***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: Nuclear factor-kappaB ( NF-kappaB ) and glucocorticoid receptor-alpha ( GR-alpha ) have diametrically opposed functions in regulating inflammation . We investigated whether unresolving acute respiratory distress syndrome ( ARDS ) is associated with systemic inflammation- induced glucocorticoid resistance and whether prolonged methylprednisolone administration accelerates the suppression of systemic inflammatory indices and normalizes the sensitivity of the immune system to glucocorticoids . Patients enrolled into a r and omized trial evaluating prolonged methylprednisolone administration in unresolving ARDS had serial plasma sample s collected before and after r and omization . In the plasma , we measured the concentrations of tumor necrosis factor-alpha ( TNF-alpha ) , interleukins ( IL ) IL-1beta and IL-6 , adrenocorticotropic hormone ( ACTH ) , and cortisol . The ability of patient plasma to influence the NF-kappaB and GR-signal transduction systems of normal peripheral blood leukocytes ( PBL ) was examined . Patients treated with methylprednisolone had progressive and sustained reductions of TNF-alpha , IL-1beta , IL-6 , ACTH , and cortisol concentrations over time . Normal PBL exposed to plasma sample s collected during methylprednisolone exhibited significant progressive increases in all aspects of GR-mediated activity and significant reductions in NF-kappaB DNA-binding and transcription of TNF-alpha and IL-1beta . These findings provide support for the presence of endogenous glucocorticoid inadequacy in the control of inflammation and systemic inflammation-induced peripheral glucocorticoid resistance in ARDS . Prolonged methylprednisolone administration accelerated the resolution of both systemic inflammation and peripheral acquired glucocorticoid resistance in ARDS ACTH stimulation is the st and ard test for assessment of adrenal function . It was suggested that the low dose ( 1 microg ) would be more sensitive for detecting mild secondary adrenal insufficiency than the usual dose of 250 microg . The aim of this study was to find the optimal diagnostic criteria and to compare st and ard dose test ( SDT ) with the low dose test ( LDT ) .  A group of patients treated with corticosteroids for the 6 months was considered to have hypothalamo-pituitary-adrenal impairment . Studies were performed in 14 corticosteroid-treated and 28 control subjects in r and om order on 2 consecutive days . Tests were analyzed using the receiver operating characteristic curve method . The best test was cortisol increment at 15 min of the LDT . It was significantly better than the cortisol concentration at 15 min of the SDT , the best test during the SDT ( receiver operating characteristic curve area and 95 % confidence interval : LDT , 0.997 and 0.956 - 0.999 ; SDT , 0.827 and 0.662 - 0.929 ; P = 0.0113 ) . For the cortisol increment at 15 min of the LDT at 100 % sensitivity , the diagnostic value was 100 mmol/L , and the specificity was 96 % . Therefore , the LDT is superior to the st and ard dose test in the assessment of secondary adrenal insufficiency BACKGROUND Exposure to intense physical and psychological stress during septic shock can result in posttraumatic stress disorder in survivors . Patients with chronic posttraumatic stress disorder often show sustained reductions in serum cortisol concentration . This investigation examines whether increasing serum cortisol levels with hydrocortisone treatment during septic shock reduces the incidence of posttraumatic stress disorder in survivors . METHODS Patients ( n = 20 ) were recruited from a prospect i ve , r and omized double-blind study on the hemodynamic effects of hydrocortisone during septic shock . Eleven patients had received placebo and nine  stress doses of hydrocortisone . Posttraumatic stress disorder was diagnosed 31 months ( median ) after intensive care unit discharge using SCID-IV ( DSM-IV- criteria ) . Furthermore , the number of categories of traumatic memory from ICU treatment was determined in both groups at that time . RESULTS Only one of nine patients from the hydrocortisone group developed posttraumatic stress disorder , compared with seven of 11 patients in the placebo group ( p = .02 ) . There was no significant difference with regard to the number of categories of traumatic memory between the hydrocortisone and placebo groups . CONCLUSIONS The administration of hydrocortisone during septic shock in a dosage similar to the endogenous maximal production rate was associated with a lower incidence of posttraumatic stress disorder in long-term survivors , which seems to be independent of the number of categories of traumatic memory Abstract . Objective : To study the time course of corticosteroid binding-globulin ( CBG ) level and the free cortisol index ( FCI ) in comparison with total cortisol and ACTH concentrations during acute and prolonged critical illness . Design : Prospect i ve observational clinical study . Setting : Twenty-bed medical/surgical intensive care unit . Patients and participants : Thirty patients with septic shock , eight patients with multitrauma , and forty healthy control subjects . Measurements and results : During 14 days or until discharge/death , we serially measured serum concentrations of CBG , cortisol , TNF-α , IL-6 , plasma ACTH immunoreactivity , and the FCI  ( = cortisol/CBG × 100 ) . We also recorded haemodynamic parameters , APACHE II , ISS , SOFA scores , shock duration , inotrope use , and ICU mortality . In both groups we found markedly decreased CBG levels in the early phase ( septic shock : 17.5±5.9 , and trauma : 16.1±2.3 mg/l ) in comparison with controls ( 37.3±5.3 mg/l ) . The FCI was high in this early phase ( septic shock : 7.2±2.7 ; trauma : 6.5±1.3 ; controls : 1.25±0.76 ) . During follow-up , CBG levels significantly increased , reaching normal levels from day 7 on . The FCI showed an opposite biphasic pattern , with near-normalising FCI values during the second phase . Regression analysis showed a negative correlation between CBG and IL-6 levels ( rs=–0.63 ; P<0.05 ) , but no relation between CBG concentrations and disease severity , shock duration or death was found . Conclusions : We found extremely low CBG levels in early stage septic shock and multitrauma . These dramatic changes are reflected in a concomitant higher FCI , indicating a higher free cortisol level . A second phase displays increasing and normalising CBG levels , independent from clinical parameters . We believe that CBG plays an active role in the glucocorticoid response to severe stress and in the regulation of cortisol availability to target tissues Objective To investigate , in patients with severe septic shock , the adrenocortical function assessed by daily plasma cortisol determinations during the first 72 h and by the short synthetic ACTH stimulation test performed within 24 h of the onset of shock . Design Prospect i ve clinical investigation . Setting Medical intensive care unit in a university teaching hospital . Patients 40 consecutive patients with documented septic shock requiring at least hemodynamic resuscitation and respiratory support . Interventions There were no intervention . Measurements and results Basal cortisol concentrations were increased with a mean value of 36.8 μg/dl ( range 7.9–113 ) . Of the overall cortisol determinations 92 % were above 15 μg/dl . No statistically significant differences in basal cortisol concentrations were found when survival , type of infection , and positive blood cultures were considered . Patients with hepatic disease had significantly higher cortisol ( 50.1(±6.2 ) μ/dl versus 35.9(±3.3 ) μg/dl , p=0.035 ) levels compared to other patients . No correlations were found between basal plasma cortisol concentrations and factors such as SAPS , OSF , hemodynamic measurements , duration of shock , and amount of vasopressor and /or inotropic agents . Cortisol concentrations had significant but weak correlation with ACTH levels in survivors ( r=0.4;p=0.03;n=28 ) but not in non-survivors ( r=0.03;p=0.85;n=52 ) . Cortisol levels in non-survivors increased significantly from enrollment time to the 72nd hour of the survey ( day 1 : 38.9(±3.8 ) μg/dl versus day 3 : 66.7(±17.1 ) μg/dl;p=0.046 ) and were significantly higher than those recorded in survivors . Responses to the short ACTH stimulation test were not significantly different between survivors and non-survivors . According to the different criteria used to interpret the response to the ACTH stimulation test , incidence of adrenocortical insufficiency was highly variable ranging from 6.25–75 % in patients with septic shock . Only one patient had absolute adrenocortical insufficiency ( basal cortisol level below 10 μg/dl ; response to the ACTH stimulation test below 18 μg/dl . Conclusion Our data suggest that in a selected population of patients with severe septic shock single plasma cortisol determination has no predictive value . The short ACTH stimulation test performed within the first 24 h of onset shock can neither predict outcome nor estimate impairment in adrenocortical function in patients with high basal cortisol level . Adrenal insufficiency is rare in septic shock and should be suspected when cortisol level is below 15 μg/dl and then confirmed by a peak cortisol level lower than 18 μg/dl during the short ACTH stimulation test CONTEXT The hypothalamic-pituitary-adrenal axis is a major determinant of the host response to stress . The relationship between its activation and patient outcome is not known . OBJECTIVE To evaluate the prognostic value of cortisol levels and a short corticotropin stimulation test in patients with septic shock . DESIGN AND SETTING Prospect i ve inception cohort study conducted between October 1991 and September 1995 in 2 teaching hospital adult intensive care units in France . PARTICIPANTS A total of 189 consecutive patients who met clinical criteria for septic shock . INTERVENTION A short corticotropin stimulation test was performed in all patients by intravenously injecting 0.25 mg of tetracosactrin ; blood sample s were taken immediately before the test ( T0 ) and 30 ( T30 ) and 60 ( T60 ) minutes afterward . MAIN OUTCOME MEASURES Twenty-eight-day mortality as a function of variables collected at the onset of septic shock , including cortisol levels before the corticotropin test and the cortisol response to corticotropin ( delta max , defined as the difference between T0 and the highest value between T30 and T60 ) . RESULTS The 28-day mortality was 58 % ( 95 % confidence interval [ CI ] , 51%-65 % ) and median time to death was 17 days ( 95 % CI , 14 - 27 days ) . In multivariate analysis , independent predictors of death ( P < or = .001 for all ) were McCabe score greater than 0 , organ system failure score greater than 2 , arterial lactate level greater than 2.8 mmol/L , ratio of PaO2 to fraction of inspired oxygen no more than 160 mm Hg , cortisol level at T0 greater than 34 microg/dL and delta max no more than 9 microg/dL. Three groups of patient prognoses were identified : good ( cortisol level at T0 < or = 34 microg/dL and delta max > 9 microg/dL ; 28-day mortality rate , 26 % ) , intermediate ( cortisol level at T0 34 microg/dL and delta max < or = 9 microg/dL or cortisol level at T0 > 34 microg/dL and delta max > 9 microg/dL ; 28-day mortality rate , 67 % ) , and poor ( cortisol level at T0 > 34 microg/dL and delta max < or = 9 microg/dL ; 28-day mortality rate , 82 % ) . CONCLUSION Our data suggest that a short corticotropin test has a good prognostic value and could be helpful in identifying patients with septic shock at high risk for death BACKGROUND Preliminary reports suggest that patients with the acquired immunodeficiency syndrome ( AIDS ) and Pneumocystis carinii pneumonia may benefit from the addition of corticosteroid treatment to antibiotic therapy . METHODS We conducted a double-blind , placebo-controlled trial to assess the efficacy of adjunctive corticosteroids in patients with AIDS and severe P. carinii pneumonia . Patients with marked abnormalities in gas exchange who had been treated with antibiotics for less than 72 hours were r and omly assigned to receive either methylprednisolone ( 40 mg ) or placebo every 6 hours for 7 days , in addition to treatment for 21 days with trimethoprim-sulfamethoxazole . The primary outcome measures were survival until hospital discharge and the development of respiratory failure . RESULTS Twenty-three patients were enrolled in the study ; there were no significant differences in base-line clinical or laboratory measures between the two treatment groups . Of 12 patients treated with corticosteroids , 9 ( 75 percent ) survived until hospital 
    Output:
    
Low doses of corticosteroids are recommended in patients with septic shock .
In the absence of vasopressor requirement , corticosteroids should not be used to treat sepsis .
High-dose corticosteroids are not recommended in severe sepsis .