Corticosteroids for severe sepsis and septic shock: a systematic review and meta-analysis

Objective To assess the effects of corticosteroids on mortality in patients with severe sepsis and septic shock.Data sources Randomised and quasi-randomised trials of corticosteroids versus placebo (or supportive treatment alone) retrieved from the Cochrane infectious diseases group''s trials register, the Cochrane central register of controlled trials, Medline, Embase, and LILACS.Review method Two pairs of reviewers agreed on eligibility of trials. One reviewer entered data on to the computer and four reviewers checked them. We obtained some missing data from authors of trials and assessed methodological quality of trials.Results 16/23 trials (n = 2063) were selected. Corticosteroids did not change 28 day mortality (15 trials, n = 2022; relative risk 0.92, 95% confidence interval 0.75 to 1.14) or hospital mortality (13 trials, n = 1418; 0.89, 0.71 to 1.11). There was significant heterogeneity. Subgroup analysis on long courses (≥ 5 days) with low dose (≤ 300 mg hydrocortisone or equivalent) corticosteroids showed no more heterogeneity. The relative risk for mortality was 0.80 at 28 days (five trials, n = 465; 0.67 to 0.95) and 0.83 at hospital discharge (five trials, n = 465, 0.71 to 0.97). Use of corticosteroids reduced mortality in intensive care units (four trials, n = 425, 0.83, 0.70 to 0.97), increased shock reversal at 7 days (four trials, n = 425; 1.60, 1.27 to 2.03) and 28 days (four trials, n = 425, 1.26, 1.04 to 1.52) without inducing side effects.Conclusions For all trials, regardless of duration of treatment and dose, use of corticosteroids did not significantly affect mortality. With long courses of low doses of corticosteroids, however, mortality at 28 days and hospital morality was reduced.     

Calcium salts bone regeneration scaffolds: a review article

A growing array of synthetic bone regeneration scaffolds has been in use over the last century. These scaffolds aim to provide a three dimensional substrate for bone cells to populate on and to function appropriately. The majority of commercially-available scaffolds are based on calcium sulphate salts, calcium phosphate salts, or composites of the two. The mechanical and biological properties of these scaffolds are a result of the properties of the constituent materials and their ratio in the composite. This review addresses the mechanical and biological characteristics and provides an up-to-date summary of the clinical data available about the use of these calcium-based scaffolds. It will also assess the benefit of using stem cell technology along with this type of scaffolds. This article links between the basic science evidence and the clinical outcomes and details the commercially-available options.     

Corticosteroids and Leukotrienes: Chronobiology and Chronotherapy

Corticosteroids and leukotrienes play opposite roles in asthma. Corticosteroids, both endogenously secreted and exogenously administered, are antiinflammatory and are very effective in the treatment of asthma. They have also been evaluated chronotherapeutically and have been found to be very effective in reducing the enhanced airway inflammation and decrement in lung function associated with nocturnal worsening of asthma. Leukotrienes are potent proinflammatory and spasmogenic mediators that have been shown to be increased at night in patients with nocturnal asthma (NA). Leu-kotriene modifiers, a new class of medications to treat asthma, improve, but do not abolish, the symptoms and decrement in lung function associated with nocturnal asthma. However, they have not been evaluated chronotherapeutically. This article addresses the roles of corticosteroids and leukotrienes in nocturnal asthma and their position as therapeutic agents or targets for therapy.     

Corticosteroids in acute traumatic brain injury: systematic review of randomised controlled trials.

OBJECTIVE: To quantify the effectiveness and safety of corticosteroids in the treatment of acute traumatic brain injury. DESIGN: Systematic review of randomised controlled trials of corticosteroids in acute traumatic brain injury. Summary odds ratios were estimated as an inverse variance weighted average of the odds ratios for each study. SETTING: Randomised trials available by March 1996. SUBJECTS: The included trials with outcome data comprised 2073 randomised participants. RESULTS: The effect of corticosteroids on the risk of death was reported in 13 included trials. The pooled odds ratio for the 13 trials was 0.91 (95% confidence interval 0.74 to 1.12). Pooled absolute risk reduction was 1.8% (-2.5% to 5.7%). For the 10 trials that reported death or disability the pooled odds ratio was 0.90 (0.72 to 1.11). For infections of any type the pooled odds ratio was 0.92 (0.69 to 1.23) and for the seven trials reporting gastrointestinal bleeding it was 1.05 (0.44 to 2.52). With only those trials with the best quality of concealment of allocation, the pooled odds ratio estimates for death and death or disability became closer to unity. CONCLUSIONS: This systematic review of randomised controlled trials of corticosteroids in acute traumatic brain injury shows that there remains considerable uncertainty over their effects. Neither moderate benefits nor moderate harmful effects can be excluded. The widely practicable nature of the drugs and the importance of the health problem suggest that large simple trials are feasible and worth while to establish whether there are any benefits from use of corticosteroids in this setting.     

Corticosteroids and Leukotrienes: Chronobiology and Chronotherapy

Corticosteroids and leukotrienes play opposite roles in asthma. Corticosteroids, both endogenously secreted and exogenously administered, are antiinflammatory and are very effective in the treatment of asthma. They have also been evaluated chronotherapeutically and have been found to be very effective in reducing the enhanced airway inflammation and decrement in lung function associated with nocturnal worsening of asthma. Leukotrienes are potent proinflammatory and spasmogenic mediators that have been shown to be increased at night in patients with nocturnal asthma (NA). Leu-kotriene modifiers, a new class of medications to treat asthma, improve, but do not abolish, the symptoms and decrement in lung function associated with nocturnal asthma. However, they have not been evaluated chronotherapeutically. This article addresses the roles of corticosteroids and leukotrienes in nocturnal asthma and their position as therapeutic agents or targets for therapy.     

Cellular and molecular effects of thiazolidinediones on bone cells: a review

Thiazolidinediones represent a class of molecules used in the treatment of type 2 diabetes mellitus. Despite interesting effects in lowering blood glucose and HbA1c levels durably, an augmentation of the fracture risk in women has emerged in the past years. This review is providing the readers with information about the cellular and molecular mechanisms involved in bone and bone cells in response to these drugs.     

Cellular and molecular mechanisms underlying bone marrow and liver fibrosis: a review

Chronic fibroproliferative diseases are an important cause of morbidity and mortality in the world. Fibrotic diseases occur in a large variety of vital organs, and the process of fibrosis seems common to all tissues. In all of fibrotic reactions, the underlying cellular and molecular mechanisms involve leukocyte infiltration, the persistence of inflammation in the tissue, and the proliferation of cells with a myofibroblast phenotype. The different cell types participating to this process sustain production of growth factors, proteolytic enzymes, angiogenic factors, and fibrogenic cytokines, which together stimulate the deposition of connective tissue elements that progressively destroy and remodel normal tissue architecture. This review focuses on the comparison of two, major, chronic fibroproliferative diseases: the myelofibrosis which develops in bone marrow, a "fluid" tissue producing circulating haematopoietic cells, and liver fibrosis, which demonstrates all the features of solid tissue damage. We discuss the etiology and histological quantification of each type of fibrosis, the implication of cell partners, cytokines and growth factors, animal models developed to study fibrosis, and antifibrotic therapies for each of these two fibroproliferative disease models.     

Biochemical-markers for the diagnosis of bone metastasis: a clinical review

The preferential metastasis of cancer cells to skeleton not only disrupts the process of bone remodeling and influences the therapeutic decision, but also results in severe complications. Although the current diagnosis of bone metastases (BM) relies on bone imaging techniques, they are not sensitive enough for early detection as well as they are invasive and expensive to use. Since factors derived from bone metabolism are potentially useful to diagnose metastatic bone disease in cancer patients, a number of clinical trials have been carried out on this area. Results suggest that higher levels of bone biomarkers are associated with an increased risk of BM. As a result, biochemical-markers are showing prospects in early diagnosis of BM. This review summarizes the available evidence on the clinical use of biochemical-markers in the diagnosis of various cancers with high incidence of BM including breast, prostate and lung.     

The clinical relevance of calcaneus bone mineral measurements: a review

The use of bone mineral content (BMC) measurements to assist in the management of osteoporosis has received increasing emphasis in recent years. Although the calcaneus, an essentially trabecular bone (90–95%), has been used extensively in the NASA experiments, few data relating to primary osteoporosis have appeared in the literature until recently. This paper is a review of the methods of measurement, their precision and methods of calibration, and the relationship of calcaneal mineral content to age, height, weight, other bone sites, degree of spinal osteoporosis, metabolic bone disease and the effects of therapeutic drugs. Prospectively, calcaneal BMC relates as well as spinal BMC to osteoporotic fracture risk. It is this use of BMC measurements which has the most promise for the future. The data indicate that osteoporosis is a systemic disease and trabecular bone losses are reflected in the calcaneus as well as in the spine itself.     

Proteomic analysis of bone cancer: a review of current and future developments

The ability of sophisticated proteomic approaches to scrutinize the dynamic nature of protein expression, cellular and subcellular protein distribution, post-translational modifications, and protein-protein interactions has culminated in the identification of many potential new therapeutic targets and an abundance of cancer-related biomarkers. From a proteomics perspective, amongst the most under-studied diseases are bone cancers, such as myeloma, osteosarcoma and breast and prostate cancer bony metastases. This review focuses on the recent advances in proteomic technology that have thrust the skeletal cancer field into this exciting age of proteomics, and highlights the future work that is required to adapt this technology to specifically interrogate the skeletal consequences of malignancy.     

Corticosteroids and the brain

Mineralocorticoid (MR) and glucocorticoid receptors (GR) are expressed in the central nervous system. Radioligand binding studies, autoradiography, immunocytochemistry and in situ hybridization have shown that MR and GR are found in abundance in neurons of the limbic system (hippocampus), a structure involved in mood, affect and subtle control of the hypothalamic-pituitary-adrenal (HPA) axis. In the hippocampus MR binds corticosterone (CORT) as well as aldosterone (ALDO) with high affinity. MR seems mainly occupied by CORT in the face of its 2-3 order higher circulating concentration. GR binds CORT with a 6-10-fold lower affinity. MR and GR gene expression, as well as the native receptor proteins, seem to be controlled in a coordinative manner. When GR is down-regulated by excess homologous steroid, MR appears to be increased. Down regulation of MR reduces GR as well. MR and GR display a differential ontogenetic pattern. Ontogeny, particularly that of GR, can be permanently influenced when animals are exposed during the first post-natal week of maternal deprivation, handling, CORT or ACTH1-24 injections. These MR and GR changes persist into senescence and have been proposed to result in altered CORT responsiveness, stress regulation, behavioural adaptation and brain aging.     

Quantitative genetics of circulating molecules associated with bone metabolism: a review

This paper reviews recent advances in the studies of various biochemical factors (biomarkers) involved in bone metabolism and remodeling. The collected data in this area suggest the existence of complex and multilevel relationships between calciotropic hormones, various cytokines and growth factors. The paper summarizes the data on the magnitude of the familial and genetic effects on the interindividual variation in circulating levels of many of these biomarkers. The majority of the cited heritability estimates are well above 20%, reaching up to 80% for some cytokines (e.g., TNFalpha and VEGF). These estimates point to potential targets for the identification of novel quantitative trait loci involved in the control of the respective molecules variation. This information is of particular importance, because the available data on the association between specific genes/polymorphisms and the respective circulating molecules variation is still very limited. The paper also provides recent findings on the genetics of co-variation between the circulating levels of various biomarkers. It shows that only in a few instances, such as for example, between IGF-I and IGFBP-3, and IGFBP-1 and leptin, significant and substantial genetic (and environmental) correlations were found. It appears that despite the prominent strong genetic effects on variation of each of the numerous biomarkers, the pleiotropic effects are rather limited. We consider briefly some important new data obtained using the gene expression approach and microarray technique. The data, for instance, indicate that the genetic effects on bone metabolism appear to be an open system, which can be activated or modulated by external factors such as drugs, e.g., PTH. Extensive molecular genetic studies in this area are both timely and imperative to detect the specific genes affecting variation (and co-variation) of the circulating factors associated with bone metabolism.