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On the Diagnosis of Adrenal Insufficiency in Severe Sepsis and Septic Shock

I read the recent article of Annane and coworkers with much interest (1). They are to be congratulated for attempting a difficult study of the use of the overnight metapyrone stimulation test for adrenal insufficiency in critically ill patients. However, I was confused by some aspects of their discussion of the accuracy of cortisol levels in identifying subjects with adrenal insufficiency. Specifically, the results in Table 4 may be misleading and perhaps mislabeled. These results state that a basal total cortisol concentration less than 10 µg/dl or a delta less than or equal to 9 µg/dl has a sensitivity of 0.45, specificity of 0.96, positive predictive value of 0.94, and a negative predictive value of 0.96 for adrenal insufficiency. It seems inconsistent to report a very high negative predictive value for a test with only 0.45 sensitivity.

Using their data in Figure 2A, I estimate the negative predictive value for the same cortisol cutoff values to be 0.52. I used the formulas as described by Sackett and coworkers (2). I believe the discrepancy has occurred because some of the results in Table 4 actually refer to diagnostic tests of cutoff values of a total cortisol level less than 44 µg/dl and a delta less than or equal to 16.8 µg/dl as is mentioned in the text on page 1323 and in Figure 3. I would ask the authors for clarification. I believe that the results in Table 4, as presented, contradict their suggested algorithm in Figure 3.

John R. Spurzem

University of Mississippi Medical Center, Jackson, Mississippi

FOOTNOTES

Conflict of Interest Statement: J.R.S. does not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript.

REFERENCES

1. Annane D, Maxime V, Ibrahim F, Alvarez JC, Abe E, Boudou P. Diagnosis of adrenal insufficiency in severe sepsis and septic shock. Am J Respir Crit Care Med 2006;174:1319–1326.[Abstract/Free Full Text]
2. Sackett DL, Haynes RB, Tugwell P. Clinical epidemiology: a basic science for clinical medicine. Boston: Little Brown and Company; 1985.

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