Free and total cortisol levels are useful prognostic markers in critically ill patients: a prospective observational study

Early enteral nutrition and mobilization following head and neck surgery with free flap reconstruction

BACKGROUND

Perioperative management methods that reduce surgery-associated invasiveness and improve the quality of postoperative recovery are being promoted as enhanced recovery after surgery programs in various areas. Early enteral nutrition and mobilization are essential elements for enhanced recovery after surgery; however, their safety and feasibility are unclear in head and neck surgery with free tissue transfer reconstruction. This study aimed to clarify these uncertainties.

METHODS

This is a retrospective before-after study. From 2018 to 2022, 187 and 173 patients received conventional management on or before April 2020 and early management on or after May 2020, respectively. The conventional management and early management groups received enteral nutrition and mobilization on postoperative days 2 and 1, respectively. The primary outcome for safety assessment was the incidence of complications. The secondary outcome was the compliance rate of conventional management or early management for feasibility assessment and the length of hospital stay.

RESULTS

The clinical tumour-node-metastasis stage and American Society of Anesthesiologists physical status showed significant differences between the groups. In multivariable analysis, the early management group demonstrated a significantly lower incidence of treatment-required complication classified Clavien-Dindo Grade 2 and above (odds ratio = 0.57; 95% confidence interval = 0.31-0.92) and lower wound infection (odds ratio = 0.53; 95% confidence interval = 0.31-0.92). The early management group had lower compliance rate than the conventional management group; however, no statistically significant difference was observed (79.8% vs. 85.0%, P = 0.21).

CONCLUSION

Early management is safe and feasible following head and neck surgery with free tissue transfer reconstruction. It could reduce the complication rate and is considered a useful postoperative management method.

Serendipitous Adrenal Hyperplasia in Patients Admitted to the Emergency Department for Suspected SARS-CoV-2 Infection is Linked to Increased Mortality

BACKGROUND

Few data are available on adrenal morphology in patients with acute diseases, although it is known that endogenous glucocorticoids are essential for survival under stress conditions and that an adequate response is driven by activation of the hypothalamic-pituitary-adrenal (HPA) axis.

AIMS

The aim of this study was to assess adrenal morphology in patients with acute disease compared with patients with non-acute disease.

METHODS

This cross-sectional study included: 402 patients admitted to the emergency department (ED) for suspected SARS-CoV-2 infection (March-May, 2020) [main cohort]; 200 patients admitted to the ED for acute conditions (December 2018-February 2019) [control group A]; 200 outpatients who underwent radiological evaluation of non-acute conditions (January-February 2019) [control group B]. Chest and/or abdominal CT scans were reviewed to identify adrenal nodules or hyperplasia.

RESULTS

In the main cohort, altered adrenal morphology was found in 24.9% of the patients (15.4% adrenal hyperplasia; 9.5% adrenal nodules). The frequency of adrenal hyperplasia was higher both in the main cohort (15.4%) and control group A (15.5%) compared to control group B (8.5%; p = 0.02 and p = 0.03, respectively). In the main cohort, 14.9% patients died within 30 d. According to a multivariate analysis, adrenal hyperplasia was an independent risk factor for mortality (p = 0.04), as were older age (p <0.001) and active cancer (p = 0.01).

CONCLUSIONS

The notable frequency of adrenal hyperplasia in patients with acute diseases suggests an exaggerated activation of the HPA axis due to stressful conditions. The increased risk of short-term mortality found in patients with adrenal hyperplasia suggests that it may be a possible hallmark of worse prognosis.

Apelin-13 as a Potential Biomarker in Critical Illness

BACKGROUND

The adrenocortical system and copeptin as prognostic markers were intensively investigated in critical illness. The potential predictive power of apelin-13 as a biomarker is largely unknown. We aimed to investigate the prognostic role of apelin-13 in relation to free cortisol, aldosterone, CRH, and copeptin in critically ill patients.

METHODS

In this prospective observational study, 124 critically ill patients (64 men, 60 women, median age: 70 (59-78) years) were consecutively enrolled at the time of admission. All routinely available clinical and laboratory parameters were evaluated and correlated to hormonal changes.

RESULTS

Serum apelin-13 was 1161 (617-2967) pg/mL in non-survivors vs. 2477 (800-3531) pg/mL in survivors (p = 0.054). The concentrations of apelin-13 and CRH had strong positive correlations (r = 0.685, p < 0.001) and were significantly higher in surviving non-septic patients (Apelin-13 (pg/mL): 2286 (790-3330) vs. 818 (574-2732) p < 0.05; CRH (pg/mL) 201 (84-317) vs. 89 (74-233) p < 0.05). Apelin-13 and free cortisol were independent determinants of survival in the multivariate Cox regression analysis, while copeptin, CRH, or aldosterone were not.

CONCLUSIONS

Beyond free cortisol, serum apelin-13 may also help refine prognostic predictions in the early phase of critical illness, especially in non-septic patients.

Chronic stress-driven glucocorticoid receptor activation programs key cell phenotypes and functional epigenomic patterns in human fibroblasts

Chronic environmental stress can profoundly impact cell and body function. Although the underlying mechanisms are poorly understood, epigenetics has emerged as a key link between environment and health. The genomic effects of stress are thought to be mediated by the action of glucocorticoid stress hormones, primarily cortisol in humans, which act via the glucocorticoid receptor (GR). To dissect how chronic stress-driven GR activation influences epigenetic and cell states, human fibroblasts underwent prolonged exposure to physiological stress levels of cortisol and/or a selective GR antagonist. Cortisol was found to drive robust changes in cell proliferation, migration, and morphology, which were abrogated by concomitant GR blockade. The GR-driven cell phenotypes were accompanied by widespread, yet genomic context-dependent, changes in DNA methylation and mRNA expression, including gene loci with known roles in cell proliferation and migration. These findings provide insights into how chronic stress-driven functional epigenomic patterns become established to shape key cell phenotypes.

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Physiological stress levels of cortisol drive robust changes in key cell phenotypes

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Stress-driven changes in cell phenotypes are abrogated by concomitant GR blockade

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GR activation induces functional and phenotypically relevant epigenomic changes

Naturalistic Stress Hormone Levels Drive Cumulative Epigenomic Changes along the Cellular Lifespan

Environmental stress is ubiquitous in modern societies and can exert a profound and cumulative impact on cell function and health phenotypes. This impact is thought to be in large part mediated by the action of glucocorticoid stress hormones, primarily cortisol in humans. While the underlying molecular mechanisms are unclear, epigenetics-the chemical changes that regulate genomic function without altering the genetic code-has emerged as a key link between environmental exposures and phenotypic outcomes. The present study assessed genome-wide DNA (CpG) methylation, one of the key epigenetic mechanisms, at three timepoints during prolonged (51-day) exposure of cultured human fibroblasts to naturalistic cortisol levels, which can be reached in human tissues during in vivo stress. The findings support a spatiotemporal model of profound and widespread stress hormone-driven methylomic changes that emerge at selected CpG sites, are more likely to spread to nearby located CpGs, and quantitatively accrue at open sea, glucocorticoid receptor binding, and chromatin-accessible sites. Taken together, these findings provide novel insights into how prolonged stress may impact the epigenome, with potentially important implications for stress-related phenotypes.

Assessment of certain biomarkers for predicting survival in response to treatment in dogs naturally infected with canine parvovirus

Canine parvovirus (CPV) enteritis is an important cause of morbidity and mortality in puppies despite aggressive treatment. Identification of reliable biomarkers for CPV enteritis is essential to determine the severity, duration of hospitalization, and predict the clinical outcome. Meanwhile, the biomarkers will assist in decision-making with clients about the further course of treatment or euthanasia. The present study was conducted to evaluate the changes of total leukocyte count (TLC), neutrophil count, and serum concentrations of creatine kinase-MB (CK-MB), lactate dehydrogenase (LDH), intestinal fatty acid binding protein-2 (IFABP-2), albumin, ceruloplasmin (Cp), cortisol, free triiodothyronine (FT₃) and free thyroxine (FT₄) in survivors and non-survivors as a predictor of the clinical outcome. Marked leukopenia, neutropenia, hypoalbuminemia, elevated levels of CK-MB, IFABP-2, Cp, and cortisol were noticed in CPV-infected dogs than healthy dogs but, LDH, FT₃ and FT₄ concentrations did not differ significantly. The CPV-infected non-survivors had persistent leukopenia, neutropenia and elevated CK-MB, IFABP-2, Cp and cortisol concentrations at 72 h of commencement of treatment. In CPV-infected survivors, TLC and neutrophil count were significantly increased, and CK-MB, IFABP-2, Cp and cortisol concentrations were significantly decreased at 72 h of commencement of treatment. The positive predictive values (PPVs) for survival using cut-off value of TLC (>3.2 × 10³/μL), neutrophil count (>1.65 × 10³/μL), CK-MB (≤234.50 U/L), IFABP-2 (≤7.61 ng/mL), Cp (≤0.605 g/L) and cortisol (≤16.90 ng/mL) were determined as 89.47%, 88.88%, 94.73%, 93.33%, 94.44% and 89.47%, respectively with better area under receiver operating characteristic (ROC) curve as well as sensitivity. The magnitude of decrease in TLC, neutrophil count, and increase in CK-MB, IFABP-2, Cp and cortisol concentrations at 72 h of initiation of treatment in dogs with parvoviral enteritis could be useful indicators for the prognosis of the disease. Based on sensitivity (%) and specificity (%) from ROC curve analysis and PPV (%), it is concluded that serum CK-MB concentration will serve as the most useful biomarker followed by Cp and absolute neutrophil count.

Thyroid axis and adrenal activity in 28 day survivor and nonsurvivor dogs involved in recent road traffic accidents: A cohort study of 420 dogs

The objective of this retrospective cohort study was to determine the impact of a recent trauma on thyroid axis and adrenal activity in dogs and to assess the usefulness of urinary cortisol-to-creatinine ratio (UCCR), basal serum thyroid-stimulating hormone (TSH), total thyroxine (tT4), and free thyroxine (fT4) concentrations in predicting outcome in dogs traumatized by a road traffic accident (RTA). An RTA exposed group of 210 dogs was evaluated within 24  hours of the trauma. Their data were compared with data from a matched group of dogs with other diagnoses. UCCR was positively correlated with the trauma severity and was higher in the exposed group than in the nonexposed group (median 101.500 vs. 21.02; p < 0.0001). tT4 values were statistically similar between the two groups, but were correlated with a trauma score, while TSH (median = 0.050 vs. 0.080 ng/mL; p < 0.0001) and fT4 (median = 15.850 vs. 17.950 pmol/L; p = 0.0037) were significantly lower for the exposed group. Nonsurvivors in comparison to survivors presented and higher median UCCR (181.800 vs. 93.850 respectively; p = 0.020), and a lower serum fT4 (12.700 vs. 16.500 pmol/L, respectively; p = 0.0046). A similar pattern had been observed for tT4. TSH levels were not predictive of survival. This study provides insights into the endocrine characteristics of dogs suffering from acute trauma. UCCR was higher while fT4 and TSH were both lower in RTA-injured dogs than in dogs affected by other conditions. Furthermore low fT4 and tT4, and a high UCCR could be useful prognostic factors in dogs affected by RTA trauma.

Cortisol-Mediated Stress Response and Mortality in Acute Coronary Syndrome

Acute coronary syndrome is a frequent cause of morbidity and mortality, and a known stress response trigger. We aim to investigate the association between cortisol, as a primary stress hormone, and prognosis/mortality in this scenario. Single-center, prospective, observational, and analytical study in patients admitted for acute coronary syndrome. Clinical characteristics and prognosis markers were registered, along with serum cortisol levels on admission and in-hospital mortality. Cortisol levels were higher in patients with a depressed ST segment (18.22 ± 13.38 μg/dL), compared to those with an isoelectric ST segment (12.66 ± 10.47 μg/dL), and highest in patients with an elevated ST segment (22.61 ± 14.45 μg/dL), with P< 0.001. Also, cortisol was significantly increased in patients with elevated troponin I values (18.90 ± 14.19 μg/dL vs 11.87 ± 8.21 μg/dL, P< 0.001). Patients with Killip-Kimball class I or II had a lower mean serum cortisol (14.66 ± 10.82 μg/dL) than those with class III or IV (41.34 ± 15.57 μg/dL), P< 0.001. Finally, we found that patients who died during hospitalization had higher cortisol on admission: 36.39 ± 17.85 μg/dL vs 15.26 ± 11.59 μg/dL, P= 0.003. Cortisol was directly related to the electrocardiographic presentation of ACS and with the maximum troponin I value. This indicates that serum cortisol levels parallel the extension of ischemia and myocardial injury, and in this way affect the clinical prognosis, evidenced by the Killip-Kimball class and the increase in mortality.

Determination of salivary cortisol to assess time-related changes of the adrenal response to stress in critically ill patients

BACKGROUND

The value of salivary cortisol measurement to study stress-related adrenal response is controversial. The study aim was to assess the role of salivary cortisol measurement to detect time-related changes of adrenal response in critically ill patients.

PATIENTS AND METHODS

Patients with organ failure, sepsis or trauma were prospectively recruited in the Emergency Department. Serum and salivary cortisol were measured at baseline (T0) and after 48 h (T48). In 33 patients ACTH test was also done.

RESULTS

Fifty-five patients were studied and classified as septic (22) or non-septic (33). We found a significant correlation between serum and salivary cortisol at T0 and T48. No patient had baseline serum cortisol < 276 nmol/L and salivary cortisol significantly decreased at T48 in almost all patients. A delta serum cortisol < 250 nmol/L after ACTH was found in only 4 patients who showed elevated baseline cortisol levels.

CONCLUSION

We found that reduced baseline and post-ACTH cortisol levels are uncommon in our samples. In patients able to provide adequate saliva samples, salivary cortisol may be used to check the degree of stress-induced response and appears as a suitable tool for multiple measurements over time.

Investigation of serum cortisol concentration as a potential prognostic marker in hospitalized dogs: a prospective observational study in a primary care animal hospital

BACKGROUND

Dogs with various medical diseases are usually treated at hospitals; however, the prognostic markers in dogs remain unknown. The aim of this study was to investigate the ability of serum cortisol concentration (SCC) to predict the prognosis of dogs with medical diseases. At 0 and 24 h after hospitalization, the neutrophil count, lymphocyte count, blood glucose concentration, and SCC were measured. Survival for 30 days from the time of hospitalization was investigated, and the dogs were divided into a survivor group and a non-survivor group.

RESULTS

The neutrophil count at 24 h, SCC at 24 h, increase in SCC from 0 to 24 h (Inc-SCC), and the rate of increase in SCC from 0 to 24 h (R-Inc-SCC) were significantly higher in the non-survivor group than in the survivor group. The area under the receiver operating characteristic (ROC) curve values for the neutrophil count at 24 h, SCC at 24 h, Inc-SCC, and R-Inc-SCC were 0.695, 0.72, 0.63, and 0.66, respectively. Using the highest area under the ROC curve value, the sensitivity and specificity of SCC at a cutoff level of 6.6 μg/dL for predicting mortality were 89.5 and 61.9%, respectively. Moreover, the Kaplan-Meier curves confirmed the significant prognostic influence of SCC at 24 h.

CONCLUSIONS

SCC as a marker of stress is a useful biomarker for predicting the prognosis of dogs with medical diseases requiring hospital treatment.

Guidelines for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in critically ill patients (Part I): Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) 2017

OBJECTIVE

To update the 2008 consensus statements for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in adult and pediatric patients.

PARTICIPANTS

A multispecialty task force of 16 international experts in Critical Care Medicine, endocrinology, and guideline methods, all of them members of the Society of Critical Care Medicine and/or the European Society of Intensive Care Medicine.

DESIGN/METHODS

The recommendations were based on the summarized evidence from the 2008 document in addition to more recent findings from an updated systematic review of relevant studies from 2008 to 2017 and were formulated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. The strength of each recommendation was classified as strong or conditional, and the quality of evidence was rated from high to very low based on factors including the individual study design, the risk of bias, the consistency of the results, and the directness and precision of the evidence. Recommendation approval required the agreement of at least 80% of the task force members.

RESULTS

The task force was unable to reach agreement on a single test that can reliably diagnose CIRCI, although delta cortisol (change in baseline cortisol at 60 min of <9 µg/dl) after cosyntropin (250 µg) administration and a random plasma cortisol of <10 µg/dl may be used by clinicians. We suggest against using plasma free cortisol or salivary cortisol level over plasma total cortisol (conditional, very low quality of evidence). For treatment of specific conditions, we suggest using intravenous (IV) hydrocortisone <400 mg/day for ≥3 days at full dose in patients with septic shock that is not responsive to fluid and moderate- to high-dose vasopressor therapy (conditional, low quality of evidence). We suggest not using corticosteroids in adult patients with sepsis without shock (conditional recommendation, moderate quality of evidence). We suggest the use of IV methylprednisolone 1 mg/kg/day in patients with early moderate to severe acute respiratory distress syndrome (PaO₂/FiO₂ < 200 and within 14 days of onset) (conditional, moderate quality of evidence). Corticosteroids are not suggested for patients with major trauma (conditional, low quality of evidence).

CONCLUSIONS

Evidence-based recommendations for the use of corticosteroids in critically ill patients with sepsis and septic shock, acute respiratory distress syndrome, and major trauma have been developed by a multispecialty task force.

Ambient Ionization Mass Spectrometry for Point-of-Care Diagnostics and Other Clinical Measurements

BACKGROUND

One driving motivation in the development of point-of-care (POC) diagnostics is to conveniently and immediately provide information upon which healthcare decisions can be based, while the patient is on site. Ambient ionization mass spectrometry (MS) allows direct chemical analysis of unmodified and complex biological samples. This suite of ionization techniques was introduced a decade ago and now includes a number of techniques, all seeking to minimize or eliminate sample preparation. Such approaches provide new opportunities for POC diagnostics and rapid measurements of exogenous and endogenous molecules (e.g., drugs, proteins, hormones) in small volumes of biological samples, especially when coupled with miniature mass spectrometers.

CONTENT

Ambient MS-based techniques are applied in diverse fields such as forensics, pharmaceutical development, reaction monitoring, and food analysis. Clinical applications of ambient MS are at an early stage but show promise for POC diagnostics. This review provides a brief overview of various ambient ionization techniques providing background, examples of applications, and the current state of translation to clinical practice. The primary focus is on paper spray (PS) ionization, which allows quantification of analytes in complex biofluids. Current developments in the miniaturization of mass spectrometers are discussed.

SUMMARY

Ambient ionization MS is an emerging technology in analytical and clinical chemistry. With appropriate MS instrumentation and user-friendly interfaces for automated analysis, ambient ionization techniques can provide quantitative POC measurements. Most significantly, the implementation of PS could improve the quality and lower the cost of POC testing in a variety of clinical settings.