Adrenal crises: perspectives and research directions

Adrenal crises (AC) are life-threatening complications of adrenal insufficiency (AI). These events have an estimated incidence of between 5 and 10 ACs/100 patient years (PY) and are responsible for some of the increased morbidity and excess mortality experienced by patients with AI. Treatment involves urgent administration of IV/IM hydrocortisone and IV fluids. Patient education regarding preventive measures, such as increasing the dose of replacement therapy (“stress dosing”) when sick, using parenteral hydrocortisone as necessary and accessing medical assistance promptly, is still considered the best approach to averting the onset of an AC at times of physiological stress, most commonly an infection. However, recent evidence has demonstrated that patient education does not prevent many AC events and the reasons for this are not fully understood. Furthermore, there is no widely accepted definition of AC. Without a validated AC definition it is difficult to interpret variations in the incidence of AC and determine the effectiveness of preventive measures. This article aims to review the clinical aspects of AC events; to explore the epidemiology; and to offer a definition for an AC and to offer a perspective on future directions for research into AC prevention

Adrenal Crisis

Glucocorticoid replacement therapy, available since the 1950s, has prolonged the survival of patients with adrenal insufficiency. However, adrenal crises, which are life-threatening medical emergencies, still develop in many affected patients. Adrenal crisis appears to be increasing in frequency, despite the availability of effective preventive strategies. This review examines the definitions, pathophysiology, epidemiology, and treatment of adrenal crises

Sacred and Mortuary Landscapes in Iron Age Cyprus: A GIS Analysis

During the Archaic period (750-480 BC) the island of Cyprus underwent a dramatic transformation as new city-kingdoms rose to dominate the political landscape of the island. This shift resulted in increased competition for resources, establishment of political boundaries, and emergence of a pronounced social hierarchy within the new polities. While many of the large settlements that became centers of power during this time have been thoroughly studied, the manifestation of the large scale changes of the Archaic in the periphery have not been as fully investigated. The rural site of Athienou-Malloura, surveyed and excavated by the Athienou Archaeological Project includes a Cypro-Archaic sanctuary and nearby tombs on the hill of Maghara-Tepesi, four of which have been excavated. The present study compares the site of Athienou-Malloura to other comparable sites from around the island, in order to ascertain the distribution and role of rural sanctuaries and cemeteries during this period of increasing social complexity and political competition. The sites are compared to locations of the city-kingdoms, as well as access to natural resources such as arable soil and copper ore. It has been proposed both on Cyprus and elsewhere that grave monuments and religious sites partly functioned to create and enforce claims during turbulent growth periods. Building from more abstract speculations on Archaic Cypriot political boundaries, this study attempts to map a more nuanced view of the interplay between topography and human use of the landscape during this time

Adrenal insufficiency due to bilateral adrenal metastases - A systematic review and meta-analysis

Objective: Bilateral adrenal metastases may cause adrenal insufficiency (AI) but it is unclear if screening for AI in patients with bilateral adrenal metastases is justified, despite the potential for adrenal crises. Method: A search using PubMed/Medline, ScienceDirect and Cochrane Reviews was performed to collect all original research articles and all case reports from the past 50 years that describe AI in bilateral adrenal metastases. Results: Twenty studies were included with 6 original research articles, 13 case reports and one case series. The quality was generally poor. The prevalence of AI was 3–8%. Of all cases of AI (n ¼ 25) the mean pooled baseline cortisol was 318 237 nmol/L and stimulated 423 238 nmol/L. Hypotension was present in 69%, hyponatremia in 9% and hyperkalemia in 100%. Lung cancer was the cause in 35%, colorectal 20%, breast cancer 15% and lymphoma 10%. The size of the adrenal metastases was 5.5 2.8 cm (left) and 5.5 3.1 cm (right), respectively. There was no correlation between basal cortisol, stimulated cortisol concentration or ACTH with the size of adrenal metastases. The median time to death was 5.0 months (IQR 0.6–6.5). However, two cases were alive after 12–24 months. Conclusion: The prevalence of AI in patients with bilateral adrenal metastases was low. Prognosis was very poor. Due to the low prevalence of AI, screening is likely only indicated in patients with symptoms and signs suggestive of hypocortisolism

Pre-hospital management of acute Addison’s Disease – Audit of patients attending a referral hospital in a regional area

Context: Adrenal crises (AC) cause morbidity and mortality in patients with Addison’s disease [primary adrenal insufficiency (PAI)]. Patient-initiated oral stress dosing, with parenteral hydrocortisone, is recommended to avert ACs. While these should be effective, the continued incidence of ACs remains largely unexplained. Methods: Audit of all attendances between 2000 and 2017 by adult patients with treated PAI to one large regional referral centre in New South Wales, Australia. Measurements were those taken on arrival at hospital. Results: There were 252 attendances by 56 patients with treated PAI during the study period. Women comprised 60.7% (n=34) of the patients. The mean age of attendees was 53.7 (19.6) years. Nearly half (45.2%, n=114) the patients had an infection. There were 61 (24.2%) ACs diagnosed by the treating clinician. Only 17.9% (n=45) of the hospital presentations followed any form of stress dosing. IM hydrocortisone was used before 7 (2.8%) attendances only. Among patients with a clinician diagnosed AC, only 32.8% (n=20) had used stress dosing before presentation. Vomiting was reported by 47.6% (n=120) of the patients but only 33 (27.5%) of these attempted stress dosing and 5 patients with vomiting used IM hydrocortisone. The number of prior presentations was a significant independent predictor of use of stress doses [1.05 (1.01,1.09)]. Conclusion: Dose escalation strategies are not used universally or correctly by unwell patients with PAI, many patients do not use IM or SC hydrocortisone injections. Previous hospital treatment increases the likelihood of stress dosing and offers the opportunity for reinforcement of prevention strategies

Farmer v. City of Fort Lauderdale, 427 So. 2d 187 (Fla. 1983)

Labor Law-POLICE OFFICER MAY NOT PROPERLY BE DISMISSED FOR REFUSAL TO SUBMIT TO A POLYGRAPH EXAMINATIO

Indoor air pollutants in occupational buildings in a sub-tropical climate: Comparison among ventilation types

© 2016 Elsevier Ltd. Few studies have concurrently assessed both abiotic and biotic air pollutants in the built environment in sub-tropical areas. The investigation comprised a field study of air pollutants in eleven indoor environments in Sydney throughout one year, to elucidate Indoor/Outdoor ratios of carbon dioxide, carbon monoxide, total volatile organic compounds, nitric oxide, nitrogen dioxide, sulfur dioxide, total suspended particulate matter, suspended particles <10 μm in diameter (PM10) and particulate matter <2.5 μm (PM2.5). Further, a concurrent assessment of airborne fungi was conducted along with the other air pollutants to determine their diversity and abundance for urban Sydney and to establish baseline Indoor/Outdoor ratios of airborne fungi. Building ventilation types were identified as natural, mechanical and mixed-type ventilation, to assess whether building ventilation type has an impact on prevalence and concentrations of indoor air pollutants. We found that generally the indoor air quality of a typical Australian office building is relatively good. The ventilation type of the buildings did affect indoor air quality; however not to the extent that occupant health was at risk in any case. Low concentrations of airborne fungi were encountered in samples, across all buildings and months, with naturally ventilated buildings having higher concentrations. Buildings with high airborne fungal concentrations also supported higher diversity of fungal species. Few organisms of concern to public health were identified. Significant differences were observed when comparing the structure of airborne fungal communities across building types, with buildings with centralised mechanical (air conditioning) systems harbouring different communities to the other ventilation types