PubMed · 9433254
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J Masanz. 1996-05-20. RN APACHE coordinator.. https://pubmed.ncbi.nlm.nih.gov/9433254/
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UNLABELLED: A trial of thyroxine in acute renal failure. BACKGROUND: Acute renal failure (ARF) remains a serious medical problem with a high mortality rate. Efforts to shorten the course of ARF might reduce this mortality. Since thyroxine has been shown in experimental models to shorten the course of ARF, we designed a trial to determine if a defined course of thyroxine would alter the course or change the mortality of clinical ARF. METHODS: A prospective, randomized, placebo-controlled, double-blind trial of thyroxine was carried out in patients with ARF. End points were the percentage requiring dialysis, the percentage recovering renal function, time to recovery, and mortality. RESULTS: Fifty-nine patients were randomized to receive either thyroxine or placebo. The groups were well matched in terms of basal and entry creatinines, age, sex, APACHE II scores at entry, and percentage oliguric. Baseline thyroid functions, including T3, T4, rT3, and thyroid stimulating hormone (TSH) levels, were equal between the two groups and typical of patients with euthyroid sick syndrome. Thyroxine resulted in a progressive and sustained suppression of TSH levels in the treated group, but had no effect on any measure of ARF severity. Mortality was higher in the thyroxine group than the control group (43 vs. 13%) and correlated with suppression of TSH. CONCLUSIONS: In contrast to the beneficial effects seen in experimental ARF, thyroxine has no effect on the course of clinical ARF and could have a negative effect on outcome through prolonged suppression of TSH. Critically ill euthyroid sick patients should not be replaced with thyroid hormone.
CONTEXT: While it is established that management strategies and outcomes differ by gender for many diseases, its effect on infection has not been adequately studied. OBJECTIVE: To investigate the role of gender among hospitalized patients treated for infection. DESIGN: Observational cohort study conducted during a 26-month period from December 1996 through January 1999. SETTING: University-affiliated hospital. PARTICIPANTS: A total of 892 patients in the surgical units of the hospital with 1470 consecutive infectious episodes (782 in men and 688 in women). MAIN OUTCOME MEASURES: Mortality during hospitalization by gender for infection episodes overall and for specific infectious sites, including lung, peritoneum, bloodstream, catheter, urine, surgical site, and skin/soft tissue. RESULTS: Among all infections, there was no significant difference in mortality based on gender (men, 11.1% vs women, 14.2%; P = .07). After logistic regression analysis, factors independently associated with mortality included higher APACHE (Acute Physiology and Chronic Health Evaluation) II score, older age, malignancy, blood transfusion, and diagnosis of infection more than 7 days after admission, but not gender (female odds ratio [OR] for death, 1.32; 95% confidence interval [CI], 0.90-1.94; P = .16). Mortality was higher in women for lung (men, 18% vs women, 34%; P = .002) and soft tissue (men, 2% vs women, 10%; P < or = .05) infection; for other infectious sites, mortality did not differ by gender. Factors associated with mortality due to pneumonia by logistic regression included higher APACHE II score, malignancy, diabetes mellitus, diagnosis of infection more than 7 days after admission, older age, transplantation, and female gender (OR for death, 2.25; 95% CI, 1.17-4.32; P = .02). CONCLUSIONS: Although gender may not be predictive of mortality among all infections, women appear to be at increased risk for death from hospital-acquired pneumonia, even after controlling for other comorbidities.
Severe acute pancreatitis is a two-phase systemic disease. The first phase is a clinical response resulting from systemic effects of proinflammatory mediators called SIRS (systemic inflammatory response syndrome), that may lead to multiple organ failure and death. The second phase, if the process is not reversed by natural defences or treatment, may be accompanied by local complications such as infected pancreatic necrosis. The severity of the disease must be established early to identify patients requiring intensive monitoring and support. The clinico-biochemical score (Ranson score) is about 80% accurate at 48 hours but is not accurate before this time; the APACHE II system has the sensitivity to predict severe pancreatitis in 61% of patients on admission. Although not perfect, the prognostic systems of severity remain better than clinical judgement. SIRS followed by local complications is accompanied by increased energy requirements and, with the absence of oral intake, a persistently negative nitrogen balance and mineral and micronutrient deficiencies. Thus, early nutritional support is indicated. Formerly, total parenteral nutrition was the standard practice for providing exogenous nutrients avoiding pancreatic stimulation. The use of early enteral feeding has recently been evaluated. Gastric atony and obstruction of the duodenum by pancreatic oedema or necrosis have been overcome by delivering enteral nutrition to the jejunum, distal to the ligament of Treitz; in this position, regular diets do not stimulate pancreatic secretions. The efficacy, tolerance, clinical outcome and cost of enteral nutrition suggest that this feeding route should be preferred in patients with severe acute pancreatitis.