***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Objectives : To examine the incidence of infections and to describe them and their outcome in intensive care unit ( ICU ) patients . Design and setting : International prospect i ve cohort study in which all patients admitted to the 28 participating units in eight countries between May 1997 and May 1998 were followed until hospital discharge . Patients : A total of 14,364 patients were admitted to the ICUs , 6011 of whom stayed less than 24 h and 8353 more than 24 h. Results : Overall 3034 infectious episodes were recorded at ICU admission ( crude incidence : 21.1 % ) . In ICU patients hospitalised longer than 24 h there were 1581 infectious episodes ( crude incidence : 18.9 % ) including 713 ( 45 % ) in patients already infected at ICU admission . These rates varied between ICUs . Respiratory , digestive , urinary tracts , and primary bloodstream infections represented about 80 % of all sites . Hospital-acquired and ICU-acquired infections were documented more frequently microbiologically than community-acquired infections ( 71 % and 86 % , respectively vs. 55 % ) . About 28 % of infections were associated with sepsis , 24 % with severe sepsis and 30 % with septic shock , and 18 % were not classified . Crude hospital mortality rates ranged from 16.9 % in non-infected patients to 53.6 % in patients with hospital-acquired infections at the time of ICU admission and acquiring infection during the ICU stay . Conclusions : The crude incidence of ICU infections remains high , although the rate varies between ICUs and patient subsets , illustrating the added burden of nosocomial infections in the use of ICU re sources OBJECTIVE The aim of the study was to evaluate the expression of tumor necrosis factor (TNF)-alpha protein in the subcutaneous and visceral adipose tIssue in correlation with adipocyte cell Volume , serum TNF-alpha , soluble TNF-receptor-2 ( sTNFR-2 ) and indirect parameters of insulin resistance in overweight/obese and lean healthy persons . DESIGN A cross-sectional case-control study was used . PATIENTS Twenty-eight overweight/obese prob and s with normal glucose tolerance ( BMI > 27 kg/m(2 ) ) and 15 lean people ( BMI < 25 kg/m(2 ) ) , all of them undergoing planned surgical operation , participated in the study . METHODS Two to four grams of subcutaneous and visceral adipose tIssue were removed and studied using semi-quantitative immunohistochemical staining of the TNF-alpha protein . Serum TNF-alpha , sTNFR-2 ( ELISA ) and fasting C-peptide ( RIA )  were measured . RESULTS TNF-alpha protein was expressed in adipocytes of both depots . The expression was evaluated visually and found to be greater in the obese patients . Significantly higher serum TNF-alpha ( 5.58+/-0.87 pg/ml vs 4.21+/-0.55 , mean+/-s.d . , P<0.01 , Mann-Whitney ) and sTNFR-2 levels ( 7.84+/-3.56 ng/ml vs 4.59+/-1.35 , P=0.005 ) were found in the obese subgroup in correlation with the fasting C-peptide level ( r=0.49 , P=0.003 ; and r=0.74 , P=0.001 ) and the C-peptide/ blood glucose ratio ( r=0.47 , Spearman , P=0.005 ; and r=0.70 , P=0.001 ) . The cell Volume of both adipocyte depots was found to have a significant positive correlation with serum TNF-alpha and sTNFR-2 levels in the total group of patients ( subcutaneous : r=0.52 , P=0.0003 ; r=0.69 , P<0.0001 ; visceral : r=0.65 , P<0.0001 ; r=0.63 , P<0.0001 ) and in both subgroups . CONCLUSIONS Adipocyte cell Volume of both the subcutaneous and visceral fat depots may be determinants of TNF-alpha , sTNFR-2 production and obesity-linked insulin resistance BACKGROUND In a single-center study published more than a decade ago involving patients presenting to the emergency department with severe sepsis and septic shock , mortality was markedly lower among those who were treated according to a 6-hour protocol of early goal -directed therapy ( EGDT )  , in which intravenous fluids , vasopressors , inotropes , and blood transfusions were adjusted to reach central hemodynamic targets , than among those receiving usual care . We conducted a trial to determine whether these findings were generalizable and whether all aspects of the protocol were necessary . METHODS In 31 emergency departments in the United States , we r and omly assigned patients with septic shock to one of three groups for 6 hours of resuscitation : protocol -based EGDT ; protocol -based st and ard therapy that did not require the placement of a central venous catheter , administration of inotropes , or blood transfusions ; or usual care . The primary end point was 60-day in-hospital mortality . We tested sequentially whether protocol -based care ( EGDT and st and ard-therapy groups combined ) was superior to usual care and whether protocol -based EGDT was superior to protocol -based st and ard therapy . Secondary outcomes included longer-term mortality and the need for organ support . RESULTS We enrolled 1341 patients , of whom 439 were r and omly assigned to protocol -based EGDT , 446 to protocol -based st and ard therapy , and 456 to usual care .  Resuscitation strategies differed significantly with respect to the monitoring of central venous pressure and oxygen and the use of intravenous fluids , vasopressors , inotropes , and blood transfusions . By 60 days , there were 92 deaths in the protocol -based EGDT group ( 21.0 % ) , 81 in the protocol -based st and ard-therapy group ( 18.2 % ) , and 86 in the usual-care group ( 18.9 % ) ( relative risk with protocol -based therapy vs. usual care , 1.04 ; 95 % confidence interval [ CI ] , 0.82 to 1.31 ; P=0.83 ; relative risk with protocol -based EGDT vs. protocol -based st and ard therapy , 1.15 ; 95 % CI , 0.88 to 1.51 ; P=0.31 ) . There were no significant differences in 90-day mortality , 1-year mortality , or the need for organ support . CONCLUSIONS In a multicenter trial conducted in the tertiary care setting , protocol -based resuscitation of patients in whom septic shock was diagnosed in the emergency department did not improve outcomes . ( Funded by the National Institute of General Medical Sciences ; ProCESS Clinical Trials.gov number , NCT00510835 . ) We report the findings from a prospect i ve study determining the magnitude of errors in the visual estimation of weight and height of critically ill patients . Forty-two consecutive patients were weighed by a physician with a calibrated stretcher scale and length measured with a steel measuring tape . The predicted body weight was calculated using the ARDSnet formulae . Attending physicians and nurses were asked to estimate patient 's actual weight , predicted weight and height . The average percent errors in estimation of actual and predicted weight were 11.4 and 14.6 % , respectively . Errors greater than 20 % in patient 's actual and predicted weight were observed in 15 and 24 % of cases , respectively . The majority of height estimations ( 86 % ) had an error < 10 % . There were non-significant differences between the estimations made by intensive care unit physicians and nurses . Our study shows that estimations of patient 's weight made by intensive care unit staff are often inaccurate . In contrast , estimations of height made by intensive care unit staff are usually adequate . Estimated body weight of critically ill patients  has implication s for drug and respiratory therapy and should be used with caution Purpose . Data suggest that obesity in critical illness is associated with improved outcomes . We postulate that these findings may be influenced by preillness comorbidities . We sought to determine if critically ill obese patients without significant comorbidity had improved mortality compared to obese patients with multiple comorbidities . Material s and Methods . We analyzed data from a prospect i ve observational study conducted in 3 tertiary ICUs . Severely obese ( body mass index ≥30 ) adults in the ICU for ≥24 hours were identified and classified into limited comorbid illnesses ( 0 - 1 ) or multiple comorbidities ( ≥2 ) . The primary outcome was the odds ratio ( OR ) of mortality at day 28 . Important secondary outcomes were ICU length of stay and ICU free days in the first 28 days . Results . 598 patients were enrolled ; 183 had BMI ≥30 . Of these , 38 had limited comorbidities and 145 had multiple comorbidities . In unadjusted analyses , obese patients with multiple comorbidities were 4.70 times ( 95 % CI 1.07–20.6 ) as likely to die by day 28 compared to patients with limited comorbidities ( P = 0.04 ) . After stratifying by admission diagnosis and adjusting for APACHE II score , the influence of comorbidities remained large and trended toward significance ( OR 4.28 , 95 % CI 0.92–20.02 , P = 0.06 ) . In adjusted analyses , obese patients with multiple comorbidities tended to have longer ICU duration ( 3.06 days , SE 2.28 , P = 0.18 ) and had significantly fewer ICU free days in the first 28 days ( −3.92 days , SE 1.83 , P = 0.03 ) . Conclusions . Not all critically ill obese patients are the same . Those with less comorbidity may have better outcomes than those with multiple comorbidities . This may be important when considering prognosis and discussing care with patients and families Background Recent sepsis guidelines have focused on the early identification and risk stratification of patients on presentation . Obesity is associated with alterations in multiple inflammatory regulators similar to changes seen in sepsis , suggesting a potential interaction between the presence of obesity and the severity of illness in sepsis . Methods We performed a retrospective chart review of patients admitted with a primary billing diagnosis of sepsis at a single United States university hospital from 2007 to 2010 . Seven hundred and ninety-two charts were identified meeting inclusion criteria . Obesity was defined as a body mass index ( BMI ) ≥ 30 kg/m2 . The data recorded included age , race , sex , vital signs , laboratory values , length of stay , comorbidities , weight , height , and survival to discharge . A modified APACHE II score was calculated to estimate disease severity . The primary outcome variable was inpatient mortality . Results Survivors had higher average BMI than nonsurvivors ( 27.6 vs. 26.3 kg/m2 , p = 0.03 ) in unadjusted analysis . Severity of illness and comorbid conditions including cancer were similar across BMI categories . Increased incidence of diabetes mellitus type 2 was associated with increasing BMI ( p < 0.01 ) and was associated with decreased mortality , with an odds ratio of 0.53 compared with nondiabetic patients . After adjusting for age , gender , race , severity of illness , length of stay , and comorbid conditions , the trend of decreased mortality for increased BMI was no longer statistically significant , however diabetes continued to be strongly protective ( odds ratio 0.52 , p = 0.03 ) . Conclusions This retrospective analysis suggests obesity may be protective against mortality in septic in patients . The protective effect of obesity may be dependent on diabetes , possibly through an unidentified hormonal intermediary . Further prospect i ve studies are necessary to elaborate the specific mechanism of this protective effect Objective : To better define the incidence of sepsis and the characteristics of critically ill patients in European intensive care units . Design : Cohort , multiple-center , observational study . Setting : One hundred and ninety-eight intensive care units in 24 European countries . Patients : All new adult admissions to a participating intensive care unit between May 1 and 15 , 2002 . Interventions : None . Measurements and Main Results : Demographic data , comorbid diseases , and clinical and laboratory data were collected prospect ively . Patients were followed up until death , until hospital discharge , or for 60 days . Of 3,147 adult patients , with a median age of 64 yrs , 1,177 ( 37.4 % ) had sepsis ; 777 ( 24.7 % ) of these patients had sepsis on admission . In patients with sepsis , the lung was the most common site of infection ( 68 % ) , followed by the abdomen ( 22 % ) . Cultures were positive in 60 % of the patients with sepsis . The most common organisms were Staphylococcus aureus ( 30 % , including 14 % methicillin-resistant ) , Pseudomonas species ( 14 % ) , and Escherichia coli ( 13 % ) . Pseudomonas species was the only microorganism independently associated with increased mortality rates . Patients with sepsis had more severe organ 
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Site of underlying infection and illness severity may have favored overweight and obese BMI s. Conclusions This is the first meta- analysis to show that overweight or obese BMI s reduce adjusted mortality in adults admitted to the ICU with sepsis , severe sepsis , or septic shock .