TITLE: Cortisol and adrenal androgens as independent predictors of mortality in septic patients_protocol
AUTHORS: Rocío De Castro, David Ruiz, Bernardo-Alio Lavín, Jose Ángel Lamsfus, Luis Vázquez, Coral Montalban, Gilberto Marcano, Raquel Sarabia, María Paz, Cristina Blanco, Miguel Santibáñez

[DESCRIPTION]
<div class = "text-blocks"><div class = "text-block">Objective: To determine the prognostic value of cortisol, Dehydroepiandrosterone (DHEA) and Dehydroepiandrosterone-sulfate (DHEAS), together with their ratios (cortisol/DHEA and cortisol/DHEAS), as independent predictors of mortality in septic patients.</div><div class = "text-block"><div class = "justify" style = "text-align:left">Methods: Prospective cohort study of 139 consecutive patients with a diagnosis of severe sepsis or septic shock. Adrenal hormones were determined within the first 24 hours of the septic process. To determine and compare the predictive ability of each marker for the risk of unfavorable evolution (in-hospital, 28-day and 90-day mortality), ROC (Receiver Operating Characteristic) curves were constructed and the area under the curve (AUC) was determined. As measures of association, adjusted odds ratios (OR) with their 95% confidence intervals (95%CI) were estimated by unconditional logistic regression. Cortisol, DHEA and DHEAS results were compared to lactate, CRP, SOFA and APACHE II Scores.</div></div><div class = "text-block"><div class = "justify" style = "text-align:left">Results: Cortisol showed the best predictive ability, with AUCs of 0.758, 0.759 and 0.705 for in-hospital mortality, and 28-day and 90-day mortality, respectively; whereas AUCs for 28 days mortality for SOFA and APACHE II scores, and other biomarkers studied, such as Lactate or CRP, were 0.644, 0.618, 0.643 and 0.647, respectively. Associations between high cortisol levels (>17.5 µg/dL) and mortality were strong and statistically significant for in-hospital and 28-day mortality: adjusted ORs 10.13 and 9.45 respectively, and lower for long term mortality (90 days): adjusted OR 4.26 (95% CI 1.34-13.56), p trend 0.014.</div></div><div class = "text-block"><div class = "justify" style = "text-align:left">Regarding adrenal androgens, only positive associations were obtained for DHEAS and most of these positive associations did not yield statistical significance.</div></div><div class = "text-block"><div class = "justify" style = "text-align:left">Regarding Cortisol/DHEA and cortisol/DHEAS ratios, they did not improve the predictive ability of cortisol. The only exception was the cortisol/DHEAS ratio, which was the best predictor of mortality at 90 days (AUC 0.737), adjusted OR for highest cortisol/DHEAS ratio values 6.33 (95%CI 1.77-22.60), p trend 0.002. </div></div><div class = "text-block"><div class = "justify" style = "text-align:left">Conclusion: Basal cortisol measured within the first 24 hours of the septic process was the best prognostic factor for in-hospital and 28-day mortality, even superior to the Sequential Organ Failure Assessment (SOFA) or Acute Physiology and Chronic Health Evaluation II (APACHE II) scores. The cortisol/DHEAS ratio was an independent predictor of long-term mortality</div></div></div>

[STEPS]
?. The collection of blood samples was performed in all cases between 8:00 a.m. and 9:00 a.m.
?. Patients did not ingest any food in the previous 10 hours.
?. Blood samples were then collected in silicone-vacuum tubes with a silica gel filter without anticoagulant to obtain serum, as well as a venous extraction syringe obtained without a compressor and placed in cold quickly for the specific determination of lactate.
?. All samples were stored before, during and after extraction at a temperature of 0-12ºC. All samples were processed within one hour of extraction. The serum tubes were left to coagulate for 20-30 minutes and then centrifuged at 2000g at room temperature.
?. General biochemical measurements were performed on the same day as the extraction. The serum to be used for the determination of specific hormonal parameters (DHEA and DHEAS) was distributed in properly identified cryotubes and frozen from -40ºC to -60ºC until further processing.