***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: Introduction The aim of the study was to assess the prognostic importance of basal cortisol concentrations and cortisol response to corticotropin , and to determine the effects of physiological dose steroid therapy on mortality in patients with sepsis . Methods Basal cortisol level and corticotropin stimulation test were performed within 24 hours in all patients . One group ( 20 patients ) received st and ard therapy for sepsis and physiological-dose steroid therapy for 10 days ; the other group ( 20 patients ) received only st and ard therapy for sepsis .  Basal cortisol level was measured on the 14th day in patients who recovered . The outcome of sepsis was compared . Results Only Sequential Organ Failure Assessment ( SOFA ) score was found related to mortality , independent from other factors in multivariate analysis . No significant difference was found between the changes in the percentage of SOFA scores of the  steroid therapy group and the st and ard therapy group in survivors , nor between the groups in basal and peak cortisol levels , cortisol response to corticotropin test and mortality . The mortality rates among patients with occult adrenal insufficiencies were 40 % in the steroid therapy group and 55.6 % in the st and ard therapy group . Discussion There was a trend towards a decrease in the mortality rates of the patients with sepsis who received physiological-dose steroid therapy . In the advancing process from sepsis to septic shock , adrenal insufficiency was not frequent as supposed . There was a trend ( that did not reach significance ) towards a decrease in the mortality rates of the patients with sepsis who received physiological-dose steroid therapy Objective : To develop consensus statements for the diagnosis and management of corticosteroid insufficiency in critically ill adult patients . Participants : A multidisciplinary , multispecialty task force of experts in critical care medicine was convened from the membership of the Society of Critical Care Medicine and the European Society of Intensive Care Medicine . In addition , international experts in endocrinology were invited to participate . Design / Methods : The task force members review ed published literature and provided expert opinion from which the consensus was derived . The consensus statements were developed using a modified Delphi methodology . The strength of each recommendation was quantified using the Modified GRADE system , which classifies recommendations as strong ( grade 1 ) or weak ( grade 2 ) and the quality of evidence as high ( grade A ) , moderate ( grade B ) , or low ( grade C ) based on factors that include the study design , the consistency of the results , and the directness of the evidence . Results : The task force coined the term critical illness – related corticosteroid insufficiency to describe the dysfunction of the hypothalamic-pituitary-adrenal axis that occurs during critical illness . Critical illness – related corticosteroid insufficiency is caused by adrenal insufficiency together with tissue corticosteroid resistance and is characterized by an exaggerated and protracted proinflammatory response . Critical illness – related corticosteroid insufficiency should be suspected in hypotensive patients who have responded poorly to fluids and vasopressor agents , particularly in the setting of sepsis . At this time , the diagnosis of tissue corticosteroid resistance remains problematic . Adrenal insufficiency in critically ill patients is best made by a delta total serum cortisol of < 9 & mgr;g/dL after adrenocorticotrophic hormone ( 250 & mgr;g ) administration or a r and om total cortisol of < 10 & mgr;g/dL. The benefit of treatment with glucocorticoids at this time seems to be limited to patients with vasopressor-dependent septic shock and patients with early severe acute respiratory distress syndrome ( Pao2/Fio2 of < 200 and within 14 days of onset ) . The adrenocorticotrophic hormone stimulation test should not be used to identify those patients with septic shock or acute respiratory distress syndrome who should receive glucocorticoids . Hydrocortisone in a dose of 200 mg/day in four divided doses or as a continuous infusion in a dose of 240 mg/day ( 10 mg/hr ) for ≥7 days is recommended for septic shock . Methylprednisolone in a dose of 1 mg·kg−1·day−1 for ≥14 days is recommended in patients with severe early acute respiratory distress syndrome . Glucocorticoids should be weaned and not stopped abruptly . Reinstitution of treatment should be considered with recurrence of signs of sepsis , hypotension , or worsening oxygenation .  Dexamethasone is not recommended to treat critical illness – related corticosteroid insufficiency . The role of glucocorticoids in the management of patients with community-acquired pneumonia , liver failure , pancreatitis , those undergoing cardiac surgery , and other groups of critically ill patients requires further investigation . Conclusion : Evidence -linked consensus statements with regard to the diagnosis and management of corticosteroid deficiency in critically ill patients have been developed by a multidisciplinary , multispecialty task force Introduction In a study conducted by Annane , patients with septic shock and unresponsive to adrenocorticotropic hormone stimulation receiving low-dose steroid therapy  had prolonged survival but not significantly improved 28-day mortality . The present study examines intravenous steroid use in PROWESS ( Recombinant Human Activated Protein C Worldwide Evaluation in Severe Sepsis ) patients meeting the Annane enrollment criteria ( AEC ) . Methods Adrenocorticotropic hormone stimulation tests were not done in PROWESS . Steroids were allowed but their use was not directed . Patients were identified using AEC ( all of : r and omization to study drug treatment within 8 hours of shock onset ; infection , fever , or hypothermia ; tachycardia ; systolic blood pressure < 90 mmHg on vasopressors ; mechanical ventilation ; and one of urine < 0.5 ml/kg per hour , lactic acidosis , or arterial oxygen tension/inspired fractional oxygen < 280 ) . We examined steroid use and mortality data ; additional analyses were done outside the 8-hour window . Results Steroid-treated patients were older , had higher Acute Physiology and Chronic Health Evaluation scores and more organ dysfunctions , and were more commonly receiving mechanical ventilation . Among patients meeting AEC , regardless of steroid treatment ( n = 97 ) , mortality in the placebo and drotrecogin alfa ( activated ) groups was 38 % ( 19/50 ) and 28 % ( 13/47 ) , respectively ( relative risk [ RR ] = 0.73 , 95 % confidence interval [ CI ] 0.41–1.30 ) . When using AEC but excluding the requirement for r and omization within 8 hours of shock onset ( n = 612 ) , placebo mortality was 38 % ( 118/313 ) and drotrecogin alfa ( activated ) mortality was 29 % ( 88/299 ; RR = 0.78 , 95 % CI 0.62–0.98 ) . Using AEC but excluding the 8-hour window and with steroids initiated at baseline and /or infusion ( n = 228 ) result ed in mortality for placebo and drotrecogin alfa ( activated ) groups of 43 % ( 51/118 ) and 33 % ( 36/110 ) , respectively ( RR = 0.76 , 95 % CI 0.54–1.06 ) . Conclusion Patients with severe sepsis from the PROWESS trial who were likely to respond to low-dose steroids according to the AEC were those patients at a high risk for death . However , when using the AEC , regardless of steroid use , patients exhibited a survival benefit from treatment with drotrecogin alfa ( activated ) STUDY OBJECTIVE To evaluate the relationship between the adequacy of antimicrobial treatment for bloodstream infections and clinical outcomes among patients requiring ICU admission . DESIGN Prospect i ve cohort study . SETTING A medical ICU ( 19 beds ) and a surgical ICU ( 18 beds ) from a university-affiliated urban teaching hospital . PATIENTS Between July 1997 and July 1999 , 492 patients were prospect ively evaluated . INTERVENTION Prospect i ve patient surveillance and data collection . RESULTS One hundred forty-seven patients ( 29.9 % ) received inadequate antimicrobial treatment  for their bloodstream infections . The hospital mortality rate of patients with a bloodstream infection receiving inadequate antimicrobial treatment ( 61.9 % ) was statistically greater than the hospital mortality rate of patients with a bloodstream infection who received adequate antimicrobial treatment ( 28.4 % ; relative risk , 2 . 18 ; 95 % confidence interval [ CI ] , 1.77 to 2.69 ; p < 0.001 ) . Multiple logistic regression analysis identified the administration of inadequate antimicrobial treatment as an independent determinant of hospital mortality ( adjusted odds ratio [ AOR ] , 6.86 ; 95 % CI , 5.09 to 9.24 ; p < 0.001 ) . The most commonly identified bloodstream pathogens and their associated rates of inadequate antimicrobial treatment included vancomycin-resistant enterococci ( n = 17 ; 100 % ) , C and ida species ( n = 41 ; 95.1 % ) , oxacillin-resistant Staphylococcus aureus ( n = 46 ; 32.6 % ) , coagulase-negative staphylococci ( n = 96 ; 21.9 % ) , and Pseudomonas aeruginosa ( n = 22 ; 10.0 % ) . A statistically significant relationship was found between the rates of inadequate antimicrobial treatment for individual microorganisms and their associated rates of hospital mortality ( Spearman correlation coefficient = 0.8287 ; p = 0.006 ) . Multiple logistic regression analysis also demonstrated that a bloodstream infection attributed to C and ida species ( AOR , 51.86 ; 95 % CI , 24.57 to 109.49 ; p < 0.001 ) , prior administration of antibiotics during the same hospitalization ( AOR , 2.08 ; 95 % CI , 1.58 to 2.74 ; p = 0.008 ) , decreasing serum albumin concentrations ( 1-g/dL decrements ) ( AOR , 1.37 ; 95 % CI , 1.21 to 1.56 ; p = 0.014 ) , and increasing central catheter duration ( 1-day increments ) ( AOR , 1.03 ; 95 % CI , 1.02 to 1.04 ; p = 0.008 ) were independently associated with the administration of inadequate antimicrobial treatment . CONCLUSIONS The administration of inadequate antimicrobial treatment to critically ill patients with bloodstream infections is associated with a greater hospital mortality compared with adequate antimicrobial treatment of bloodstream infections . These data suggest that clinical efforts should be aim ed at reducing the administration of inadequate antimicrobial treatment to hospitalized patients with bloodstream infections , especially individuals infected with antibiotic-resistant bacteria and C and ida species Arterial hypotension often signifies inadequate systemic perfusion . We hypothesize that in a heterogeneous emergency department ( ED ) population with clinical ly suspected circulatory shock , the severity of hypotension on presentation predicts in-hospital outcome . We performed a secondary analysis of patients with nontraumatic shock enrolled in a noninterventional , r and omized , controlled trial . The setting was an urban , tertiary ED , census > 100,000 visits per year . Patients included nontrauma ED patients , aged > 17 years , with initial ED vital signs consistent with shock ( systolic blood pressure < 100 mmHg or shock index > 1.0 ) , and agreement of two independent observers for at least one sign and symptom of inadequate tissue perfusion . Measurements included interobserver agreement for signs and symptoms of shock , relationship between the depth and duration of ED hypotension and adverse hospital outcome ( in-hospital mortality , need for intensive care unit services , and acute organ failure ) and logistic regression analysis for independent predictors of adverse hospital outcome . Of 202 patients who qualified , 190 patients were included ;  the in-hospital mortality rate was 15 % . The sign or symptom of shock with the highest interobserver agreement was “ unresponsive ” ( κ = 0.74 ) . The adverse hospital outcomes increased with each decile decrease in the lowest ED systolic blood pressure ( SBP ) from 17 % if SBP > 89 mmHg versus 50 % if SBP < 80 mmHg . Forty percent of patients with an adverse hospital outcome had sustained hypotension ( all ED SBP < 100 mmHg for ≥60 min ) . Sustained hypotension was the strongest independent predictor of an adverse hospital outcome ( odds ratio 3.1 ; 95 % CI 1.5–7.1 ) . Mortality among patients who present to the ED with undifferentiated shock is high . The depth and duration of systolic blood pressure appears to have a dose – response relationship to adverse hospital outcome PURPOSE To examine the effect of inappropriate initial antimicrobial therapy on the prognosis of patients with sepsis who were enrolled in a clinical trial of an immun 
    Output:
    
In patients with septic shock , corticosteroid therapy appears to be safe but does not reduce 28-day all-cause mortality rates .
It does , however , significantly reduce the incidence of vasopressor-dependent shock , which may be a clinical ly worthwhile goal