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To the Editor: Dr Annane and colleagues¹ found that corticosteroids reduced the risk of mortality in septic shock only among patients who did not respond to a corticotropin stimulation test. Some of these "nonresponders" had a baseline cortisol of less than 34 µg/dL with an increase of less than 9 µg/dL, and thus many of those may have had absolute adrenal deficiency. Such patients have a high risk of mortality² and it may be inappropriate to randomize them to receive placebo. It would also be of interest to know how many of the nonresponders in this study had absolute adrenal deficiency and the effect of removing such patients from the analysis.

Julian M. Brown, MB, ChB
Department of Anaesthesia
Frenchay Hospital
Bristol, England

1. Annane D, Sebille V, Charpentier C, et al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA. 2002;288:862-871. FREE FULL TEXT 2. Soni A, Pepper GM, Wyrwinski PM, et al. Adrenal insufficiency occurring during septic shock: incidence, outcome, and relationship to peripheral cytokine levels. Am J Med. 1995;98:266-271. FULL TEXT | WEB OF SCIENCE | PUBMED

Letters Section Editor: Stephen J. Lurie, MD, PhD, Senior Editor.

JAMA. 2003;289:41.

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