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To the Editor: We have several concerns about the study of Dr Annane and colleagues.¹ First, the sample size calculations were based on a prior study involving 32 patients with septic shock, of whom 13 patients (100%) with a poor response died.² The power of the current study was dependent on the consideration that mortality in nonresponders is really 100%, or 95% as used in the study. It would have been better to determine the sample size after the first interim analysis; at that time mortality rates and treatment effects were more clear and offered the opportunity of a sequential study design.

Second, diagnostic criteria for relative adrenal insufficiency syndrome remain poorly defined.³ Cortisol levels in intensive care patients appear to be increased.⁴ There may be a relationship between high cortisol levels, blunted response to a corticotropin stimulation test, and increased mortality rate. But the question to consider is whether . . . [Full Text of this Article]

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