Variability of cortisol assays can confound the diagnosis of adrenal insufficiency in the critically ill population

Objective: To compare the total plasma cortisol values obtained from three widely used immunoassays and a high pressure liquid chromatography (HPLC) technique on samples obtained from patients with sepsis. Design and setting: Observational interventional in the general intensive care unit of a metropolitan hospital. Patients and participants: Patients admitted to the intensive care unit with a diagnosis of sepsis and fulfilling criteria of systemic inflammatory response syndrome. Interventions: Standard short synacthen test performed with 250 mu g cosyntropin. Measurements and results: Two of the three immunoassays returned results significantly higher than those obtained by HPLC: Immulite by 95% (95%CI 31-188%) and TDx by 79% (21-165%). The limits of agreement for all three immunoassays with HPLC ranged from -62% to 770%. In addition, by classifying the patients into responders and non-responders to ACTH by standard criteria there was concordance in all assays in only 44% of patients. Conclusions: Immunoassay estimation of total plasma cortisol in septic patients shows wide assay related variation that may have significant impact in the diagnosis of relative adrenal insufficiency.

Using distributions as statistical evidence in well-structured and ill-structured problems

Research has suggested that understanding in well-structured settings often does not transfer to the everyday, less-structured problems encountered outside of school. Little is known, beyond anecdotal evidence, about how teachers' consideration of distributions as evidence in well-structured settings compares with their use in ill-structured problem contexts. A qualitative study of preservice secondary teachers examined their use of distributions as evidence in four tasks of varying complexity and ill-structuredness. Results suggest that teachers' incorporation of distributions in well-structured settings does not imply that they will be incorporated in less structured problems (and vice-versa). Implications for research and teaching are discussed.

Increased availability and scalability for clustered services via the wait time calculation, trust based filtering and redirection of TCP connection requests

The paper describes two new transport layer (TCP) options and an expanded transport layer queuing strategy that facilitate three functions that are fundamental to the dispatching-based clustered service. A transport layer option has been developed to facilitate. the use of client wait time data within the service request processing of the cluster. A second transport layer option has been developed to facilitate the redirection of service requests by the cluster dispatcher to the cluster processing member. An expanded transport layer service request queuing strategy facilitates the trust based filtering of incoming service requests so that a graceful degradation of service delivery may be achieved during periods of overload - most dramatically evidenced by distributed denial of service attacks against the clustered service. We describe how these new options and queues have been implemented and successfully tested within the transport layer of the Linux kernel.