Outcomes of surgery for benign and malignant adrenal disease from the British Association of Endocrine and Thyroid Surgeons' national registry.

BACKGROUND: This study investigated the indications, procedures and outcomes for adrenal surgery from the UK Registry of Endocrine and Thyroid Surgery database from 2005 to 2017, and compared outcomes between benign and malignant disease. METHODS: Data on adrenalectomies were extracted from a national surgeon-reported registry. Preoperative diagnosis, surgical technique, length of hospital stay, morbidity and in-hospital mortality were examined. RESULTS: Some 3994 adrenalectomies were registered among patients with a median age of 54 (i.q.r. 43-65) years (55·9 per cent female). Surgery was performed for benign disease in 81·5 per cent. Tumour size was significantly greater in malignant disease: 60 (i.q.r. 34-100) versus 40 (24-55) mm (P < 0·001). A minimally invasive approach was employed in 90·2 per cent of operations for benign disease and 48·2 per cent for cancer (P < 0·001). The conversion rate was 3·5-fold higher in malignant disease (17·3 versus 4·7 per cent; P < 0·001). The length of hospital stay was 3 (i.q.r. 2-5) days for benign disease and 5 (3-8) days for malignant disease (P < 0·050). In multivariable analysis, risk factors for morbidity were malignant disease (odds ratio (OR) 1·69, 1·22 to 2·36; P = 0·002), tumour size larger than 60 mm (OR 1·43, 1·04 to 1·98; P = 0·028) and conversion to open surgery (OR 3·48, 2·16 to 5·61; P < 0·001). The in-hospital mortality rate was below 0·5 per cent overall, but significantly higher in the setting of malignant disease (1·2 versus 0·2 per cent; P < 0·001). Malignant disease (OR 4·88, 1·17 to 20·34; P = 0·029) and tumour size (OR 7·47, 1·52 to 39·61; P = 0·014) were independently associated with mortality in multivariable analysis. CONCLUSION: Adrenalectomy is a safe procedure but the higher incidence of open surgery for malignant disease appears to influence postoperative outcomes.

ANTECEDENTES: Este estudio investigó las indicaciones, procedimientos y resultados de la cirugía de la glándula suprarrenal a partir de la base de datos de la UKRETS desde 2005-2017 y comparó los resultados entre enfermedad benigna y maligna. MÉTODOS: Se examinó un registro nacional con datos notificados por cirujanos que incluye 3.994 suprarrenalectomías; 57% mujeres, mediana de edad 53 (8-88 años). Se evaluaron el diagnóstico preoperatorio, la técnica quirúrgica, la duración de la estancia hospitalaria, la morbilidad y la mortalidad hospitalaria. RESULTADOS: En el 82% de los casos la cirugía se realizó por enfermedad benigna. El tamaño del tumor fue significativamente mayor en la enfermedad maligna: 60 mm (34-100 mm) versus 40 mm (24-55 mm), P < 0,001. Se utilizó un abordaje mínimamente invasivo en el 90% de los casos de enfermedad benigna y en el 48% de las operaciones por cáncer (P < 0,001). La tasa de conversión fue 3,5 veces más alta en la enfermedad maligna (17% versus 4,9%, P < 0,001). La duración de la estancia fue 3 días (rango intercuartílico, interquartile range, IQR 2-5) para la enfermedad benigna y 5 (IQR 3-8) días para la enfermedad maligna (P < 0,05). En el análisis multivariable, los factores de riesgo para la morbilidad fueron: enfermedad maligna (razón de oportunidades, odds ratio, OR 1,64, 1,217-2,359; P = 0,002), tamaño del tumor (OR 1,433, 1.040-1,967; P = 0,028) y conversión a cirugía abierta (OR 3,483, 2,160-5,612; P < 0,0001). La mortalidad hospitalaria global fue baja (< 0,5%) pero significativamente mayor en el escenario de la enfermedad maligna (1,2% versus 0,2%, P < 0,001). La enfermedad maligna (OR 4,881, 1,171-20,343; P = 0,029) y el tamaño del tumor (OR 7,474, 1,515-39,610; P = 0,014) se asociaron de forma independiente con la mortalidad en el análisis multivariable. CONCLUSIÓN: La suprarrenalectomía es un procedimiento seguro, pero la mayor incidencia de cirugía abierta para la enfermedad maligna parece tener un impacto sobre los resultados postoperatorios.

WNT signaling, the development of the sympathoadrenal-paraganglionic system and neuroblastoma.

Neuroblastoma (NB) is a tumor of the sympathoadrenal system arising in children under 15 years of age. In Germany, NB accounts for 7% of childhood cancer cases, but 11% of cancer deaths. It originates from highly migratory progenitor cells that leave the dorsal neural tube and contribute neurons and glial cells to sympathetic ganglia, and chromaffin and supportive cells to the adrenal medulla and paraganglia. Clinically, histologically and molecularly, NBs present as extremely heterogeneous, ranging from very good to very poor prognosis. The etiology of NB still remains unclear and needs to be elucidated, however, aberrant auto- and paracrine embryonic cell communications seem to be likely candidates to initiate or facilitate the emergence, progression and regression of NB. The wingless-type MMTV integration site (WNT) family of proteins represents an evolutionary highly conserved signaling system that orchestrates embryogenesis. At least 19 ligands in the human, numerous receptors and co-receptors are known, which control not only proliferation, but also cell polarity, migration and differentiation. Here we seek to interconnect aspects of WNT signaling with sympathoadrenal and paraganglionic development to define new WNT signaling cues in the etiology and progression of NB.

Risk factors for complications after adrenalectomy: results from a comprehensive national database.

PURPOSE: Most knowledge regarding outcome after adrenal surgery stems from retrospective studies reported by highly specialized centres. The aim of this study was to report a national experience of adrenalectomy with particular attention to predictive factors for postoperative complications, conversion from endoscopic to open surgery and length of hospital stay. METHODS: Adrenalectomies reported in the Scandinavian Quality Register for Thyroid, Parathyroid and Adrenal Surgery (SQRTPA) 2009-2014 were included. Risk factors for complications, conversion and hospital stay >3 days were assessed using univariable and multivariable logistic regression analysis. RESULTS: There were 659 operations. Endoscopic adrenalectomy was performed in 513 (77.8%) operations and almost half of these were robotic assisted. The median length of hospital stay was 3 (range 1-30) days. There was no 30-day mortality. In 43 (6.6%) patients, at least one complication was registered. The only factor associated with complications in multivariable analysis was conversion to open surgery odds ratio (OR) 3.61 (95% confidence interval 1.07 to 12.12). The risk for conversion was associated with tumour size OR 1.03 (1.00 to 1.06) and with malignancy on histopathology OR 8.33 (2.12 to 32.07). Length of hospital stay increased in patients with operation of bilateral tumours OR 3.13, left-sided tumours OR 1.98, hyper secretion of catecholamines OR 2.32, conversion to open surgery OR 42.05 and open surgery OR 115.18. CONCLUSIONS: The present study shows that endoscopic surgery is widely used. Complications were associated with conversion and the risk for conversion was associated with tumour size and malignant tumour. Hospital stay was short.

High serum levels of free cortisol indicate severity of cirrhosis in hemodynamically stable patients.

BACKGROUND AND AIM: We investigated: (i) the association between severity of cirrhosis and serum levels of free cortisol (SFC) and total cortisol (STC), measured before and 30 min after (T(30)) the low-dose 1-µg short synacthen test (LD-SST); and (ii) the prognostic value of SFC and STC. METHODS: Consecutive, hemodynamically stable, cirrhotic patients (34 Child-Pugh class A, 29B, and 32C) underwent the LD-SST. Patients were followed for at least 12 months to assess non-transplant-related mortality. RESULTS: Child-Pugh class C patients had significantly higher basal levels of SFC than Child-Pugh class A or B patients. Prevalence of suspected adrenal dysfunction ranged between 7.4% (T(0) STC < 138 nmol/L) and 49.4% (change in STC < 250 nmol/L) according to the threshold used. In receiver-operator curve analysis, the area-under-the-curve values were 0.67 for T(30) SFC (0.51-0.79), 0.81 for Child-Pugh score (0.70-0.88), and 0.79 for albumin level (0.63-0.88). During the follow-up period, 16 patients with high T(30) SFC (≥ 78.9 nmol/L) (26.2%) and one patient with low T(30) SFC (< 78.9 nmol/L) (3.4%) died (P = 0.027 for high vs low T(30) SFC, log-rank test). Albeit not statistically significant, the risk of death for patients with T(30) SFC ≥ 78.9 nmol/L was fivefold higher than for patients with lower levels after adjusting for cirrhosis severity and level of albumin. CONCLUSIONS: One-year, non-transplant-related mortality is high among patients with T(30) levels of SFC ≥ 78.9 nmol/L (26.2%). These findings might result from latent inflammatory stress in hemodynamically stable cirrhotic patients, detected by adrenal testing.

Is same-day discharge associated with increased 30-day postoperative complications and readmissions in patients undergoing laparoscopic adrenalectomy?

BACKGROUND: Advances in minimally invasive surgery and perioperative care have decreased substantially the duration of time that patients spend recovering in hospital, with many laparoscopic procedures now being performed on an ambulatory basis. There are limited studies, however, on same-day discharge after laparoscopic adrenalectomy. The objectives of this study were to investigate the outcomes and trends of ambulatory laparoscopic adrenalectomy in a multicenter cohort of patients. METHODS: Adult patients who underwent elective laparoscopic adrenalectomy between 2005 and 2016 were identified in the database of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). Baseline demographics and 30-day outcomes were compared between patients who underwent ambulatory laparoscopic adrenalectomy and those who were discharged after an inpatient stay. Multivariable logistic regression and Cox proportional hazards modelling were used to investigate the association between same-day discharge and 30-day complications and unplanned readmissions. RESULTS: Of the 4,807 patients included in the study, 88 (1.8%) underwent ambulatory laparoscopic adrenalectomy and 4,719 (98.2%) were admitted after the adrenalectomy. The same-day discharge group contained fewer obese patients (37.2% vs 50%; P = .04), a lesser proportion of American Society of Anesthesiologists class III patients (45.5% vs 61%; P = .003), and more patients with primary aldosteronism (14.8% vs 6%; P = .002) compared with the inpatient group. After adjustment for confounders, same-day discharge was not associated with 30-day overall complications (OR 1.17, 95% CI 0.35-3.85; P = .80) or unplanned readmissions (HR 2.77, 95% CI 0.86-8.96; P = .09). The percentage of laparoscopic adrenalectomies performed on an ambulatory basis at hospitals participating in the ACS NSQIP remained low throughout the study period (0-3.1% per year) with no evidence of an increasing trend over time (P = .21). CONCLUSION: Ambulatory laparoscopic adrenalectomy is a safe and feasible alternative to inpatient hospitalization in selected patients. Further study is needed to determine the cost savings, barriers to uptake, and optimal selection criteria for this approach.

Results of adrenal surgery. Data of a Spanish National Survey.

PURPOSE: Given the availability of laparoscopy and the rising detection of incidentalomas, indications for adrenalectomy may be changing. The Endocrine Surgery Section of the Spanish Association of Surgeons designed a survey to assess its indications, techniques, and results in Spanish Surgical Departments. METHODS: Collected data included hospital and department type, yearly hospital volume of procedures; location studies and preoperative preparation performed, indications, surgical approach and instruments used, and results in terms of morbidity and overall hospital stay. The analysis included a comparison between results of high- or low-volume centers and surgeons, using the Student's t test for quantitative and chi-square test for qualitative variables. Level of significance was set at 0.05. RESULTS: Nineteen centers returned the questionnaire, including 155 adrenalectomies performed in 2008. Most frequent indications were pheochromocytoma (23.2%), aldosteronoma (16.7%), incidentaloma (12.2%), metastasis (10.3%), Cushing adenoma (9.6%), and carcinoma (3.8%). Laparoscopy was performed in 83.9% of cases (9.4% required conversion to laparotomy). Four patients required urgent reoperation. Average hospital stay: 4.6 days (3.3 days after laparoscopy, 7 days after laparotomy). High-volume centers had a greater proportion of laparoscopically treated cases (p = 0.008), more malignant lesions treated (p = 0.03), a shorter overall stay (p < 0.0001), and a shorter stay after laparotomic adrenalectomy (p = 0.01). High-volume surgeons had similar results, and less in-hospital morbidity (p = 0.02). CONCLUSIONS: In Spain, adrenalectomy is performed in hospitals of varying complexity. Laparoscopic approach is the rule, with good results in terms of morbidity and stay. High-volume centers and surgeons had best results in terms of use of minimally invasive surgery and hospital stay.

[Analysis of 10 cases died from the acute infectious disease with the severe adrenalitis, necrosis and hemorrhage].

OBJECTIVE: To discuss the potential mechanisms and the role of adrenalitis with extensive hemorrhage and necrosis in acute critical infectious diseases. Methods Forensic autopsy cases from 1987 to 2007 were retrospectively analyzed. And 10 cases of them were involved in the primary and critical infection with acute inflammation, hemorrhage and necrosis of adrenal glands. Results Clinical diagnoses of 10 cases were respiratory tract infection (n=6), septic shock (n=2), acute esophagitis (n=1), and undefined causes (n=1), and the quickly aggravating conditions resulted in death ultimately. However, systematic autopsy confirmed that 7 cases died of acute lymphocytic pancarditis, 2 cases acute and lymphocytic interstitial pneumonia and 1 case epidemic cerebrospinal meningitis with septicemia. And severe complications of all cases included hemorrhagic necrotizing adrenalitis, systemic inflammatory response syndrome and multiple organ failure (MOF). Conclusions Hemorrhagic necrotizing adrenalitis should be considered as one of the important pathological changes in fatal MOF resulting from severe infection and trauma etc. More attention should be paid in clinical treatment.

Impact of underlying chronic adrenal insufficiency on clinical course of hospitalized patients with adrenal crisis: A nationwide cohort study.

BACKGROUND: Chronic adrenal insufficiency (AI) is an established risk factor for adrenal crisis (AC). However, the proportion of patients with newly diagnosed chronic AI during admission for AC is unclear. METHODS: This retrospective cohort study used a Japanese claims database involving 7.39 million patients at 145 acute care hospitals between 2003 and 2014. Study patients with AC met these criteria: 1) newly coded in claims as AI; 2) glucocorticoid therapy administered; 3) admission; and 4) age ≥ 18 years. We investigated the prevalence of underlying chronic AI and assessed in-hospital mortality. Additionally, we explored risk factors for in-hospital mortality through multivariate analysis using a Cox proportional hazards model. RESULTS: Among 504 patients with AC, chronic AI was diagnosed before and during admission in 73 (14.5%) and 86 (17.1%) patients, respectively. In-hospital mortality rates were 1.4% and 5.8%, respectively, lower than that of the total population (14.1%). Significant risk factors for increased mortality were: age (hazard ratio [HR] 1.45/10 years; 95% confidence interval [CI] 1.17-1.78), requiring mechanical ventilation (HR 3.81; 95% CI 1.88-7.72), vasopressor administration (HR 2.05; 95% CI 1.16-3.64), sepsis (HR 3.79; 95% CI 1.57-9.14), AI-related symptoms (HR 2.00; 95% CI 1.02-3.93), and liver disease (HR 3.24; 95% CI 1.10-9.58). CONCLUSIONS: Relative to patients without chronic AI, those diagnosed before admission tended to survive to discharge; however, the difference with those diagnosed during admission was not significant. Hospital admission due to nonspecific AI-related symptoms was associated with an increased risk of in-hospital mortality.

Characteristics and relative numbers of lethal snake bite cases in medicolegal practice in central Myanmar - A five year study.

Clinical and pathological case files of lethal snakebites were reviewed from the Magway Region General Hospital, Magway, Myanmar, over a five-year period (January 2013 December 2017). A total of 2069 postmortem examinations were performed which included 84 cases of lethal snake bite (4.1%). The annual numbers ranged from 10 out of a total of 268 autopsies in 2013 (3.7%), to 31 out of a total of 501 autopsies in 2016 (6.2%). There were 54 males (64%) and 30 females (36%) (M:F = 1.9:1; age range 5-75yrs, mean 33yrs). The most common time for lethal envenomation was August (16/84-19%), the middle of the monsoon season. 45/84 (54%) had acute renal failure, 27/84 (32%) were shocked, and the remaining 12/84 (14%) had disseminated intravascular coagulation. Twenty cases (24%) died within 24 h after envenomation. Fang marks were identified on the legs (either right or left) in 73/84 cases (87%) and on the arms in five cases (6%). The predominant findings at autopsy were of acute renal injury (82/84-98%), pituitary haemorrhage/necrosis (36/84-43%), and adrenal gland haemorrhage (30/84-36%). Despite the reduction in fatalities over the years snakebite from Russell's viper in particular remains an important contributor to mortality in central Myanmar despite the availability of antivenom.

High mortality within 90 days of diagnosis in patients with Cushing's syndrome: results from the ERCUSYN registry.

OBJECTIVE: Patients with Cushing's syndrome (CS) have increased mortality. The aim of this study was to evaluate the causes and time of death in a large cohort of patients with CS and to establish factors associated with increased mortality. METHODS: In this cohort study, we analyzed 1564 patients included in the European Registry on CS (ERCUSYN); 1045 (67%) had pituitary-dependent CS, 385 (25%) adrenal-dependent CS, 89 (5%) had an ectopic source and 45 (3%) other causes. The median (IQR) overall follow-up time in ERCUSYN was 2.7 (1.2-5.5) years. RESULTS: Forty-nine patients had died at the time of the analysis; 23 (47%) with pituitary-dependent CS, 6 (12%) with adrenal-dependent CS, 18 (37%) with ectopic CS and two (4%) with CS due to other causes. Of 42 patients whose cause of death was known, 15 (36%) died due to progression of the underlying disease, 13 (31%) due to infections, 7 (17%) due to cardiovascular or cerebrovascular disease and 2 due to pulmonary embolism. The commonest cause of death in patients with pituitary-dependent CS and adrenal-dependent CS were infectious diseases (n = 8) and progression of the underlying tumor (n = 10) in patients with ectopic CS. Patients who had died were older and more often males, and had more frequently muscle weakness, diabetes mellitus and ectopic CS, compared to survivors. Of 49 deceased patients, 22 (45%) died within 90 days from start of treatment and 5 (10%) before any treatment was given. The commonest cause of deaths in these 27 patients were infections (n = 10; 37%). In a regression analysis, age, ectopic CS and active disease were independently associated with overall death before and within 90 days from the start of treatment. CONCLUSION: Mortality rate was highest in patients with ectopic CS. Infectious diseases were the commonest cause of death soon after diagnosis, emphasizing the need for careful clinical vigilance at that time, especially in patients presenting with concomitant diabetes mellitus.

Corticotropin releasing factor receptor 1-deficient mice display decreased anxiety, impaired stress response, and aberrant neuroendocrine development.

Corticotropin releasing factor (CRF) is a major integrator of adaptive responses to stress. Two biochemically and pharmacologically distinct CRF receptor subtypes (CRFR1 and CRFR2) have been described. We have generated mice null for the CRFR1 gene to elucidate the specific developmental and physiological roles of CRF receptor mediated pathways. Behavioral analyses revealed that mice lacking CRFR1 displayed markedly reduced anxiety. Mutant mice also failed to exhibit the characteristic hormonal response to stress due to a disruption of the hypothalamic-pituitary-adrenal (HPA) axis. Homozygous mutant mice derived from crossing heterozygotes displayed low plasma corticosterone concentrations resulting from a marked agenesis of the zona fasciculata region of the adrenal gland. The offspring from homozygote crosses died within 48 hr after birth due to a pronounced lung dysplasia. The adrenal agenesis in mutant animals was attributed to insufficient adrenocorticotropic hormone (ACTH) production during the neonatal period and was rescued by ACTH replacement. These results suggest that CRFR1 plays an important role both in the development of a functional HPA axis and in mediating behavioral changes associated with anxiety.

Adrenal surgery in the pediatric population.

Adrenal tumors in children may be benign or malignant. In addition, both benign and malignant tumors may be hormonally active, leading to hypertension, metabolic crises, and endocrinopathies. These tumors may be found incidentally or secondary to signs and symptoms of the aforementioned disorders. Both a metabolic and a radiographic work-up are required before treatment of an adrenal tumor. The primary therapy for most adrenal lesions is surgical, though some are treated medically or require chemotherapy before excision. Laparoscopy has become the surgical approach of choice in both adult and pediatric patients with localized disease. Open surgical approaches remain necessary in patients with extensive locally invasive or metastatic disease.

Prospective evaluation of unilateral adrenal masses in patients with operable non-small-cell lung cancer.

Although adrenal metastases are frequently noted with non-small-cell lung cancer (NSCLC) at autopsy, their incidence in patients with operable NSCLC is unclear. We prospectively assessed consecutive patients with otherwise operable NSCLC for the incidence and histology of unilateral adrenal masses. Assessment included blood chemistries, lung function tests, bronchoscopy, chest x-ray, bone scan, and computed tomography (CT) of the head, chest, and upper abdomen. Of 246 patients with otherwise operable NSCLC, 10 (4.1%) had a unilateral adrenal mass. Unilateral adrenal masses were needle-aspirated under CT control. If cytology was nondiagnostic, adrenalectomy was performed. Four (40%) of 10 patients had adrenal metastases proven by needle aspiration. Of the six (60%) patients with benign unilateral adrenal masses, one was demonstrated by needle aspiration. In the other five patients, a nondiagnostic needle aspiration led to adrenalectomy, which yielded two adenomas, two hyperplastic nodules, and one hemorrhagic cyst. There was no significant difference between the patients with benign and metastatic unilateral adrenal masses with respect to patient age or stage and size of adrenal mass. Patients with benign unilateral adrenal masses underwent curative resection of their NSCLC and had significantly prolonged survival compared with patients with metastatic unilateral adrenal masses treated with chemotherapy (P = .037). Median survival of patients with benign and metastatic unilateral adrenal masses was greater than 30 months and 9 months, respectively. In conclusion, the presence of unilateral adrenal masses in patients with otherwise operable NSCLC should not preclude thoracotomy without pathologic proof of metastatic disease.

Adrenal Gland and Lung Lesions in Gulf of Mexico Common Bottlenose Dolphins (Tursiops truncatus) Found Dead following the Deepwater Horizon Oil Spill.

A northern Gulf of Mexico (GoM) cetacean unusual mortality event (UME) involving primarily bottlenose dolphins (Tursiops truncatus) in Louisiana, Mississippi, and Alabama began in February 2010 and continued into 2014. Overlapping in time and space with this UME was the Deepwater Horizon (DWH) oil spill, which was proposed as a contributing cause of adrenal disease, lung disease, and poor health in live dolphins examined during 2011 in Barataria Bay, Louisiana. To assess potential contributing factors and causes of deaths for stranded UME dolphins from June 2010 through December 2012, lung and adrenal gland tissues were histologically evaluated from 46 fresh dead non-perinatal carcasses that stranded in Louisiana (including 22 from Barataria Bay), Mississippi, and Alabama. UME dolphins were tested for evidence of biotoxicosis, morbillivirus infection, and brucellosis. Results were compared to up to 106 fresh dead stranded dolphins from outside the UME area or prior to the DWH spill. UME dolphins were more likely to have primary bacterial pneumonia (22% compared to 2% in non-UME dolphins, P = .003) and thin adrenal cortices (33% compared to 7% in non-UME dolphins, P = .003). In 70% of UME dolphins with primary bacterial pneumonia, the condition either caused or contributed significantly to death. Brucellosis and morbillivirus infections were detected in 7% and 11% of UME dolphins, respectively, and biotoxin levels were low or below the detection limit, indicating that these were not primary causes of the current UME. The rare, life-threatening, and chronic adrenal gland and lung diseases identified in stranded UME dolphins are consistent with exposure to petroleum compounds as seen in other mammals. Exposure of dolphins to elevated petroleum compounds present in coastal GoM waters during and after the DWH oil spill is proposed as a cause of adrenal and lung disease and as a contributor to increased dolphin deaths.

Adrenal hemorrhage in the adult.

Bilateral adrenal gland hemorrhage was found in 22 of 2,000 (1.1%) consecutive general hospital autopsies. Clinical features of these 22 patients with diffuse or focal bilateral adrenal hemorrhage have been analyzed and compared with previous series. In our experience, patients with this postmortem finding rarely manifest features of adrenocortical insufficiency and appear instead to die as a consequence of concomitant overwhelming illness, such as septicemia, body surface burns or cardiovascular catastrophe. Two-thirds of the current series had impaired renal function at the time of adrenal hemorrhage and three patients had pituitary gland necrosis. Experimental and clinical observations indicate that the "stressed" adrenal gland--under substantive endogenous or exogenous ACTH stimulation--is unusually susceptible to hemorrhage. While our own experience indicates that bilateral adrenal hemorrhage can infrequently be implicated as a factor contributing to patients' death, the possibility of adrenocortical insufficiency must be considered in patients at risk for adrenal hemorrhage. Such patients are those who are azotemic and have bacteremia, burns, or recent cardiovascular catastrophe, particularly when the latter is managed with anticoagulant administration. In these patients, unexplained clinical deterioration or the appearance of findings consistent with adrenocortical insufficiency mandate measurement of serum cortisol concentration and institution of stress-level corticosteroid replacement therapy until a diagnosis of acute adrenocortical insufficiency can be established or refuted.

Adrenal surgery: trends during the seventies.

Surgical experience with adrenal disease from 1970 to 1979 was reviewed in 315 patients. The pathologic conditions that were encountered were hypercortisolism (74 patients), hyperaldosteronism (46 patients), adrenocortical carcinoma (35 patients), pheochromocytoma (77 patients), and nonfunctioning adenoma (47 patients). In addition, 5 patients with metastatic lesions, 14 with cysts, and 4 with myelolipoma were surgically treated. The accuracy of localizing adrenal lesions increased from about 50 percent to almost 100 percent during the decade studied. The increase was due mainly to the introduction of computerized tomography, the most important advance in the management of adrenal disease. The present study shows that adrenal surgery can be performed with low morbidity and mortality. Operative deaths were confined to patients with malignant disease or increased secretion of cortisol or catecholamines. Only patients with adrenocortical carcinoma (2 year survival probability, 34 percent) or hypercortisolism due to cortical hyperplasia (5 year survival probability, 76 percent) had significantly decreased survival.

[Massive bilateral adrenal hemorrhage: role of imaging]. / Hémorragie surrénalienne bilatérale massive: apport de l'imagerie.

Bilateral adrenal hemorrhage is a rare and potentially life threatening situation in adults. The clinical presentation is non-specific, and the diagnosis is based on imaging. The purpose of this report is to provide an illustrative case of spontaneous bilateral adrenal hemorrhage that occurred during pregnancy. The sonographic and computed tomographic findings included large bilateral adrenal hematomas with no evidence of underlying malignancy. Since bilateral adrenal hemorrhage is a rare but potentially life threatening situation, prompt laboratory and imaging evaluation are essential and may reduce both morbidity and mortality.

[Aspects of hypertension of endocrine and adrenal origin]. / Nekotorye aspekty gipertenzii éndokrinno-nadpochechnikovogo geneza.

The authors discuss the results of observation of 269 patients with adrenal arterial hypertension 247 of whom underwent operation. The malignant hypertension syndrome developed in 39% of the patients. It is presumed that its development was caused by the combination of adrenal and renal affections as well as by specific hormonal shifts: relative norepinephrine hyperproduction and reduced intensity of catecholamine metabolism. In all groups of the patients with the malignant hypertension syndrome, a higher daily excretion of aldosterone and increased blood renin activity were also found. The character of the drug therapy and the late results of surgical treatment are discussed. A new variant of hyperaldosteronism, dexamethasone-inhibited form of aldosteroma, is described.

[Forensic medical identification of sudden death due to tuberculosis of adrenal glands].

Two cases died of tuberculosis of adrenal glands were reported. The pathological findings are presented and their medico-legal significance was also discussed. In particular, emphasis is placed on the importance of histopathologic examination of the adrenal glands in the tuberculous subjects dying suddenly and in whom no obvious cause of death was found at necropsy.