The hepatoadrenal syndrome: A common yet unrecognized clinical condition

Objective: Adrenal failure is common in critically ill patients, particularly those with sepsis. As liver failure and sepsis are both associated with increased circulating levels of endotoxin and proinflammatory mediators and reduced levels of apoprotein-1/ high-density lipoprotein, we postulated that adrenal failure may be common in patients with liver disease. Design: Clinical study. Setting: Liver transplant intensive care unit. Patients: The study cohort included 340 patients with liver disease. Interventions: Based on preliminary observational data, all patients admitted to our 28-bed liver transplant intensive care unit (LTICU) undergo adrenal function testing. An honest broker system was used to extract clinical, hemodynamic, medication, and laboratory data on patients admitted to the LTICU from March 2002 to March 2004. A random (stress) cortisol level <20 μg/dL in a highly stressed patient (respiratory failure, hypotension) was used to diagnose adrenal insufficiency. In all other patients, a random cortisol level <15 μg/dL or a 30-min level <20 μg/dL post-low-dose (1 μg) cosyntropin was considered diagnostic of adrenal insufficiency. Patients were grouped as follows: a) chronic liver failure; b) fulminant hepatic failure; c) patients immediately status post-orthotopic liver transplantation receiving a steroid-free protocol of immunosuppression; and d) patients status post-remote liver transplant (≥6 months). The decision to treat patients with stress doses of hydrocortisone was at the discretion of the treating intensivist and transplant surgeon. Measurements and Main Results: Two-hundred and forty-five (72%) patients met our criteria for adrenal insufficiency (the hepatoadrenal syndrome). Eight (33%) patients with fulminant hepatic failure, 97 (66%) patients with chronic liver disease, 31(61%) patients with a remote history of liver transplantation, and 109 (92%) patients who had undergone liver transplantation under steroid-free immunosuppression were diagnosed with adrenal insufficiency. The high-density lipoprotein level at the time of adrenal testing was the only variable predictive of adrenal insufficiency (p < .0001). In vasopressor-dependent patients with adrenal insufficiency, treatment with hydrocortisone was associated with a significant reduction (p = .02) in the dose of norepinephrine at 24 hrs, whereas the dose of norepinephrine was significantly higher (p = .04) in those patients with adrenal failure not treated with hydrocortisone. In vasopressor-dependent patients without adrenal insufficiency, treatment with hydrocortisone did not affect vasopressor dose at 24 hrs. One hundred and forty-one patients (26.4%) died during their hospitalization. The baseline serum cortisol was 18.8 ± 16.2 μg/dL in the nonsurvivors compared with 13.0 ± 11.8 μg/dL in the survivors (p < .001). Of those patients with adrenal failure who were treated with glucocorticoids, the mortality rate was 26% compared with 46% (p = .002) in those who were not treated. In those patients receiving vasopressor agents at the time of adrenal testing, the baseline cortisol was 10.0 ± 4.8 μg/dL in those with adrenal insufficiency compared with 35.6 ± 21.2 μg/dL in those with normal adrenal function. Vasopressor-dependent patients who did not have adrenal failure had a mortality rate of 75%. Conclusions: Patients with liver failure and patients post-liver transplantation have an exceedingly high incidence of adrenal failure, which may be pathophysiologically related to low levels of high-density lipoprotein. Treatment of patients with adrenal failure may improve outcome. High baseline serum cortisol levels may be a maker of disease severity and portend a poor prognosis. Copyright © 2005 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins

Cohen and Milstein Strategic Analysis

Cohen Milstein is a medium-sized law firm operating out of six U.S. cities. It is a boutique-style firm specializing in niche areas of law and litigates higher-profile cases other firms avoid. This paper will examine Cohen and Milstein to understand its market position and competitiveness within the legal industry. The legal industry provides a unique set of challenges to firms as technology advances, new laws are imposed, and customer relationships evolve. To explore Cohen and Milstein, I will employ various tools, including Porter’s Five Forces, PESTEL, and SWOT analyses. Following the firm\u27s evaluation through these metrics, strategic recommendations will be provided for Cohen and Milstein

De l’ostinato au pastiche : approche comparée du comique de répétition en poésie et en musique au XXe siècle

De l’ostinato au pastiche, la production poétique et musicale du XXe siècle met en oeuvre divers procédés comiques fonctionnant sur des techniques de répétition qu’une approche comparatiste permet d’appréhender. L’élaboration d’une typologie qui prenne en compte, dans leur articulation chaque fois neuve, techniques de répétition, nature du comique engendré, enjeux formels et esthétiques qui en découlent, est à la fois nécessaire et utopique. Utopique en raison du nombre excessif de critères à considérer ; nécessaire parce que ces procédés offrent à l’analyste matière rêvée pour saisir quelques-unes des similarités de fonctionnement qui légitiment la comparaison entre langage poétique et langage musical.With ostinato, parody and pastiche, poetry and music of the 20th century use various comic processes based on repetition, that can be analysed in a comparative way. The elaboration of a typology that takes into account the different techniques of repetition, the nature of comical effects, the formal and aesthetic aspects, is both necessary and impossible. Impossible because of the myriad criteria that must be taken into consideration; necessary, because these processes help the analyst understand the similarities that legitimate the comparison between poetic and musical languages

Scouts BSA Wood Badge Through the Lens of Senge’s Disciplines of a Learning Organization

This qualitative case study used researcher participation, participant surveys and participant interviews to explore the presence of the five disciplines of Senge’s learning organization in the training of adult volunteer leaders in Scouts BSA’s Wood Badge in 2021. It also examined how the prevalence of Senge’s five disciplines affected Scouters’ perceptions of Wood Badge training.The study included survey results from 30 participants and interviews with four participants at Northern Star Council’s Wood Badge course in 2021. Findings indicated that all five of Senge’s disciplines were present in Scouts BSA’s Wood Badge course. The study confirmed that Scouts BSA is a learning organization

Assessment of Total Suspended Solids and Total Phosphorus Removal by Wetlands and Best Management Practices in Lincoln, Nebraska

The availability and quality of local surface and ground water, as well as water in the world’s oceans is essential to all. Urbanization brings with it changes in landscape that decreases soils capacity for infiltration of rain, and increase contaminants found in runoff conveyed to surface waters including oceans. Stormwater runoff occurs with small to large size rain events, flowing over a diverse range of impermeable surfaces removing and carrying with it total suspended solids (TSS) and total phosphorus (TP). For these reasons, best management practices (BMPs) were developed, and integrated into existing and future development. The objective is to identify what forms of wetlands and BMPs are used in Lincoln, Nebraska for stormwater management; assessing effectiveness in treatment of stormwater runoff. This assessment will examine the use of BMPs in preventing or reducing runoff by increasing infiltration of rainwater into soil, and investigate the efficiency of wetlands and BMPs in removing TSS and TP. Finally, it will evaluate the influence of flow rate on the effectiveness of wetlands and BMPs water adsorption rate

Interval - mtype Oscillation Criteria for Half - Linear PDE with Damping

Using the Riccati substitution we derive new sufficient conditions which ensure that the half-linear partial differential equation with p-Laplacian and damping in the form of Equation (E) in the paper is oscillatory. These criteria, called interval criteria in theory of ODE\u27s, allow to eliminate “bad parts” of the potential function c(x) from our considerations. Some of the results are new even in the case when (E) becomes linear ordinary differential equation