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Taylor MA, Kokiko-Cochran ON. Context is key: glucocorticoid receptor and corticosteroid therapeutics in outcomes after traumatic brain injury. Front Cell Neurosci 2024; 18:1351685. [PMID: 38529007 PMCID: PMC10961349 DOI: 10.3389/fncel.2024.1351685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 02/21/2024] [Indexed: 03/27/2024] Open
Abstract
Traumatic brain injury (TBI) is a global health burden, and survivors suffer functional and psychiatric consequences that can persist long after injury. TBI induces a physiological stress response by activating the hypothalamic-pituitary-adrenal (HPA) axis, but the effects of injury on the stress response become more complex in the long term. Clinical and experimental evidence suggests long lasting dysfunction of the stress response after TBI. Additionally, pre- and post-injury stress both have negative impacts on outcome following TBI. This bidirectional relationship between stress and injury impedes recovery and exacerbates TBI-induced psychiatric and cognitive dysfunction. Previous clinical and experimental studies have explored the use of synthetic glucocorticoids as a therapeutic for stress-related TBI outcomes, but these have yielded mixed results. Furthermore, long-term steroid treatment is associated with multiple negative side effects. There is a pressing need for alternative approaches that improve stress functionality after TBI. Glucocorticoid receptor (GR) has been identified as a fundamental link between stress and immune responses, and preclinical evidence suggests GR plays an important role in microglia-mediated outcomes after TBI and other neuroinflammatory conditions. In this review, we will summarize GR-mediated stress dysfunction after TBI, highlighting the role of microglia. We will discuss recent studies which target microglial GR in the context of stress and injury, and we suggest that cell-specific GR interventions may be a promising strategy for long-term TBI pathophysiology.
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Affiliation(s)
| | - Olga N. Kokiko-Cochran
- Department of Neuroscience, Chronic Brain Injury Program, Institute for Behavioral Medicine Research, College of Medicine, The Ohio State University, Columbus, OH, United States
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2
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Martínez-Camacho MÁ, Jones-Baro RA, Gómez-González A, Lugo-García DS, Astorga PCG, Melo-Villalobos A, Gonzalez-Rodriguez BK, Pérez-Calatayud ÁA. Prolonged intensive care: muscular functional, and nutritional insights from the COVID-19 pandemic. Acute Crit Care 2024; 39:47-60. [PMID: 38303585 PMCID: PMC11002617 DOI: 10.4266/acc.2023.01284] [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: 10/10/2023] [Revised: 10/27/2023] [Accepted: 10/31/2023] [Indexed: 02/03/2024] Open
Abstract
During the coronavirus disease 2019 (COVID-19) pandemic, clinical staff learned how to manage patients enduring extended stays in an intensive care unit (ICU). COVID-19 patients requiring critical care in an ICU face a high risk of experiencing prolonged intensive care (PIC). The use of invasive mechanical ventilation in individuals with severe acute respiratory distress syndrome can cause numerous complications that influence both short-term and long-term morbidity and mortality. Those risks underscore the importance of proactively addressing functional complications. Mitigating secondary complications unrelated to the primary pathology of admission is imperative in minimizing the risk of PIC. Therefore, incorporating strategies to do that into daily ICU practice for both COVID-19 patients and those critically ill from other conditions is significantly important.
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Affiliation(s)
| | - Robert Alexander Jones-Baro
- Department of Critical Care Rehabilitation, Hospital General de México “Dr. Eduardo Liceaga”, Mexico City, Mexico
| | - Alberto Gómez-González
- Department of Critical Care Rehabilitation, Hospital General de México “Dr. Eduardo Liceaga”, Mexico City, Mexico
| | - Dalia Sahian Lugo-García
- Department of Critical Care Rehabilitation, Hospital General de México “Dr. Eduardo Liceaga”, Mexico City, Mexico
| | | | - Andrea Melo-Villalobos
- Department of Critical Care Rehabilitation, Hospital General de México “Dr. Eduardo Liceaga”, Mexico City, Mexico
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3
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Patas K, Baker DG, Chrousos GP, Agorastos A. Inflammation in Posttraumatic Stress Disorder: Dysregulation or Recalibration? Curr Neuropharmacol 2024; 22:524-542. [PMID: 37550908 PMCID: PMC10845099 DOI: 10.2174/1570159x21666230807152051] [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: 11/02/2022] [Revised: 01/04/2023] [Accepted: 01/06/2023] [Indexed: 08/09/2023] Open
Abstract
Despite ample experimental data indicating a role of inflammatory mediators in the behavioral and neurobiological manifestations elicited by exposure to physical and psychologic stressors, causative associations between systemic low-grade inflammation and central nervous system inflammatory processes in posttraumatic stress disorder (PTSD) patients remain largely conceptual. As in other stress-related disorders, pro-inflammatory activity may play an equivocal role in PTSD pathophysiology, one that renders indiscriminate employment of anti-inflammatory agents of questionable relevance. In fact, as several pieces of preclinical and clinical research convergingly suggest, timely and targeted potentiation rather than inhibition of inflammatory responses may actually be beneficial in patients who are characterized by suppressed microglia function in the face of systemic low-grade inflammation. The deleterious impact of chronic stress-associated inflammation on the systemic level may, thus, need to be held in context with the - often not readily apparent - adaptive payoffs of low-grade inflammation at the tissue level.
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Affiliation(s)
- Kostas Patas
- Department of Biopathology and Laboratory Medicine, Eginition University Hospital, Athens, Greece
| | - Dewleen G. Baker
- Department of Psychiatry, University of California, San Diego (UCSD), La Jolla, CA, USA
- VA Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, La Jolla, San Diego, CA, USA
| | - George P. Chrousos
- University Research Institute of Maternal and Child Health and Precision Medicine and UNESCO Chair on Adolescent Health Care, National and Kapodistrian University of Athens, Medical School, Aghia Sophia Children's Hospital, Athens, Greece
| | - Agorastos Agorastos
- VA Center of Excellence for Stress and Mental Health, VA San Diego Healthcare System, La Jolla, San Diego, CA, USA
- Department of Psychiatry, Division of Neurosciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Central Macedonia, Greece
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4
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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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5
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Reddy ASS, Rao SS, D Shenoy V, Shetty S. Role of Nuclear Factor-Kappa B Activation and Inflammatory Biomarkers in Critically Ill Children. Indian J Pediatr 2023:10.1007/s12098-023-04858-5. [PMID: 37751042 DOI: 10.1007/s12098-023-04858-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 08/25/2023] [Indexed: 09/27/2023]
Abstract
Mortality prediction is important for cautious monitoring and optimal management of critically ill children. The serum cytokine levels are elevated early in critical illness before the physiological parameters are deranged. This cross-sectional descriptive study included the critically ill children admitted in intensive care unit. Serial serum levels of IL-6, NF-κB and PELOD 2 scoring were measured and compared in 45 children (40 survivors, 5 non-survivors). The median IL-6 levels at 24 h and 72 h were significantly high in non-survivors when compared to survivors [median (IQR) = 1122 (1305) pg/ml vs. 564.39 (153) pg/ml and 1263 (626) pg/ml vs. 82 (191) pg/ml respectively; p <0.0001)]. There was an increasing trend of IL-6 in non-survivors when compared to the survivors. The NF-κB values were comparable. The IL-6 levels correlated well with the illness severity. IL-6 had superior prognostic value compared with NF-κB in predicting mortality.
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Affiliation(s)
- Akula Sai Sneha Reddy
- Department of Pediatrics, Nitte (Deemed to be University), KS Hegde Medical Academy, Mangalore, Karnataka, India
| | - Swathi Sunil Rao
- Department of Pediatrics, Nitte (Deemed to be University), KS Hegde Medical Academy, Mangalore, Karnataka, India.
| | - Vijaya D Shenoy
- Department of Pediatrics, Nitte (Deemed to be University), KS Hegde Medical Academy, Mangalore, Karnataka, India
| | - Shilpa Shetty
- Central Research Laboratory, Nitte (Deemed to be University), KS Hegde Medical Academy, Mangalore, Karnataka, India
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Salton F, Confalonieri P, Meduri GU, Mondini L, Trotta L, Barbieri M, Bozzi C, Torregiani C, Lerda S, Bellan M, Confalonieri M, Ruaro B, Tavano S, Pozzan R. Theory and Practice of Glucocorticoids in COVID-19: Getting to the Heart of the Matter-A Critical Review and Viewpoints. Pharmaceuticals (Basel) 2023; 16:924. [PMID: 37513836 PMCID: PMC10385094 DOI: 10.3390/ph16070924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/18/2023] [Accepted: 06/21/2023] [Indexed: 07/30/2023] Open
Abstract
Prolonged, low-dose glucocorticoids (GCs) have shown the highest efficacy among pharmacological and non-pharmacological treatments for COVID-19. Despite the World Health Organization's recommendation against their use at the beginning of the pandemic, GCs at a dose equivalent to dexamethasone 6 mg/day for 10 days are now indicated in all COVID-19 cases who require respiratory support. However, the efficacy of the intervention depends on the timing of initiation, the dose, and other individual factors. Indeed, patients treated with similar GC protocols often experience different outcomes, which do not always correlate with the presence of comorbidities or with the severity of respiratory involvement at baseline. This prompted us to critically review the literature on the rationale, pharmacological principles, and clinical evidence that should guide GC treatment. Based on these data, the best treatment protocol probably involves an initial bolus dose to saturate the glucocorticoid receptors, followed by a continuous infusion to maintain constant plasma levels, and eventually a slow tapering to interruption. Methylprednisolone has shown the highest efficacy among different GC molecules, most likely thanks to its higher ability to penetrate the lung. Decreased tissue sensitivity to glucocorticoids is thought to be the main mechanism accounting for the lower response to the treatment in some individuals. We do not have a readily available test to identify GC resistance; therefore, to address inter-individual variability, future research should aim at investigating clinical, physiological, and laboratory markers to guide a personalized GC treatment approach.
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Affiliation(s)
- Francesco Salton
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University Hospital of Cattinara, University of Trieste, 34149 Trieste, Italy
| | - Paola Confalonieri
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University Hospital of Cattinara, University of Trieste, 34149 Trieste, Italy
| | - Gianfranco Umberto Meduri
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Lucrezia Mondini
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University Hospital of Cattinara, University of Trieste, 34149 Trieste, Italy
| | - Liliana Trotta
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University Hospital of Cattinara, University of Trieste, 34149 Trieste, Italy
| | - Mariangela Barbieri
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University Hospital of Cattinara, University of Trieste, 34149 Trieste, Italy
| | - Chiara Bozzi
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University Hospital of Cattinara, University of Trieste, 34149 Trieste, Italy
| | - Chiara Torregiani
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University Hospital of Cattinara, University of Trieste, 34149 Trieste, Italy
| | - Selene Lerda
- Business School, University of Milano, 20149 Milano, Italy
| | - Mattia Bellan
- Department of Translational Medicine, Università del Piemonte Orientale (UPO), 28100 Novara, Italy
- Center for Autoimmune and Allergic Disease (CAAD), Università del Piemonte Orientale (UPO), 28100 Novara, Italy
- A.O.U. Maggiore della Carità, 28100 Novara, Italy
| | - Marco Confalonieri
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University Hospital of Cattinara, University of Trieste, 34149 Trieste, Italy
| | - Barbara Ruaro
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University Hospital of Cattinara, University of Trieste, 34149 Trieste, Italy
| | - Stefano Tavano
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University Hospital of Cattinara, University of Trieste, 34149 Trieste, Italy
| | - Riccardo Pozzan
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University Hospital of Cattinara, University of Trieste, 34149 Trieste, Italy
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7
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Chen S, Saeed AFUH, Liu Q, Jiang Q, Xu H, Xiao GG, Rao L, Duo Y. Macrophages in immunoregulation and therapeutics. Signal Transduct Target Ther 2023; 8:207. [PMID: 37211559 DOI: 10.1038/s41392-023-01452-1] [Citation(s) in RCA: 132] [Impact Index Per Article: 132.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 03/06/2023] [Accepted: 04/26/2023] [Indexed: 05/23/2023] Open
Abstract
Macrophages exist in various tissues, several body cavities, and around mucosal surfaces and are a vital part of the innate immune system for host defense against many pathogens and cancers. Macrophages possess binary M1/M2 macrophage polarization settings, which perform a central role in an array of immune tasks via intrinsic signal cascades and, therefore, must be precisely regulated. Many crucial questions about macrophage signaling and immune modulation are yet to be uncovered. In addition, the clinical importance of tumor-associated macrophages is becoming more widely recognized as significant progress has been made in understanding their biology. Moreover, they are an integral part of the tumor microenvironment, playing a part in the regulation of a wide variety of processes including angiogenesis, extracellular matrix transformation, cancer cell proliferation, metastasis, immunosuppression, and resistance to chemotherapeutic and checkpoint blockade immunotherapies. Herein, we discuss immune regulation in macrophage polarization and signaling, mechanical stresses and modulation, metabolic signaling pathways, mitochondrial and transcriptional, and epigenetic regulation. Furthermore, we have broadly extended the understanding of macrophages in extracellular traps and the essential roles of autophagy and aging in regulating macrophage functions. Moreover, we discussed recent advances in macrophages-mediated immune regulation of autoimmune diseases and tumorigenesis. Lastly, we discussed targeted macrophage therapy to portray prospective targets for therapeutic strategies in health and diseases.
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Affiliation(s)
- Shanze Chen
- Department of Respiratory Diseases and Critic Care Unit, Shenzhen Institute of Respiratory Disease, Shenzhen Key Laboratory of Respiratory Disease, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, 518020, China
| | - Abdullah F U H Saeed
- Department of Cancer Biology, Beckman Research Institute of City of Hope National Medical Center, Los Angeles, CA, 91010, USA
| | - Quan Liu
- Department of Laboratory Medicine, Huazhong University of Science and Technology Union Shenzhen Hospital (Nanshan Hospital), Shenzhen University, Shenzhen, 518052, China
| | - Qiong Jiang
- Department of Respiratory Diseases and Critic Care Unit, Shenzhen Institute of Respiratory Disease, Shenzhen Key Laboratory of Respiratory Disease, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, 518020, China
| | - Haizhao Xu
- Department of Respiratory Diseases and Critic Care Unit, Shenzhen Institute of Respiratory Disease, Shenzhen Key Laboratory of Respiratory Disease, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, 518020, China
- Department of Respiratory, The First Affiliated Hospital, School of Medicine, Southern University of Science and Technology, Shenzhen, 518055, China
| | - Gary Guishan Xiao
- State Key Laboratory of Fine Chemicals, Department of Pharmaceutical Sciences, School of Chemical Engineering, Dalian University of Technology, Dalian, China.
| | - Lang Rao
- Institute of Biomedical Health Technology and Engineering, Shenzhen Bay Laboratory, Shenzhen, 518132, China.
| | - Yanhong Duo
- Department of Microbiology, Tumor and Cell Biology (MTC), Karolinska Institutet, Stockholm, Sweden.
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8
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Tang J, Li Z, Qiang C, Han Y, Yang L, Zhu L, Dang T, Chen G, Ye Y. A long-wavelength mitochondria-targeted fluorescent probe for imaging of peroxynitrite during dexamethasone treatment. SPECTROCHIMICA ACTA. PART A, MOLECULAR AND BIOMOLECULAR SPECTROSCOPY 2023; 292:122429. [PMID: 36750010 DOI: 10.1016/j.saa.2023.122429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 01/12/2023] [Accepted: 01/30/2023] [Indexed: 06/18/2023]
Abstract
Peroxynitrite (ONOO-), as a strong oxidizing reactive nitrogen substance (RNS), is generated endogenously by cells. Its visualization research is crucial to understand relevant disease processes. Herein, we reported a long-wavelength mitochondria-targeted fluorescence "turn on" probe TL. The probe TL could react with ONOO- by using 4-(Bromomethyl)benzeneboronic as a reactive site, which exhibited outstanding characteristics for detection of ONOO-, thus improving response time (about 50 s), sensitivity (DL, 10.1 nM), and emission wavelength (667 nm). Besides, TL displayed well mitochondria targeting and biological visualizing of exogenous and endogenous ONOO- in biological systems. Finally, TL was used to monitor high concentration of dexamethasone-induced an up-regulation of ONOO-. This indicated that TL has excellent potential to study the fluctuation of ONOO- in the physiological and pathological system.
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Affiliation(s)
- Jun Tang
- School of Chemistry and Materials Engineering, Xinxiang University, Xinxiang, Henan 453003, China.
| | - Ziyi Li
- School of Chemistry and Materials Engineering, Xinxiang University, Xinxiang, Henan 453003, China
| | - Chuchu Qiang
- School of Chemistry and Materials Engineering, Xinxiang University, Xinxiang, Henan 453003, China
| | - Yan Han
- School of Chemistry and Materials Engineering, Xinxiang University, Xinxiang, Henan 453003, China
| | - Lifang Yang
- School of Chemistry and Materials Engineering, Xinxiang University, Xinxiang, Henan 453003, China
| | - Li Zhu
- School of Chemistry and Materials Engineering, Xinxiang University, Xinxiang, Henan 453003, China
| | - Tan Dang
- School of Chemistry and Materials Engineering, Xinxiang University, Xinxiang, Henan 453003, China
| | - Gairong Chen
- School of Chemistry and Materials Engineering, Xinxiang University, Xinxiang, Henan 453003, China
| | - Yong Ye
- Green Catalysis Center, and College of Chemistry, Zhengzhou University, Zhengzhou 450001, China
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Mondini L, Salton F, Trotta L, Bozzi C, Pozzan R, Barbieri M, Tavano S, Lerda S, Hughes M, Confalonieri M, Confalonieri P, Ruaro B. Host-Based Treatments for Severe COVID-19. Curr Issues Mol Biol 2023; 45:3102-3121. [PMID: 37185727 PMCID: PMC10136924 DOI: 10.3390/cimb45040203] [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: 03/03/2023] [Revised: 03/29/2023] [Accepted: 04/02/2023] [Indexed: 05/17/2023] Open
Abstract
COVID-19 has been a global health problem since 2020. There are different spectrums of manifestation of this disease, ranging from asymptomatic to extremely severe forms requiring admission to intensive care units and life-support therapies, mainly due to severe pneumonia. The progressive understanding of this disease has allowed researchers and clinicians to implement different therapeutic alternatives, depending on both the severity of clinical involvement and the causative molecular mechanism that has been progressively explored. In this review, we analysed the main therapeutic options available to date based on modulating the host inflammatory response to SARS-CoV-2 infection in patients with severe and critical illness. Although current guidelines are moving toward a personalised treatment approach titrated on the timing of presentation, disease severity, and laboratory parameters, future research is needed to identify additional biomarkers that can anticipate the disease course and guide targeted interventions on an individual basis.
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Affiliation(s)
- Lucrezia Mondini
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University Hospital of Cattinara, University of Trieste, 34149 Trieste, Italy
| | - Francesco Salton
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University Hospital of Cattinara, University of Trieste, 34149 Trieste, Italy
| | - Liliana Trotta
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University Hospital of Cattinara, University of Trieste, 34149 Trieste, Italy
| | - Chiara Bozzi
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University Hospital of Cattinara, University of Trieste, 34149 Trieste, Italy
| | - Riccardo Pozzan
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University Hospital of Cattinara, University of Trieste, 34149 Trieste, Italy
| | - Mariangela Barbieri
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University Hospital of Cattinara, University of Trieste, 34149 Trieste, Italy
| | - Stefano Tavano
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University Hospital of Cattinara, University of Trieste, 34149 Trieste, Italy
| | - Selene Lerda
- Graduate School, University of Milan, 20149 Milano, Italy
| | - Michael Hughes
- Division of Musculoskeletal and Dermatological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester & Salford Royal NHS Foundation Trust, Manchester M6 8HD, UK
| | - Marco Confalonieri
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University Hospital of Cattinara, University of Trieste, 34149 Trieste, Italy
| | - Paola Confalonieri
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University Hospital of Cattinara, University of Trieste, 34149 Trieste, Italy
| | - Barbara Ruaro
- Pulmonology Unit, Department of Medical Surgical and Health Sciences, University Hospital of Cattinara, University of Trieste, 34149 Trieste, Italy
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10
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Salton F, Confalonieri P, Centanni S, Mondoni M, Petrosillo N, Bonfanti P, Lapadula G, Lacedonia D, Voza A, Carpenè N, Montico M, Reccardini N, Meduri GU, Ruaro B, Confalonieri M. Prolonged higher dose methylprednisolone vs. conventional dexamethasone in COVID-19 pneumonia: a randomised controlled trial (MEDEAS). Eur Respir J 2022; 61:13993003.01514-2022. [PMID: 36356972 PMCID: PMC9650195 DOI: 10.1183/13993003.01514-2022] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 10/23/2022] [Indexed: 11/12/2022]
Abstract
IntroductionDysregulated systemic inflammation is the primary driver of mortality in severe COVID-19 pneumonia. Current guidelines favor a 7–10-day course of any glucocorticoid equivalent to dexamethasone 6 mg·day−1. A comparative RCT with a higher dose and a longer duration of intervention was lacking.MethodsWe conducted a multi-center, open-label RCT to investigate methylprednisolone 80 mg as a continuous daily infusion for 8 days followed by slow taperingversusdexamethasone 6 mg daily for up to 10 days in adult patients with COVID-19 pneumonia requiring oxygen or noninvasive respiratory support. Primary outcome: reduction in 28-day mortality. Secondary outcomes: mechanical ventilation-free days at 28 days, need for ICU referral, length of hospitalisation, need for tracheostomy, changes in PaO2:FiO2 ratio, C-reactive protein levels and WHO clinical progression scale at days 3, 7, and 14.Results677 randomised patients were included. Findings are reported as methylprednisolone (n=337)versusdexamethasone (n=340). By day 28, there were no significant differences in mortality (35[10.4%]versus41[12.1%]; p=0.49), nor in the median mechanical ventilation-free days (23[14]versus24[16]; p=0.49). ICU referral was necessary in 41[12.2%]versus45[13.2%]; p=0.68 and tracheostomy in 8[2.4%]versus9[2.6%]; p=0.82. Survivors in the methylprednisolone group required a longer median hospitalisation (15[11]versus14[11] days; p=0.005) and experienced an improvement in C-reactive protein levels, but not in PaO2:FiO2ratio, at days 7 and 14. There were no differences in disease progression at the prespecified timepoints.ConclusionProlonged, higher dose methylprednisolone did not reduce mortality at 28 days compared to conventional dexamethasone in COVID-19 pneumonia.
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11
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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: 14] [Impact Index Per Article: 7.0] [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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12
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Ascorbic acid along with ciprofloxacin regulates S. aureus induced microglial inflammatory responses and oxidative stress through TLR-2 and glucocorticoid receptor modulation. Inflammopharmacology 2022; 30:1303-1322. [PMID: 35704229 DOI: 10.1007/s10787-022-01012-z] [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: 10/21/2021] [Accepted: 05/13/2022] [Indexed: 11/05/2022]
Abstract
Microglial inflammatory responses play a central role in the pathogenesis of S. aureus induced brain infections. Upon activation, microglia produces free radicals (ROS/RNS) and disrupts the cellular antioxidant defense to combat invading microorganisms. Despite conventional antibiotic or steroid therapy, microglial over-activation could not be controlled. So, an attempt had been taken by using a natural antioxidant ascorbic acid along with ciprofloxacin to regulate microglial over-activation by involving TLR-2 and glucocorticoid receptor (GR) in an in-vitro cell culture-based study. Combinatorial treatment during TLR-2 neutralization effectively reduced the bacterial burden at 60 min compared to the GR blocking condition (p < 0.05). Moreover, the infection-induced H2O2, O2.-, and NO release in microglial cell culture was diminished possibly by enhancing SOD and catalase activities in the same condition (p < 0.05). The arginase activity was markedly increased after TLR-2 blocking in the combinatorial group compared to single treatments (p < 0.05). Experimental results indicated that combinatorial treatment may act through up-regulating GR expression by augmenting endogenous corticosterone levels. However, better bacterial clearance could further suppress the TLR-2 mediated pro-inflammatory NF-κB signaling. From Western blot analysis, it was concluded that ciprofloxacin-ascorbic acid combination in presence of anti-TLR-2 antibody exhibited 81.25% inhibition of TLR-2 expression while the inhibition for GR was 3.57% with respect to the infected group. Therefore, during TLR-2 blockade ascorbic acid combination might be responsible for the restoration of redox balance in microglia via modulating TLR-2/GR interaction. The combination treatment could play a major role in the neuroendocrine-immune regulation of S. aureus induced microglial activation.
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13
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Shao S, Wang Y, Zhao Y, Xu Y, Wang T, Du K, Bao S, Wang X, Zhang L. Identification of multiple isoforms of glucocorticoid receptor in nasal polyps of patients with chronic rhinosinusitis. J Otolaryngol Head Neck Surg 2022; 51:25. [PMID: 35690807 PMCID: PMC9188707 DOI: 10.1186/s40463-022-00561-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 02/08/2022] [Indexed: 11/22/2022] Open
Abstract
Background The conventional belief that glucocorticosteroid (GC) acts through a single brand glucocorticoid receptor (GR)α protein has changed dramatically with the discovery of multiple GR isoforms. We aimed to evaluate whether multiple GR protein isoforms are expressed in chronic rhinosinusitis with nasal polyps (CRSwNP) and whether GR protein isoform expression profiles differ between different endotypes of CRSwNP. Methods Thirty-eight patients with CRSwNP and ten healthy volunteers were included. The protein expression of multiple GR isoforms in nasal polyps (NPs) tissue and control mucosae was examined by western blot analysis with different GR antibodies. Results Five bands, including three bands for known proteins (GRα-A/B, GRα-C, and GRα-D) and two bands for unidentified proteins at 67 kilodaltons (kDa) and 60 kDa, were identified with both total GR antibody (PA1-511A) and GRα-specific antibody (PA1-516). GRα-D intensity, which was abundant in nasal mucosa, was significantly increased in the CRSwNP group and was especially elevated in the noneosinophilic CRSwNP (NE-CRSwNP) group (PA1-511A: P < 0.001 and P = 0.0018; PA1-516: P < 0.003 and P = 0.006, respectively). Additionally, the intensities of the newly recognized 67 kDa and 60 kDa bands were much greater in the NE-CRSwNP subgroup than in the eosinophilic CRSwNP (E-CRSwNP) subgroup; in the E-CRSwNP subgroup, the median intensities were even lower than those in the control group. Conclusions This study provides evidence that nasal tissues express multiple GR protein isoforms. GR protein isoforms presented disease and tissue-specific expression profiles that differed between the CRSwNP and control groups and between the E-CRSwNP and NE-CRSwNP subgroups. Graphical abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1186/s40463-022-00561-1.
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Affiliation(s)
- Shan Shao
- Department of Otorhinolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, 10073, China.,Department of Otolaryngology Head and Neck Surgery, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, China
| | - Yue Wang
- Department of Otorhinolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, 10073, China
| | - Yan Zhao
- Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology, No. 17, Hougou Hutong, Dong Cheng District, Beijing, 100005, China
| | - Yuan Xu
- Departments of Oncology, Community Health Sciences, and Surgery, Cumming School of Medicine, and The Center for Health Informatics, University of Calgary, Calgary, AB, Canada
| | - Tie Wang
- MIID Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Kun Du
- Department of Otorhinolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, 10073, China
| | - Shiping Bao
- Department of Otolaryngology Head and Neck Surgery, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, China
| | - Xiangdong Wang
- Department of Otorhinolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, 10073, China. .,Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology, No. 17, Hougou Hutong, Dong Cheng District, Beijing, 100005, China.
| | - Luo Zhang
- Department of Otorhinolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, 10073, China. .,Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology, No. 17, Hougou Hutong, Dong Cheng District, Beijing, 100005, China.
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14
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Téblick A, Van Dyck L, Van Aerde N, Van der Perre S, Pauwels L, Derese I, Debaveye Y, Wouters PJ, Vanhorebeek I, Langouche L, Van den Berghe G. Impact of duration of critical illness and level of systemic glucocorticoid availability on tissue-specific glucocorticoid receptor expression and actions: A prospective, observational, cross-sectional human and two translational mouse studies. EBioMedicine 2022; 80:104057. [PMID: 35584557 PMCID: PMC9117556 DOI: 10.1016/j.ebiom.2022.104057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 04/19/2022] [Accepted: 04/27/2022] [Indexed: 12/24/2022] Open
Abstract
Background Reduced glucocorticoid-receptor (GR) expression in blood suggested that critically ill patients become glucocorticoid-resistant necessitating stress-doses of glucocorticoids. We hypothesised that critical illness evokes a tissue-specific, time-dependent expression of regulators of GR-action which adaptively guides glucocorticoid action to sites of need. Methods We performed a prospective, observational, cross-sectional human study and two translational mouse studies. In freshly-isolated neutrophils and monocytes and in skeletal muscle and subcutaneous adipose tissue of 137 critically ill patients and 20 healthy controls and in skeletal muscle and adipose tissue as well as in vital tissues (heart, lung, diaphragm, liver, kidney) of 88 septic and 26 healthy mice, we quantified gene expression of cortisone-reductase 11β-HSD1, glucocorticoid-receptor-isoforms GRα and GRβ, GRα-sensitivity-regulating-co-chaperone FKBP51, and GR-action-marker GILZ. Expression profiles were compared in relation to illness-duration and systemic-glucocorticoid-availability. Findings In patients’ neutrophils, GRα and GILZ were substantially suppressed (p≤0·05) throughout intensive care unit (ICU)-stay, while in monocytes low/normal GRα coincided with increased GILZ (p≤0·05). FKBP51 was increased transiently (neutrophils) or always (monocytes,p≤0·05). In patients’ muscle, 11β-HSD1 and GRα were low-normal (p≤0·05) and substantially suppressed in adipose tissue (p≤0·05); FKBP51 and GILZ were increased in skeletal muscle (p≤0·05) but normal in adipose tissue. GRβ was undetectable. Increasing systemic glucocorticoid availability in patients independently associated with further suppressed muscle 11β-HSD1 and GRα, further increased FKBP51 and unaltered GILZ (p≤0·05). In septic mouse heart and lung, 11β-HSD1, FKBP51 and GILZ were always high (p≤0·01). In heart, GRα was suppressed (p≤0·05), while normal or high in lung (all p≤0·05). In diaphragm, 11β-HSD1 was high/normal, GRα low/normal and FKBP51 and GILZ high (p≤0·01). In kidney, 11β-HSD1 transiently increased but decreased thereafter, GRα was normal and FKBP51 and GILZ high (p≤0·01). In liver, 11β-HSD1 was suppressed (p≤0·01), GRα normal and FKBP51 high (p≤0·01) whereas GILZ was transiently decreased but elevated thereafter (p≤0·05). Only in lung and diaphragm, treatment with hydrocortisone further increased GILZ. Interpretation Tissue-specific, time-independent adaptations to critical illness guided GR-action predominantly to vital tissues such as lung, while (partially) protecting against collateral harm in other cells and tissues, such as neutrophils. These findings argue against maladaptive generalised glucocorticoid-resistance necessitating glucocorticoid-treatment. Funding Research-Foundation-Flanders, Methusalem-Program-Flemish-Government, European-Research-Council, European-Respiratory-Society.
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Affiliation(s)
- Arno Téblick
- Clinical division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Lisa Van Dyck
- Clinical division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Nathalie Van Aerde
- Clinical division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Sarah Van der Perre
- Clinical division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Lies Pauwels
- Clinical division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Inge Derese
- Clinical division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Yves Debaveye
- Clinical division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Pieter J Wouters
- Clinical division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Ilse Vanhorebeek
- Clinical division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Lies Langouche
- Clinical division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Greet Van den Berghe
- Clinical division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium.
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15
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Meduri GU, Shih MC, Bridges L, Martin TJ, El-Solh A, Seam N, Davis-Karim A, Umberger R, Anzueto A, Sriram P, Lan C, Restrepo MI, Guardiola JJ, Buck T, Johnson DP, Suffredini A, Bell WA, Lin J, Zhao L, Uyeda L, Nielsen L, Huang GD. Low-dose methylprednisolone treatment in critically ill patients with severe community-acquired pneumonia. Intensive Care Med 2022; 48:1009-1023. [PMID: 35723686 PMCID: PMC9208259 DOI: 10.1007/s00134-022-06684-3] [Citation(s) in RCA: 63] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 03/16/2022] [Indexed: 12/15/2022]
Abstract
Purpose Severe community-acquired pneumonia (CAP) requiring intensive care unit admission is associated with significant acute and long-term morbidity and mortality. We hypothesized that downregulation of systemic and pulmonary inflammation with prolonged low-dose methylprednisolone treatment would accelerate pneumonia resolution and improve clinical outcomes. Methods This double-blind, randomized, placebo-controlled clinical trial recruited adult patients within 72–96 h of hospital presentation. Patients were randomized in 1:1 ratio; an intravenous 40 mg loading bolus was followed by 40 mg/day through day 7 and progressive tapering during the 20-day treatment course. Randomization was stratified by site and need for mechanical ventilation (MV) at the time of randomization. Outcomes included a primary endpoint of 60-day all-cause mortality and secondary endpoints of morbidity and mortality up to 1 year of follow-up. Results Between January 2012 and April 2016, 586 patients from 42 Veterans Affairs Medical Centers were randomized, short of the 1420 target sample size because of low recruitment. 584 patients were included in the analysis. There was no significant difference in 60-day mortality between the methylprednisolone and placebo arms (16% vs. 18%; adjusted odds ratio 0.90, 95% CI 0.57–1.40). There were no significant differences in secondary outcomes or complications. Conclusions In patients with severe CAP, prolonged low-dose methylprednisolone treatment did not significantly reduce 60-day mortality. Treatment was not associated with increased complications. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-022-06684-3.
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Affiliation(s)
- G Umberto Meduri
- Pulmonary, Critical Care and Sleep Medicine Services, Memphis VA Medical Center, Memphis, USA. .,University of Tennessee Health Science Center, Memphis, USA.
| | - Mei-Chiung Shih
- VA Cooperative Studies Program Coordinating Center, Palo Alto, USA.,Department of Biomedical Data Sciences, Stanford University, Stanford, USA
| | - Lisa Bridges
- Pulmonary, Critical Care and Sleep Medicine Services, Memphis VA Medical Center, Memphis, USA.,University of Tennessee Health Science Center, Memphis, USA
| | - Thomas J Martin
- Salem VA Health Care System, Salem, USA.,Virginia Tech Carilion School of Medicine, Roanoke, USA.,Edward Via Virginia College of Osteopathic Medicine, Blacksburg, USA
| | - Ali El-Solh
- VA Western New York Health Care System, Buffalo, USA.,University at Buffalo, Buffalo, USA
| | - Nitin Seam
- National Institutes of Health Clinical Center, Bethesda, USA
| | - Anne Davis-Karim
- VA Cooperative Studies Program Pharmacy Coordinating Center, Albuquerque, USA
| | - Reba Umberger
- University of Tennessee Health Science Center, Memphis, USA
| | - Antonio Anzueto
- South Texas Veterans Health San Antonio, San Antonio, USA.,University of Texas Health Science Center, Houston, USA
| | | | - Charlie Lan
- Michael E Debakey VA Medical Center, Houston, USA
| | - Marcos I Restrepo
- South Texas Veterans Health San Antonio, San Antonio, USA.,University of Texas Health Science Center, Houston, USA
| | - Juan J Guardiola
- Robley Rex VA Medical Center, Louisville, USA.,University of Louisville, Louisville, USA
| | - Teresa Buck
- Bay Pines VA Healthcare Center, Bay Pines, USA
| | | | | | | | - Julia Lin
- VA Cooperative Studies Program Coordinating Center, Palo Alto, USA
| | - Lan Zhao
- VA Cooperative Studies Program Coordinating Center, Palo Alto, USA
| | - Lauren Uyeda
- VA Cooperative Studies Program Coordinating Center, Palo Alto, USA
| | - Lori Nielsen
- VA Cooperative Studies Program Coordinating Center, Palo Alto, USA
| | - Grant D Huang
- Office of Research and Development, Department of Veterans Affairs, Baltimore, USA
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16
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Rudzki S. Is PTSD an Evolutionary Survival Adaptation Initiated by Unrestrained Cytokine Signaling and Maintained by Epigenetic Change? Mil Med 2022; 188:usac095. [PMID: 35446412 DOI: 10.1093/milmed/usac095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 03/01/2022] [Accepted: 03/24/2022] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Treatment outcomes for PTSD with current psychological therapies are poor, with very few patients achieving sustained symptom remission. A number of authors have identified physiological and immune disturbances in Post Traumatic Stress Disorder (PTSD) patients, but there is no unifying hypothesis that explains the myriad features of the disorder. MATERIALS AND METHODS The medical literature was reviewed over a 6-year period primarily using the medical database PUBMED. RESULTS The literature contains numerous papers that have identified a range of physiological and immune dysfunction in association with PTSD. This paper proposes that unrestrained cytokine signaling induces epigenetic changes that promote an evolutionary survival adaptation, which maintains a defensive PTSD phenotype. The brain can associate immune signaling with past threat and initiate a defensive behavioral response. The sympathetic nervous system is pro-inflammatory, while the parasympathetic nervous system is anti-inflammatory. Prolonged cholinergic withdrawal will promote a chronic inflammatory state. The innate immune cytokine IL-1β has pleiotropic properties and can regulate autonomic, glucocorticoid, and glutamate receptor functions, sleep, memory, and epigenetic enzymes. Changes in epigenetic enzyme activity can potentially alter phenotype and induce an adaptation. Levels of IL-1β correlate with severity and duration of PTSD and PTSD can be prevented by bolus administration of hydrocortisone in acute sepsis, consistent with unrestrained inflammation being a risk factor for PTSD. The nervous and immune systems engage in crosstalk, governed by common receptors. The benefits of currently used psychiatric medication may arise from immune, as well as synaptic, modulation. The psychedelic drugs (3,4-Methylenedioxymethamphetamine (MDMA), psilocybin, and ketamine) have potent immunosuppressive and anti-inflammatory effects on the adaptive immune system, which may contribute to their reported benefit in PTSD. There may be distinct PTSD phenotypes induced by innate and adaptive cytokine signaling. CONCLUSION In order for an organism to survive, it must adapt to its environment. Cytokines signal danger to the brain and can induce epigenetic changes that result in a persistent defensive phenotype. PTSD may be the price individuals pay for the genomic flexibility that promotes adaptation and survival.
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Affiliation(s)
- Stephan Rudzki
- Canberra Sports Medicine, Deakin, Australian Capital Territory 2600, Australia
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17
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Matisz C, Gruber A. Neuroinflammatory remodeling of the anterior cingulate cortex as a key driver of mood disorders in gastrointestinal disease and disorders. Neurosci Biobehav Rev 2022; 133:104497. [DOI: 10.1016/j.neubiorev.2021.12.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 11/10/2021] [Accepted: 12/09/2021] [Indexed: 02/08/2023]
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18
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Selected Immunoendocrine Measures for Monitoring Responses to Training and Match Load in Professional Association Football: A Review of the Evidence. Int J Sports Physiol Perform 2022; 17:1654-1663. [DOI: 10.1123/ijspp.2022-0226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 08/13/2022] [Accepted: 09/02/2022] [Indexed: 11/09/2022]
Abstract
Biomarkers relating to player “stress balance,” immunological (ie, immunoglobulin-A), and hormonal (ie, testosterone and cortisol [T:C]) status are now commonly used in football. This article is our critical review of the scientific literature relating to the response of these measures to player load and their relationships with player health. The commonly reported relationship between immunoglobulin-A and training or match load highlights its sensitivity to changes in psychophysiological stress and the increased risk of compromised mucosal immunity. This is supported by its close relationship with symptoms of upper respiratory tract infection and its association with perceived fatigue in football players. Testosterone and cortisol concentrations and the testosterone–cortisol ratio are sensitive to changes in player load, but the direction of their response is often inconsistent and is likely influenced by player training status and non-sport-related stressors. Some evidence indicates that sustained periods of high training volume can increase resting testosterone and that sustained periods of low and high training intensity can increase resting cortisol, compromising the testosterone–cortisol ratio. These findings are noteworthy, as recent findings indicate interrelationships between testosterone, cortisol, and testosterone:cortisol and perceived measures of fatigue, sleep quality, and muscle soreness in football players. Variability in individual responses suggests the need for a multivariate and individualized approach to player monitoring. Overall, we consider that there is sufficient evidence to support the use of salivary immunoglobulin-A, testosterone, cortisol, and testosterone:cortisol measures as part of a multivariate, individualized player monitoring system in professional football.
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19
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Yedinak C, Ross IL. Significant risk of COVID-19 and related-hospitalization among patients with adrenal insufficiency: A large multinational survey. Front Endocrinol (Lausanne) 2022; 13:1042119. [PMID: 36440212 PMCID: PMC9684629 DOI: 10.3389/fendo.2022.1042119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 10/19/2022] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE To determine self-reported incidence and potential risk factors for COVID-19 in patients with adrenal insufficiency (AI). METHODS A 27-item AI survey was developed for AI and COVID-19 status, vetted by specialists and patients, and distributed via social media, websites, and advocacy groups. Participation was voluntary and anonymous. Data were collected from September 20th, 2020 until December 31st, 2020. RESULTS Respondents (n=1291) with self-reported glucocorticoid treatment for AI, completed the survey, with 456 who reported having symptoms and were screened for COVID-19 during 2020; 40 tested positive (+ve), representing an 8.8% incidence. Of the COVID-19+ve, 31 were female (78%), with mean age of 39.9 years. COVID-19 among AI patients occurred most commonly in those aged 40-59 years (n=17; 42.5%); mean time since AI diagnosis was 13.5 years (range 0.2-42.0 years). Pulmonary disease, congenital adrenal hyperplasia, and higher maintenance doses of glucocorticoids were significantly associated with +ve COVID-19 (p=0.04, p=0.01, and p=0.001, respectively. In respondents the cumulative incidence of COVID-19+ve during 2020 was 3.1%; greater than the 1.03% worldwide-incidence reported by WHO, by December 31st, 2020. There was a 3-fold (95% CI 2.16-3.98) greater relative risk (RR) of COVID-19 infection and a 23.8- fold (95% CI 20.7-31.2) RR of hospitalization in patients with AI, compared with the global population. CONCLUSION A markedly raised RR of COVID-19 and hospitalization in respondents reporting chronic AI was detected. We found that a diagnosis of congenital adrenal hyperplasia, age>40 years, male gender, pulmonary disease, and higher maintenance doses of glucocorticoids were associated with greatest risk.
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Affiliation(s)
- Christine Yedinak
- Department of Neurosurgical Services, Oregon Health and Science University, Portland, OR, United States
- *Correspondence: Christine Yedinak,
| | - Ian Louis Ross
- Department of Medicine, University of Cape Town, Cape Town, South Africa
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20
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Filippa MG, Tektonidou MG, Mantzou A, Kaltsas GA, Chrousos GP, Sfikakis PP, Yavropoulou MP. Adrenocortical dysfunction in rheumatoid arthritis: Α narrative review and future directions. Eur J Clin Invest 2022; 52:e13635. [PMID: 34097322 DOI: 10.1111/eci.13635] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 06/01/2021] [Accepted: 06/03/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Iatrogenic adrenal insufficiency (AI) secondary to long-term treatment with exogenous glucocorticoids (GC) is common in patients with systematic rheumatic diseases, including rheumatoid arthritis (RA). Moreover, a proportion of these patients is always in need of even small doses of glucocorticoids to maintain clinical remission, despite concomitant treatment with conventional and biologic disease-modifying drugs. METHODS We conducted a literature review up to December 2020 on (a) the incidence of AI in both long-term GC-treated and GC-treatment naïve RA patients; (b) the potential effects of increased levels of circulating proinflammatory cytokines, as well as of chronic stress, in adrenocortical function in RA; (c) the circadian cortisol rhythm in RA; and (d) established and evolving methods of assessment of adrenocortical function. RESULTS Up to 48% of RA patients develop glucocorticoid-induced AI; however, predictors are not established, while adrenocortical dysfunction may also occur in GC-treatment naïve RA patients. Experimental and clinical data have suggested that inadequate production of endogenous cortisol relative to enhanced clinical needs associated with the systemic inflammatory response, coined as the 'disproportion principle', may operate in RA. Although the underlying mechanisms are unknown, both proinflammatory cytokines and chronic stress may contribute the most in the adrenals hyporesponsiveness and the target tissue glucocorticoid resistance that have been described, but not systematically studied. A precise longitudinal assessment of endogenous cortisol production may be needed for optimal RA management. CONCLUSION Apart from iatrogenic AI, an intrinsically compromised adrenal reserve in RA may have a pathogenetic role and interfere with effective management, thus deserving further research.
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Affiliation(s)
- Maria G Filippa
- 1st Department of Propaedeutic and Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria G Tektonidou
- 1st Department of Propaedeutic and Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Aimilia Mantzou
- University Research Institute of Maternal and Child Health and Precision Medicine and UNESCO Chair on Adolescent Health Care, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Gregory A Kaltsas
- 1st Department of Propaedeutic and Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - George P Chrousos
- University Research Institute of Maternal and Child Health and Precision Medicine and UNESCO Chair on Adolescent Health Care, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Petros P Sfikakis
- 1st Department of Propaedeutic and Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria P Yavropoulou
- 1st Department of Propaedeutic and Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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21
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Bergström H, Helde Frankling M, Klasson C, Lövgren Sandblom A, Diczfalusy U, Björkhem-Bergman L. CYP3A Activity in End-of-Life Cancer Patients Measured by 4β-Hydroxycholesterol/cholesterol Ratio, in Men and Women. Cancers (Basel) 2021; 13:cancers13184689. [PMID: 34572915 PMCID: PMC8465465 DOI: 10.3390/cancers13184689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 09/16/2021] [Indexed: 11/16/2022] Open
Abstract
Simple Summary The elimination of drugs by enzymes in the liver may be impaired in cancer patients that are close to death (end-of-life). This could cause unwanted side effects or lack of effect of drugs and compromise the quality of life in patients. Blood samples collected in 137 deceased end-of-life cancer patients were analyzed for the marker 4β-hydroxycholesterol/cholesterol (4β-OHC/C), representing the activity of the most important drug eliminating enzyme, CYP3A. In addition, samples from young (n = 280) and elderly (n = 30) controls were analyzed for 4β-OHC/C. The average 4β-OHC/C was higher in male and female end-of-life cancer patients than in young and elderly controls without cancer. This finding may suggest that the ability to eliminate drugs by CYP3A is maintained until end of life and that drugs metabolized by CYP3 may not need dose adjustment or discontinuation in cancer patients close to death. Abstract More than 50% of all drugs are metabolized by the cytochrome P450 3A enzyme (CYP3A). The aim of this study was to investigate if the CYP3A activity, measured by the endogenous marker 4β-hydroxycholesterol/cholesterol ratio (4β-OHC/C), is changed during the last weeks and days of life in men and women. To this end, serum samples from 137 deceased patients (median age 70 years) collected at a single time point 1–60 days before death, were analyzed and compared to 280 young (median 27 years), and 30 elderly (median age 70 years) non-cancer controls. There were no significant differences in the 4β-OHC/C ratio between men and women in end-of-life patients (p < 0.25). The median 4β-OHC/C was significantly higher in end-of-life male patients compared to both young (p < 0.0001) and elderly (p < 0.05) male controls. In a similar manner, 4β-OHC/C in end-of-life female patients was significantly higher compared to young and elderly female controls, p < 0.0001 and p < 0.001, respectively. There was no significant correlation between 4β-OHC/C and survival time. The results from this study suggest maintained CYP3A activity to the very last days of life and even a capacity of induction of the enzyme in end-of-life cancer patients.
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Affiliation(s)
- Helena Bergström
- Department of Neurobiology, Care Sciences and Society (NVS), Division of Clinical Geriatrics, Karolinska Institutet, Blickagången 16, Neo Floor 7, SE-141 83 Huddinge, Sweden; (M.H.F.); (C.K.); (L.B.-B.)
- Correspondence:
| | - Maria Helde Frankling
- Department of Neurobiology, Care Sciences and Society (NVS), Division of Clinical Geriatrics, Karolinska Institutet, Blickagången 16, Neo Floor 7, SE-141 83 Huddinge, Sweden; (M.H.F.); (C.K.); (L.B.-B.)
- Department of Cancer, Section of Head, Neck, Lung and Skin Tumors, Karolinska University Hospital, Eugeniavägen 11, SE-171 76 Stockholm, Sweden
| | - Caritha Klasson
- Department of Neurobiology, Care Sciences and Society (NVS), Division of Clinical Geriatrics, Karolinska Institutet, Blickagången 16, Neo Floor 7, SE-141 83 Huddinge, Sweden; (M.H.F.); (C.K.); (L.B.-B.)
- Department of Palliative Medicine, Stockholms Sjukhem, Mariebergsgatan 22, SE-112 19 Stockholm, Sweden
| | - Anita Lövgren Sandblom
- Department of Laboratory Medicine, Division of Clinical Chemistry, Karolinska Institute, SE-141 52 Stockholm, Sweden; (A.L.S.); (U.D.)
- Department of Clinical Chemistry, Karolinska University Laboratory, Karolinska University Hospital, SE-141 86 Huddinge, Sweden
| | - Ulf Diczfalusy
- Department of Laboratory Medicine, Division of Clinical Chemistry, Karolinska Institute, SE-141 52 Stockholm, Sweden; (A.L.S.); (U.D.)
- Department of Clinical Chemistry, Karolinska University Laboratory, Karolinska University Hospital, SE-141 86 Huddinge, Sweden
| | - Linda Björkhem-Bergman
- Department of Neurobiology, Care Sciences and Society (NVS), Division of Clinical Geriatrics, Karolinska Institutet, Blickagången 16, Neo Floor 7, SE-141 83 Huddinge, Sweden; (M.H.F.); (C.K.); (L.B.-B.)
- Department of Palliative Medicine, Stockholms Sjukhem, Mariebergsgatan 22, SE-112 19 Stockholm, Sweden
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22
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Luo MH, Qian YQ, Huang DL, Luo JC, Su Y, Wang H, Yu SJ, Liu K, Tu GW, Luo Z. Tailoring glucocorticoids in patients with severe COVID-19: a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1261. [PMID: 34532398 PMCID: PMC8421952 DOI: 10.21037/atm-21-1783] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 06/10/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To discuss the pathogenesis of severe coronavirus disease 2019 (COVID-19) infection and the pharmacological effects of glucocorticoids (GCs) toward this infection. To review randomized controlled trials (RCTs) using GCs to treat patients with severe COVID-19, and investigate whether GC timing, dosage, or duration affect clinical outcomes. Finally. to discuss the use of biological markers, respiratory parameters, and radiological evidence to select patients for improved GC therapeutic precision. BACKGROUND COVID-19 has become an unprecedented global challenge. As GCs have been used as key immunomodulators to treat inflammation-related diseases, they may play key roles in limiting disease progression by modulating immune responses, cytokine production, and endothelial function in patients with severe COVID-19, who often experience excessive cytokine production and endothelial and renin-angiotensin system (RAS) dysfunction. Current clinical trials have partially proven this efficacy, but GC timing, dosage, and duration vary greatly, with no unifying consensus, thereby creating confusion. METHODS Publications through March 2021 were retrieved from the Web of Science and PubMed. Results from cited references in published articles were also included. CONCLUSIONS GCs play key roles in treating severe COVID-19 infections. Pharmacologically, GCs could modulate immune cells, reduce cytokine and chemokine, and improve endothelial functions in patients with severe COVID-19. Benefits of GCs have been observed in multiple clinical trials, but the timing, dosage and duration vary across studies. Tapering as an option is not widely accepted. However, early initiation of treatment, a tailored dosage with appropriate tapering may be of particular importance, but evidence is inconclusive and more investigations are needed. Biological markers, respiratory parameters, and radiological evidence could also help select patients for specific tailored treatments.
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Affiliation(s)
- Ming-Hao Luo
- Shanghai Medical College, Fudan University, Shanghai, China
| | - Yi-Qi Qian
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Dan-Lei Huang
- Shanghai Medical College, Fudan University, Shanghai, China
| | - Jing-Chao Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ying Su
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Huan Wang
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shen-Ji Yu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Kai Liu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Guo-Wei Tu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhe Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
- Department of Critical Care Medicine, Xiamen Branch, Zhongshan Hospital, Fudan University, Xiamen, China
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23
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Romanou V, Koukaki E, Chantziara V, Stamou P, Kote A, Vasileiadis I, Koutsoukou A, Rovina N. Dexamethasone in the Treatment of COVID-19: Primus Inter Pares? J Pers Med 2021; 11:556. [PMID: 34203880 PMCID: PMC8232727 DOI: 10.3390/jpm11060556] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 06/08/2021] [Accepted: 06/13/2021] [Indexed: 02/06/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has rapidly spread globally, becoming a huge public health challenge. Even though the vast majority of patients are asymptomatic, some patients present with pneumonia, acute respiratory distress syndrome (ARDS), septic shock, and death. It has been shown in several studies that the severity and clinical outcomes are related to dysregulated antiviral immunity and enhanced and persistent systemic inflammation. Corticosteroids have been used for the treatment of COVID-19 patients, as they are reported to elicit benefits by reducing lung inflammation and inflammation-induced lung injury. Dexamethasone has gained a major role in the therapeutic algorithm of patients with COVID-19 pneumonia requiring supplemental oxygen or on mechanical ventilation. Its wide anti-inflammatory action seems to form the basis for its beneficial action, taming the overwhelming "cytokine storm". Amid a plethora of scientific research on therapeutic options for COVID-19, there are still unanswered questions about the right timing, right dosing, and right duration of the corticosteroid treatment. The aim of this review article was to summarize the data on the dexamethasone treatment in COVID-19 and outline the clinical considerations of corticosteroid therapy in these patients.
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Affiliation(s)
| | | | | | | | | | | | | | - Nikoletta Rovina
- 1st Department of Respiratory Medicine, Medical School, National and Kapodistrian University of Athens and “Sotiria” Chest Disease Hospital, 11527 Athens, Greece; (V.R.); (E.K.); (V.C.); (P.S.); (A.K.); (I.V.); (A.K.)
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24
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One Size Does Not Fit All: Moving Towards a Personalized Approach for Steroids in COVID-19. Chest 2021; 159:1693-1695. [PMID: 33965120 PMCID: PMC8097316 DOI: 10.1016/j.chest.2021.01.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 01/20/2021] [Indexed: 01/08/2023] Open
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25
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Hajjar LA, Costa IBSDS, Rizk SI, Biselli B, Gomes BR, Bittar CS, de Oliveira GQ, de Almeida JP, de Oliveira Bello MV, Garzillo C, Leme AC, Elena M, Val F, de Almeida Lopes M, Lacerda MVG, Ramires JAF, Kalil Filho R, Teboul JL, Landoni G. Intensive care management of patients with COVID-19: a practical approach. Ann Intensive Care 2021; 11:36. [PMID: 33604873 PMCID: PMC7891474 DOI: 10.1186/s13613-021-00820-w] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 01/29/2021] [Indexed: 02/06/2023] Open
Abstract
SARS-CoV-2, the causative agent of coronavirus disease 2019 (COVID-19), is responsible for the largest pandemic facing humanity since the Spanish flu pandemic in the early twentieth century. Since there is no specific antiviral treatment, optimized support is the most relevant factor in the patient's prognosis. In the hospital setting, the identification of high-risk patients for clinical deterioration is essential to ensure access to intensive treatment of severe conditions in a timely manner. The initial management of hypoxemia includes conventional oxygen therapy, high-flow nasal canula oxygen, and non-invasive ventilation. For patients requiring invasive mechanical ventilation, lung-protective ventilation with low tidal volumes and plateau pressure is recommended. Cardiovascular complications are frequent and include myocardial injury, thrombotic events, myocarditis, and cardiogenic shock. Acute renal failure is a common complication and is a marker of poor prognosis, with significant impact in costs and resources allocation. Regarding promising therapies for COVID-19, the most promising drugs until now are remdesivir and corticosteroids although further studies may be needed to confirm their effectiveness. Other therapies such as, tocilizumab, anakinra, other anti-cytokine drugs, and heparin are being tested in clinical trials. Thousands of physicians are living a scenario that none of us have ever seen: demand for hospital exceed capacity in most countries. Until now, the certainty we have is that we should try to decrease the number of infected patients and that an optimized critical care support is the best strategy to improve patient's survival.
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Affiliation(s)
- Ludhmila Abrahão Hajjar
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil.
- Instituto Do Câncer, Universidade de São Paulo, São Paulo, Brazil.
| | | | - Stephanie Itala Rizk
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil
- Instituto Do Câncer, Universidade de São Paulo, São Paulo, Brazil
- Hospital Sírio Libanês, São Paulo, SP, Brazil
| | - Bruno Biselli
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil
| | - Brenno Rizerio Gomes
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil
| | - Cristina Salvadori Bittar
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil
- Instituto Do Câncer, Universidade de São Paulo, São Paulo, Brazil
| | | | - Juliano Pinheiro de Almeida
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil
| | | | - Cibele Garzillo
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil
| | - Alcino Costa Leme
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil
| | - Moizo Elena
- IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fernando Val
- Instituto Leônidas & Maria Deane, Fiocruz, Manaus, Brazil
| | | | | | - José Antonio Franchini Ramires
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil
| | - Roberto Kalil Filho
- Instituto Do Coração, University of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, SP, Brazil
- Instituto Do Câncer, Universidade de São Paulo, São Paulo, Brazil
- Hospital Sírio Libanês, São Paulo, SP, Brazil
| | - Jean-Louis Teboul
- Medical Intensive Care Unit, Bicêtre Hospital, Paris-Sud University Hospitals, Le Kremlin Bicêtre, France
| | - Giovanni Landoni
- IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
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26
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The ten reasons why corticosteroid therapy reduces mortality in severe COVID-19. Author's reply. Intensive Care Med 2021; 47:357-358. [PMID: 33507321 PMCID: PMC7840620 DOI: 10.1007/s00134-020-06335-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2020] [Indexed: 12/15/2022]
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27
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Meduri GU, Annane D, Confalonieri M, Chrousos GP, Rochwerg B, Busby A, Ruaro B, Meibohm B. Pharmacological principles guiding prolonged glucocorticoid treatment in ARDS. Intensive Care Med 2020; 46:2284-2296. [PMID: 33150472 PMCID: PMC7641258 DOI: 10.1007/s00134-020-06289-8] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 10/08/2020] [Indexed: 12/15/2022]
Abstract
Current literature addressing the pharmacological principles guiding glucocorticoid (GC) administration in ARDS is scant. This paucity of information may have led to the heterogeneity of treatment protocols and misinterpretation of available findings. GCs are agonist compounds that bind to the GC receptor (GR) producing a pharmacological response. Clinical efficacy depends on the magnitude and duration of exposure to GR. We updated the meta-analysis of randomized trials investigating GC treatment in ARDS, focusing on treatment protocols and response. We synthesized the current literature on the role of the GR in GC therapy including genomic and non-genomic effects, and integrated current clinical pharmacology knowledge of various GCs, including hydrocortisone, methylprednisolone and dexamethasone. This review addresses the role dosage, timing of initiation, mode of administration, duration, and tapering play in achieving optimal response to GC therapy in ARDS. Based on RCTs’ findings, GC plasma concentration–time profiles, and pharmacodynamic studies, optimal results are most likely achievable with early intervention, an initial bolus dose to achieve close to maximal GRα saturation, followed by a continuous infusion to maintain high levels of response throughout the treatment period. In addition, patients receiving similar GC doses may experience substantial between-patient variability in plasma concentrations affecting clinical response. GC should be dose-adjusted and administered for a duration targeting clinical and laboratory improvement, followed by dose-tapering to achieve gradual recovery of the suppressed hypothalamic–pituitary–adrenal (HPA) axis. These findings have practical clinical relevance. Future RCTs should consider these pharmacological principles in the study design and interpretation of findings.
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Affiliation(s)
- Gianfranco Umberto Meduri
- Memphis Veterans Affairs Medical Center Research Service, Departments of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA. .,Pulmonary, Critical Care, and Sleep Medicine Service and Research Service, Memphis Veterans Affairs Medical Center, 1030 Jefferson Avenue, Suite room #CW444, Memphis, TN, 38104, USA.
| | - Djillali Annane
- Department of Critical Care, Raymond Poincaré Hospital (AP-HP), Laboratory Infection and Inflammation, U1173, Faculty of Health Science Simone Veil, University of Versailles SQY, University Paris Saclay, INSERM, FHU SEPSIS, RHU RECORDS, Versailles, France
| | - Marco Confalonieri
- Pulmonology Department, University Hospital of Cattinara, University of Trieste, Trieste, Italy
| | - George P Chrousos
- University Research Institute of Maternal and Child Health and Precision Medicine, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Bram Rochwerg
- Department of Medicine, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Amanda Busby
- Health Research Methods Unit, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - Barbara Ruaro
- Pulmonology Department, University Hospital of Cattinara, University of Trieste, Trieste, Italy
| | - Bernd Meibohm
- Department of Pharmaceutical Sciences, University of Tennessee Health Science Center, Memphis, TN, USA
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28
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Arabi YM, Chrousos GP, Meduri GU. The ten reasons why corticosteroid therapy reduces mortality in severe COVID-19. Intensive Care Med 2020; 46:2067-2070. [PMID: 33026460 PMCID: PMC7538533 DOI: 10.1007/s00134-020-06223-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 08/19/2020] [Indexed: 12/29/2022]
Affiliation(s)
- Yaseen M Arabi
- Intensive Care Department, King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia.
| | - George P Chrousos
- University Research Institute of Maternal and Child Health and Precision Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - G Umberto Meduri
- Memphis Veterans Affairs Medical Center Research Service and Pulmonary, Critical Care, and Sleep Medicine Service, Memphis, TN, USA.,Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
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29
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Holly JMP, Biernacka K, Maskell N, Perks CM. Obesity, Diabetes and COVID-19: An Infectious Disease Spreading From the East Collides With the Consequences of an Unhealthy Western Lifestyle. Front Endocrinol (Lausanne) 2020; 11:582870. [PMID: 33042029 PMCID: PMC7527410 DOI: 10.3389/fendo.2020.582870] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 08/17/2020] [Indexed: 01/08/2023] Open
Abstract
The pandemic of COVID-19, caused by the coronavirus, SARS-CoV-2, has had a global impact not seen for an infectious disease for over a century. This acute pandemic has spread from the East and has been overlaid onto a slow pandemic of metabolic diseases of obesity and diabetes consequent from the increasing adoption of a Western-lifestyle characterized by excess calorie consumption with limited physical activity. It has become clear that these conditions predispose individuals to a more severe COVID-19 with increased morbidity and mortality. There are many features of diabetes and obesity that may accentuate the clinical response to SARS-CoV-2 infection: including an impaired immune response, an atherothrombotic state, accumulation of advanced glycation end products and a chronic inflammatory state. These could prime an exaggerated cytokine response to viral infection, predisposing to the cytokine storm that triggers progression to septic shock, acute respiratory distress syndrome, and multi-organ failure. Infection leads to an inflammatory response and tissue damage resulting in increased metabolic activity and an associated increase in the mechanisms by which cells ingest and degrade tissue debris and foreign materials. It is becoming clear that viruses have acquired an ability to exploit these mechanisms to invade cells and facilitate their own life-cycle. In obesity and diabetes these mechanisms are chronically activated due to the deteriorating metabolic state and this may provide an increased opportunity for a more profound and sustained viral infection.
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Affiliation(s)
- Jeff M. P. Holly
- Faculty of Medicine, School of Translational Health Science, Southmead Hospital, University of Bristol, Bristol, United Kingdom
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30
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Salton F, Confalonieri P, Meduri GU, Santus P, Harari S, Scala R, Lanini S, Vertui V, Oggionni T, Caminati A, Patruno V, Tamburrini M, Scartabellati A, Parati M, Villani M, Radovanovic D, Tomassetti S, Ravaglia C, Poletti V, Vianello A, Gaccione AT, Guidelli L, Raccanelli R, Lucernoni P, Lacedonia D, Foschino Barbaro MP, Centanni S, Mondoni M, Davì M, Fantin A, Cao X, Torelli L, Zucchetto A, Montico M, Casarin A, Romagnoli M, Gasparini S, Bonifazi M, D'Agaro P, Marcello A, Licastro D, Ruaro B, Volpe MC, Umberger R, Confalonieri M. Prolonged Low-Dose Methylprednisolone in Patients With Severe COVID-19 Pneumonia. Open Forum Infect Dis 2020; 7:ofaa421. [PMID: 33072814 PMCID: PMC7543560 DOI: 10.1093/ofid/ofaa421] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 09/09/2020] [Indexed: 12/15/2022] Open
Abstract
Background In hospitalized patients with coronavirus disease 2019 (COVID-19) pneumonia, progression to acute respiratory failure requiring invasive mechanical ventilation (MV) is associated with significant morbidity and mortality. Severe dysregulated systemic inflammation is the putative mechanism. We hypothesize that early prolonged methylprednisolone (MP) treatment could accelerate disease resolution, decreasing the need for intensive care unit (ICU) admission and mortality. Methods We conducted a multicenter observational study to explore the association between exposure to prolonged, low-dose MP treatment and need for ICU referral, intubation, or death within 28 days (composite primary end point) in patients with severe COVID-19 pneumonia admitted to Italian respiratory high-dependency units. Secondary outcomes were invasive MV-free days and changes in C-reactive protein (CRP) levels. Results Findings are reported as MP (n = 83) vs control (n = 90). The composite primary end point was met by 19 vs 40 (adjusted hazard ratio [aHR], 0.41; 95% CI, 0.24-0.72). Transfer to ICU and invasive MV were necessary in 15 vs 27 (P = .07) and 14 vs 26 (P = .10), respectively. By day 28, the MP group had fewer deaths (6 vs 21; aHR, 0.29; 95% CI, 0.12-0.73) and more days off invasive MV (24.0 ± 9.0 vs 17.5 ± 12.8; P = .001). Study treatment was associated with rapid improvement in PaO2:FiO2 and CRP levels. The complication rate was similar for the 2 groups (P = .84). Conclusion In patients with severe COVID-19 pneumonia, early administration of prolonged MP treatment was associated with a significantly lower hazard of death (71%) and decreased ventilator dependence. Treatment was safe and did not impact viral clearance. A large randomized controlled trial (RECOVERY trial) has been performed that validates these findings. Clinical trial registration. ClinicalTrials.gov NCT04323592.
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Affiliation(s)
- Francesco Salton
- Department of Pulmonology, University Hospital of Cattinara, Trieste, Italy
| | - Paola Confalonieri
- Department of Pulmonology, University Hospital of Cattinara, Trieste, Italy
| | - G Umberto Meduri
- Pulmonary, Critical Care, and Sleep Medicine Service and Research Service, Memphis VA Medical Center and Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Pierachille Santus
- Department of Biomedical and Clinical Sciences (DIBIC), Università degli Studi di Milano, "L. Sacco" University Hospital, ASST-Fatebenefratelli-Sacco, Milano, Italy
| | - Sergio Harari
- Department of Medical Sciences, San Giuseppe Hospital MultiMedica IRCCS, and Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Raffaele Scala
- Pulmonology and Respiratory Intensive Care Unit, S. Donato Hospital, Arezzo, Italy
| | - Simone Lanini
- National Institute for the Infectious Diseases "L. Spallanzani," Rome, Italy
| | | | | | - Antonella Caminati
- Division of Pulmonary and Critical Care Medicine, San Giuseppe Hospital MultiMedica IRCCS, Milan, Italy
| | - Vincenzo Patruno
- Pulmonology Department, S. Maria della Misericordia University Hospital, Udine, Italy
| | - Mario Tamburrini
- S.C. Pneumologia, Azienda Ospedaliera Friuli Occidentale, Pordenone, Italy
| | | | - Mara Parati
- Department of Pulmonology and Respiratory High-Dependency Unit, Ospedale Maggiore, Crema, Italy
| | - Massimiliano Villani
- Department of Pulmonology and Respiratory High-Dependency Unit, Ospedale Maggiore, Crema, Italy
| | - Dejan Radovanovic
- Department of Biomedical and Clinical Sciences (DIBIC), Università degli Studi di Milano, "L. Sacco" University Hospital, ASST-Fatebenefratelli-Sacco, Milano, Italy
| | - Sara Tomassetti
- Department of Experimental and Clinical Medicine, Careggi University Hospital, Florence, Italy
| | - Claudia Ravaglia
- Department of Respiratory and Thorax Diseases, GB Morgagni Hospital, Forlì, Italy
| | - Venerino Poletti
- Department of Respiratory and Thorax Diseases, GB Morgagni Hospital, Forlì, Italy
| | - Andrea Vianello
- Division of Respiratory Pathophysiology and Intensive Care, University-City Hospital, Padova, Italy
| | | | - Luca Guidelli
- Pulmonology and Respiratory Intensive Care Unit, S. Donato Hospital, Arezzo, Italy
| | - Rita Raccanelli
- Division of Pulmonary and Critical Care Medicine, San Giuseppe Hospital MultiMedica IRCCS, Milan, Italy
| | - Paolo Lucernoni
- Pulmonology Department, Vittorio Veneto Hospital, Vittorio Veneto, Italy
| | - Donato Lacedonia
- Department of Medical and Surgical Science-University of Foggia, Policlinico Riuniti, Italy
| | | | | | | | - Matteo Davì
- Pulmonology Department, S. Paolo Hospital, Milan, Italy
| | - Alberto Fantin
- Pulmonology Department, S. Maria della Misericordia University Hospital, Udine, Italy
| | - Xueyuan Cao
- Department of Acute and Tertiary Care, College of Nursing, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Lucio Torelli
- Department of Clinical, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Antonella Zucchetto
- Scientific Directorate, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Marcella Montico
- Scientific Directorate, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Annalisa Casarin
- Centre for Health Services and Clinical Research, University of Hertfordshire, Hatfield, UK
| | | | - Stefano Gasparini
- Department of Biomedical Sciences and Public Health, Polytechnic University of Marche Region-Azienda Ospedali Riuniti, Ancona, Italy
| | - Martina Bonifazi
- Department of Biomedical Sciences and Public Health, Polytechnic University of Marche Region-Azienda Ospedali Riuniti, Ancona, Italy
| | - Pierlanfranco D'Agaro
- Laboratorio di Riferimento per SARS-CoV-2, Regione Friuli-Venezia Giulia, Azienda Sanitaria Universitaria Integrata Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Alessandro Marcello
- Laboratory of Molecular Virology, International Centre for Genetic Engineering and Biotechnology (ICGEB), Trieste, Italy
| | - Danilo Licastro
- ARGO Open Lab Platform for Genome Sequencing, Area Science Park, Trieste, Italy
| | - Barbara Ruaro
- Department of Pulmonology, University Hospital of Cattinara, Trieste, Italy
| | | | - Reba Umberger
- Department of Acute and Tertiary Care, College of Nursing, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Marco Confalonieri
- Department of Pulmonology, University Hospital of Cattinara, Trieste, Italy.,University of Trieste, Trieste, Italy
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31
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Chrousos GP, Meduri GU. Critical COVID-19 disease, homeostasis, and the "surprise" of effective glucocorticoid therapy. Clin Immunol 2020; 219:108550. [PMID: 32745524 PMCID: PMC7832484 DOI: 10.1016/j.clim.2020.108550] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 07/27/2020] [Indexed: 12/15/2022]
Affiliation(s)
| | - G Umberto Meduri
- University of Tennessee, Health Sciences Center, Memphis, TN, United States.
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32
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Franco R, Rivas-Santisteban R, Serrano-Marín J, Rodríguez-Pérez AI, Labandeira-García JL, Navarro G. SARS-CoV-2 as a Factor to Disbalance the Renin–Angiotensin System: A Suspect in the Case of Exacerbated IL-6 Production. THE JOURNAL OF IMMUNOLOGY 2020; 205:1198-1206. [DOI: 10.4049/jimmunol.2000642] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 07/01/2020] [Indexed: 02/06/2023]
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