Factors associated with dietary behaviour among patients With Type 2 Diabetes Mellitus in rural Indonesia / Journal of the ASEAN Federation of Endocrine Societies

Background@#Type 2 Diabetes Mellitus (T2DM) is one of the fastest-growing diseases and most serious major health problems worldwide. Few studies have focused on the association of social support with diabetes-related dietary behaviour.@*Objective@#To examine the relationship between social support and dietary behaviour among patients with diabetes in a rural area of Indonesia.@*Methodology@#This was a descriptive cross-sectional study that included 120 physically healthy patients above 18 years old with T2DM for at least 6 months. Data analysis was done using a stepwise regression model.@*Results@#The mean age was 61.97 years (SD = 7.85, range = 52-74); 86.7% of the participants were females. Social support (β = 0.272, p = <0.001), diabetes medications (β = 0.169, p = 0.003), duration of diabetes (β = 0.118, p = 0.0047), and presence of diabetes complications (β = 0.197, p = 0.008) were significant predictors of dietary behaviour and accounted for 34.2% of the variance.@*Conclusions@#Social support, diabetes medications, presence of diabetes complications, and duration of diabetes were associated with improved dietary behaviour. Therefore, social support should be considered when designing dietary interventions for patients with type 2 diabetes mellitus.

The Development of a Protocol for Critical Illness-Related Corticosteroid Insufficiency (CIRCI) at a Tertiary Hospital / Journal of the ASEAN Federation of Endocrine Societies

Objectives@#The diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) remains a challenge. This initiative aimed to develop a protocol for the diagnosis and management of CIRCI which will facilitate informed decision-making among clinicians through consensus-building among a multi-disciplinary team.@*Methodology@#This was a single-center, qualitative study which utilized the modified Delphi method, consisting of a sequential iterative process with two rounds of voting. A cut-off value of 70% was set as the threshold for reaching consensus.@*Results@#The protocol on the diagnosis and management of CIRCI was approved after two rounds of voting, with all the components reaching 83.3%-100% agreement. This protocol on CIRCI provided a framework for the clinical approach to refractory shock. It was advocated that all cases of probable CIRCI should immediately be started on hydrocortisone at 200 mg/day. The definitive diagnosis of CIRCI is established through a random serum cortisol <10 mcg/dL or increase in cortisol of <9 mcg/dL at 60 minutes after a 250 mcg ACTH stimulation test in patients with indeterminate random cortisol levels@*Conclusion@#The presence of refractory shock unresponsive to fluid resuscitation and vasopressors should warrant the clinical suspicion for the existence of CIRCI and should trigger a cascade of management strategies.

Critical Illness-Related Corticosteroid Insufficiency (CIRCI) among patients with refractory shock at a tertiary hospital: A look into clinical practices and patient outcomes

@#<p style="text-align: justify;"><strong>Introduction.</strong> A significant number of critically ill patients, as high as 60% among patients with septic shock, suffer from critical illness-related corticosteroid insufficiency (CIRCI), which refers to an inadequate corticosteroid response to the level of stress.</p><p style="text-align: justify;"><strong>Objectives.</strong> This study aimed to determine the strategies employed in managing patients with critical illness-related corticosteroid insufficiency and the outcomes of these patients at a tertiary hospital.</p><p style="text-align: justify;"><strong>Methods.</strong> This was a single-center, mixed-methods study which consisted of a review of charts of patients 19 years old and above admitted for shock or developed refractory hypotension from January 2017-December 2019, and key informant interviews and focus group discussion among clinicians who have experience in managing CIRCI.</p><p style="text-align: justify;"><strong>Results.</strong> A total number of 362 patient charts reviewed showed a relatively low rate of initiation of corticosteroids for patients with refractory shock, at just 28.57% of the entire population. After corticosteroids were initiated, patients were in shock for a median of just one day and the median blood pressure improved to 100/60 mm Hg. In this cohort, patients who were started on steroids had more severe illness, as measured by the Mortality Probability Model (MPM) score, which had a median of 43.65% for the group on steroids and just 25.0% for the non-steroid group (p ? 0.0001). Patients who were started on steroids had a statistically significant longer median days on a ventilator, 5 days vs. 3 days for the non-steroid group (p = 0.0297); longer median length of intensive care unit (ICU) stay, 8 days vs. 5 days for the non-steroid group (p = 0.0410), and a higher morbidity and mortality rate. The need for steroids, the presence of septic shock, and a higher MPM score were significant predictors of mortality.</p><p style="text-align: justify;">Discussions among clinicians revealed significant variability in practices in the management of CIRCI.</p><p style="text-align: justify;"><strong>Conclusion.</strong> The presence of clinical features of CIRCI is a poor prognostic factor. Timely recognition, work-up, and interventions to address CIRCI are paramount in critical care.</p>

Advances in the research of severe burn-related corticosteroid insufficiency / 中华烧伤杂志

Despite considerable advances in diagnosis and treatment of the critical illness-related corticosteroid insufficiency (CIRCI), it is still not clear that whether it is common in severe burn patients or not, and how clinical diagnosis, treatment, and research progress. Severe burn is a systemic disease involving the damage of multiple organs of the whole body. The course of the disease is relatively long, and there often exists persistent inflammation, immunosuppression, and catabolism. On the basis of CIRCI study, the epidemiological evidence, possible mechanism, suspicious clinical manifestations, diagnosis and treatment of severe burn-related corticosteroid insufficiency (SBRCI) were briefly reviewed in this article in order to help clinical diagnosis and treatment of SBRCI.

Interpretation of Society of Critical Care Medicine and European Society of Intensive Care Medicine of clinical practice guideline on critical illness-related corticosteroid insufficiency in 2017 / 中华危重病急救医学

Great progress of critical illness-related corticosteroid insufficiency (CIRCI) has been made in diagnosis and treatment, but it still has high mortality. Meanwhile, corticosteroids are widely used in critically ill patients. Recently, the Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) published a practice guideline which had updated the diagnosis and management of CIRCI. In order to master and promote the guideline, this article interprets the new guideline to assist Chinese clinicians for better understanding CICRI at a more comprehensive level.

Effect of low-dose glucocorticoid on corticosteroid insufficient patients with acute exacerbation of chronic obstructive pulmonary disease / 世界急诊医学杂志（英文）

@#BACKGROUND: This study aimed to investigate the prevalence rate of critical illness-related corticosteroid insufficiency (CIRCI) and the effect of low-dose glucocorticoid on prognosis of CIRCI in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). METHODS: Since January 2010 to December 2012, 385 patients, who met the criteria of AECOPD, were enrolled in the Intensive Care Unit (ICU) of the First People's Hospital and Municipal Central Hospital of Xiangtan City. The AECOPD patients complicated with CIRCI screened by an adrenalcorticotrophic hormone test within 12 hours after admission to ICU were divided into a treatment group (n=32) and a control group (n=31) for a prospective, randomized and controlled clinical trial. Hydrocortisone (150 mg/d) or normal saline was injected intravenously for 7 days. The patients were followed up for 28 days after injection. The endpoint included 28-day survival time, non-shock time, ICU stay and the period of non-mechanical ventilation. The markers of inflammation C-reactive protein, tumor necrosis factor-α, interleukin 6 and procalcitonin were measured at baseline and 7 days after treatment. The variables were analyzed by Student's t test, the non-parametric statistical test, the Chi-square test or the Kaplan-Meier method with SPSS18.0 statistic software. A P value <0.05 was considered statistically significant. RESULTS: Totally 63 patients were diagnosed with CIRCI by an adrenalcorticotrophic hormone test and the prevalence rate was 16.4％. The shock rate of the AECOPD patients complicated with CIRCI was higher than that of the AECOPD patients without CIRCI (23.8％ vs. 8.7％, P<0.01). Kaplan-Meier analysis revealed that the 28-day survival time of the treatment group was obviously longer than that of the control group (P<0.05). Compared with the control group, shock-free days within 28 days was longer in the treatment group (18.2±9.5 vs. 25.8±4.1, P<0.05). Treatment with low-dose glucocorticoid obviously decreased the markers of infection and inflammation (P<0.01), such as C-reactive protein (13.2±5.5 mg/L vs. 8.3±3.1 mg/L for the control group; 13.5±5.9 mg/L vs. 5.1±2.3 mg/L for the treatment group), tumor necrosis factor-α (26.1±16.2 g/L vs. 17.5±11.7 g/L for the control group; 25.0±14.8 g/L vs. 10.4±7.8 g/L for the treatment group) and procalcitonin (3.88 g/L vs. 2.03 g/L for the control group; 3.77 g/L vs. 1.26 g/L for the treatment group). Furthermore, the markers in the treatment group decreased more obviously than those in the control group (P<0.01). CONCLUSION: The prevalence rate of CIRCI was higher in the patients with AECOPD in the department of critical medicine, and low-dose glucocorticoid treatment for one week reduced the 28-day mortality, shock time and markers of infection and inflammation.

Changes in cortisol, adrenocorticotropic hormones in term infants with critical illness and their clinical significance / 中华实用儿科临床杂志

Objective To investigate the changes in cortisol, adrenocorticotropic hormones (ACTH) in term infants with critical illness and to evaluate their functional status.Methods One hundred and fifty term infants who were transferred to the hospital within 72 hours after birth were involved (gestational age ≥ 37 weeks).These term infants were evaluated by neonatal critical illness scores (NCIS) at the time of admission, and they were divided into a mild group and a severe group according to the NCIS scores.Serum cortisol and ACTH concentrations were measured at the time of admission on day 7 and day 14 after birth.Results (1) Within 72 hours after birth, the basic serum cortisol concentration of severe illness infants [(283.5 ± 196.0) μg/L] was significantly higher than that of the infants with mild illness[(175.0 ± 186.5) μg/L], and there was a significant difference (t =-3.830, P =0.000).The basic serum cortisol concentration of the term infants with severe illness was higher than that of the term infants with mild illness,but there was no significant difference[7 d:(94.1 ±41.3) μg/L vs (62.5 ±37.9) μg/L,14 d:(68.6 ±47.7)μg/L vs (50.9 ± 38.4) μg/L, all P ＞ 0.05].(2) Among the infants with critical illness, the basic serum cortisol concentration within 72 hours after birth was significantly higher than those of day 7 and day 14 after birth (t--5.994, 2.848;P =0.000,0.036).(3) Among the mild infants, the basic serum cortisol concentration within 72 hours after birth was significantly higher than those of day 7 and day 14 after birth (t =4.691,3.076;P =0.000,0.037).(4) The basic serum ACTH concentrations had no significant difference between the severe group and the mild group[≤72 h: (101.55±61.52) ng/Lvs (85.54±59.83) ng/L,7 d:(54.91±22.75) ng/Lvs (71.07±20.51) ng/L,14 d: (44.67 ± 28.30) ng/L vs (44.92 ± 24.68) ng/L, all P ＞ 0.05].(5) The serum cortisol and ACTH concentration within 72 hours after birth of the dead infants[(351.9 ± 179.7) μg/L, (215.5 ± 165.9) ng/L] were significantly higher than those of the survivors [(201.4 ± 161.4) μg/L, (83.5 ± 54.0) ng/L], and there were significant differences(t =-2.547,-3.833;P =0.012,0.000).(6) The basic serum cortisol concentration within 72 hours after birth had a negative correlation with NCIS(r =-0.293, P =0.043), pH (r =-0.336, P =0.000) and base excess (BE) (r =-0.261 ,P =0.002);but it had a positive correlation with ACTH concentration within 72 hours after birth (r =0.443 ,P =0.000).The serum basic ACTH within 72 hours after birth had a negative correlation with BE (r =-0.181 ,P =0.031) ,and had positive correlation with the basic serum cortisol concentration within 72 hours and day 7 (r =0.443,0.268;P =0.000,0.048).Conclusions The term infants have the ability to response to external stimuli by regulating cortisol secretion.The basic serum cortisol concentration of term infants is related to the critical illness.The worse the condition is,the higher the base serum cortisol concentration is.

Effect of low-dose glucocorticoid on corticosteroid insufficient patients with acute exacerbation of chronic obstructive pulmonary disease / 中华急诊医学杂志

Objective To investigate the effect of low-dose glucocorticoid on prognosis of critical illness-related corticosteroid insufficient (CIRCI) patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD).Methods A total of 385 eligible patients met the criteria of AECOPD were admitted from January 2010 to December 2012.The AECOPD patients co-morbid with CIRCI screened by an adrenal corticotrophic hormone test within 12 hours after admission were randomly divided into treatment group (n =32) and control group (n =31) for prospective,randomized (random number) and controlled clinical study.Hydrocortison (150mg/d) for treatment group or normal saline instead for control group was injected intravenously for 7 days.The 28-day mortality,shock-free days,length of ICU stay within 28 days and ventilator-free days were evaluated.And the markers of inflammation C-reactive protein,tumor necrosis factor-α,interleukin 6 and procalcitonin were measured before and 7 days after treatment.The variables were analyzed by Student' s t-test,non-parametric statistical test,Chi-square test or KaplanMeier test with SPSS 18.0 statistic software.P ＜ 0.05 was considered statistically significant.Results A cohort of 385 patients with AECOPD was screened,and the prevalence rate of CIRCI was 16.4％.The shock rate was higher in the AECOPD patients co-morbid with CIRCI than that in the AECOPD patients without CIRCI (23.8％ vs 8.7％,P ＜0.01).Compared with the control group,the 28-day mortality was significantly lower in treatment group (2/32 vs 8/31,P ＜ 0.05),and shock-free days within 28 days longer in the treatment group (18.2 ± 9.5 vs 25.8 ± 4.1,P ＜ 0.05).However,there was no difference in the shock rate,days of ICU stay and ventilator-free days between the two groups.After treatment,the levels of infection markers were decreased and obviously lower than those in control group (P ＜ 0.01),such as Creactive protein (13.2 ± 5.5 mg/L vs 8.3 ± 3.1 mg/L for control group; 13.5 ± 5.9 mg/L vs 5.1 ± 2.3mg/L for treatment group),tumor necrosis factor-α (26.1 ± 16.2 μg/L vs 17.5 ± 11.7 μg/L for control group ; 25.0 ± 14.8 μg/L vs 10.4 ± 7.8 μg/L for treatment group) and procalcitonin [3.88 (0.25,8.5) μg/L vs 2.03 (0.15,5.1) μg/L for control group; 3.77 (0.21,8.0) μg/L vs 1.26 (0.10,3.2) μg/L for treatment group],furthermore,the levels of infection markers were decrease more obviously in the treatment group than those in the control group (P ＜ 0.01).Conclusions There was high prevalence rate of CIRCI in the patients with AECOPD in the department of critical medicine,and low-dose glucocorticoid reduced 28-day mortality,shock days and markers of infection and inflammation.

Diagnosis of adrenal failure in critically ill patients / Diagnóstico de insuficiência adrenal em pacientes críticos

In the last two decades there was important evolution on the knowledge of the function of the hypothalamic-pituitary-adrenal axis. In the last decade, the expression "relative adrenal insufficiency" (RAI) was created, and more recently "critical illness-related corticosteroid insufficiency" (CIRCI) was used to designate those patients in which cortisol production was not sufficiently increased in stress situations. Patients with CIRCI have elevated hospital morbidity and mortality. Currently, there is a wide discussion about diagnostic criteria for this dysfunction. Besides basal cortisol, some publications now study the role of other tests, such as cortrosyn test - either in low (1 μg) or high doses (250 μg); free cortisol, salivary cortisol, metyrapone test and others. With this review, we aimed at summarizing the results of the most influent papers that intended to define diagnostic criteria for CIRCI. We also suggest an approach for CIRCI diagnosis and make it clear that the decision about steroid therapy in septic shock patients is matter apart from RAI.

Nas últimas décadas, houve uma importante evolução no conhecimento sobre a função do eixo hipotálamo-pituitária-adrenal. Na última década, foi cunhada a expressão "insuficiência adrenal relativa" (IAR) e, mais recentemente, a expressão "insuficiência adrenal relacionada à doença grave" (CIRCI) foi utilizada para designar aqueles pacientes nos quais a produção de cortisol não era suficientemente elevada em situações de estresse. Pacientes com CIRCI apresentam elevada morbidade e mortalidade em hospitais. Atualmente, há uma ampla discussão sobre os critérios de diagnóstico para essa desordem. Além do cortisol basal, algumas publicações analisaram o papel de outros testes, tais como o teste de estímulo com ACTH (cortrosina), com doses baixas (1 mg) ou altas (250 mg), cortisol livre, cortisol salivar, teste da metirapona e outros. O objetivo desta revisão foi resumir os resultados dos artigos mais importantes que buscaram definir os critérios de diagnóstico para a CIRCI. Também sugerimos uma abordagem para o diagnóstico da CIRCI e deixamos claro que a decisão sobre a terapia com esteroides em pacientes em choque séptico é uma questão separada da IAR.

The diagnosis and treatment of critical illness-related corticosteroid insufficiency / 中国小儿急救医学

In recent years,relative adrenal insufficiency in critical patients has become a hot issue.With progression of studies,this definition is insufficient in accuracy.Thus a new definition of critical illnessrelated corticosteroid insufficiency(CIRCI)is developed.Now CIRCI have not had consentaneous diagnostic criteria.Moreover,the benefits of this diagnose to corticosteroid treatment in critical patients remains unclear.This article will review on the diagnosis of CIRCI and current situation of corticosteroid treatment.