Narrow Pulse Pressure Research Articles

Pestilent relationship between smoking and hypertension or pulse pressure among males over 15 years in India: NFHS-5 Survey.

The Global Adult Tobacco Survey conducted in India has divulged that 28.6% of the populace aged 15 years and above partakes in tobacco consumption in various modalities. Despite the availability of numerous studies on the correlation between smoking and hypertension, the nexus between tobacco smoking and hypertension remains enigmatic. Smoking has predominantly been linked to blood pressure, with scant investigations exploring the plausible association that may subsist between smoking and pulse pressure. This study is based on secondary data analysis from the fifth National Family Health Survey (NFHS-5). 17 Field Agencies gathered information from 636,699 households, 724,115 women, and 101,839 men. The data related to only men was included and analysed in this present study. Male participants had a mean age of 32.2+1.2 years, an average waist circumference of 80.4+12.2 cm, and mean systolic and diastolic blood pressure of 123.4+13.8 mmHg and 80.5+10.2 mmHg. Daily smokers had a slightly higher likelihood of hypertension compared to non-smokers (OR = 1.2, p <0.001). Male quitters had significantly lower odds of hypertension (OR = 0.9, p <0.001). Quitters had reduced odds of narrow pulse pressure but increased odds of wide pulse pressure (OR = 0.81 and 1.14, respectively). The study found that regular smoking was associated with hypertension, while factors such as age, obesity, urban dwelling, wealth, and tribal residence were linked to increased blood pressure. Male quitters had a lower likelihood of hypertension, and middle-aged men and those with central obesity showed distinct associations with deranged pulse pressure.

A parametric study on pulse duplicator design and valve hemodynamics.

In vitro assessment is mandatory for artificial heart valve development. This study aims to investigate the effects of pulse duplicator features on valve responsiveness, conduct a sensitivity analysis across valve prosthesis types, and contribute on the development of versatile pulse duplicator systems able to perform reliable prosthetic aortic valve assessment under physiologic hemodynamic conditions. A reference pulse duplicator was established based on literature. Further optimization process led to new designs that underwent a parametric study, also involving different aortic valve prostheses. These designs were evaluated on criteria such as mean pressure differential and pulse pressure (assessed from high-fidelity pressure measurements), valve opening and closing behavior, flow, and regurgitation. Finally, the resulting optimized setup was tested under five different hemodynamic settings simulating a range of physiologic and pathologic conditions. The results show that both, pulse duplicator design and valve type significantly influence aortic and ventricular pressure, flow, and valve kinematic response. The optimal design comprised key features such as a compliance chamber and restrictor for diastolic pressure maintenance and narrow pulse pressure. Additionally, an atrial reservoir was included to prevent atrial-aortic interference, and a bioprosthetic valve was used in mitral positionto avoid delayed valve closing effects. This study showed that individual pulse duplicator features can have a significant effect on valve's responsiveness. The optimized versatile pulse duplicator replicated physiologic and pathologic aortic valve hemodynamic conditions, serving as a reliable characterization tool for assessing and optimizing aortic valve performance.

Hypothyroid on cardiopulmonary bypass usage in children with congenital heart disease: A literature review

Congenital heart disease (CHD) is a birth defect that affects the structure or function of the heart. Cardiopulmonary bypass (CPB) is frequently used to treat CHD, which raises the risk of hypothyroidism. The disorder can cause circulatory problems, edema, and pleural effusion, all of which indicate heart failure. Hypothyroid conditions can cause decreased cardiac output due to poor relaxation of cardiac smooth muscle cells and reduced endothelial nitric oxide accessibility. This causes a chain reaction of increasing arterial stiffness, which raises systemic vascular resistance (SVR). Thyroid hormones also have an effect on the renin-angiotensin-aldosterone pathway, promoting the synthesis of renin substrates in the liver. This causes higher diastolic blood pressure, narrow pulse pressure, and decrease in renin levels in hypothyroid patients. Thyroid hormones also regulate the transcription of pacemaker genes, hence hypothyroid patients have a slower heartbeat. Hypothyroidism raises the likelihood of atrial fibrillation.

Early Abnormal Vital Signs Predict Poor Outcomes in Normotensive Patients Following Penetrating Trauma

IntroductionBecause trauma patients in class II shock (blood loss of 15%-30% of total blood volume) arrive normotensive, this makes the identification of shock and subsequent prognostication of outcomes challenging. Our aim was to identify early predictive factors associated with worse outcomes in normotensive patients following penetrating trauma. We hypothesize that abnormalities in initial vital signs portend worse outcomes in normotensive patients following penetrating trauma. MethodsA retrospective review was performed from 2006 to 2021 using our trauma database and included trauma patients presenting with penetrating trauma with initial normotensive blood pressures (systolic blood pressure ≥90 mmHg). We compared those with a narrow pulse pressure (NPP ≤25% of systolic blood pressure), tachycardia (heart rate ≥100 beats per minute), and elevated shock index (SI ≥ 0.8) to those without. Outcomes included mortality, intensive care unit admission, and ventilator use. Chi-squared, Mann–Whitney tests, and regression analyses were performed as appropriate. ResultsWe identified 7618 patients with penetrating injuries and normotension on initial trauma bay assessment. On univariate analysis, NPP, tachycardia, and elevated SI were associated with increases in mortality compared to those without. On multivariable logistic regression, only NPP and tachycardia were independently associated with mortality. Tachycardia and an elevated SI were both independently associated with intensive care unit admission. Only an elevated SI had an independent association with ventilator requirements, while an NPP and tachycardia did not. ConclusionsImmediate trauma bay NPP and tachycardia are independently associated with mortality and adverse outcomes and may provide an opportunity for improved prognostication in normotensive patients following penetrating trauma.

Gastric Dieulafoy lesion as a cause of upper gastro-intestinal bleeding in a 4-year-old child: a case report

Dieulafoy lesion, although rare, is a significant gastrointestinal condition that can affect children. These quiescent lesions can easily be overlooked and bleeding lesions are occasionally misidentified on endoscopy. So, accurate diagnosis depends on increased knowledge and improvements in endoscopic procedures. Treatment of Dieulafoy lesion in children usually involves in different modalities of endoscopic interventions to stop the bleeding and promote healing. In more severe cases or when endoscopic treatments are unsuccessful, surgical intervention may be required to remove the lesion. In this case report, we present the case of a boy of 4 years and 4 months old, who presented with hematemesis with melena. He appeared mildly pale, moderately dehydrated, had a moderate pulse volume, prolonged capillary refill time, a narrow pulse pressure and tenderness in the epigastrium when the abdomen was examined. His tests showed a low hemoglobin level (7.5 g/dl), a normal coagulation profile and several bleeding sites in the fundus and upper part of stomach on endoscopic examination, which are consistent with Dieulafoy lesions. BIRDEM Med J 2023; 13(3): 163-166

Cognitive impairment in post-acute sequelae of COVID-19 and short duration myalgic encephalomyelitis patients is mediated by orthostatic hemodynamic changes.

Cognitive impairment is experienced by people with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and post-acute sequelae of COVID-19 (PASC). Patients report difficulty remembering, concentrating, and making decisions. Our objective was to determine whether orthostatic hemodynamic changes were causally linked to cognitive impairment in these diseases. This prospective, observational cohort study enrolled PASC, ME/CFS, and healthy controls. All participants underwent clinical evaluation and assessment that included brief cognitive testing before and after an orthostatic challenge. Cognitive testing measured cognitive efficiency which is defined as the speed and accuracy of subject's total correct responses per minute. General linear mixed models were used to analyze hemodynamics and cognitive efficiency during the orthostatic challenge. Additionally, mediation analysis was used to determine if hemodynamic instability induced during the orthostatic challenge mediated the relationship between disease status and cognitive impairment. Of the 276 participants enrolled, 256 were included in this study (34 PASC, 71 < 4 year duration ME/CFS, 69 > 10 year ME/CFS duration, and 82 healthy controls). Compared to healthy controls, the disease cohorts had significantly lower cognitive efficiency scores immediately following the orthostatic challenge. Cognitive efficiency remained low for the >10 year ME/CFS 2 and 7 days after orthostatic challenge. Narrow pulse pressure less than 25% of systolic pressure occurred at 4 and 5 min into the orthostatic challenge for the PASC and ME/CFS cohorts, respectively. Abnormally narrow pulse pressure was associated with slowed information processing in PASC patients compared to healthy controls (-1.5, p = 0.04). Furthermore, increased heart rate during the orthostatic challenge was associated with a decreased procedural reaction time in PASC and < 4 year ME/CFS patients who were 40 to 65 years of age. For PASC patients, both their disease state and hemodynamic changes during orthostatic challenge were associated with slower reaction time and decreased response accuracy during cognitive testing. Reduced cognitive efficiency in <4 year ME/CFS patients was associated with higher heart rate in response to orthostatic stress. Hemodynamic changes did not correlate with cognitive impairment for >10 year ME/CFS patients, but cognitive impairment remained. These findings underscore the need for early diagnosis to mitigate direct hemodynamic and other physiological effects on symptoms of cognitive impairment.

Differentiating Shock Associated with Multi-inflammatory Syndrome in COVID-19 and Dengue – A Case Report

In India where dengue is endemic, differentiating dengue shock and shock due to multi-inflammatory syndrome in COVID become important. Only a few case reports of such cases are present in the literature and we describe a child who was being managed as dengue developed shock and fitted in definition of multisystem inflammatory syndrome in children (MIS-C). She had positive for dengue NS1 and had raised COVID-19 antibodies. Her capillary refill time was prolonged and her blood pressure was 72/37 mm of Hg. In view of shock, she was given fluid bolus and started on adrenaline infusion. She was given intravenous immunoglobulin and methyl prednisolone. With this management, she improved. When we consider type of shock in dengue, it is narrow pulse pressure, while in our child, this was wide pulse pressure. Hence, we decided to treat with inotropes after initial fluid bolus of 20 mL/kg. We conclude that while differentiating dengue shock from MIS-C shock, pulse pressure may be important adjunct.

Dilated Cardiomyopathy in Children: Early Detection and Treatment.

Cardiomyopathy is segregated into primary and secondary categories, leading to different phenotypes, including dilated, hypertrophic, and restrictive patterns. Dilated cardiomyopathy (DCM) is a mixed bag of heart diseases with the unique features of cardiac dilatation and subnormal to poor myocardial contractility. Dilated cardiomyopathy in the pediatric age group is generally characterized by unobstructed, dilated, and contracting left ventricular chamber defects and is associated with heart failure. Other causes include genetic juvenile-onset cardiomyopathy, drug-induced cardiomyopathy, stress-induced cardiomyopathy, hemochromatosis, endocrine causes (thyroid disorder and pheochromocytoma), autoimmune diseases, and nutritional deficiencies (selenium and thiamine). It is characterized by thinning of the left ventricle, a dilated left ventricle or biventricular dilatation, left ventricular systolic dysfunction, left ventricular diastolic dysfunction, global hypokinesia, and cardiomegaly (seen on a chest X-ray). Decreased cardiac output leads to fatigue, cachexia, narrow pulse pressure, dicrotic pulse/hypokinetic pulse, dyspnea, cool extremities, decreased blood supply to the brain (cognitive dysfunction), and reduced blood supply to the kidney (renal failure). Left ventricular diastolic dysfunction can result in dyspnea, orthopnea, and paroxysmal nocturnal dyspnea. Cardiomyopathy can also occur with or without left ventricular dysfunction, as in left ventricular non-compaction cardiomyopathy (LVNC), which is a rare heart disease occurring due to two (likely) pathogenic nonsense mutations: DSG2-p.S363X and TBX20-p.D278X. The study of familial forms of LVNC is helpful for risk prediction and genetic counseling of relatives. Right ventricular chamber failure can be identified on the electrocardiogram as sinus tachycardia and non-specific ST/T changes. The complications include arrhythmia (atrial fibrillation) and thromboembolism (left ventricular mural thrombosis). It is of utmost importance in the field of heart transplantation as the definitive treatment of the disease. Heart transplantation is now an acceptable treatment option for patients with dilated cardiomyopathy. This short review highlights different methods for the detection and diagnosis of dilated cardiomyopathy and the treatment modalities available for the same.

Invasive And Non-invasive Assessment Of Arterial Blood Oxygen Saturation In Patients With Continuous Flow LVADs: Is There A Correlation?

<h3>Background</h3> Patients with continuous flow left ventricular assist devices (CF-LVAD) typically have a narrow pulse pressure. This may pose a challenge for transcutaneous automated pulse oximeter devices to accurately measure arterial blood saturation. This study aimed to assess their accuracy in a CF-LVAD population by comparing pulse oximetry readings to invasive arterial blood gas (ABG) measurements. <h3>Methods</h3> A total of eighteen patients with a CF-LVAD were identified using chart review at the University of Minnesota and Minneapolis Heart Institute. All, except one patient were implanted with a HeartMate III device (Abbott Laboratories, Minneapolis, MN). Non-invasively assessed oxygen saturation was compared to simultaneously obtained arterial blood oxygen saturation. Two patients were receiving mechanical ventilation, one received BiPAP support, and 15 patients were either breathing room air or receiving supplemental oxygen by nasal cannula. <h3>Results</h3> A non-invasive pulse oximeter read was obtained on every patient. There was a moderate correlation between the invasively and non-invasively obtained oxygen saturation values as shown in Figure 1 (R²=0.624). Waveform quality, as assessed by the treating physician, qualified as good or acceptable in 16 cases and as poor for 2 patients. Data points for these 2 patients are marked in red in Figure 1. <h3>Conclusion</h3> Despite a narrow pulse pressure in patients with CF-LVAD, non-invasive pulse oximetry provided a reliable assessment of arterial blood saturation when compared to the gold standard ABG measurement. This finding presents an opportunity to conduct future studies in this patient population in which continuous monitoring of oxygen saturation may be necessary, such as evaluation for obstructive sleep apnea.

A Rare Cause of Severe Biventricular Dyssynchrony During Venoarterial Extracorporeal Membrane Oxygenation for COVID-19 Respiratory Failure

A Rare Cause of Severe Biventricular Dyssynchrony During Venoarterial Extracorporeal Membrane Oxygenation for COVID-19 Respiratory Failure

Is Isolated Diastolic Hypertension an Important Phenotype?

Isolated diastolic hypertension (IDH) is a frequent hypertension phenotype. We review IDH pathophysiology, risk stratification, and therapeutic decisions. Recent guidelines lowering blood pressure cutoff levels have increased IDH prevalence and likely decreased associated cardiovascular risk. Long-term cardiovascular risk and pharmacological intervention in IDH are controversial. Narrow pulse pressure and other physiological and epidemiological characteristics are shared with a systodiastolic hypertension (SDH) subgroup. We propose that IDH be incorporated into a broader category, predominantly diastolic hypertension (PDH), defined by pulse pressure ≤ 45mmHg and includes IDH and SDH with a narrow pulse pressure. IDH-PDH is associated with cardiovascular risk in the long term, especially in young patients. Standardization of the IDH definition and population may contribute to future research to understand genetics, pathophysiology, and eventually therapy in this important subgroup of hypertensive patients.

Yes Is No

Yes Is No

Prehospital Narrow Pulse Pressure Predicts Need for Resuscitative Thoracotomy and Emergent Intervention After Trauma

BackgroundThe pulse pressure (PP) is the difference between systolic and diastolic blood pressures. Narrow PP in the Emergency Department (ED) has recently been shown to predict hemorrhagic shock after trauma. This study examined the impact of prehospital narrow PP on outcomes after trauma. MethodsPatients presenting to our ACS-verified Level I trauma center (2008-2020) were retrospectively screened. Exclusions were unrecorded prehospital/ED vitals, age <16 or >60, transfers, on-scene cardiac arrest, and missing discharge disposition. Prehospital blood pressure defined study groups: Narrow PP (<30 mmHg) vs. Hypotensive (SBP<90 mmHg) vs. Others (herein referred to as Normotensive). Univariable/multivariable analyses compared outcomes and determined independent predictors of mortality; resuscitative thoracotomy; emergent intervention; and need for trauma intervention (NFTI), a contemporary measure of major trauma. ResultsIn total, 39,144 patients met inclusion/exclusion criteria: 5% (n=1,834) Narrow PP, 3% (n=1,062) Hypotensive, and 92% (n=36,248) Normotensive. Penetrating trauma was more frequent among Narrow PP and Hypotensive patients (23% vs. 32% vs. 14%, p<0.001). ISS was higher among Narrow PP and Hypotensive patients (5[1-14] vs. 10[2-21] vs. 4[1-9], p<0.001). Mortality was highest among the Hypotensive (n=130, 12%) followed by Narrow PP (n=92, 5%) and Normotensive patients (n=502, 1%) (p<0.001). On multivariable analysis, prehospital narrow PP was independently associated with resuscitative thoracotomy (OR 1.609, p=0.009), emergent intervention (OR 1.356, p=0.001), and NFTI (OR 1.237, p=0.009). ConclusionPrehospital narrow PP independently predicts severe trauma, resuscitative thoracotomy, and emergent intervention. Although prehospital narrow PP is not currently a TTA criterion, these patients have a mortality rate and ISS intermediate to those of hypotensive and normotensive patients. Prehospital narrow PP should be recognized as a proxy for major trauma in patients with heightened surgical and interventional needs so that appropriate in-hospital preparations may be made prior to patient arrival.

How COVID broke my heart: a case report of tamponade after SARS-CoV-2 infection

: SARS-CoV-2 leading to COVID-19 is a global pandemic, the likes of which have been unprecedented in our lifetime, with many presentations, unknown complications, and few effective treatment options. The most common organ affected by COVID-19 is the lungs, but another well-known effect of COVID-19 infection is thromboembolic phenomena. In this case, a patient previously infected with SARS-CoV-2 developed chest pain radiating to the back, shortness of breath, and marked hypertension and was diagnosed with an acute ST-segment elevation myocardial infarction (STEMI) complicated by a moderate pericardial effusion which led to a cardiac tamponade. The patient had all three of the components of Beck’s Triad: muffled heart sounds, jugular venous distention, and hypotension as well as a narrow pulse pressure and had COVID-19 induced myocarditis resulting in a pericardial effusion and tamponade physiology. This COVID-19 associated pericardial effusion has, to our knowledge, been reported only six times in the literature and this presentation was unique because the patient was in the subacute phase with COVID-19, had a cardiac tamponade, and had a thrombosed stent during the catheterization despite being on long term apixaban. The patient underwent emergency percutaneous coronary intervention (PCI) with two stents and was transferred to the intensive care unit where he was noted to have worsening hypotension despite aggressive vasopressor support. Ultimately, despite an emergent bedside pericardiocentesis, the patient succumbed to complications of COVID-19 infection. To our knowledge, there have only been six reported cases in the literature of COVID-19 associated pericardial effusions, and four had cardiac tamponade. It is imperative that clinicians be wary of, and educated about, the less common effects of COVID-19 infection even after the acute phase has passed, which include a persistent prothrombotic state.

Fluid requirement in adult dengue haemorrhagic fever patients during the critical phase of the illness: an observational study

BackgroundDengue fever prevalence is rising globally and it causes significant morbidity and mortality. Fluid extravasation during the critical phase of dengue haemorrhagic fever (DHF) leads to shock, multi-organ failure and death if not resuscitated appropriately with fluids. The mainstay of management is judicious fluid replacement using a guideline based, calculated fluid quota of maintenance (M) fluid plus 5% deficit (M + 5% deficit) to prevent organ hypoperfusion.MethodsWe conducted an observational follow-up study in Sri Lanka from January–July 2017 to identify the fluid requirements of DHF patients and to identify whether features of fluid overload are present in patients who exceeded the fluid quota. Patients who developed DHF following admission to the place of study, were recruited and the amount of fluid received during the critical phase was documented.ResultsA total of 115 DHF patients with a mean age of 30.3 (SD 12.2) years were recruited to the study. There were 65 (56.5%) males and the mean fluid requirement was 5279.7 ml (SD 735) over the 48 h. Majority of the study participants (n = 80, 69.6%) received fluid in excess of the recommended maintenance + 5% deficit and this group had higher body mass index (22.75 vs 20.76, p0.03) and a lower white cell count at the onset of the critical phase (3.22 × 103 vs 4.78 × 103, p < 0.001). The highest fluid requirement was seen within the first 12 and 24 h of the critical phase in patients requiring fluid M + 5%–7.5% deficit and ≥ M + 7.5% deficit respectively. Patients exceeding M + 5% deficit had narrow pulse pressure and hypotension compared to the rest. DHF grades III and IV were seen exclusively in patients exceeding the fluid quota indicating higher amount of fluid was given for resuscitation. Fluid overload was detected in 14 (12.1%) patients and diuretic therapy was required in 6 (5.2%) patients.ConclusionsThe majority of patients received fluid in excess of the recommended quota and this group represents patients with narrow pulse pressure and hypotension. Although, fluid overload was infrequent in the study population, clinicians should be cautious when administering fluid in excess of M + 7.5% deficit.

Hemodynamics during the 10-minute NASA Lean Test: evidence of circulatory decompensation in a subset of ME/CFS patients

BackgroundLightheadedness, fatigue, weakness, heart palpitations, cognitive dysfunction, muscle pain, and exercise intolerance are some of the symptoms of orthostatic intolerance (OI). There is substantial comorbidity of OI in ME/CFS (Myalgic Encephalomyelitis/Chronic Fatigue Syndrome). The 10-minute NASA Lean Test (NLT) is a simple, point-of-care method that can aid ME/CFS diagnosis and guide management and treatment of OI. The objective of this study was to understand the hemodynamic changes that occur in ME/CFS patients during the 10-minute NLT.MethodsA total of 150 ME/CFS patients and 75 age, gender and race matched healthy controls (HCs) were enrolled. We recruited 75 ME/CFS patients who had been sick for less than 4 years (< 4 ME/CFS) and 75 ME/CFS patients sick for more than 10 years (> 10 ME/CFS). The 10-minute NLT involves measurement of blood pressure and heart rate while resting supine and every minute for 10 min while standing with shoulder-blades on the wall for a relaxed stance. Spontaneously reported symptoms are recorded during the test. ANOVA and regression analysis were used to test for differences and relationships in hemodynamics, symptoms and upright activity between groups.ResultsAt least 5 min of the 10-minute NLT were required to detect hemodynamic changes. The < 4 ME/CFS group had significantly higher heart rate and abnormally narrowed pulse pressure compared to > 10 ME/CFS and HCs. The < 4 ME/CFS group experienced significantly more OI symptoms compared to > 10 ME/CFS and HCs. The circulatory decompensation observed in the < 4 ME/CFS group was not related to age or medication use.ConclusionsCirculatory decompensation characterized by increased heart rate and abnormally narrow pulse pressure was identified in a subgroup of ME/CFS patients who have been sick for < 4 years. This suggests inadequate ventricular filling from low venous pressure. The 10-minute NLT can be used to diagnose and treat the circulatory decompensation in this newly recognized subgroup of ME/CFS patients. The > 10 ME/CFS group had less pronounced hemodynamic changes during the NLT possibly from adaptation and compensation that occurs over time. The 10-minute NLT is a simple and clinically useful point-of-care method that can be used for early diagnosis of ME/CFS and help guide OI treatment.

Narrow pulse pressure is independently associated with massive transfusion and emergent surgery in hemodynamically stable trauma patients

IntroductionNarrow pulse pressure (PP) is a sign of Class-II hemorrhage, but its clinical relevance is unknown. We hypothesized narrow PP is related to significant transfusion and need for emergent surgery. MethodsHemodynamically stable (SBP >/ = 90 mmHg) trauma patients were retrospectively reviewed. Narrow PP patients (<40 mmHg) were compared to normal patients (>/ = 40 mmHg). Outcomes included need for significant transfusion (>/ = 10 units) and emergent cavitary surgery. ResultsFrom 18,978 hemodynamically stable trauma patients admitted, 13% had narrow PP. They statistically required more massive transfusion, emergent surgery, or both (p < 0.0001), as well as higher mortality, longer hospital stay, and ICU stay (p < 0.0001). After controlling for age, gender, injury, ISS and GCS, NPP was independently associated with both significant transfusion and emergent surgery. ConclusionIn hemodynamically stable trauma patients, narrow PP is independently associated with three-fold increase in significant transfusion need and two-fold increase in emergent surgery need. Early identification of these patients may lead to more accurate and optimal intervention.

Serum chymase levels correlate with severe dengue warning signs and clinical fluid accumulation in hospitalized pediatric patients

Dengue induces a spectrum of severity in humans from the milder dengue fever to severe disease, or dengue hemorrhagic fever (DHF). Chymase is a candidate biomarker that may aid dengue prognosis. This prospective study aimed to identify whether warning signs of severe dengue, including hypovolemia and fluid accumulation, were associated with elevated chymase. Serum chymase levels were quantified prospectively and longitudinally in hospitalized pediatric dengue patients in Sri Lanka. Warning signs were determined based on daily clinical assessments, laboratory tests and ultrasound findings. Chymase was significantly elevated during the acute phase of disease in DHF or Severe dengue, defined by either the 1997 or 2009 WHO diagnosis guidelines, and persisted longer in the most severe patients. Chymase levels were higher in patients with narrow pulse pressure and clinical warning signs such as severe leakage, fluid accumulation, pleural effusion, gall-bladder wall thickening and rapid haematocrit rise concurrent with thrombocytopenia. No association between chymase and liver enlargement was observed. This study confirms that serum chymase levels are associated with DHF/Severe dengue disease in hospitalized pediatric patients. Chymase levels correlate with warning signs of vascular dysfunction highlighting the possible functional role of chymase in vascular leakage during dengue.

Ruptured appendicitis associated with intraabdominal cystic lymphangioma and shock

Abstract Acute abdominal pain is a frequently encountered symptom, often indicating a life-threatening, underlying medical condition. Abdominal pain may be caused by peritonitis, usually due to perforate appendicitis, may cause sepsis that can progress to septic shock. A 5-year 8-month-old boy presented to the emergency ward diagnosed with septic shock. He had felt low-grade fever and abdominal discomfort for 5 days in duration. At admission he looked severely ill, hypotensive and tachycardia with narrow pulse pressure. Abdomen was tender on palpation and peritoneal sign was found on the patient. Skin mottling was found with cold extremities. An initial management of septic shock was done. Leukocytosis and high serum C-reactive protein was found. Dengue and typhoid serology were negative. Abdominal radiography, ultrasonography, and CT-Scan with contrast identified several loculated ascites. Surgical exploration found intracystic hemorrhage and multicystic mass rupture within the greater omentum adjacent to the jejunum and ileum. The appendix was dilated and perforated. Cyst resection and appendectomy were performed. Histopathologic examination confirmed acute transmural appendicitis with concurrent cystic lymphangioma of the omentum. Enterococcus faecalis was identified from blood and intra-abdominal culture. Intraabdominal cystic lymphangioma is a rare and possible differential diagnosis in a child presenting with acute abdominal pain.

Narrowed pulse pressure predicts massive transfusion and emergent operative intervention following penetrating trauma

IntroductionThe early identification of hemorrhagic shock may be challenging. The objective of this study was to examine the utility of a narrowed pulse pressure in identifying the need for emergent interventions following penetrating trauma. MethodsIn this 2.5-year retrospective study of adult patients with a penetrating mechanism, patients with a narrowed pulse pressure (<30 mmHg) were compared to those without. Main outcomes measures were the need for a massive transfusion or emergent operation. ResultsThere were 957 patients, of which the majority were male (86%) and 55% presented with gunshot wounds. On multivariate analysis, a narrowed pulse pressure was associated with the need for massive transfusion (OR 3.74, 95% C.I. 1.8–7.7, p = 0.0003) and emergent surgery (OR 1.68, 95% C.I. 1.14–2.48, p = 0.009). ConclusionsA narrowed pulse pressure is associated with the presence of hemorrhagic shock and need for emergent interventions among patients with penetrating torso trauma.