Bergman PJ. Prognostic value of serum total thyroxine concentration at admission to an intensive care unit for critically ill dogs. J Am Vet Med Assoc 2021; 257:57-61. [PMID: 32538707 DOI: 10.2460/javma.257.1.57] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine whether serum total thyroxine (TT4) concentration at admission to an intensive care unit (ICU) was associated with mortality rate and duration of hospitalization for critically ill dogs. ANIMALS 166 client-owned dogs that were hospitalized in the ICU of a private veterinary practice from January 2013 through December 2016 and for which serum TT4 concentration had been measured at admission. PROCEDURES Medical records were reviewed to collect data regarding patient signalment, concurrent illnesses, medications, reason for hospitalization, outcome (death, euthanasia, or survival to hospital discharge), duration of hospitalization, and initial serum TT4 concentration. RESULTS Mean age of the 166 dogs was 8.6 years (range, 1 to 16 years). Overall mortality rate was 15.7%, with 26 dogs failing to survive to hospital discharge. Of these 26 dogs, 7 died and 19 were euthanized. No significant association was identified between serum TT4 concentration at admission and survival to discharge (yes or no) or duration of hospitalization. Age was significantly associated with survival to discharge, with older dogs less likely to survive than younger dogs. Duration of hospitalization was also associated with survival to discharge, with longer hospital stays associated with a lower likelihood of survival to discharge. CONCLUSIONS AND CLINICAL RELEVANCE Findings suggested that serum TT4 concentration at admission to an ICU had no prognostic value in this population of critically ill dogs.
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20
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Stanculescu D, Larsson L, Bergquist J. Hypothesis: Mechanisms That Prevent Recovery in Prolonged ICU Patients Also Underlie Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS). Front Med (Lausanne) 2021; 8:628029. [PMID: 33585528 PMCID: PMC7876311 DOI: 10.3389/fmed.2021.628029] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 01/08/2021] [Indexed: 12/13/2022] Open
Abstract
Here the hypothesis is advanced that maladaptive mechanisms that prevent recovery in some intensive care unit (ICU) patients may also underlie Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). Specifically, these mechanisms are: (a) suppression of the pituitary gland's pulsatile secretion of tropic hormones, and (b) a "vicious circle" between inflammation, oxidative and nitrosative stress (O&NS), and low thyroid hormone function. This hypothesis should be investigated through collaborative research projects.
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Affiliation(s)
| | - Lars Larsson
- Basic and Clinical Muscle Biology, Department of Physiology and Pharmacology, Karolinska Institute, Solna, Sweden
| | - Jonas Bergquist
- Analytical Chemistry and Neurochemistry, Department of Chemistry – Biomedical Center, Uppsala University, Uppsala, Sweden
- The Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) Collaborative Research Centre at Uppsala University, Uppsala, Sweden
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21
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Guo J, Hong Y, Wang Z, Li Y. Analysis of the Incidence of Euthyroid Sick Syndrome in Comprehensive Intensive Care Units and Related Risk Factors. Front Endocrinol (Lausanne) 2021; 12:656641. [PMID: 34177801 PMCID: PMC8220065 DOI: 10.3389/fendo.2021.656641] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 04/27/2021] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE A low concentration of plasma triiodothyronine (T3) indicates euthyroid sick syndrome (ESS), which could be associated with a poor outcome in patients in intensive care units (ICUs). This study evaluated the relationship between ESS and prognostic indicators in patients admitted to an ICU and examined the free T3 (FT3) cut-off points that could be associated with 28-day mortality. METHODS This prospective observational study included patients admitted to the ICU of The Third Hospital of Hebei Medical University between February and November 2018. Baseline variables and data on the occurrence of low FT3 were collected. The patients were divided into ESS (FT3 < 3.28 pmol/L) and non-ESS groups. The relationship between ESS and prognostic indicators in patients admitted to the ICU was evaluated, and the FT3 cut-off points that could be associated with 28-day mortality were examined. RESULTS Out of a total of 305 patients, 118 (38.7%) were in the ESS group. Levels of FT3 (P < 0.001) and FT4 (P = 0.001) were lower, while the 28-day mortality rate (P < 0.001) and hospitalization expenses in the ICU (P = 0.001) were higher in the ESS group. A univariable analysis identified ESS, FT3, free thyroxine (FT4)/FT3, the APACHE II score, the sequential organ failure (SOFA) score, the duration of mechanical ventilation, creatinine (CREA) levels, the oxygenation index (HGB), white blood cells, albumin (ALB) levels, age, and brain natriuretic peptide (BNP) levels as factors associated with 28-day mortality (all P < 0.05). The cut-off value of FT3 for 28-day mortality was 2.88 pmol/L, and the 28-day mortality rate and hospitalization expenses in the ICU were higher in patients with ESS. The syndrome was confirmed to be independently associated with 28-day mortality. CONCLUSION This study determined the incidence of ESS in the comprehensive ICU to be 38.7%. APACHE II, SOFA, BNP, APTT, HGB, PLT, CREA, ALB, FT4, SBP, and DBP are closely related to ESS, while BNP, PLT, and ALB are independent risk factors for the syndrome.
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Affiliation(s)
- Jianying Guo
- Department of Endocrinology, The Third Hospital of Hebei Medical University, Shijiazhuang, China
- Department of Critical Care Medicine, The Third Hospital of Hebei Medical University, Shijiazhuang, China
- *Correspondence: Yukun Li, ; Jianying Guo,
| | - Yanyan Hong
- Department of School Infirmary, Infirmary of Shijiazhuang Institute of Technology, Shijiazhuang, China
| | - Zhiyong Wang
- Department of Critical Care Medicine, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yukun Li
- Department of Endocrinology, The Third Hospital of Hebei Medical University, Shijiazhuang, China
- *Correspondence: Yukun Li, ; Jianying Guo,
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Alzahrani AS, Mukhtar N, Aljomaiah A, Aljamei H, Bakhsh A, Alsudani N, Elsayed T, Alrashidi N, Fadel R, Alqahtani E, Raef H, Butt MI, Sulaiman O. The Impact of COVID-19 Viral Infection on the Hypothalamic-Pituitary-Adrenal Axis. Endocr Pract 2020; 27:83-89. [PMID: 33554871 PMCID: PMC7837186 DOI: 10.1016/j.eprac.2020.10.014] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 10/09/2020] [Accepted: 10/21/2020] [Indexed: 02/06/2023]
Abstract
Objective To study the adrenocortical response to an acute coronavirus disease-2019 (COVID-19) infection. Methods Morning plasma cortisol, adrenocorticotropic hormone (ACTH), and dehydroepiandrosterone sulfate levels were measured in 28 consecutive patients with COVID-19 (16 men, 12 women, median age 45.5 years, range 25-69 years) on day 1 to 2 of hospital admission. These tests were repeated twice in 20 patients and thrice in 15 patients on different days. The hormone levels were correlated with severity of the disease. Results The median morning cortisol level was 196 (31-587) nmol/L. It was <100 nmol/L in 8 patients (28.6%), <200 nmol/L in 14 patients (50%), and <300 nmol/L in 18 patients (64.3%). The corresponding ACTH values had a median of 18.5 ng/L (range 4-38 ng/L), and the ACTH level was <10 ng/L in 7 patients (26.9%), <20 ng/L in 17 patients (60.7%), and <30 ng/L in 23 patients (82.1%). The repeated testing on different days showed a similar pattern. Overall, if a cutoff level of <300 nmol/L is considered abnormal in the setting of acute disease, 9 patients (32%) had cortisol levels below this limit, regardless of whether the test was done only once (3 patients) or 3 times (6 patients). When the disease was more severe, the patients had lower cortisol and ACTH levels, suggesting a direct link between the COVID-19 infection and impaired glucocorticoid response. Conclusion Unexpectedly, the adrenocortical response in patients with COVID-19 infection was impaired, and a significant percentage of the patients had plasma cortisol and ACTH levels consistent with central adrenal insufficiency.
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Affiliation(s)
- Ali S Alzahrani
- Department of Medicine, King Faisal Specialist Hospital & Research Centre, Riyadh, 11211, Saudi Arabia.
| | - Noha Mukhtar
- Department of Medicine, King Faisal Specialist Hospital & Research Centre, Riyadh, 11211, Saudi Arabia
| | - Abeer Aljomaiah
- Department of Medicine, King Faisal Specialist Hospital & Research Centre, Riyadh, 11211, Saudi Arabia
| | - Hadeel Aljamei
- Department of Medicine, King Faisal Specialist Hospital & Research Centre, Riyadh, 11211, Saudi Arabia
| | - Abdulmohsen Bakhsh
- Department of Medicine, King Faisal Specialist Hospital & Research Centre, Riyadh, 11211, Saudi Arabia
| | - Nada Alsudani
- Department of Medicine, King Faisal Specialist Hospital & Research Centre, Riyadh, 11211, Saudi Arabia
| | - Tarek Elsayed
- Department of Medicine, King Faisal Specialist Hospital & Research Centre, Riyadh, 11211, Saudi Arabia
| | - Nahlah Alrashidi
- Department of Medicine, King Faisal Specialist Hospital & Research Centre, Riyadh, 11211, Saudi Arabia
| | - Roqayh Fadel
- Department of Medicine, King Faisal Specialist Hospital & Research Centre, Riyadh, 11211, Saudi Arabia
| | - Eman Alqahtani
- Department of Medicine, King Faisal Specialist Hospital & Research Centre, Riyadh, 11211, Saudi Arabia
| | - Hussein Raef
- Department of Medicine, King Faisal Specialist Hospital & Research Centre, Riyadh, 11211, Saudi Arabia
| | - Muhammad Imran Butt
- Department of Medicine, King Faisal Specialist Hospital & Research Centre, Riyadh, 11211, Saudi Arabia
| | - Othman Sulaiman
- Department of Critical Care, King Faisal Specialist Hospital & Research Centre, Riyadh, 11211, Saudi Arabia
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Akura B, Batubara JRL, Munasir Z, Gunanti, Prihartono J, Satari HI, Immanuel S, Somasetia DH. IL-1, IL-6, TNF-α, and MIF in relative adrenal insufficiency in septic shock: a piglet model. MEDICAL JOURNAL OF INDONESIA 2020. [DOI: 10.13181/mji.oa.202943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Inflammatory mediators released during septic shock are involved in the mechanism of adrenal insufficiency. This study investigated the role of interleukin (IL)-6, IL-1, tumor necrosis factor (TNF)-α, and macrophage migration inhibitory factor (MIF) in septic shock with relative adrenal insufficiency (RAI).
METHODS We conducted a 6-month experimental study in 20 piglets. Following endotoxin administration, their hemodynamics were monitored and blood samples were drawn to test the levels of cytokines IL-1, IL-6, TNF-α, and MIF every 15 min until septic shock onset as well as during a corticotropin stimulation test. Septic shock was managed by administering fluid resuscitation, inotropic drugs, and hydrocortisone. At the end of the study, the piglet models were classified as either RAI or non-RAI. Immunohistochemistry staining was performed on the hypothalamus of the RAI group.
RESULTS The level of IL-6 at 45 min was higher in the RAI group than the non-RAI group (p = 0.008), and that of IL-1 was similar in the two groups during septic shock. The RAI group had higher TNF-α levels at 15 min (p = 0.002) and at 30 min (p = 0.007) than the non-RAI group, and the MIF level during septic shock was higher in the RAI group (p = 0.003) than the non-RAI group.
CONCLUSIONS Cytokine-induced inflammatory process of adrenal gland reflected in TNF-α level in 15 min and 30 min, IL-6 in 45 min, and MIF in septic shock condition but not in IL-1.
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Abstract
Hypothyroidism is a common condition in which the thyroid gland provides insufficient amounts of thyroid hormone for the needs of peripheral tissues. The most common cause in adults is chronic lymphocytic thyroiditis (Hashimoto thyroiditis), but there are many other causes. Because most of the clinical features of hypothyroidism are nonspecific, the diagnosis requires laboratory testing. Serum thyroid-stimulating hormone (TSH) measurement is the best diagnostic test; an elevated TSH level almost always signals primary hypothyroidism. Serum free thyroxine levels may be below the reference range (overt hypothyroidism) or within the reference range (subclinical hypothyroidism). All patients with overt hypothyroidism should be treated, but those with subclinical hypothyroidism do not always benefit from treatment, especially elderly patients and those with baseline TSH levels below 10 mU/L. Oral L-thyroxine is the treatment of choice because of its well-demonstrated efficacy, safety, and ease of use. Therapy goals are symptom relief and maintenance of serum TSH levels within the reference range. Myxedema coma is a life-threatening form of decompensated hypothyroidism that must be treated with aggressive L-thyroxine replacement and other supportive measures in the inpatient setting.
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Petini M, Drigo M, Zoia A. Prognostic value of systemic inflammatory response syndrome and serum concentrations of acute phase proteins, cholesterol, and total thyroxine in cats with panleukopenia. J Vet Intern Med 2020; 34:719-724. [PMID: 31977127 PMCID: PMC7096634 DOI: 10.1111/jvim.15704] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 01/10/2020] [Indexed: 01/08/2023] Open
Abstract
Background Feline parvovirus (FPV) is a common and potentially lethal infectious agent in cats. Objective To assess the prognostic value of age, neuter status, serum concentrations of serum amyloid A (SAA), haptoglobin, cholesterol and total thyroxine (tT4), and the presence of systemic inflammatory response syndrome (SIRS) in cats with panleukopenia. Animals Client‐owned cats with FPV infection diagnosed by a positive fecal ELISA test, positive PCR on feces or blood or both. Methods Retrospective cohort study. The electronic medical database was searched for cats with FPV infection presented between January 2010 and January 2018. Cats were divided into survivors and nonsurvivors according to their survival status 28 days after hospital admission. The prognostic importance of each variable was investigated univariately and by multivariable Cox's proportional‐hazards regression. Finally, receiver operator characteristic (ROC) curve analysis was used to identify the best cutoff value for discriminating survivors from nonsurvivors for the statistically significant prognostic predictors identified by multivariable analysis. Results Seventy cats were enrolled in the study. Multivariable analysis determined that only serum tT4 concentration at hospital admission was significantly (P = .01) associated with survival. A cutoff value of 0.82 μg/dL was identified by ROC curve analysis for serum tT4 concentration in discriminating survivors from nonsurvivors. Sensitivity at this cutoff was 73.9% and specificity was 82.9% (area under the curve, 0.783; 95% confidence interval, 0.668‐0.873; P < .0001). Conclusion and Clinical Relevance Serum tT4 concentration at hospital admission has prognostic value in cats with FPV infection.
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Affiliation(s)
- Matteo Petini
- Division of Internal Medicine, San Marco Veterinary Clinic, Padua, Italy
| | - Michele Drigo
- Department of Animal Medicine, Production and Health, University of Padova, Legnaro, Italy
| | - Andrea Zoia
- Division of Internal Medicine, San Marco Veterinary Clinic, Padua, Italy
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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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Abstract
OBJECTIVES Interventional trials on glucocorticoids in sepsis have yielded capricious results. Recent studies have identified multiple glucocorticoid receptor isoforms. The relative abundance of these isoforms in septic patients and following murine cecal ligation and puncture is unknown. The objective of this study is to determine the effects of cecal ligation and puncture on glucocorticoid receptor isoform abundance. DESIGN Determination of effects of cecal ligation and puncture on glucocorticoid receptor isoform subtype abundance in C57BL/6 mice. Examination of glucocorticoid receptor isoform abundance in tissues harvested from patients immediately after death from sepsis or nonseptic critical illness. SETTING Research laboratory. SUBJECTS C57BL/6 mice and human tissue sections from recently deceased critically ill patients. INTERVENTIONS C57BL/6 mice were subjected to cecal ligation and puncture or sham operation. Abundance of the activating glucocorticoid receptor α and the inactivating glucocorticoid receptor β isoforms was determined in mouse and human tissue using immunoblotting. Cardiac output with or without stimulation with dexamethasone was assessed using echocardiography. The expression of the gene encoding the glucocorticoid-dependent enzyme glucose-6-phosphatase was identified using polymerase chain reaction. Statistical significance (p < 0.05) was determined using analysis of variance. MEASUREMENTS AND MAIN RESULTS Results in baseline and sham operation mice were identical. At baseline, glucocorticoid receptor αA predominated in heart, lung, and skeletal muscle; abundance was decreased post cecal ligation and puncture. All glucocorticoid receptor α subtypes were identified in liver. Cecal ligation and puncture decreased the summed abundance of hepatic glucocorticoid receptor α subtypes and those of glucocorticoid receptors αA, B, and D. However, glucocorticoid receptor αC abundance was unchanged. Cecal ligation and puncture increased glucocorticoid receptor β protein abundance in the heart and lung. Relative to T0, cecal ligation and puncture decreased cardiac output and attenuated the cardiac output response to dexamethasone. Cecal ligation and puncture also decreased expression of glucose-6-phosphatase. Compared with nonseptic patients, human sepsis decreased the abundance of glucocorticoid receptor α and increased the abundance of glucocorticoid receptor β in heart and liver biopsies. CONCLUSIONS Cecal ligation and puncture altered glucocorticoid receptor α and glucocorticoid receptor β isoform expression in tissues and decreased functional responses in heart and liver. Decreases in glucocorticoid receptor α and increases in glucocorticoid receptor β might explain the diminished glucocorticoid responsiveness observed in sepsis.
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Badke CM, Marsillio LE, Weese-Mayer DE, Sanchez-Pinto LN. Autonomic Nervous System Dysfunction in Pediatric Sepsis. Front Pediatr 2018; 6:280. [PMID: 30356758 PMCID: PMC6189408 DOI: 10.3389/fped.2018.00280] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 09/14/2018] [Indexed: 12/17/2022] Open
Abstract
The autonomic nervous system (ANS) plays a major role in maintaining homeostasis through key adaptive responses to stress, including severe infections and sepsis. The ANS-mediated processes most relevant during sepsis include regulation of cardiac output and vascular tone, control of breathing and airway resistance, inflammation and immune modulation, gastrointestinal motility and digestion, and regulation of body temperature. ANS dysfunction (ANSD) represents an imbalanced or maladaptive response to injury and is prevalent in pediatric sepsis. Most of the evidence on ANSD comes from studies of heart rate variability, which is a marker of ANS function and is inversely correlated with organ dysfunction and mortality. In addition, there is evidence that other measures of ANSD, such as respiratory rate variability, skin thermoregulation, and baroreflex and chemoreflex sensitivity, are associated with outcomes in critical illness. The relevance of understanding ANSD in the context of pediatric sepsis stems from the fact that it might play an important role in the pathophysiology of sepsis, is associated with outcomes, and can be measured continuously and noninvasively. Here we review the physiology and dysfunction of the ANS during critical illness, discuss methods for measuring ANS function in the intensive care unit, and review the diagnostic, prognostic, and therapeutic value of understanding ANSD in pediatric sepsis.
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Affiliation(s)
- Colleen M. Badke
- Division of Critical Care Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Lauren E. Marsillio
- Division of Critical Care Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Debra E. Weese-Mayer
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
- Center for Autonomic Medicine in Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
- Stanley Manne Children's Research Institute, Chicago, IL, United States
| | - L. Nelson Sanchez-Pinto
- Division of Critical Care Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
- Stanley Manne Children's Research Institute, Chicago, IL, United States
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Qin SL, He Q, Hu L, He CY, Gao LC, Young CA, Chen J, Jiang CF, Luo XF, Zhou Y, Sheng X, Li ZH, Chen ML, Xu G. The relationship between inflammatory factors, oxidative stress and DIO-1 concentration in patients with chronic renal failure accompanied with or without euthyroid sick syndrome. J Int Med Res 2018; 46:4061-4070. [PMID: 30152254 PMCID: PMC6166338 DOI: 10.1177/0300060518778190] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Objective To investigate the relationship between inflammatory factors, oxidative
stress and type 1 deiodinase (DIO-1) concentration in patients with chronic
renal failure (CRF) with or without euthyroid sick syndrome (ESS). Methods This study recruited patients with CRF and divided them into two groups:
group 1 had low free triiodothyronine (FT3) levels; and group 2 had normal
FT3 levels. Group 3 consisted of healthy volunteers. Serum levels of
interleukin (IL)-6, IL-1β, tumour necrosis factor (TNF)-α, 8-isoprostane and
DIO-1 were measured using enzyme-linked immunosorbent assays. Multiple
regression analysis was used to analyse correlations between parameters. Results Sixty patients were enrolled into each group and the groups were comparable
in terms of vital signs, white blood cell count, free thyroxine and thyroid
stimulating hormone concentrations. The serum DIO-1 concentration was
significantly higher in group 2 than in groups 1 and 3. Multivariate
regression analysis revealed that the DIO-1 concentration was inversely
correlated with the TNF-α concentration. Conclusions Patients with CRF without ESS showed higher concentrations of DIO-1 than
patients with ESS. The DIO-1 concentration was inversely correlated with the
TNF-α concentration, which might indicate that the inflammatory response was
milder in the patients with CRF without ESS than in those with ESS.
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Affiliation(s)
- Shu-Lan Qin
- 1 Department of Endocrinology, Third Affiliated Hospital, Nanchang University, Nanchang, Jiangxi Province, China
| | - Qi He
- 1 Department of Endocrinology, Third Affiliated Hospital, Nanchang University, Nanchang, Jiangxi Province, China
| | - Ling Hu
- 1 Department of Endocrinology, Third Affiliated Hospital, Nanchang University, Nanchang, Jiangxi Province, China
| | - Chun-Yan He
- 3 Department of Experimental Centre, Jiangxi Health Vocational College, Nanchang, Jiangxi Province, China
| | - Li-Cheng Gao
- 1 Department of Endocrinology, Third Affiliated Hospital, Nanchang University, Nanchang, Jiangxi Province, China
| | | | - Juan Chen
- 3 Department of Experimental Centre, Jiangxi Health Vocational College, Nanchang, Jiangxi Province, China
| | - Cheng-Fang Jiang
- 3 Department of Experimental Centre, Jiangxi Health Vocational College, Nanchang, Jiangxi Province, China
| | - Xiang-Feng Luo
- 1 Department of Endocrinology, Third Affiliated Hospital, Nanchang University, Nanchang, Jiangxi Province, China
| | - Ying Zhou
- 1 Department of Endocrinology, Third Affiliated Hospital, Nanchang University, Nanchang, Jiangxi Province, China
| | - Xia Sheng
- 1 Department of Endocrinology, Third Affiliated Hospital, Nanchang University, Nanchang, Jiangxi Province, China
| | - Zhi-Hong Li
- 1 Department of Endocrinology, Third Affiliated Hospital, Nanchang University, Nanchang, Jiangxi Province, China
| | - Mei-Ling Chen
- 1 Department of Endocrinology, Third Affiliated Hospital, Nanchang University, Nanchang, Jiangxi Province, China
| | - Gaosi Xu
- 2 Department of Nephrology, Second Affiliated Hospital, Nanchang University, Nanchang, Jiangxi Province, China
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Giunti M, Troia R, Battilani M, Giardino L, Dondi F, Andreani G, Fracassi F. Retrospective evaluation of circulating thyroid hormones in critically ill dogs with systemic inflammatory response syndrome. J Vet Sci 2018; 18:471-477. [PMID: 28057899 PMCID: PMC5746440 DOI: 10.4142/jvs.2017.18.4.471] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 08/09/2016] [Accepted: 11/23/2016] [Indexed: 11/20/2022] Open
Abstract
Critical illness can be associated with transient alterations in circulating thyroid hormone concentrations, indicating the presence of non-thyroidal illness (NTI). NTI is well described in humans, but there are few reports on its occurrence and prognostic significance in dogs. This retrospective study assessed the occurrence of NTI in a population of dogs with systemic inflammatory response syndrome (SIRS) and investigated its association with disease severity (APPLEfast scores). A total of 41 SIRS dogs were included and were divided by SIRS origin (non-septic SIRS, n = 10; septic SIRS, n = 41) and final outcome (survivors, n = 37; non-survivors, n = 4). Healthy, age-matched dogs (n = 15) were included as controls. Serum thyroid hormone levels including total T3, free T3, total T4, and reverse T3 were measured upon admission. Compared to controls, there were significant changes in serum thyroid hormone concentrations in SIRS dogs, suggesting the presence of NTI. Septic SIRS dogs had higher APPLEfast scores and lower serum thyroid hormones concentrations than those in non-septic SIRS and control dogs. In conclusion, NTI was frequent in dogs with SIRS and may be associated with the presence of sepsis or high illness severity.
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Affiliation(s)
- Massimo Giunti
- Department of Veterinary Medical Sciences, Alma Mater Studiorum-University of Bologna, 40126 Bologna, Italy
| | - Roberta Troia
- Department of Veterinary Medical Sciences, Alma Mater Studiorum-University of Bologna, 40126 Bologna, Italy
| | - Mara Battilani
- Department of Veterinary Medical Sciences, Alma Mater Studiorum-University of Bologna, 40126 Bologna, Italy
| | - Luciana Giardino
- Department of Veterinary Medical Sciences, Alma Mater Studiorum-University of Bologna, 40126 Bologna, Italy
| | - Francesco Dondi
- Department of Veterinary Medical Sciences, Alma Mater Studiorum-University of Bologna, 40126 Bologna, Italy
| | - Giulia Andreani
- Department of Veterinary Medical Sciences, Alma Mater Studiorum-University of Bologna, 40126 Bologna, Italy
| | - Federico Fracassi
- Department of Veterinary Medical Sciences, Alma Mater Studiorum-University of Bologna, 40126 Bologna, Italy
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Abstract
Much of what we now do in Critical Care carries an air of urgency, a pressing need to discover and act, with priorities biased toward a reactive response. However, efficacy often depends not simply upon what we do, but rather on whether, when, and how persistently we intervene. The practice of medicine is based upon diagnosis, integration of multiple sources of information, keen judgment, and appropriate intervention. Timing may not be everything, as the well-known adage suggests, but in the intensive care unit (ICU) timing issues clearly deserve more attention than they are currently given. Successfully or not, the patient is continually attempting to adapt and re-adjust to acute illness, and this adaptive process takes time. Knowing that much of what we do carries potential for unintended harm as well as benefit, the trick is to decide whether the patient is winning or losing the adaptive struggle and whether we can help. Costs of modern ICU care is enormous and the trend line shows no encouraging sign of moderation. To sharpen our effectiveness, reduce hazard, and pare cost we must learn to time our interventions, help the patient adapt, and at times withhold treatment rather than jump in on the impulse to rescue and/or to alter the natural course of disease. Indeed, much of the progress made in our discipline has resulted both from timely intervention when called for and avoidance or moderation of hazardous treatments when not. Time-sensitive ICU therapeutics requires awareness of trends in key parameters, respect for adaptive chronobiology, level-headed evaluation of the need to intervene, and awareness of the costs of disrupting a potentially constructive natural response to illness.
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Critical Illness-Related Corticosteroid Insufficiency (CIRCI): A Narrative Review from a Multispecialty Task Force of the Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM). Crit Care Med 2017; 45:2089-2098. [PMID: 28938251 DOI: 10.1097/ccm.0000000000002724] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To provide a narrative review of the latest concepts and understanding of the pathophysiology of critical illness-related corticosteroid insufficiency (CIRCI). PARTICIPANTS A multi-specialty task force of international experts in critical care medicine and endocrinology and members of the Society of Critical Care Medicine and the European Society of Intensive Care Medicine. DATA SOURCES Medline, Database of Abstracts of Reviews of Effects (DARE), Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Database of Systematic Reviews. RESULTS Three major pathophysiologic events were considered to constitute CIRCI: dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, altered cortisol metabolism, and tissue resistance to glucocorticoids. The dysregulation of the HPA axis is complex, involving multidirectional crosstalk between the CRH/ACTH pathways, autonomic nervous system, vasopressinergic system, and immune system. Recent studies have demonstrated that plasma clearance of cortisol is markedly reduced during critical illness, explained by suppressed expression and activity of the primary cortisol-metabolizing enzymes in the liver and kidney. Despite the elevated cortisol levels during critical illness, tissue resistance to glucocorticoids is believed to occur due to insufficient glucocorticoid alpha-mediated anti-inflammatory activity. CONCLUSIONS Novel insights into the pathophysiology of CIRCI add to the limitations of the current diagnostic tools to identify at-risk patients and may also impact how corticosteroids are used in patients with CIRCI.
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Mateos Moreno L, Palacios García N, Estrada García FJ. Adrenal insufficiency in critical patients: New ethiopathogenic concepts and therapeutic implications. ENDOCRINOL DIAB NUTR 2017; 64:557-563. [PMID: 29137961 DOI: 10.1016/j.endinu.2017.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 09/14/2017] [Accepted: 09/23/2017] [Indexed: 11/15/2022]
Abstract
Recently, there have been advances in understanding of the changes that occur in the hypothalamic-pituitary-adrenal axis during the different stages of critical disease. Such advances have led to a paradigm change, so that the aforementioned adaptations are no longer considered the result of adrenal axis activation, but a consequence of decreased cortisol metabolism illness. Knowledge of this new pathophysiological bases should lead to reconsider the diagnosis and treatment of adrenal insufficiency in critically ill patients, a condition poorly understood to date.
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Affiliation(s)
- Laura Mateos Moreno
- Servicio de Endocrinología y Nutrición, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España.
| | - Nuria Palacios García
- Servicio de Endocrinología y Nutrición, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España
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Critical illness-related corticosteroid insufficiency (CIRCI): a narrative review from a Multispecialty Task Force of the Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM). Intensive Care Med 2017; 43:1781-1792. [DOI: 10.1007/s00134-017-4914-x] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 08/16/2017] [Indexed: 01/02/2023]
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The Metabolic Response to Stress and Infection in Critically Ill Children: The Opportunity of an Individualized Approach. Nutrients 2017; 9:nu9091032. [PMID: 28926994 PMCID: PMC5622792 DOI: 10.3390/nu9091032] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 09/06/2017] [Accepted: 09/14/2017] [Indexed: 01/04/2023] Open
Abstract
The metabolic response to stress and infection is closely related to the corresponding requirements of energy and nutrients. On a general level, the response is driven by a complex endocrine network and related to the nature and severity of the insult. On an individual level, the effects of nutritional interventions are highly variable and a possible source of complications. This narrative review aims to discuss the metabolic changes in critically-ill children and the potential of developing personalized nutritional interventions. Through a literature search strategy, we have investigated the importance of blood glucose levels, the nutritional aspects of the different phases of acute stress response, and the reliability of the available tools to assess the energy expenditure. The dynamics of metabolism during stressful events reveal the difficult balance between risk of hypo- or hyperglycemia and under- or overfeeding. Within this context, individualized and accurate measurement of energy expenditure may help in defining the metabolic needs of patients. Given the variability of the metabolic response in critical conditions, randomized clinical studies in ill children are needed to evaluate the effect of individualized nutritional intervention on health outcomes.
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Wendon, J, Cordoba J, Dhawan A, Larsen FS, Manns M, Samuel D, Simpson KJ, Yaron I, Bernardi M. EASL Clinical Practical Guidelines on the management of acute (fulminant) liver failure. J Hepatol 2017; 66:1047-1081. [PMID: 28417882 DOI: 10.1016/j.jhep.2016.12.003] [Citation(s) in RCA: 495] [Impact Index Per Article: 70.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 12/07/2016] [Indexed: 02/06/2023]
Abstract
The term acute liver failure (ALF) is frequently applied as a generic expression to describe patients presenting with or developing an acute episode of liver dysfunction. In the context of hepatological practice, however, ALF refers to a highly specific and rare syndrome, characterised by an acute abnormality of liver blood tests in an individual without underlying chronic liver disease. The disease process is associated with development of a coagulopathy of liver aetiology, and clinically apparent altered level of consciousness due to hepatic encephalopathy. Several important measures are immediately necessary when the patient presents for medical attention. These, as well as additional clinical procedures will be the subject of these clinical practice guidelines.
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Bertoli A, Valentini A, Cianfarani MA, Gasbarra E, Tarantino U, Federici M. Low FT3: a possible marker of frailty in the elderly. Clin Interv Aging 2017; 12:335-341. [PMID: 28228654 PMCID: PMC5312686 DOI: 10.2147/cia.s125934] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Introduction Frailty is associated with a functional decline of multiple physiological systems, of which they may be a cause or consequence. The objective of the study was to evaluate the prevalence of thyroid hormone modifications in elderly frail subjects and its relationship with frailty. Study population and methods An observational study was carried out at the University Hospital “Tor Vergata” in Rome among ambulatory and hospitalized patients. The study population consisted of 112 elderly subjects: 62 were hospitalized following hip fracture and 50 control subjects were outpatients. Participating patients received a multidimensional geriatric evaluation. The Survey of Health, Ageing and Retirement in Europe Frailty Instrument (SHARE-FI) was used to assess the degree of frailty. Thyroid stimulating hormone (TSH), free triiodothyronine (FT3), and free thyroxine (FT4) were measured to evaluate thyroid status. Results FT3, but not FT4, was significantly correlated with Frailty score, both in patients with hip fracture and in patients from the control group. In the entire study population, FT3 under normal limits is effective in discriminating frail/prefrail subjects from nonfrail subjects. Discussion The reduction in serum concentrations of FT3 is a clear manifestation of stress associated with fractures. Numerous preexisting factors, such as the fracture patients’ nutritional status, sarcopenia, disability and comorbidities, which characterize the condition of frailty and influence its pathogenesis, are strongly correlated with FT3 values, suggesting the existence of latent nonthyroidal illness syndrome (NTIS). Conclusion We conclude that measuring FT3 can be a useful laboratory parameter in clinical assessment, which can play an important role in identifying vulnerable elderly subjects and in quantifying the condition of frailty.
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Affiliation(s)
- Aldo Bertoli
- Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Alessia Valentini
- Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | | | - Elena Gasbarra
- Department of Orthopaedics and Traumatology, University of Rome "Tor Vergata", Rome, Italy
| | - Umberto Tarantino
- Department of Orthopaedics and Traumatology, University of Rome "Tor Vergata", Rome, Italy
| | - Massimo Federici
- Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
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Chatzitomaris A, Hoermann R, Midgley JE, Hering S, Urban A, Dietrich B, Abood A, Klein HH, Dietrich JW. Thyroid Allostasis-Adaptive Responses of Thyrotropic Feedback Control to Conditions of Strain, Stress, and Developmental Programming. Front Endocrinol (Lausanne) 2017; 8:163. [PMID: 28775711 PMCID: PMC5517413 DOI: 10.3389/fendo.2017.00163] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 06/27/2017] [Indexed: 12/21/2022] Open
Abstract
The hypothalamus-pituitary-thyroid feedback control is a dynamic, adaptive system. In situations of illness and deprivation of energy representing type 1 allostasis, the stress response operates to alter both its set point and peripheral transfer parameters. In contrast, type 2 allostatic load, typically effective in psychosocial stress, pregnancy, metabolic syndrome, and adaptation to cold, produces a nearly opposite phenotype of predictive plasticity. The non-thyroidal illness syndrome (NTIS) or thyroid allostasis in critical illness, tumors, uremia, and starvation (TACITUS), commonly observed in hospitalized patients, displays a historically well-studied pattern of allostatic thyroid response. This is characterized by decreased total and free thyroid hormone concentrations and varying levels of thyroid-stimulating hormone (TSH) ranging from decreased (in severe cases) to normal or even elevated (mainly in the recovery phase) TSH concentrations. An acute versus chronic stage (wasting syndrome) of TACITUS can be discerned. The two types differ in molecular mechanisms and prognosis. The acute adaptation of thyroid hormone metabolism to critical illness may prove beneficial to the organism, whereas the far more complex molecular alterations associated with chronic illness frequently lead to allostatic overload. The latter is associated with poor outcome, independently of the underlying disease. Adaptive responses of thyroid homeostasis extend to alterations in thyroid hormone concentrations during fetal life, periods of weight gain or loss, thermoregulation, physical exercise, and psychiatric diseases. The various forms of thyroid allostasis pose serious problems in differential diagnosis of thyroid disease. This review article provides an overview of physiological mechanisms as well as major diagnostic and therapeutic implications of thyroid allostasis under a variety of developmental and straining conditions.
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Affiliation(s)
- Apostolos Chatzitomaris
- Medical Department I, Endocrinology and Diabetology, Bergmannsheil University Hospitals, Ruhr University of Bochum, Bochum, Germany
- *Correspondence: Apostolos Chatzitomaris,
| | - Rudolf Hoermann
- Private Consultancy, Research and Development, Yandina, QLD, Australia
| | | | - Steffen Hering
- Department for Internal Medicine, Cardiology, Endocrinology, Diabetes and Medical Intensive Care Medicine, Krankenhaus Bietigheim-Vaihingen, Bietigheim-Bissingen, Germany
| | - Aline Urban
- Department for Anesthesiology, Intensive Care and Palliative Medicine, Eastern Allgäu-Kaufbeuren Hospitals, Kaufbeuren, Germany
| | | | - Assjana Abood
- Medical Department I, Endocrinology and Diabetology, Bergmannsheil University Hospitals, Ruhr University of Bochum, Bochum, Germany
| | - Harald H. Klein
- Medical Department I, Endocrinology and Diabetology, Bergmannsheil University Hospitals, Ruhr University of Bochum, Bochum, Germany
- Ruhr Center for Rare Diseases (CeSER), Ruhr University of Bochum and Witten/Herdecke University, Bochum, Germany
| | - Johannes W. Dietrich
- Medical Department I, Endocrinology and Diabetology, Bergmannsheil University Hospitals, Ruhr University of Bochum, Bochum, Germany
- Ruhr Center for Rare Diseases (CeSER), Ruhr University of Bochum and Witten/Herdecke University, Bochum, Germany
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Hoermann R, Midgley JEM, Larisch R, Dietrich JW. Recent Advances in Thyroid Hormone Regulation: Toward a New Paradigm for Optimal Diagnosis and Treatment. Front Endocrinol (Lausanne) 2017; 8:364. [PMID: 29375474 PMCID: PMC5763098 DOI: 10.3389/fendo.2017.00364] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 12/12/2017] [Indexed: 12/26/2022] Open
Abstract
In thyroid health, the pituitary hormone thyroid-stimulating hormone (TSH) raises glandular thyroid hormone production to a physiological level and enhances formation and conversion of T4 to the biologically more active T3. Overstimulation is limited by negative feedback control. In equilibrium defining the euthyroid state, the relationship between TSH and FT4 expresses clusters of genetically determined, interlocked TSH-FT4 pairs, which invalidates their statistical correlation within the euthyroid range. Appropriate reactions to internal or external challenges are defined by unique solutions and homeostatic equilibria. Permissible variations in an individual are much more closely constrained than over a population. Current diagnostic definitions of subclinical thyroid dysfunction are laboratory based, and do not concur with treatment recommendations. An appropriate TSH level is a homeostatic concept that cannot be reduced to a fixed range consideration. The control mode may shift from feedback to tracking where TSH becomes positively, rather than inversely related with FT4. This is obvious in pituitary disease and severe non-thyroid illness, but extends to other prevalent conditions including aging, obesity, and levothyroxine (LT4) treatment. Treatment targets must both be individualized and respect altered equilibria on LT4. To avoid amalgamation bias, clinically meaningful stratification is required in epidemiological studies. In conclusion, pituitary TSH cannot be readily interpreted as a sensitive mirror image of thyroid function because the negative TSH-FT4 correlation is frequently broken, even inverted, by common conditions. The interrelationships between TSH and thyroid hormones and the interlocking elements of the control system are individual, dynamic, and adaptive. This demands a paradigm shift of its diagnostic use.
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Affiliation(s)
- Rudolf Hoermann
- Department for Nuclear Medicine, Klinikum Lüdenscheid, Lüdenscheid, Germany
- *Correspondence: Rudolf Hoermann,
| | | | - Rolf Larisch
- Department for Nuclear Medicine, Klinikum Lüdenscheid, Lüdenscheid, Germany
| | - Johannes W. Dietrich
- Medical Department I, Endocrinology and Diabetology, Bergmannsheil University Hospitals, Ruhr University of Bochum, Bochum, Germany
- Ruhr Center for Rare Diseases (CeSER), Ruhr University of Bochum, Bochum, Germany
- Ruhr Center for Rare Diseases (CeSER), Witten/Herdecke University, Bochum, Germany
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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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Kaynar AM, Bakalov V, Laverde SM, Cambriel AIF, Lee BH, Towheed A, Gregory AD, Webb SAR, Palladino MJ, Bozza FA, Shapiro SD, Angus DC. Cost of surviving sepsis: a novel model of recovery from sepsis in Drosophila melanogaster. Intensive Care Med Exp 2016; 4:4. [PMID: 26791145 PMCID: PMC4720623 DOI: 10.1186/s40635-016-0075-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 01/05/2016] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Multiple organ failure, wasting, increased morbidity, and mortality following acute illness complicates the health span of patients surviving sepsis. Persistent inflammation has been implicated, and it is proposed that insulin signaling contributes to persistent inflammatory signaling during the recovery phase after sepsis. However, mechanisms are unknown and suitable pre-clinical models are lacking. We therefore developed a novel Drosophila melanogaster model of sepsis to recapitulate the clinical course of sepsis, explored inflammation over time, and its relation to impaired mobility, metabolic disturbance, and changes in lifespan. METHODS We used wild-type (WT), Drosomycin-green fluorescent protein (GFP), and NF-κB-luc reporter male Drosophila melanogaster 4-5 days of age (unmanipulated). We infected Drosophila with Staphylococcus aureus (infected without treatment) or pricked with aseptic needles (sham). Subsets of insects were treated with oral linezolid after the infection (infected with antibiotics). We assessed rapid iterative negative geotaxis (RING) in all the groups as a surrogate for neuromuscular functional outcome up to 96 h following infection. We harvested the flies over the 7-day course to evaluate bacterial burden, inflammatory and metabolic pathway gene expression patterns, NF-κB translation, and metabolic reserve. We also followed the lifespan of the flies. RESULTS Our results showed that when treated with antibiotics, flies had improved survival compared to infected without treatment flies in the early phase of sepsis up to 1 week (81 %, p = 0.001). However, the lifespan of infected with antibiotics flies was significantly shorter than that of sham controls (p = 0.001). Among infected with antibiotic sepsis survivors, we observed persistent elevation of NF-κB in the absence of any obvious infection as shown by culturing flies surviving sepsis. In the same group, geotaxis had an early (18 h) and sustained decline compared to its baseline. Geotaxis in infected with antibiotics sepsis survivors was significantly lower than that in sham and age-matched unmanipulated flies at 18 and 48 h. Expression of antimicrobial peptides (AMP) remained significantly elevated over the course of 7 days after sepsis, especially drosomycin (5.7-fold, p = 0.0145) on day 7 compared to that of sham flies. Infected with antibiotics flies had a trend towards decreased Akt activation, yet their glucose stores were significantly lower than those of sham flies (p = 0.001). Sepsis survivors had increased lactate levels and LDH activity by 1 week, whereas ATP and pyruvate content was similar to that of the sham group. CONCLUSIONS In summary, our model mimics human survivors of sepsis with persistent inflammation, impaired motility, dysregulated glucose metabolism, and shortened lifespan.
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Affiliation(s)
- Ata Murat Kaynar
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Laboratory, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 612 Scaife Hall, 3550 Terrace Street, Pittsburgh, 15261, PA, USA.
| | - Veli Bakalov
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Laboratory, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 612 Scaife Hall, 3550 Terrace Street, Pittsburgh, 15261, PA, USA
| | - Silvia Martinez Laverde
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15261, USA
| | | | - Byoung-Hoon Lee
- Department of Pulmonology and Allergy, Eulji University, Seoul, 139-711, Korea
| | - Atif Towheed
- Department of Pharmacology and Chemical Biology, Pittsburgh, PA, 15260, USA
- Present address: Center of Mitochondrial and Epigenomic Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
| | - Alyssa D Gregory
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15261, USA
| | - Steven A R Webb
- School of Population Health, University of Western Australia, Crawly, Perth, WA, 6009, Australia
| | | | - Fernando A Bozza
- Instituto de Pesquisa Clínica Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, 21040-360, Brazil
| | - Steven D Shapiro
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15261, USA
| | - Derek C Angus
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Laboratory, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 612 Scaife Hall, 3550 Terrace Street, Pittsburgh, 15261, PA, USA
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Bergquist M, Huss F, Fredén F, Hedenstierna G, Hästbacka J, Rockwood AL, Kushnir MM, Bergquist J. Altered adrenal and gonadal steroids biosynthesis in patients with burn injury. CLINICAL MASS SPECTROMETRY 2016. [DOI: 10.1016/j.clinms.2016.10.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Campanha FVG, Perone D, de Campos DHS, Luvizotto RDAM, De Síbio MT, de Oliveira M, Olimpio RMC, Moretto FCF, Padovani CR, Mazeto GMFS, Cicogna AC, Nogueira CR. Thyroxine increases Serca2 and Ryr2 gene expression in heart failure rats with euthyroid sick syndrome. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2016; 60:582-586. [PMID: 27737323 PMCID: PMC10522172 DOI: 10.1590/2359-3997000000208] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 04/11/2016] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The current study was aimed at analyzing sarcoplasmic reticulum Ca2+ ATPase (Serca2) and ryanodine receptor type 2 (Ryr2) gene expression in rats subjected to surgery that induced HF and were subsequently treated with T4 using physiological doses. MATERIALS AND METHODS HF was induced in 18 male Wistar rats by clipping the ascending thoracic aorta to generate aortic stenosis (HFS group), while the control group (9-sham) underwent thoracotomy. After 21 weeks, the HFS group was subdivided into two subgroups. One group (9 Wistar rats) with HF received 1.0 µg of T4/100 g of body weight for five consecutive days (HFS/T4); the other group (9 Wistar rats) received isotonic saline solution (HFS/S). The animals were sacrificed after this treatment and examined for signs of HF. Samples from the left ventricles of these animals were analyzed by RT-qPCR for the expression of Serca2 and Ryr2 genes. RESULTS Rats with HF developed euthyroid sick syndrome (ESS) and treatment with T4 restored the T3 values to the Sham level and increased Serca2 and Ryr2 gene expression, thereby demonstrating a possible benefit of T4 treatment for heart function in ESS associated with HF. CONCLUSION The T4 treatment can potentially normalize the levels of T3 as well elevated Serca2 and Ryr2 gene expression in the myocardium in heart failure rats with euthyroid sick syndrome.
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Affiliation(s)
- Fábio V. G. Campanha
- Unidade de Pesquisa ExperimentalFaculdade de Medicina de BotucatuUniversidade Estadual PaulistaBotucatuSPBrasil Departamento de Clínica Médica, Unidade de Pesquisa Experimental (Unipex), Faculdade de Medicina de Botucatu, Universidade Estadual Paulista (Unesp), Botucatu, SP, Brasil
| | - Denise Perone
- Unidade de Pesquisa ExperimentalFaculdade de Medicina de BotucatuUniversidade Estadual PaulistaBotucatuSPBrasil Departamento de Clínica Médica, Unidade de Pesquisa Experimental (Unipex), Faculdade de Medicina de Botucatu, Universidade Estadual Paulista (Unesp), Botucatu, SP, Brasil
| | - Dijon H. S. de Campos
- Unidade de Pesquisa ExperimentalFaculdade de Medicina de BotucatuUniversidade Estadual PaulistaBotucatuSPBrasil Departamento de Clínica Médica, Unidade de Pesquisa Experimental (Unipex), Faculdade de Medicina de Botucatu, Universidade Estadual Paulista (Unesp), Botucatu, SP, Brasil
| | - Renata de A. M. Luvizotto
- Instituto de Ciências da SaúdeUniversidade Federal de Mato GrossoSinopMTBrasilInstituto de Ciências da Saúde, Universidade Federal de Mato Grosso (UFMT), Sinop, MT, Brasil
| | - Maria T. De Síbio
- Unidade de Pesquisa ExperimentalFaculdade de Medicina de BotucatuUniversidade Estadual PaulistaBotucatuSPBrasil Departamento de Clínica Médica, Unidade de Pesquisa Experimental (Unipex), Faculdade de Medicina de Botucatu, Universidade Estadual Paulista (Unesp), Botucatu, SP, Brasil
| | - Miriane de Oliveira
- Unidade de Pesquisa ExperimentalFaculdade de Medicina de BotucatuUniversidade Estadual PaulistaBotucatuSPBrasil Departamento de Clínica Médica, Unidade de Pesquisa Experimental (Unipex), Faculdade de Medicina de Botucatu, Universidade Estadual Paulista (Unesp), Botucatu, SP, Brasil
| | - Regiane M. C. Olimpio
- Unidade de Pesquisa ExperimentalFaculdade de Medicina de BotucatuUniversidade Estadual PaulistaBotucatuSPBrasil Departamento de Clínica Médica, Unidade de Pesquisa Experimental (Unipex), Faculdade de Medicina de Botucatu, Universidade Estadual Paulista (Unesp), Botucatu, SP, Brasil
| | - Fernanda C. F. Moretto
- Unidade de Pesquisa ExperimentalFaculdade de Medicina de BotucatuUniversidade Estadual PaulistaBotucatuSPBrasil Departamento de Clínica Médica, Unidade de Pesquisa Experimental (Unipex), Faculdade de Medicina de Botucatu, Universidade Estadual Paulista (Unesp), Botucatu, SP, Brasil
| | - Carlos R. Padovani
- Departamento de BioestatísticaInstituto de BiociênciasUniversidade Estadual PaulistaBotucatuSPBrasilDepartamento de Bioestatística, Instituto de Biociências, Universidade Estadual Paulista (Unesp), Botucatu, SP, Brasil
| | - Gláucia M. F. S. Mazeto
- Unidade de Pesquisa ExperimentalFaculdade de Medicina de BotucatuUniversidade Estadual PaulistaBotucatuSPBrasil Departamento de Clínica Médica, Unidade de Pesquisa Experimental (Unipex), Faculdade de Medicina de Botucatu, Universidade Estadual Paulista (Unesp), Botucatu, SP, Brasil
| | - Antonio C. Cicogna
- Unidade de Pesquisa ExperimentalFaculdade de Medicina de BotucatuUniversidade Estadual PaulistaBotucatuSPBrasil Departamento de Clínica Médica, Unidade de Pesquisa Experimental (Unipex), Faculdade de Medicina de Botucatu, Universidade Estadual Paulista (Unesp), Botucatu, SP, Brasil
| | - Célia R. Nogueira
- Unidade de Pesquisa ExperimentalFaculdade de Medicina de BotucatuUniversidade Estadual PaulistaBotucatuSPBrasil Departamento de Clínica Médica, Unidade de Pesquisa Experimental (Unipex), Faculdade de Medicina de Botucatu, Universidade Estadual Paulista (Unesp), Botucatu, SP, Brasil
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Su YW, Hsu CY, Guo YW, Chen HS. Usefulness of the plasma glucose concentration-to-HbA 1c ratio in predicting clinical outcomes during acute illness with extreme hyperglycaemia. DIABETES & METABOLISM 2016; 43:40-47. [PMID: 27663631 DOI: 10.1016/j.diabet.2016.07.036] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 07/30/2016] [Accepted: 07/31/2016] [Indexed: 10/21/2022]
Abstract
AIMS To evaluate the correlation between the plasma glucose-to-glycated haemoglobin ratio (GAR) and clinical outcome during acute illness. METHODS This retrospective observational cohort study enrolled 661 patients who visited the emergency department of our hospital between 1 July 2008 and 30 September 2010 with plasma glucose concentrations>500mg/dL. Systolic blood pressure, heart rate, white blood cells, neutrophils, haematocrit, blood urea nitrogen, serum creatinine, liver function and plasma glucose concentration were recorded at the initial presentation to the emergency department. Data on glycated haemoglobin over the preceding 6 months were reviewed from our hospital database. The glucose-to-HbA1c ratio (GAR) was calculated as the plasma glucose concentration divided by glycated haemoglobin. RESULTS The GAR of those who died was significantly higher than that of the survivors (81.0±25.9 vs 67.6±25.0; P<0.001). There was a trend towards a higher 90-day mortality rate in patients with higher GARs (log-rank test P<0.0001 for trend). On multivariate Cox regression analysis, the GAR was significantly related to 90-day mortality (hazard ratio [HR] for 1 standard deviation [SD] change: 1.41, 95% confidence interval [CI]: 1.22-1.63; P<0.001), but not to plasma glucose (HR: 0.89, 95% CI: 0.70-1.13; P=0.328). Rates of intensive care unit (ICU) admission and mechanical ventilator use were also higher in those with higher GARs. CONCLUSION GAR independently predicted 90-day mortality, ICU admission and use of mechanical ventilation. It was also a better predictor of patient outcomes than plasma glucose alone in patients with extremely high glucose levels.
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Affiliation(s)
- Y-W Su
- Division of Endocrinology and Metabolism, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - C-Y Hsu
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan; Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan; Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan; Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Division of Cardiology and Cardiovascular Research Center, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Y-W Guo
- Department of Medicine, Taipei City Hospital, Zhongxing Branch, Taipei, Taiwan
| | - H-S Chen
- Division of Endocrinology and Metabolism, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan.
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Morell-Garcia D, Bauça JM, Elorza MA, Barcelo A. Two-step thyroid screening strategy in the critical patient. Clin Biochem 2016; 49:925-8. [PMID: 27208556 DOI: 10.1016/j.clinbiochem.2016.05.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 05/04/2016] [Accepted: 05/05/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Thyroid function biochemical tests are known for their usefulness in prognosis of long-term critical patients, although current data are controversial regarding the clinical benefit of both free triiodothyronine and thyroxine as prognostic thyroid markers during the first 48h after Intensive Care Unit (ICU) admission. METHODS The aim of this study was to evaluate the usefulness of two strategies for thyroid function assessment in the first 48h after admission at the ICU. The usefulness of a two-step biochemical thyroid strategy (initial isolated TSH determination, followed by subsequent fT4 and fT3) was compared with a complete one-step biochemical profile (TSH+fT4+fT3). RESULTS No significant differences were found between the rates of thyroid dysfunction detection when using both strategies (2.8% vs. 2.4%; p=0.71). Using the two-step strategy and a 2.5μUI/mL cut-off value for TSH, sensitivity and negative predictive value were 100%. Among patients with an altered fT3 only, mortality was 14% if TSH≤2.5μUI/mL, whereas it was 7% if TSH>2.5μUI/mL (p=0.008). CONCLUSIONS For patients with critical illness, the early two-step thyroid screening strategy (starting with an isolated TSH determination between 24 and 48h after admission) led to a saving of 50% in fT4 and fT3 tests, with a false-negative rate of 1.3%. This represents an improved diagnostic approach, hence avoiding the performance of unnecessary complementary biochemical measurements.
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Affiliation(s)
- Daniel Morell-Garcia
- Department of Laboratory Medicine, Hospital Universitari Son Espases, Palma, Balearic Islands, Spain; Institut d'Investigació Sanitària de Palma (IdISPa), Palma, Balearic Islands, Spain.
| | - Josep Miquel Bauça
- Department of Laboratory Medicine, Hospital Universitari Son Espases, Palma, Balearic Islands, Spain; Institut d'Investigació Sanitària de Palma (IdISPa), Palma, Balearic Islands, Spain
| | - Miguel Angel Elorza
- Department of Laboratory Medicine, Hospital Universitari Son Espases, Palma, Balearic Islands, Spain
| | - Antonia Barcelo
- Department of Laboratory Medicine, Hospital Universitari Son Espases, Palma, Balearic Islands, Spain; Institut d'Investigació Sanitària de Palma (IdISPa), Palma, Balearic Islands, Spain
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Lee WK, Hwang S, Kim D, Lee SG, Jeong S, Seol MY, Kim H, Ku CR, Shin DY, Chung WY, Lee EJ, Lee J, Jo YS. Distinct Features of Nonthyroidal Illness in Critically Ill Patients With Infectious Diseases. Medicine (Baltimore) 2016; 95:e3346. [PMID: 27057916 PMCID: PMC4998832 DOI: 10.1097/md.0000000000003346] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Nonthyroidal illness (NTI), often observed in critically ill patients, arises through diverse alterations in the hypothalamus-pituitary-thyroid (HPT) axis. However, the causal relationship between underlying disease and NTI diversity in critically ill patients is poorly understood.The aim of this study was to examine NTI severity and adverse outcomes in critically ill patients with respect to their underlying disease(s).The medical records of 616 patients admitted to the intensive care unit (ICU) between January 2009 and October 2014 were retrospectively reviewed. Patients with known diseases or taking medications that affect thyroid function were excluded. All-cause mortality (ACM) and length of stay (LOS) in the ICU were assessed as adverse outcomes.The enrolled patients (n = 213) were divided into the following 4 groups according to the severity of NTI at the nadir of their thyroid function test (TFT): normal (n = 11, 5.2%), mild NTI (n = 113, 53.1%), moderate NTI (n = 78, 36.6%), and severe NTI (n = 11, 5.2%). There was no significant difference between the groups in terms of age and gender. NTI severity showed a significantly strong association with ACM (P < 0.0001) and a significant positive association with LOS in the ICU (P = 0.031). After adjusting for age, gender, and current medications affecting TFT, increasing NTI severity led to increased ACM (odds ratio = 3.101; 95% confidence interval = 1.711-5.618; P < 0.0001). Notably, the prevalence of moderate-to-severe NTI was markedly higher in patients with infectious disease than in those with noninfectious disease (P = 0.012). Consistent with this, serum C-reactive protein levels were higher in patients with moderate-to-severe NTI (P = 0.016).NTI severity is associated with increased ACM, LOS, and underlying infectious disease. Future studies will focus on the biological and clinical implications of infectious disease on the HPT axis.
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Affiliation(s)
- Woo Kyung Lee
- From the Department of Internal Medicine (WKL, SH, DK, SJ, CRK, DYS, EJL, YSJ); Department of Surgery (SGL, M-YS, HK, WYC, JL); Open NBI Convergence Technology Research Laboratory, Severance Hospital, Yonsei Cancer Center, Yonsei University College of Medicine; and Brain Korea 21 PLUS Project for Medical Science (WKL, EJL), Yonsei University, Seoul, Korea
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Abstract
In this review, we discuss the characteristics, pathophysiology, and therapeutic implications of the euthyroid sick syndrome. Multiple mechanisms have been identified to contribute to the development of euthyroid sick syndrome, including alterations in the iodothyronine deiodinases, thyroid-stimulating hormone secretion, thyroid hormone binding to plasma protein, transport of thyroid hormone in peripheral tissues, and thyroid hormone receptor activity. The euthyroid sick syndrome appears to be a complex mix of physiologic adaptation and pathologic response to acute illness. The underlying cause for these alterations has not yet been elucidated. Treatment of the euthyroid sick syndrome with thyroid hormone to restore normal serum thyroid hormone levels in an effort to improve disease prognosis and outcomes continues to be a focus of many clinical studies, although currently available data do not provide evidence of a clear benefit of treatment.
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Affiliation(s)
- Sun Lee
- Section of Endocrinology, Diabetes and Nutrition, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Alan P Farwell
- Section of Endocrinology, Diabetes and Nutrition, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts, USA
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Kanczkowski W, Sue M, Bornstein SR. Adrenal Gland Microenvironment and Its Involvement in the Regulation of Stress-Induced Hormone Secretion during Sepsis. Front Endocrinol (Lausanne) 2016; 7:156. [PMID: 28018291 PMCID: PMC5155014 DOI: 10.3389/fendo.2016.00156] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 11/29/2016] [Indexed: 01/11/2023] Open
Abstract
Survival of all living organisms depends on maintenance of a steady state of homeostasis, which process relies on its ability to react and adapt to various physical and emotional threats. The defense against stress is executed by the hypothalamic-pituitary-adrenal axis and the sympathetic-adrenal medullary system. Adrenal gland is a major effector organ of stress system. During stress, adrenal gland rapidly responds with increased secretion of glucocorticoids (GCs) and catecholamines into circulation, which hormones, in turn, affect metabolism, to provide acutely energy, vasculature to increase blood pressure, and the immune system to prevent it from extensive activation. Sepsis resulting from microbial infections is a sustained and extreme example of stress situation. In many critical ill patients, levels of both corticotropin-releasing hormone and adrenocorticotropin, the two major regulators of adrenal hormone production, are suppressed. Levels of GCs, however, remain normal or are elevated in these patients, suggesting a shift from central to local intra-adrenal regulation of adrenal stress response. Among many mechanisms potentially involved in this process, reduced GC metabolism and activation of intra-adrenal cellular systems composed of adrenocortical and adrenomedullary cells, endothelial cells, and resident and recruited immune cells play a key role. Hence, dysregulated function of any of these cells and cellular compartments can ultimately affect adrenal stress response. The purpose of this mini review is to highlight recent insights into our understanding of the adrenal gland microenvironment and its role in coordination of stress-induced hormone secretion.
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Affiliation(s)
- Waldemar Kanczkowski
- Department of Internal Medicine III, Technische Universität Dresden, Dresden, Germany
- *Correspondence: Waldemar Kanczkowski,
| | - Mariko Sue
- Department of Internal Medicine III, Technische Universität Dresden, Dresden, Germany
| | - Stefan R. Bornstein
- Department of Internal Medicine III, Technische Universität Dresden, Dresden, Germany
- Department of Endocrinology and Diabetes, King’s College London, London, UK
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Abstract
OBJECTIVE To assess current nutritional practices in critically ill children worldwide. DESIGN A two-part online, international survey. The first part, "the survey", was composed of 59 questions regarding nutritional strategies and protocols (July-November 2013). The second part surveyed the "point prevalence" of nutritional data of patients present in a subgroup of the responding PICUs (May-September 2014). SETTING Members of the World Federation of Pediatric Intensive and Critical Care Societies were asked to complete the survey. SUBJECTS Pediatric critical care providers. INTERVENTIONS Survey. MEASUREMENTS AND MAIN RESULTS We analyzed 189 responses from 156 PICUs in 52 countries (survey). We received nutritional data on 295 patients from 41 of these 156 responding PICUs in 27 countries (point prevalence). According to the "survey", nutritional protocols and support teams were available in 52% and 57% of the PICUs, respectively. Various equations were in use to estimate energy requirements; only in 14% of PICUs, indirect calorimetry was used. Nutritional targets for macronutrients, corrected for age/weight, varied widely. Enteral nutrition would be started early (within 24 hr of admission) in 60% of PICUs, preferably by the gastric route (88%). In patients intolerant to enteral nutrition, parenteral nutrition would be started within 48 hours in 55% of PICUs. Overall, in 72% of PICUs supplemental parenteral nutrition would be used if enteral nutrition failed to meet at least 50% of energy delivery goal. Several differences between the intended (survey) and the actual (point prevalence) nutritional practices were found in the responding PICUs, predominantly overestimating the ability to adequately feed patients. CONCLUSION Nutritional practices vary widely between PICUs worldwide. There are significant differences in macronutrient goals, estimating energy requirements, timing of nutrient delivery, and threshold for supplemental parenteral nutrition. Uniform consensus-based nutrition practices, preferably guided by evidence, are desirable in the PICU.
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