Acute Disease

Importance: Adrenal insufficiency is a syndrome of cortisol deficiency and is categorized as primary, secondary, or glucocorticoid induced. Although primary and secondary adrenal insufficiency are rare, affecting less than 279 per 1 million individuals, glucocorticoid-induced adrenal insufficiency is common.

Observations: Primary adrenal insufficiency, which involves deficiency of all adrenocortical hormones, is caused by autoimmune destruction, congenital adrenal hyperplasia, pharmacological inhibition (eg, high doses of azole antifungal therapy), infection (eg, tuberculosis, fungal infections), or surgical removal of adrenal cortical tissue. Secondary adrenal insufficiency is caused by disorders affecting the pituitary gland, such as tumors, hemorrhage, inflammatory or infiltrative conditions (eg, hypophysitis, sarcoidosis, hemochromatosis), surgery, radiation therapy, or medications that suppress corticotropin production, such as opioids. Glucocorticoid-induced adrenal insufficiency is caused by administration of supraphysiological doses of glucocorticoids. Patients with adrenal insufficiency typically present with nonspecific symptoms, including fatigue (50%-95%), nausea and vomiting (20%-62%), and anorexia and weight loss (43%-73%). Glucocorticoid-induced adrenal insufficiency should be suspected in patients who have recently tapered or discontinued a supraphysiological dose of glucocorticoids. Early-morning (approximately 8 am) measurements of serum cortisol, corticotropin, and dehydroepiandrosterone sulfate (DHEAS) are used to diagnose adrenal insufficiency. Primary adrenal insufficiency is typically characterized by low morning cortisol levels (<5 µg/dL), high corticotropin levels, and low DHEAS levels. Patients with secondary and glucocorticoid-induced adrenal insufficiency typically have low or intermediate morning cortisol levels (5-10 µg/dL) and low or low-normal corticotropin and DHEAS levels. Patients with intermediate early-morning cortisol levels should undergo repeat early-morning cortisol testing or corticotropin stimulation testing (measurement of cortisol before and 60 minutes after administration of cosyntropin, 250 µg). Treatment of adrenal insufficiency involves supplemental glucocorticoids (eg, hydrocortisone, 15-25 mg daily, or prednisone, 3-5 mg daily). Mineralocorticoids (eg, fludrocortisone, 0.05-0.3 mg daily) should be added for patients with primary adrenal insufficiency. Adrenal crisis, a syndrome that can cause hypotension and shock, hyponatremia, altered mental status, and death if untreated, can occur in patients with adrenal insufficiency who have inadequate glucocorticoid therapy, acute illness, and physical stress. Therefore, all patients with adrenal insufficiency should be instructed how to increase glucocorticoids during acute illness and prescribed injectable glucocorticoids (eg, hydrocortisone, 100 mg intramuscular injection) to prevent or treat adrenal crisis.

Conclusions and relevance: Although primary and secondary adrenal insufficiency are rare, glucocorticoid-induced adrenal insufficiency is a common condition. Diagnosis of adrenal insufficiency involves early-morning measurement of cortisol, corticotropin, and DHEAS. All patients with adrenal insufficiency should be treated with glucocorticoids and instructed how to prevent and treat adrenal crisis.

Author/s:

Anand Vaidya, James Findling, Irina Bancos

Prevention, Diagnosis, and Treatment of Acute Altitude Illness

Erin Blanchette — Mon, 28 Oct 2024 14:13:06 +0000

Date Added:

October 28, 2024

Journal/Publication:

JAMA

Publisher:

American Medical Association

Publication Date:

October 24, 2024

URL:

Prevention, Diagnosis, and Treatment of Acute Altitude Illness

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2024.19562

Keywords

Acute Altitude Illness

Altitude Illness

Altitude sickness

PMID (1):

39446318

MeSH

Pulmonary edema of mountaineers

A summary of recommended measures to prevent and treat altitude sickness. James W. Mold, MD, MPH

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People traveling to high altitude are at risk of developing acute altitude illnesses, including AMS, HACE, and HAPE. Incidence and risk are assessed by history of acute altitude illness, sleeping elevation above sea level on day 1 of travel, and rate of ascent. AMS incidence can range from approximately 3% in persons traveling to 2000 m (6561 ft) to 25% to 40% at altitudes above 4300 m (14 107 ft), with symptoms varying from mild to marked.3 While rare, HACE and HAPE are potentially life-threatening if untreated.

Author/s:

Mia Derstine, Elan Small, Andrew M Davis

Syncope and the Risk of Subsequent Motor Vehicle Crash A Population-Based Retrospective Cohort Study

Aubrey Delammermore — Thu, 08 Sep 2022 05:00:00 +0000

Date Added:

September 8, 2022

Journal/Publication:

JAMA Internal Medicine

Publisher:

JAMA

Publication Date:

September 1, 2022

Issue:

Volume:

182

Pages:

934-942

URL:

Syncope and the Risk of Subsequent Motor Vehicle Crash A Population-Based Retrospective Cohort Study

Type:

Clinical Research Results

DOI (1):

10.1001/jamainternmed.2022.2865

Keywords

middle aged

Retrospective Studies

middle aged

motor vehicle accidents

Medical driving restrictions

PMID (1):

35913711

MeSH

Accidents

Traffic

Acute Disease

Syncope* / epidemiology

Canada / epidemiology

Motor Vehicles

This retrospective study found no increase in motor vehicle accidents in patients presenting to the ER with their first episode of syncope.

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Importance Medical driving restrictions are burdensome, yet syncope recurrence while driving can cause a motor vehicle crash (MVC). Few empirical data inform current driving restrictions after syncope.

Objective To examine MVC risk among patients visiting the emergency department (ED) after first-episode syncope.

Design, Setting, and Participants A population-based, retrospective observational cohort study of MVC risk after first-episode syncope was performed in British Columbia, Canada. Patients visiting any of 6 urban EDs for syncope and collapse were age- and sex-matched to 4 control patients visiting the same ED in the same month for a condition other than syncope. Patients’ ED medical records were linked to administrative health records, driving history, and detailed crash reports. Crash-free survival among individuals with syncope was then compared with that among matched control patients. Data analyses were performed from May 2020 to March 2022.

Exposures Initial ED visit for syncope.

Main Outcomes and Measures Involvement as a driver in an MVC in the year following the index ED visit. Crashes were identified using insurance claim data and police crash reports.

Results The study cohort included 43 589 patients (9223 patients with syncope and 34 366 controls; median [IQR] age, 54 [35-72] years; 22 360 [51.3%] women; 5033 [11.5%] rural residents). At baseline, crude MVC incidence rates among both the syncope and control groups were higher than among the general population (12.2, 13.2, and 8.2 crashes per 100 driver-years, respectively). In the year following index ED visit, 846 first crashes occurred in the syncope group and 3457 first crashes occurred in the control group, indicating no significant difference in subsequent MVC risk (9.2% vs 10.1%; adjusted hazard ratio [aHR], 0.93; 95% CI, 0.87-1.01; P = .07). Subsequent crash risk among patients with syncope was not significantly increased in the first 30 days after index ED visit (aHR, 1.07; 95% CI, 0.84-1.36; P = .56) or among subgroups at higher risk of adverse events after syncope (eg, age >65 years; cardiogenic syncope; Canadian Syncope Risk Score ≥1).

Conclusions and Relevance The findings of this population-based retrospective cohort study suggest that patients visiting the ED with first-episode syncope exhibit a subsequent crash risk no different than the average ED patient. More stringent driving restrictions after syncope may not be warranted.

Author/s:

Staples, J. A., Erdelyi, S., Merchant, K., Yip, C., Khan, M., Redelmeier, D. A., Chan, H., Brubacher, J. R.