Synergistic Impact of Systolic Blood Pressure and Perfusion Status on Mortality in Acute Heart Failure.

BACKGROUND: Physical examination remains the cornerstone in the assessment of acute heart failure. There is a lack of adequately powered studies assessing the combined impact of both systolic blood pressure (SBP) and hypoperfusion on short-term mortality. METHODS: Patients with acute heart failure from 41 Spanish emergency departments were recruited consecutively in 3 time periods between 2011 and 2016. Logistic regression models were used to assess the association of 30-day mortality with SBP (<90, 90-109, 110-129, and ≥130 mm Hg) and with manifestations of hypoperfusion (cold skin, cutaneous pallor, delayed capillary refill, livedo reticularis, and mental confusion) at admission. RESULTS: Among 10 979 patients, 1143 died within the first 30 days (10.2%). There was an inverse association between 30-day mortality and initial SBP (35.4%, 18.9%, 12.4%, and 7.5% for SBP<90, SBP 90-109, SBP 110-129, and SBP≥130 mm Hg, respectively; P<0.001) and a positive association with hypoperfusion (8.0%, 14.8%, and 27.6% for those with none, 1, ≥2 signs/symptoms of hypoperfusion, respectively; P<0.001). After adjustment for 11 risk factors, the prognostic impact of hypoperfusion on 30-day mortality varied across SBP categories: SBP≥130 mm Hg (odds ratio [OR]=1.03 [95% CI, 0.77-1.36] and OR=1.18 [95% CI, 0.86-1.62] for 1 and ≥2 compared with 0 manifestations of hypoperfusion), SBP 110 to 129 mm Hg (OR=1.23 [95% CI, 0.86-1.77] and OR=2.18 [95% CI, 1.44-3.31], respectively), SBP 90 to 109 mm Hg (OR=1.29 [95% CI, 0.79-2.10] and OR=2.24 [95% CI, 1.36-3.66], respectively), and SBP<90 mm Hg (OR=1.34 [95% CI, 0.45-4.01] and OR=3.22 [95% CI, 1.30-7.97], respectively); P-for-interaction =0.043. CONCLUSIONS: Hypoperfusion confers an incremental risk of 30-day all-cause mortality not only in patients with low SBP but also in normotensive patients. On admission, physical examination plays a major role in determining prognosis in patients with acute heart failure.

'Diagnosing food protein-induced enterocolitis syndrome'.

Food protein-induced enterocolitis syndrome is still a mysterious disease, pathogenically poorly characterized, although the first FPIES case has been described in 1967. Mainly, food protein-induced enterocolitis syndrome diagnosis is based on clinical history. The oral food challenge remains the gold standard to confirm the diagnosis, especially in particular situations. Although there are no diagnostic laboratory or imaging tests which are specific for diagnosis, they could, however, sometimes be helpful to rule out clinical conditions which are similar to food protein-induced enterocolitis syndrome reactions. The purpose of this review is to define the clinical features of FPIES and to summarize the current available tools for the diagnosis of FPIES. This review is intended to be a practical guide for the clinician facing a patient with food protein-induced enterocolitis syndrome avoiding delayed diagnosis with unnecessary laboratory tests and detrimental treatments. Moreover, it highlights the unmet needs in diagnosis that require urgent attention from the scientific community to improve the management of patients with FPIES.

Developmental screening tool: Accuracy and feasibility of non-invasive anaemia estimation.

Anaemia is predicted as one of the serious communal health issue in the world. The deficiency exists most common among children and women. A substantial issue prevails in providing quality healthcare services to rural communities, which remains a challenge to health service providers throughout the world. Traditionally physician and health workers recognized anaemia from certain clinical findings, such as pallor of the conjunctivae, nail beds, lips, tongue, and oral mucosa. Confirmation of anaemic condition through physical examination of Dorsum of a tongue or lower bulbar conjunctiva is a subjective analysis. Invasive methods have a possibility to spread infection through the needle. The existing non-invasive techniques need costly equipment and qualified technicians. Growing developments in science and technologies play an important role in medicine. This proposal introduces a new non-invasive diagnostic tool correlating the hemoglobin with conjunctiva pallor colour scores and classification using neural networks. In this study, the eye images were obtained using a mobile camera were processed using the HSI model, which estimates different colour scores of the selected region. These scores were correlated with laboratory haemoglobin value. Feedforward neural network and Elman neural network were used for classifying anaemic and non-anaemic cases. This proposed tool will be useful for the health workers to identify the mass screening of anaemia in rural areas.

Clinicohematological Study of Pancytopenia in a Tertiary Care Hospital of Western Region of Nepal.

INTRODUCTION: Pancytopenia is a relatively common hematological entity and is a manifestation of many illnesses which can be life threatening at times. The severity of pancytopenia and the underlying pathology determine the management and prognosis. This study was conducted to evaluate hematological and bone marrow findings in patients presenting with pancytopenia. METHODS: A prospective observational study was conducted in Department of Pathology, Manipal College of Medical Sciences, Pokhara from January 2011 to December 2016. Clinical and hematological parameters including bone marrow aspiration and biopsy were evaluated in all patients who presented with pancytopenia. RESULTS: Among 138 cases studied, patients' age ranged from 2 to 82 years with a mean age of 43.95 years, and there was male predominance. Most of the patients presented with generalized weakness, pallor, dypnoea and fever. Hypoplastic marrow was seen in 38 (27.5%) cases, followed by 26 (18.8%) cases of megaloblastic anemia and 19 (13.76%) cases of acute leukemia. Other findings included one case each of hemophagocyosis, leishmaniasis, plasmodium vivex malaria and metastatic carcinoma. CONCLUSIONS: This study highlights that pancytopenia is a common hematological problem and that the study of detailed primary hematological investigations along with bone marrow study in patients with pancytopenia will help to identify the cause for further planning and management.

Study of clinical and aetiological profile of 100 patients of pancytopenia at a tertiary care centre in India.

Pancytopenia is not a disease but an important clinico-haematological entity encountered in our day-to-day clinical practice with findings that may result from a number of disease processes. A total of 100 patients of pancytopenia admitted in medicine wards of Civil Hospital, Ahmedabad, Gujuarat, India, were studied. The most common cause of pancytopenia was megaloblastic anaemia (45%) followed by infections (20%) and hypersplenism (15%). As compared with other causes, megaloblastic anaemia was statistically significant cause (P < 0.01) of pancytopenia, in our study. The most common clinical presentation of patients with megaloblastic anaemia was lethargy (100%) and pallor (100%). In patients with megaloblastic anaemia, mean haemoglobin (Hb) was 5.6 ± 1.7 g/dl, mean white blood corpuscle (WBC) count was 2735 ± 4152 and mean platelet count was 52,250 ± 24,213. Mean corpuscular volume (MCV) was 101.2 ± 11 in patients of megaloblastic anaemia. Morphology of RBC was marocytic in 95% of patients with megaloblastic anaemia, whereas hypersegmented neutrophils and macrovalocytes were seen in 60-65% patients of megaloblastic anaemia.

Validity of non-invasive assessment of anaemia in pregnancy.

OBJECTIVE: To test the accuracy of clinical symptoms and signs for anaemia in pregnant women, as assessed by nurse-midwives, in two locations in Northern Tanzania. METHODS: One location was at 1000 m above sea level, the other at 1800 m. Midwives performed examinations and conducted structured interviews to detect severe anaemia at the first antenatal care visit before haemoglobin (hb) results were revealed; 369 and 535 women of all parities were examined in consecutive order at the two locations. Severe anaemia was defined as hb <75 g/l in the first and <80 g/l in the second (higher) location, based on altitude effect on hb distributions. RESULTS: Hb distribution differed substantially between the two locations, with much higher hb levels among those living at 1800 m. Sensitivities for detection of severe anaemia based on individual signs (pallor, conjunctiva, etc.) were 0.85, but only 0.33 to 0.44 for those living at lower and for those at higher altitudes, respectively. Conversely, specificities were around 0.90 at higher and 0.55 at lower altitudes, respectively. Symptoms (headache, dizziness, palpitations, etc.) were too common among those without anaemia to be useful as distinguishing features. Changing the definition of severe anaemia to higher cut-off hb values did not materially alter the results. CONCLUSION: Validity of non-invasive tests to detect severe anaemia in pregnant women varies by locality. In a high-altitude area detection rate was low (sensitivity around 40%). In lower-lying areas detection rate was high, at the cost of low specificity (around 45% false positive tests). Symptoms like headache, dizziness and fatigue were too common to discriminate those with severe anaemia.

Recognition of pallor associated with severe anaemia by primary caregivers in western Kenya.

OBJECTIVES: To explore which pallor signs and symptoms of severe anaemia could be recognized by primary caregivers following minimal instructions. METHODS: Data from three community-based cross-sectional surveys were used. Test characteristics to predict haemoglobin (Hb) concentrations < 5 and < 7 g/dl were compared for different combinations of pallor signs (eyelid, tongue, palmar and nailbed) and symptoms. RESULTS: Pallor signs and haemoglobin levels were available for 3782 children under 5 years of age from 2609 households. Comparisons of the sensitivity and specificity at a range of haemoglobin cut-offs showed that Hb < 5 g/dl was associated with the greatest combined sensitivity and specificity for pallor at any anatomical site (sensitivity = 75.6%, specificity = 63.0%, Youden index = 38.6). Higher or lower haemoglobin cut-offs resulted in more children being misclassified. Similar results were obtained for all individual pallor sites. Combining a history of soil eating with pallor at any site improved the sensitivity (87.8%) to detect Hb < 5 g/dl with a smaller reduction in specificity (53.3%; Youden index 41.1). Other combinations including respiratory signs or poor feeding resulted in lower accuracy. CONCLUSION: Primary caregivers can recognize severe anaemia (Hb < 5 g/dl) in their children, but only with moderate accuracy. Soil eating should be considered as an additional indicator of severe anaemia. The effect of training caretakers to improve recognition of severe anaemia and care-seeking behaviour at the household level should be assessed in prospective community-based studies.

A case-controlled multicenter study of vasovagal reactions in blood donors: influence of sex, age, donation status, weight, blood pressure, and pulse.

BACKGROUND: Vasovagal reactions occur in a small, but significant number of blood donors. These reactions may decrease return donation and disrupt blood collection activities. The purpose of this study was to define the contributory role of sex, age, weight, blood pressure, and pulse in vasovagal reactions with syncope in blood donors. STUDY DESIGN AND METHODS: A retrospective case-control study involved 1890 blood donors with syncope from three large United States blood centers during 1994 and 1995. Case controls and random population controls were used in a logistic regression analysis to determine the significance of individual variables to syncopal reactions. RESULTS: Female donors, young donors, first-time donors, low-weight donors, and donors with low predonation blood pressure had higher absolute donation reaction rates than other donors. When each variable was adjusted for other variables by regression analysis, age, weight, and donation status (first-time or repeat donor) were significant (p<0.0001), and sex, predonation blood pressure, and predonation pulse were not. The most important variables, in descending order, were age, weight, and donation status (first-time or repeat donor). CONCLUSIONS: Donation-related vasovagal syncopal reactions are a multifactorial process determined largely by age, weight, and first-time donor status.

Familial lipoprotein lipase deficiency in infancy: clinical, biochemical, and molecular study.

OBJECTIVES: To describe the characteristics of lipoprotein lipase (LPL)-deficient patients seen in infancy and to evaluate the safety and efficacy of severe fat restriction. METHODS: Children <1 year old presenting with chylomicronemia between 1972 and 1995 were identified, and their clinical courses were reviewed retrospectively. RESULTS: LPL deficiency was demonstrated in 16 infants who presented with irritability (n = 7), lower intestinal bleeding (n = 2), pallor, anemia, or splenomegaly (n = 5), and a family history or fortuitous discovery (n = 2). All plasma samples were lactescent at presentation. Chylomicronemia responded rapidly to dietary fat restriction, and it was possible to maintain satisfactory metabolic control for a prolonged period of time. Only 1 adolescent girl had an episode of pancreatitis associated with the use of oral contraceptives. No persistent adverse effects on growth were seen. We obtained abnormal values for serum iron, alkaline phosphatase, and total calcium. CONCLUSIONS: The presentation of LPL deficiency is heterogeneous during infancy. Close dietary monitoring is required to avoid nutritional deficiencies. Estrogen therapy should be avoided in LPL-deficient patients.

[Comparison of evaluation methods on changes of facial microcirculation during induction of motion sickness].

In order to increase the accuracy of motion sickness grading criteria, infrared thermography and Laser Doppler microcirculation blood-flow detector were used in 60 healthy male individuals: before, immediately, and 20 min after paralleled-swing stimulation. Facial skin temperature and microvessel blood-flow were recorded. The results showed that facial skin temperature and blood flow in facial microvessels fell together with the appearance of pallor. However, the degree of pallor observed with naked eye was inconsistent with that found by thermography or facial blood flow. It suggests that the accuracy of grading might be improved with the use of thermography or measurement of facial microvessel blood flow.

Visceral leishmaniasis in Pakistani children.

Visceral leishmaniasis is endemic in Pakistan. No studies of visceral leishmaniasis in childhood have been reported from Pakistan. We prospectively studied clinical and laboratory features in 58 Pakistani children with visceral leishmaniasis. Mean age of the children was 2.9 years. Fever, pallor, and abdominal distention were the most common clinical manifestations, and hematologic abnormalities were the most common laboratory findings. All children recovered after antimicrobial therapy. Pakistani children with visceral leishmaniasis tended to be younger than affected children from Africa and were less likely to have lymphadenopathy.

Autonomic changes during cancer chemotherapy induced nausea and emesis.

Certain autonomic variables have been shown to be responsive to motion induced nausea and vomiting. Here we report preliminary data on changes in heart rate, blood volume pulse, pallor and skin temperature assessed during a one hour period at baseline, a one hour period of peak nausea, and a one hour period of emesis in five female patients receiving identical cancer chemotherapy and antiemetic drugs according to a common protocol. Examination of coefficients of variation showed that heart rate and face temperature were more stable measures across each of the three time periods than blood volume pulse and pallor. Furthermore, the four measures were found to be more variable during times of emesis than times of nausea. The four measures were shown to be responsive to patient reported nausea and vomiting. Temperature and pallor showed a linear change from baseline to nausea to vomiting. Heart rate and blood volume pulse significantly decreased from baseline time during nausea and then significantly increased from a time of nausea to during emesis. Variations in the time course of each variable change during nausea supported a view that nausea may be more related to a rebound of parasympathetic activity than a slow decrease of sympathetic activity. Replication with larger samples is needed. Examination of the nausea and vomiting of pregnancy, general anaesthesia or different chemotherapeutic agents could help explore whether results reported here are singular or representative of a more generalisable autonomic response associated with patient reported nausea.

Spacelab experiments on space motion sickness.

Recent research results from ground and flight experiments on motion sickness and space sickness conducted by the Man Vehicle Laboratory are reviewed. New tools developed include a mathematical model for motion sickness, a method for quantitative measurements of skin pallor and blush in ambulatory subjects, and a magnitude estimation technique for ratio scaling of nausea or discomfort. These have been used to experimentally study the time course of skin pallor and subjective symptoms in laboratory motion sickness. In prolonged sickness, subjects become hypersensitive to nauseogenic stimuli. Results of a Spacelab-1 flight experiment are described in which four observers documented the stimulus factors for and the symptoms/signs of space sickness. The clinical character of space sickness differs somewhat from acute laboratory motion sickness. However SL-1 findings support the view that space sickness is fundamentally a motion sickness. Symptoms were subjectively alleviated by head movement restriction, maintenance of a familiar orientation with respect to the visual environment, and wedging between or strapping onto surfaces which provided broad contact cues confirming the absence of body motion.