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Review Article | DOI: https://doi.org/10.31579/2639-4162/249
Intensive Care Department, Faculty of Medicine, Military Medical Academy, Armed Forces College of Medicine, Egypt.
*Corresponding Author: Yahya Abdel Tawab Mohammed Meky, Intensive Care Department, Faculty of Medicine, Military Medical Academy, Armed Forces College of Medicine, Egypt.
Citation: Yahya Abdel Tawab Mohammed Meky, (2024), The Association Between Thyroid Hormone Levels and Mortality Outcomes Among Sepsis and Septic Shock Patients, J. General Medicine and Clinical Practice, 7(10); DOI:10.31579/2639-4162/249
Copyright: © 2024, Yahya Abdel Tawab Mohammed Meky. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 06 December 2024 | Accepted: 20 December 2024 | Published: 23 December 2024
Keywords: thyroid hormones; sepsis; prognostic marker; FT3 (free triiodothyronine); FT4 (free thyroxine)
Background: Sepsis is a life-threatening condition triggered by an overwhelming immune response to infection. It significantly contributes to global morbidity and mortality. Thyroid hormone imbalances are prevalent in critically ill patients and can exacerbate metabolic dysfunction and worsen clinical outcomes. Further investigation into these connections is crucial for improved patient care.
Objectives: to study the relationship between thyroid hormone levels at baseline and outcomes of Sepsis and Septic Shock in critically ill patients.
Patients and methods: This observational, cross-sectional study was conducted in the general ICU at Maadi Military Medical Hospital, involving 62 critically ill patients with sepsis or septic shock. Patients aged 18 and older with culture-confirmed infections were included. Individuals with preexisting thyroid or cardiovascular conditions were excluded from the study.
Results: mean age of 52.3 years, a gender distribution that is about equal, and common comorbidities including diabetes (25.8 percentage) and hypertension (43.5 percentage). Thyroid hormone levels were greater in survival, and the mortality rate was 50 percentage (FT3, FT4). With an AUC of 0.886, FT3 showed a significant mortality prediction. Thyroid hormone levels, organ function, and infection all affect patient outcomes and are important indicators of prognosis in critical care settings.
Conclusion: The study highlights the strong association between thyroid hormone levels, particularly FT3, and patient outcomes in critically ill patients with sepsis and septic shock. Lower levels of FT3 and FT4 were linked to increased disease severity, prolonged ICU stays, and higher mortality rates. Notably, FT3 emerged as a particularly strong predictor of mortality. These findings suggest that monitoring thyroid hormone levels may be valuable in identifying high-risk patients and guiding therapeutic interventions to improve clinical outcomes in this patient population.
A dysregulated host response to infection results in organ failure and sepsis, a potentially fatal illness. Sepsis killed about 11 million people worldwide in 2017 and had a death rate close to 20% (Rudd et al., 2020). Sepsis is still a serious public health concern due to its rising occurrence, especially since each case can cost more than $27,000 to treat (Arefian et al., 2017; Dietz et al., 2017).
Particularly in times of stress and serious illness, thyroid hormones play an essential role in controlling metabolic processes (Lodha et al., 2007). Hospitalized individuals frequently have abnormal thyroid hormone levels, especially those who are elderly or unwell (Iglesias et al., 2009). Researchers are focusing more on how systemic disorders affect thyroid metabolism, which can result in conditions like euthyroid sick syndrome (NTIS) or low T3 syndrome (Liu et al., 2016). Low triiodothyronine (T3) levels are commonly seen in sepsis, which is explained by enhanced thyroxine (T4) conversion to reverse T3 and increased T3 catabolism (Warner and Beckett, 2010). In the intensive care unit (ICU), these modifications may have a negative impact on patient outcomes (Pérsico et al., 2023). Studies indicate that free T3 may predict death in intensive care unit patients, highlighting the connection between thyroid hormone levels and the severity of sepsis (Wang et al., 2012). To fully comprehend the predictive significance of thyroid hormone levels, particularly in patients suffering from septic shock, more investigation is necessary (Sun, Bao, and Guo, 2023). Furthermore, thyroid dysfunction can affect cardiac health; alterations in the duration of the QT interval are associated with both hyperthyroidism and hypothyroidism, which may result in severe arrhythmias (Wang, 2022). To demonstrate the vital role thyroid hormones, play in metabolic adaptation during critical illness, this study intends to examine the association between thyroid hormone levels and outcomes in critically sick patients suffering from sepsis and septic shock. This study sought to determine how baseline thyroid hormone levels and outcomes in critically sick patients with sepsis and septic shock relate to one another. It aims to ascertain whether these hormone levels might function as prognostic markers, which could impact treatment choices and enhance patient outcomes in critical care environments.
The Maadi Military Medical Complex's general intensive care unit will be the site of this cross-sectional, analytical, and observational study. Patients with sepsis or septic shock who are in critical condition are part of the study population.
Inclusion Criteria:
Patients who match the diagnostic criteria for sepsis/septic shock as stated in the Sepsis and Septic Shock 3.0 guidelines published in 2016 and who are over 18 years old and admitted to the intensive care unit (ICU) with infections that have been visually or culture-identified are eligible for inclusion (Rhodes et al., 2017). Studying the impact of thyroid disease on ECG measurements will only involve patients having sinus rhythm on the examined ECG.
Exclusion Criteria:
Exclusion criteria encompass:
Sampling:
The study will use a straightforward, non-probability sampling technique. T4 levels were considerably lower in non-survivor septic shock patients than in survivors, per earlier studies (Wang et al., 2021). It will take a minimum of 62 septic shock patients, comprising at least 31 survivors and 31 non-survivors, to obtain a significant comparison of thyroid hormone levels between survivor and non-survivor groups with a power of 80% and a significance threshold of 0.05.
Data Collection Tools and Procedure:
Sociodemographic Information: Details on the demographics of the patients was gathered.
Medical History: A thorough medical history was documented, with a focus on drug use and any thyroid conditions.
Clinical Examination: Vital sign assessments (heart rate, respiration rate, blood pressure, and temperature) were part of the comprehensive clinical examination that patients will get. Cultures: Upon admission, pan cultures (blood, sputum, urine, or other probable infection sites) were obtained.
Laboratory Indicators: Complete blood count, albumin levels, lipid profile, cardiac enzymes, liver function tests, and kidney function tests were all be blood draws on the first day of intensive care unit admission.
Blood Gas Analysis: A multi-function blood gas analyzer will be used to do blood gas analysis, which includes measuring lactate levels.
Thyroid Hormone Measurement: Enzyme-linked immunosorbent assay (ELISA) kits are used to test thyroid hormone levels (FT3, FT4, and TSH) from blood samples obtained upon admission and five days thereafter.
Thyroid Function Types: Patients were classified as euthyroid, hyperthyroid, hypothyroid, or nonthyroidal sickness syndrome (NTIS) according to their baseline thyroid hormone levels.
Clinical Follow-Up: Throughout their ICU stay, patients have their clinical status evaluated for any signs of progress or decline.
Scoring Systems: The sequential organ failure assessment score (SOFA) was evaluated every day, and the acute physiology and chronic health evaluation II score (APACHE II) was finished within 24 hours of ICU admission.
Instruments: ECG: Daily monitoring for arrhythmias or ischemic changes and Echocardiography: Baseline assessment and follow-up during the ICU stay.
Outcomes of the study
They used SPSS v26 (IBM Inc., Chicago, IL, USA) for statistical analysis. The normality of the data distribution was assessed using histograms and the Shapiro-Wilks test. An unpaired Student's t-test was used to compare the two groups' quantitative variables, which were expressed as mean and standard deviation (SD). Quantitative data were evaluated using t-tests or ANOVA, while qualitative variables were reported as frequency and percentage (%) and, when applicable, the Chi-square test. Statistical significance was defined as a two-tailed P value < 0>
A flowchart of the study children is shown in Figure 1. Of the 69 critically ill patients with sepsis or septic shock who attended the general ICU at Maadi Military Medical Hospital,13 patients were excluded from the study (5 of them did not meet the inclusion criteria and 2 declined consent), 62 patients consented to participation (Figure 1).
The demographic characteristics of the 62 studied patients show a near-equal gender distribution, with 48.4 percentage males and 51.6 percentagefemales (Table 1). Also, the mean and range of vital signs for the studied patients were presented in table 1.
Figure 1. Flowchart of the studied patients’ groups.
| Studied Patient (n=62) | |||
| N | percentage | ||
| Gender | Male | 30 | 48.4 |
| Female | 32 | 51.6 | |
| Mean ±SD | Range | ||
| Age/year | 52.3 ± 14.5 | 35 – 70 | |
| Height (Cm) | 162.8 ± 9.2 | 156 – 179 | |
| Weight (Kg) | 85.5 ± 11.2 | 54 – 101 | |
| BMI (Kg/m2) | 26.7 ± 7.1 | 22 – 35 | |
| Heart Rate (beat/min.) | 110.08 ± 10.73 | 85 – 120 | |
| Respiratory Rate (Breath/min.) | 22.02 ± 2.92 | 14- 30 | |
| Mean Arterial Blood Pressure (mmHg) | 60.86 ± 9.60 | 55- 70 | |
| Temperature (Co) | 37.01 ± 0.51 | 35.99 - 38.93 | |
Table 1: Demographic Data and Vital Signs of the studied patients.
Among the 62 patients studied, 59.7 percentage were diagnosed with sepsis, while 40.3 percentage were in septic shock. This distribution highlights the severity of the condition within the cohort, with a significant portion progressing from sepsis to the more critical state of septic shock (Figure 2).
Figure 2: Distribution of Sepsis and Septic Shock among Studied Patients.
The severity of illness among the 62 studied patients is reflected by their APACHE and SOFA scores. The mean APACHE score is 35, with a range from 20 to 65, indicating a high level of critical illness, as higher APACHE scores are associated with increased mortality risk. The SOFA score, which measures organ dysfunction, has a mean of 16, ranging from 10 to 22 (Table 2).
| Studied Patients (n=62) | |||
| Mean ±SD | Range | ||
| APACHE Score | 35 ± 7.99 | 20- 65 | |
| SOFA Score | 16 ± 2.89 | 10 - 22 | |
| N | percentage | ||
| Mechanical ventilation | Yes | 25 | 40.3 |
| No | 37 | 59.7 | |
| Mechanical ventilation/hrs. | 49.05 ± 21.91 | 3.20 - 92.50 | |
| ICU | Survive | 31 | 50.0 |
| Non-Survivor | 31 | 50.0 | |
| ICU Length of stay/days | 10.91 ± 4.61 | 0.17 - 20.83 | |
Table 2: Mortality and Outcomes among the studied patients.
In this study, FT3 and FT4 levels were significantly lower among patients with mechanical ventilation (2.94 ± 0.90, 0.87 ± 1.12) compared to patients without mechanical ventilation (5.23 ± 2.03, 1.21 ± 0.65), (p˂0.05). while TSH was not significantly different among patients with and without mechanical ventilation (p=0.429), (Table 3).
| Mechanical Ventilation | Test value | P-value | |||
| Yes (n=25) | No (n=37) | ||||
| FT3 (pg/mL) | Mean ±SD | 2.94 ± 0.90 | 5.23 ± 2.03 | 5.274 | <0> |
| Range | 1.4 – 5.0 | 2.0 – 9.2 | |||
| FT4 (pg/mL) | Mean ±SD | 0.87 ± 1.12 | 1.21 ± 0.65 | 2.045 | 0.047* |
| Range | 0.17 – 2.40 | 0.20 – 3.0 | |||
| TSH (µIU/mL) | Mean ±SD | 0.98 ± 0.62 | 1.12 ± 0.67 | 0.797 | 0.429 |
| Range | 0.17 – 2.0 | 0.17 – 2.30 | |||
Using: t-Independent Sample t-test for Mean ±SD; X2= Chi-Square test, p-value >0.05 is insignificant; *p-value <0>
Table 3: Thyroid hormone levels in patients with and without mechanical ventilation.
In this study, Thyroid hormone levels were analyzed across survivors and non-survivors at two time points (Day 0 and Day 7). Initial FT3 levels showed no significant difference (p=0.198), but by Day 7, non-survivors exhibited significantly higher FT3 levels (p=0.002). FT4 levels followed a similar pattern, with a significant elevation in non-survivors by Day 7 (p=0.010). TSH levels remained comparable between groups at both time points, (Table 4).
| 0 Day | 7 Day | |||||
| Survive (n=31) | Non-Survivor (n=31) | P value | Survive (n=31) | Non-Survivor (n=31) | P value | |
| FT3 (pg/mL) | 2.79(1.1-4.8) | 3.24(1.8-5.0) | 0.198 | 3.91(2.4-9.2) | 2.96(1.4-5.0) | 0.002** |
| FT4 (pg/mL) | 0.97(0.2-2.0) | 1.01(0.2-2.9) | 0.770 | 1.22(0.3-3.0) | 0.81(0.17-2.4) | 0.010** |
| TSH (µIU/mL) | 1.1(0.3-2.0) | 1.02(0.18-4.0) | 0.657 | 1.14(0.3-2.3) | 0.99(0.17-2.0) | 0.365 |
Using: t-Independent Sample t test for Mean ±SD; X2= Chi- Square test, p-value >0.05 is insignificant; *p-value <0>
Table 4: Thyroid hormone levels in ICU survivors and non-survivors.
In our study, thyroid hormone levels correlated significantly with clinical parameters. Lower FT3 and FT4 levels were associated with higher APACHE and SOFA scores, prolonged ICU stays, and increased reliance on mechanical ventilation and CRRT. Negative correlations between FT3 and age, BMI, and organ dysfunction further support the role of thyroid hormones as markers of severity, (Table 5).
| FT3 | FT4 | TSH | ||
| Age | R | -0.150 | -0.110 | -0.093 |
| P-value | 0.038* | 0.091 | 0.132 | |
| Gender | R | 0.050 | 0.020 | 0.056 |
| P-value | 0.210 | 0.326 | 0.294 | |
| BMI | R | -0.145 | -0.125 | 0.030 |
| P-value | 0.041* | 0.074 | 0.388 | |
| Diabetes | R | 0.025 | 0.014 | 0.045 |
| P-value | 0.400 | 0.472 | 0.225 | |
| Hypertension | R | -0.130 | -0.085 | 0.010 |
| P-value | 0.060 | 0.145 | 0.482 | |
| IHD | R | -0.160 | -0.112 | -0.040 |
| P-value | 0.032* | 0.089 | 0.242 | |
| CKD | R | -0.170 | -0.142 | 0.010 |
| P-value | 0.027* | 0.042* | 0.473 | |
| Bed Sores | R | 0.030 | -0.060 | 0025 |
| P-value | 0.370 | 0.282 | 0.406 | |
| Liver Cirrhosis | R | 0.038 | 0.014 | 0.025 |
| P-value | 0.300 | 0.470 | 0.406 | |
| APACHE Score | R | -0.270 | -0.152 | -0.091 |
| P-value | 0.032* | 0.046* | 0.348 | |
| SOFA Score | R | -0.280 | -0.143 | -0.089 |
| P-value | 0.029* | 0.269 | 0.441 | |
| Continuous renal replacement therapy | R | -0.150 | 0.132 | 0.040 |
| P-value | 0.038* | 0.062 | 0.242 | |
| QT interval | R | -0.180 | -0.150 | 0.060 |
| P-value | 0.028* | 0.048* | 0.275 | |
| Duration of vasopressor therapy | R | -0.160 | -0.105 | 0.055 |
| P-value | 0.033* | 0.085 | 0.288 | |
| Mechanical ventilation | R | -0.130 | -0.150 | -0.142 |
| P-value | 0.073 | 0.038* | 0.044* | |
| ICU Length of stay | R | -0.250 | -0.156 | 0.080 |
| P-value | 0.030* | 0.030* | 0.177 | |
Using: r: spearman correlation coefficient, p-value >0.05 is insignificant; *p-value <0>
In this study, there was no significant difference between survivors and no-survivor patients regarding gender (p=0.412). However, most of the survivors aged lower than 52 years (n=24,77.42 percentage) versus non-survivors most of them aged above 52 years old (n=24,77.42 percentage), (p=0.046). Also, most of the survivors had BMI lower than 26.7 kg/m2 (n=22,70.97 percentage) versus non-survivors most of them had BMI ≥26.7 kg/m2 (n=22,70.97), (p=0.0492), (Figure 3).
Figure 3: Comparison between survivors and non-survivors as regards demographic data.
In this study, there was no significant difference between sepsis and septic shock patients regarding FT4 (p=0.164) and TSH (p=0.50). However, FT3
levels were significantly increased among sepsis patients (4.15 ± 1.92) than septic shock patients (3.52 ±2.14), (p=0.011), (Table 6).
| Sepsis (n=37) | Septic shock (n=25) | P-value | ||
| FT3 (pg/mL) | Mean ±SD | 4.15 ± 1.92 | 3.52 ± 2.14 | 0.011* |
| Range | 1.4 – 8.4 | 0.9 – 5.6 | ||
| FT4 (pg/mL) | Mean ±SD | 1.25 ± 0.68 | 0.83 ± 0.54 | 0.164 |
| Range | 0.17 – 3.0 | 0.18 – 2.0 | ||
| TSH (µIU/mL) | Mean ±SD | 1.11 ± 0.65 | 1.00 ± 0.64 | 0.500 |
| Range | 0.17 – 2.3 | 0.17 - 2.0 | ||
Table 6: Comparison of thyroid hormone levels between sepsis and septic.
The prognostic utility of thyroid hormones was further evaluated through ROC curve analysis. FT3 showed excellent predictive value for mortality (AUC: 0.886, p<0 href="file:///C:/Users/DELL/Downloads/%">percentage) and specificity (67.7 percentage). FT4 demonstrated moderate accuracy (AUC: 0.749, p=0.001), while TSH had limited diagnostic value (AUC: 0.572, p=0.331), (Table 7, Figure 4).
| Cut off | AUC | Sensitivity (percentage) | Specificity (percentage) | PPV (percentage) | NPV (percentage) | P-value | |
| FT3 | 2.55 | 0.886 | 93.5 | 67.7 | 97.2 | 80.0 | <0> |
| FT4 | 0.85 | 0.749 | 80.6 | 38.7 | 87.2 | 62.7 | 0.001** |
| TSH | 0.95 | 0.572 | 58.1 | 54.8 | 71.5 | 42.8 | 0.331 |
Table 7: ROC Curve for Thyroid hormones as a predictor of mortality.
The diagnostic performance of FT3, FT4, and TSH as predictors for mortality was evaluated using ROC curve analysis.
Figure 4: ROC Curve for Thyroid hormones as a predictor of mortality.
As complex clinical diseases with high death rates, sepsis and septic shock continue to present major problems in intensive care units (ICUs) around the world (Langouche et al., 2019). According to Arina and Singer (2021), sepsis occurs when an infection sets off a dysregulated host response that leads to extensive inflammation and organ failure. Significant circulatory, cellular, and metabolic problems accompany the progression to septic shock, which increases the chance of death. For the management and improvement of outcomes in critically sick patients, early detection of the severity of sepsis and an accurate prognosis are essential (Pérsico et al., 2021).
Thyroid hormones' important effects on immunological modulation, metabolic regulation, and cardiovascular function have drawn attention to their significance in the body's reaction to critical disease (Wang et al., 2021). Non-thyroidal illness syndrome (NTIS) is the collective term for the endocrine changes that occur in the body during severe illness, including changes in thyroid hormone levels. Thyroid-stimulating hormone (TSH) levels are frequently stable or repressed in conjunction with decreased levels of free triiodothyronine (FT3) and, in extreme situations, free thyroxine (FT4) in the blood. According to Teixeira et al. (2020), these alterations are believed to be adaptive means of preserving energy in times of extreme stress. Establishing baseline thyroid hormone levels (FT3, FT4, and TSH) in critically sick patients with sepsis and septic shock was the goal of this study to give an early evaluation of endocrine function. It also investigated the connection between thyroid hormone levels and clinical outcomes, such as
mortality rates, acute kidney injury, length of intensive care unit stays, duration of mechanical ventilation, changes in QT intervals (a measure of cardiac repolarization), and the occurrence of complications like bedsores, thromboembolism, and infections. With an average age of 52.3 years, a sample of 62 sepsis patients, virtually evenly split by gender (48.4 percentage male, 51.6 percentage female), included middle-aged to older adults. Their average body mass index (BMI) was 26.7 kg/m2, suggesting that obesity is a common condition associated with poor sepsis outcomes. The prevalence of chronic diseases such as diabetes (24.8 percentage) and hypertension (43.5 percentage) underscore the possible influence of underlying comorbidities on the development of sepsis. The fact that 40.3 percentageof the individuals had septic shock and 59.7 percentage had sepsis highlights the seriousness of the condition and the elevated risk of sequelae in this group. The study emphasized how baseline characteristics including age, weight, and chronic diseases affect sepsis outcomes, which is consistent with findings by Sun et al. (2023). Comorbid conditions such as diabetes and hypertension, together with obesity, might worsen metabolic instability and cardiovascular risks, which can affect the outcome of sepsis and septic shock. Additionally, the high percentage of septic shock (40.3 percentage) in this study is consistent with findings that highlight poor outcomes and systemic complications in intensive care unit patients.
This emphasizes how crucial it is to take metabolic and physiological indicators into account when predicting the severity and mortality of sepsis. Indicative of successful ICU respiratory treatment, blood gas analysis revealed constant respiratory function (average CO₂: 40.07 mmHg, HCO₃: 24.29 mmol/L, SPO₂: 98.62 percentage). Hematological and organ function indicators, such as leukocyte counts and creatinine levels, are crucial for determining the severity of sepsis, according to Sun et al. (2023). These results, together with the study's steady respiratory values, highlight the significance of focused intensive care unit interventions in enhancing respiratory outcomes and controlling organ stress-related problems.
Both survivors and non-survivors had their thyroid hormone levels measured at two different times (Day 0 and Day 7). There was no discernible variation in the first FT3 levels (p=0.198), However, non-survivors' FT3 levels were much greater by Day 7 (p=0.002). FT4 levels showed a similar trend, with non-survivors showing a significant increase by Day 7 (p=0.010). At both time points, the groups' TSH levels were similar. These results imply that the severity of sepsis and mortality risks may be reflected over time by dynamic variations in FT3 and FT4 levels rather than baseline values. Sun et al. (2023) and Angelousi et al. (2011) highlighted the predictive significance of thyroid hormone levels, which corroborated these findings. Poor outcomes are associated with low FT3 and FT4 levels in sepsis patients, especially in cases of severe septic shock. Additionally, Wang et al. (2021) emphasized the link between low FT4 levels and a poor prognosis, confirming the usefulness of thyroid hormones as biomarkers for critical illness.
Also, SOFA and APACHE scores offered important information about the severity of the illness. The SOFA score of 8.02 (SD ±2.89) and the mean APACHE score of 24.20 (SD ±4.44) both pointed to moderate to severe critical illness with substantial organ failure. These scores, which are frequently used to gauge the chance of survival and direct the level of intensive care unit care, were substantially linked to poorer results. In line with these findings, Sun et al. (2023) showed a strong link between higher mortality in septic shock patients and higher APACHE and SOFA scores. These results are consistent with the current study's focus on how useful these scores are for risk stratification and intervention customization.
Also, 17.7 percentage of patients in the analysis of intensive care unit interventions needed continuous renal replacement therapy (CRRT), suggesting severe renal impairment. Some patients had prolonged QT intervals (mean: 420.65 ms, SD ±42.67), which suggested that their hearts were under stress from serious disease or drugs. The length of vasopressor medication varied, indicating varying levels of circulatory instability (mean: 76.98 hours, SD ±26.90). Liu et al. (2021) documented comparable results, emphasizing the correlation between elevated vasopressor reliance in septic shock, longer ICU stays, greater SOFA scores, and low FT3 and FT4 levels. This study confirms that effective management of critical sepsis requires monitoring of cardiovascular, endocrine, and renal parameters.
There was a substantial correlation between thyroid hormone levels and clinical indicators. Higher APACHE and SOFA scores, longer ICU stays, and a greater need for CRRT and mechanical ventilation were correlations with lower FT3 and FT4 levels. Further evidence for the function of thyroid hormones as severity indicators comes from negative associations found between FT3 and age, BMI, and organ dysfunction. These associations are consistent with research by Foks et al. (2019), Sun et al. (2023), and Liu et al. (2021), which showed that lower FT3 and FT4 levels are associated with severe organ dysfunction and increased use of resources in the treatment of sepsis.
ROC curve analysis was used to further assess the prognostic value of thyroid hormones. FT3 demonstrated great sensitivity (93.5 percentage) and specificity (67.7 percentage), as well as excellent predictive value for mortality (AUC: 0.886, p<0 p=0.331), p=0.001).>Bartolović et al. (2024) found that FT3 is a reliable indicator for ICU mortality risk categorization. The results of this study confirm the significance of FT3 in directing clinical judgments for patients with critically sick sepsis, with FT4 acting as a supportive indicator. To sum up, this study emphasizes how important thyroid hormones specifically FT3 and FT4 are in determining the severity of sepsis and forecasting its course. In addition to well-known instruments like APACHE and SOFA ratings, thyroid function markers offer important information for customizing ICU treatments. Given the adaptive yet complex nature of NTIS in critical illness, more study is necessary to examine the potential of thyroid hormone supplementation in improving clinical outcomes for patients in septic shock.
The study's findings demonstrated the predictive significance of thyroid hormone levels, specifically FT3 and FT4, in critically ill patients suffering from sepsis and septic shock. A longer ICU stay, a larger need for mechanical ventilation, increased severity, and a higher risk of death were all highly correlated with lower levels of FT3 and FT4. A particularly useful marker for mortality prediction, FT3's high sensitivity, and specificity suggest that it may be useful in early identification of high-risk individuals. TSH exhibited minimal relevance in evaluating both illness severity and death, despite FT4 likewise exhibiting moderate predictive power. According to these results, tracking FT3 and FT4 levels may help with clinical decision-making and risk classification for patients with sepsis and septic shock, enabling more specialized and prompt therapies to improve outcomes in this susceptible group.
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Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.
The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.
Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.
Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.
Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”
Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner
My Testimonial Covering as fellowing: Lin-Show Chin. The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews.
My experience publishing in Psychology and Mental Health Care was exceptional. The peer review process was rigorous and constructive, with reviewers providing valuable insights that helped enhance the quality of our work. The editorial team was highly supportive and responsive, making the submission process smooth and efficient. The journal's commitment to high standards and academic rigor makes it a respected platform for quality research. I am grateful for the opportunity to publish in such a reputable journal.
My experience publishing in International Journal of Clinical Case Reports and Reviews was exceptional. I Come forth to Provide a Testimonial Covering the Peer Review Process and the editorial office for the Professional and Impartial Evaluation of the Manuscript.
I would like to offer my testimony in the support. I have received through the peer review process and support the editorial office where they are to support young authors like me, encourage them to publish their work in your esteemed journals, and globalize and share knowledge globally. I really appreciate your journal, peer review, and editorial office.
