***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: OBJECTIVE To determine the effect of immunomodulatory therapies on the development of severe disease in hospitalized adults with laboratory-confirmed p and emic influenza A ( H1N1 ) 2009 complicated by pneumonia . METHODS Observational , prospect i ve cohort study at thirteen tertiary hospitals in Spain . The use of corticosteroids , macrolides and statins was recorded . The outcome of interest was severe disease , defined as the composite of intensive care unit admission or death after the first day of hospitalization . RESULTS Of the 197 patients with p and emic influenza A ( H1N1 ) 2009 complicated by pneumonia , 68 ( 34.5 % ) received some anti-inflammatory therapy since hospital admission ( corticosteroids in 37 , macrolides in 31 and statins in 12 ) . Severe disease occurred in 29 ( 14.7 % ) patients . After adjustment for confounding factors , immunomodulatory therapies as a group were not associated with a lower risk for developing severe disease ( odds ratio [ OR ] 0.64 ; 95 % confidence interval [ CI ] 0.22 - 1.86 ) . In a further a priori analysis , corticosteroids , macrolides and statins were included in a multivariate model . None of these therapies was found to be associated with a lower risk for developing severe disease . CONCLUSIONS Immunomodulatory therapies use since hospital admission did not prevent the development of severe disease in adults with p and emic influenza A ( H1N1 ) 2009 complicated by pneumonia BACKGROUND Clinical trials yielded conflicting data about the benefit of adding systemic corticosteroids for treatment of community-acquired pneumonia . We assessed whether short-term corticosteroid treatment reduces time to clinical stability in patients admitted to hospital for community-acquired pneumonia . METHODS In this double-blind , multicentre , r and omised , placebo-controlled trial , we recruited patients aged 18 years or older with community-acquired pneumonia from seven tertiary care hospitals in Switzerl and within 24 h of presentation . Patients were r and omly assigned ( 1:1 ratio ) to receive either prednisone 50 mg daily for 7 days or placebo . The computer-generated r and omisation was done with variable block sizes of four to six and stratified by study centre . The primary endpoint was time to clinical stability defined as time ( days ) until stable vital signs for at least 24 h , and analysed by intention to treat . This trial is registered with Clinical Trials.gov , number NCT00973154 . FINDINGS From Dec 1 , 2009 , to May 21 , 2014 , of 2911 patients assessed for eligibility , 785 patients were r and omly assigned to either the prednisone group ( n=392 ) or the placebo group ( n=393 ) . Median time to clinical stability was shorter in the prednisone group ( 3·0 days , IQR 2·5 - 3·4 ) than in the placebo group ( 4·4 days , 4·0 - 5·0 ; hazard ratio [ HR ] 1·33 , 95 % CI 1·15 - 1·50 , p<0·0001 ) . Pneumonia-associated complications until day 30 did not differ between groups ( 11 [ 3 % ] in the prednisone group and 22 [ 6 % ] in the placebo group ; odds ratio [ OR ] 0·49 [ 95 % CI 0·23 - 1·02 ] ; p=0·056 ) . The prednisone group had a higher incidence of in-hospital hyperglycaemia needing insulin treatment ( 76 [ 19 % ] vs 43 [ 11 % ] ; OR 1·96 , 95 % CI 1·31 - 2·93 , p=0·0010 ) . Other adverse events compatible with corticosteroid use were rare and similar in both groups . INTERPRETATION Prednisone treatment for 7 days in patients with community-acquired pneumonia admitted to hospital shortens time to clinical stability without an increase in complications . This finding is relevant from a patient perspective and an important determinant of hospital costs and efficiency . FUNDING Swiss National Science Foundation , Viollier AG , Nora van Meeuwen Haefliger Stiftung , Julia und Gottfried Bangerter-Rhyner Stiftung In a double-blind , r and omised , placebo-controlled trial of hospitalised patients with community-acquired pneumonia ( CAP ) , we demonstrated shorter time to clinical stability ( TTCS ) with adjunct corticosteroid therapy compared with placebo . We did a pre-planned , exploratory analysis of any association between microbiological diagnosis , antibiotic treatment and procalcitonin level and effect of prednisone on TTCS , mortality , and CAP complications  ( n=726 participants , enrolled between December 2009 and May 2014 ) .  Multiplex viral real time PCR was systematic ally performed in nasopharyngeal swabs beginning November 2011 ( n=489 ) . Other investigations and treatments were at the discretion of the physician . Effect modification was tested with inclusion of interaction terms in the statistical models . Reduced TTCS with prednisone was seen in all microbiological , antibiotic , procalcitonin and afebrile patient subgroups . We found evidence for a different prednisone response in patients with pneumococcal pneumonia in whom intravenous antibiotic duration was not shorter ( interaction p=0.01 ) with prednisone , as was observed in the remaining study population . In patients without macrolide treatment  , rehospitalisations were not lower with prednisone ( interaction p=0.04 ) . After adjustment for multiple testing , these subgroup effects were no longer significant . Prednisone was associated with shorter TTCS independent of CAP aetiology . In pneumococcal pneumonia , prednisone effects on secondary endpoints may be less favourable . Prednisone was beneficial in all microbiological , antibiotic , procalcitonin and afebrile patient subgroups Background The effect of corticosteroids on influenza A(H1N1)pdm09 viral pneumonia patients remains controversial , and the impact of dosage has never been studied . Methods Using data of hospitalized adolescent and adult patients with influenza A(H1N1)pdm09 viral pneumonia , prospect ively collected from 407 hospitals in mainl and China , the effects of low‐to‐moderate‐dose ( 25‐150 mg d−1 ) and high‐dose ( > 150 mg d−1 ) corticosteroids on 30‐day mortality , 60‐day mortality , and nosocomial infection were assessed with multivariate Cox regression and propensity score‐matched case – control analysis . Results In total , 2141 patients ( median age : 34 years ; morality rate : 15.9 % ) were included . Among them , 1160 ( 54.2 % ) had PaO2/FiO2<300 mm Hg on admission , and 1055 ( 49.3 % ) received corticosteroids therapy . Corticosteroids , without consideration of dose , did not influence either 30‐day or 60‐day mortality . Further analysis revealed that , as compared with the no‐corticosteroid group , low‐to‐moderate‐dose corticosteroids were related to reduced 30‐day mortality ( adjusted hazard ratio [ aHR ] 0.64 [ 95 % CI 0.43‐0.96 , P=.033 ] ) . In the subgroup analysis among patients with PaO2/FiO2<300 mm Hg , low‐to‐moderate‐dose corticosteroid treatment significantly reduced both 30‐day mortality ( aHR 0.49 [ 95 % CI 0.32‐0.77 ] ) and 60‐day mortality ( aHR 0.51 [ 95 % CI 0.33‐0.78 ] ) , while high‐dose corticosteroid therapy yielded no difference . For patients with PaO2/FiO2 ≥300 mm Hg , corticosteroids ( irrespective of dose ) showed no benefit and even increased 60‐day mortality ( aHR 3.02 [ 95 % CI 1.06‐8.58 ] ) . Results were similar in the propensity model analysis . Conclusions Low‐to‐moderate‐dose corticosteroids might reduce mortality of influenza A(H1N1)pdm09 viral pneumonia patients with PaO2/FiO2<300 mm Hg . Mild patients with PaO2/FiO2 ≥300 mm Hg could not benefit from corticosteroid therapy We aim ed to study factors influencing outcomes of adults hospitalised for seasonal and p and emic influenza . Individual-patient data from three Asian cohorts ( Hong Kong , Singapore and Beijing ; N=2649 ) were analysed . Adults hospitalised for laboratory-confirmed influenza ( prospect ively diagnosed ) during 2008–2011 were studied . The primary outcome measure was 30-day survival . Multivariate Cox regression models ( time-fixed and time-dependent ) were used . Patients had high morbidity ( respiratory/nonrespiratory complications in 68.4 % , respiratory failure in 48.6 % , pneumonia in 40.8 % and bacterial superinfections in 10.8 % ) and mortality ( 5.9 % at 30 days and 6.9 % at 60 days ) . 75.2 % received neuraminidase inhibitors ( NAI ) ( 73.8 % received oseltamivir and 1.4 % received peramivir/zanamivir ; 44.5 % of patients received NAI ≤2 days and 65.5 % ≤5 days after onset of illness ) ; 23.1 % received systemic corticosteroids . There were fewer deaths among NAI-treated patients ( 5.3 % versus 7.6 % ; p=0.032 ) . NAI treatment was independently associated with survival ( adjusted hazard ratio ( HR ) 0.28 , 95 % CI 0.19–0.43 ) , adjusted for treatment-propensity score and patient characteristics . Superinfections increased ( adjusted HR 2.18 , 95 % CI 1.52–3.11 ) and chronic statin use decreased ( adjusted HR 0.44 , 95 % CI 0.23–0.84 ) death risks . Best survival was shown when treatment started within ≤2 days ( adjusted HR 0.20 , 95 % CI 0.12–0.32 ) , but there was benefit with treatment within 3–5 days ( adjusted HR 0.35 , 95 % CI 0.21–0.58 ) . Time-dependent analysis showed consistent results of NAI treatment ( adjusted HR 0.39 , 95 % CI 0.27–0.57 ) . Corticosteroids increased superinfection ( 9.7 % versus 2.7 % ) and deaths when controlled for indications ( adjusted HR 1.73 , 95 % CI 1.14–2.62 ) . Early NAI treatment was associated with shorter length of stay in a sub analysis . NAI treatment may improve survival of hospitalised influenza patients ; benefit is greatest from , but not limited to , treatment started within 2 days of illness . Superinfections and corticosteroids increase mortality .  Antiviral and non-antiviral management strategies should be considered . NAI treatment , secondary infections and corticosteroids may impact on survival of hospitalised influenza patients Introduction This study was aim ed at characterizing basal and adrenocorticotropic hormone (ACTH)-induced steroidogenesis in sepsis and nonsepsis patients with a suspicion of critical illness-related corticosteroid insufficiency ( CIRCI ) , taking the use of etomi date -inhibiting 11β-hydroxylase into account . Method This was a prospect i ve study in a mixed surgical/medical intensive care unit ( ICU ) of a university hospital . The patients were 62 critically ill patients with a clinical suspicion of CIRCI . The patients underwent a 250-μg ACTH test ( n = 67 ) . ACTH , adrenal steroids , substrates , and precursors ( modified t and em mass spectrometry ) also were measured . Clinical characteristics including use of etomi date to facilitate intubation ( n = 14 within 72 hours of ACTH testing ) were recorded . Results At the time of ACTH testing , patients had septic ( n = 43 ) or nonseptic critical illness ( n = 24 ) . Baseline cortisol directly related to sepsis and endogenous ACTH , independent of etomi date use . Etomi date was associated with a lower baseline cortisol and cortisol/11β-deoxycortisol ratio as well as higher 11β-deoxycortisol , reflecting greater 11β-hydroxylase inhibition in nonsepsis than in sepsis . Cortisol increases < 250 mM in exogenous ACTH were associated with relatively low baseline ( HDL- ) cholesterol , and high endogenous ACTH with low cortisol/ACTH ratio , independent of etomi date . Although cortisol increases with exogenous ACTH , levels were lower in sepsis than in nonsepsis patients , and etomi date was associated with diminished increases in cortisol with exogenous ACTH , so that its use increased , albeit n 
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Risk of bias was greatest in the ' comparability domain ' of the Newcastle-Ottawa scale , consistent with potential confounding by indication .
Reported doses of corticosteroids  used were high and indications for their use were not well reported .
Currently , we do not have sufficient evidence in this review to determine the effectiveness of corticosteroids for patients with influenza