Predictive factors of adrenal insufficiency in patients admitted to acute medical wards: a case control study.

BACKGROUND: Adrenal insufficiency is a rare and potentially lethal disease if untreated. Several clinical signs and biological markers are associated with glucocorticoid failure but the importance of these factors for diagnosing adrenal insufficiency is not known. In this study, we aimed to assess the prevalence of and the factors associated with adrenal insufficiency among patients admitted to an acute internal medicine ward. METHODS: Retrospective, case-control study including all patients with high-dose (250 μg) ACTH-stimulation tests for suspected adrenal insufficiency performed between 2008 and 2010 in an acute internal medicine ward (n = 281). Cortisol values <550 nmol/l upon ACTH-stimulation test were considered diagnostic for adrenal insufficiency. Area under the ROC curve (AROC), sensitivity, specificity, negative and positive predictive values for adrenal insufficiency were assessed for thirteen symptoms, signs and biological variables. RESULTS: 32 patients (11.4%) presented adrenal insufficiency; the others served as controls. Among all clinical and biological parameters studied, history of glucocorticoid withdrawal was the only independent factor significantly associated with patients with adrenal insufficiency (Odds Ratio: 6.71, 95% CI: 3.08 -14.62). Using a logistic regression, a model with four significant and independent variable was obtained, regrouping history of glucocorticoid withdrawal (OR 7.38, 95% CI [3.18 ; 17.11], p-value <0.001), nausea (OR 3.37, 95% CI [1.03 ; 11.00], p-value 0.044), eosinophilia (OR 17.6, 95% CI [1.02; 302.3], p-value 0.048) and hyperkalemia (OR 2.41, 95% CI [0.87; 6.69], p-value 0.092). The AROC (95% CI) was 0.75 (0.70; 0.80) for this model, with 6.3 (0.8 - 20.8) for sensitivity and 99.2 (97.1 - 99.9) for specificity. CONCLUSIONS: 11.4% of patients with suspected adrenal insufficient admitted to acute medical ward actually do present with adrenal insufficiency, defined by an abnormal response to high-dose (250 μg) ACTH-stimulation test. A history of glucocorticoid withdrawal was the strongest factor predicting the potential adrenal failure. The combination of a history of glucocorticoid withdrawal, nausea, eosinophilia and hyperkaliemia might be of interest to suspect adrenal insufficiency

Impact of smoking on fertility and age of menopause: a population-based assessment.

Studies in patients seeking medically assisted reproduction have shown that smoking reduces fertility, but little information is available in the general population. We assessed the associations between smoking and the number of children, childbearing planning and age at menopause in a representative sample of the population of Lausanne, Switzerland. Data from 6711 participants (3530 women, age range 35-75 years) collected between 2003 and 2006 and again in 2009 and 2012. Smoking status, number of offsprings and age of menopause were assessed. Women who currently smoke had significantly less children than former or never smokers: the number of children per women (average±SD) was 1.38±1.05, 1.45±1.07 and 1.576±1.16, respectively (p<0.001). Women who currently smoke had their first child at an earlier age than the others: 26.7±5.2, 27.4±5.4 and 26.9±5.2 years old for current, former and never smokers, respectively, (p=0.01). Similar findings were found for men: number of children per men 1.475±1.16, 1.67±1.13 and 1.55±1.22 for current, former and never smokers, respectively (p<0.001); no difference was found regarding age at the first child. The difference persisted after multivariate adjustment (adjusted for age, body mass index, Caucasian origins, alcohol consumption, caffeinated drinks consumption, educational level, receiving social help and women taking contraceptives) for the age at first child among women. No association was found between Heaviness of Smoking Index and the number of children among current smokers in both genders. Women who smoke had their menopause more than 1 year prior than never-smoking women (48.9±0.2 years compared with 47.8±0.3 years, respectively, p=0.002). Smoking is associated with an earlier age of having the first child and of menopause among women

Conceptualizing resilience in engineering systems: An analysis of the literature

It is now widely recognized that many important events in the life cycle of complex engineering systems cannot be foreseen in advance. From its origin in ecological systems, operating without the use of foresight, resilience theory prescribes presuming ignorance about the future, and designing systems to manage unexpected events in whatever form they may take. However, much confusion remains as to what constitutes a resilient system and the implications for engineering systems. Taking steps toward a synthesis across a fragmented body of research, this paper analyses 251 definitions in the resilience literature, aiming to clarify key distinctions in the resilience concept. Asking resilience of what, to what, and how, we first distinguish systems serving higher ends and systems that are ends in themselves, and, within these, performance variables to be minimized, preserved, or maximized. Second, we distinguish systems subject to adverse events, adverse change, turbulence, favorable events, favorable change, and variation. Finally, we distinguish systems capable of recovery, absorption, improvement, graceful degradation, minimal deterioration, and survival. Together, these distinctions outline a morphology of resilient systems and suggest answers to the principal design questions, which must be asked of any resilient engineering system