Diagnostic Performance of Blood Pressure Measurement Modalities in Living Kidney Donor Candidates.

BACKGROUND AND OBJECTIVES: Precise BP measurement to exclude hypertension is critical in evaluating potential living kidney donors. Ambulatory BP monitoring is considered the gold standard method for diagnosing hypertension, but it is cumbersome to perform. We sought to determine whether lower BP cutoffs using office and automated BP would reduce the rate of missed hypertension in potential living donors. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We measured BP in 578 prospective donors using three modalities: (1) single office BP, (2) office automated BP (average of five consecutive automated readings separated by 1 minute), and (3) ambulatory BP. Daytime ambulatory BP was considered the gold standard for diagnosing hypertension. We assessed both the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7) and the American College of Cardiology/American Heart Association (ACC/AHA) definitions of hypertension in the cohort. Empirical thresholds of office BP and automated BP for the detection of ambulatory BP-diagnosed hypertension were derived using Youden index, which maximizes the sum of sensitivity and specificity and gives equal weight to false positive and false negative values. RESULTS: Hypertension was diagnosed in 90 (16%) prospective donors by JNC-7 criteria and 198 (34%) prospective donors by ACC/AHA criteria. Masked hypertension was found in 3% of the total cohort by JNC-7 using the combination of office or automated BP, and it was seen in 24% by ACC/AHA guidelines. Using Youden index, cutoffs were derived for both office and automated BP using JNC-7 (<123/82 and <120/78 mm Hg) and ACC/AHA (<119/79 and <116/76 mm Hg) definitions. Using these lower cutoffs, the sensitivity for detecting hypertension improved from 79% to 87% for JNC-7 and from 32% to 87% by ACC/AHA definition, with negative predictive values of 95% and 87%, respectively. Missed (masked) hypertension was reduced to 2% and 4% of the entire cohort by JNC-7and ACC/AHA, respectively. CONCLUSIONS: The prevalence of hypertension was higher in living donor candidates using ACC/AHA compared JNC-7 definitions. Lower BP cutoffs in the clinic improved sensitivity and led to a low overall prevalence of missed hypertension in prospective living kidney donors.

An unambiguous definition of pediatric hypotension is still lacking: Gaps between two percentile-based definitions and Pediatric Advanced Life Support/Advanced Trauma Life Support guidelines.

BACKGROUND: Data are lacking to provide cutoffs for hypotension in children based on outcome studies and Pediatric Advanced Life Support (PALS), and Advanced Trauma Life Support (ATLS) definitions are based on normal populations. The goal of this study was to compare different normal population based cutoffs including fifth percentile of systolic blood pressure (P5-SBP) in children and adolescents from the German Health Examination Survey for Children and Adolescents (KiGGS), US population data (Fourth Report), and cutoffs from PALS and ATLS guidelines. METHODS: Fifth percentile of systolic blood pressure according to age, sex, and height was modeled based on standardized resting oscillometric BP measurements (12,199 children aged 3-17 years) from KiGGS 2003-2006. In addition, we applied the age-adjusted pediatric shock index in the KiGGS study. RESULTS: The KiGGS P5-SBP was on average 7 mm Hg higher than Fourth Report P5-SBP (5-10 mm Hg depending on age-sex group). For children aged 3 to 9 years, KIGGS P5-SBP at median height follows the formula 82 mm Hg + age; for age 10 to 17 years, the increase was not linear and is presented in a simplified table. Pediatric Advanced Life Support/ATLS thresholds were between KiGGS and Fourth Report until age of 11 years. The adult threshold of 90 mm Hg was reached by KiGGS P5-SBP median height at 8 years, PALS/ATLS at age of 10 years, and Fourth Report P5-SBP at 12 years. The pediatric shock index, which is supposed to identify severely injured children, was exceeded by 2.3% nonacutely ill KiGGS participants. CONCLUSION: Our study shows that percentile cutoffs vary by reference population. The 90 mm Hg cutoff for adolescents targets only those in the less than 1% of the low SBP range and represents an undertriage compared with P5 at younger ages according to both KiGGS and Fourth Report. Finally, current pediatric shock index cutoffs when applied to a healthy cohort lead to a relevant percentage of false positives. LEVEL OF EVIDENCE: Epidemiologic/prognostic, level III.

Intradialytic hypotension related episodes identification based on the most effective features of photoplethysmography signal.

BACKGROUND AND OBJECTIVE: One of the most adverse conditions facing the hemodialysis patient is repetitive hypotension during their dialysis session. Different factors can be used to monitor patient conditions and prevent Intradialytic Hypotension (IDH) during hemodialysis. These factors include blood pressure, blood volume, and electrical Impedance factors. In this paper, pre-IDH and IDH episodes were recognized and classified by using the features of the finger photoplethysmography (PPG) signal. In other words, the goal of present study is to use PPG signal features to predict the risk of acute hypotension. METHODS: Since the PPG signal is non-stationary in nature, the main signal was divided in five-minute intervals with no overlap and then each interval was analyzed separately and fifteen PPG signal features in time and seven features in the frequency domain were extracted. Then different feature selection and classification methods were applied on the normalized feature matrix to select the best features and detect IDH and pre-IDH episodes in dialysis sessions. RESULTS: The best results were achieved from a genetic algorithm and AdaBoost. The obtained results on our developed database indicated that the mean and maximum accuracy of the proposed algorithm were 94.5 ±â€¯1.0 and 96.6 respectively. CONCLUSION: Some PPG signal features can be useful during hemodialysis session for hypotension management.

A functional supervised learning approach to the study of blood pressure data.

In this work, a functional supervised learning scheme is proposed for the classification of subjects into normotensive and hypertensive groups, using solely the 24-hour blood pressure data, relying on the concepts of Fréchet mean and Fréchet variance for appropriate deformable functional models for the blood pressure data. The schemes are trained on real clinical data, and their performance was assessed and found to be very satisfactory.

Hypotensive syndromes are not associated with cognitive impairment in geriatric patients.

To investigate the association of the hypotensive syndromes orthostatic hypotension (OH), postprandial hypotension (PPH), and carotid sinus hypersensitivity (CSH) with cognitive impairment (mild cognitive impairment/dementia). Continuous measurements of blood pressure (Finapres) were performed during active standing, meal test, and carotid sinus massage, among 184 elderly patients presenting with falls. Mild cognitive impairment (MCI) and dementia were diagnosed following a multidisciplinary assessment. The study design was a retrospective cohort study. The OH, PPH, and CSH were observed in 104 (58%), 108 (64%), and 78 (51%) patients, respectively. A total of 79 (43%) patients were cognitively impaired (MCI impairment n = 44; dementia n = 35). The prevalence of cognitive impairment varied little across the hypotensive syndromes (32%-43%) and was similar in patients with and without hypotensive syndromes (P = .59). In this geriatric population with a high prevalence of both hypotensive syndromes and cognitive impairment, patients with one or more hypotensive syndromes were not likely to have cognitive impairment.

The early flat anterior chamber after trabeculectomy: a randomized, prospective study of 3 methods of management.

PURPOSE: To evaluate prospectively 3 different approaches to the management of a flat anterior chamber (FAC) because of overfiltration in the early postoperative period after trabeculectomy. MATERIALS AND METHODS: Thirty-six eyes diagnosed with a FAC with total iridocorneal touch, but no lenticular touch (grade II) because of overfiltration in the first 14 days after trabeculectomy were randomized prospectively into 3 groups: group 1--anterior chamber reformation with viscoelastic substance; group 2--anterior chamber reformation with balanced salt solution and concurrent drainage of choroidal effusion; and group 3--pharmacologic therapy with atropine, phenylephrine, and in select cases oral acetazolamide. Outcome measures were visual acuity, amount of intraocular pressure (IOP) reduction, and achievement of predetermined target IOP. RESULTS: Treatment group 2 had a greater number of eyes with acuity decline of two or more lines relative to group 3 (P=0.04). Group 1 had more eyes with acuity decline of two or more lines relative to group 3, but this was not significant (P>0.05). CONCLUSIONS: For grade II FACs because of overfiltration in the early postoperative period after trabeculectomy, reformation of the anterior chamber with drainage of choroidal effusion may be associated with greater long-term trabeculectomy success, but is associated with greater visual acuity loss relative to medicinal therapy alone. Reformation with viscoelastic resulted in a trend toward lowest final IOP in comparison to medicinal therapy alone.

[Easy echo diagnosis for hypotension and shock].

Hypotension and shock can be classified as hypotension caused by reduced or maintained left ventricular (LV) ejection. Reduced left ventricular ejection can result from intrinsic left ventricular, aortic valve or mitral valve failure, which includes dilated or ischemic cardiomyopathy, left main trunk disease, acute myocarditis, etc. Acute and subacute severe aortic regurgitation can also cause shock. Echocardiography allows noninvasive diagnosis of infective endocarditis and Takayasu's arteritis to cause severe arotic regurgitation and can also be used to diagnose obstruction of the left ventricular outflow tract. Reduced left ventricular preload can be caused by pericardial effusion and right ventricular ejection failure, and can result from pulmonary embolism, tricuspid regurgitation, right ventricular infarction, tension pneumothorax, hypovolemia and others characterized by a small left ventricle with good ejection fraction. Normal left ventricular ejection may be associated with hypotension. Sepsis, anaphylactic shock and neural disorder are associated with hypotension and normal cardiac output. Pseudohypotension may result from aortic dissection, Takayasu's arteritis, arteriosclerosis obliterans and aortic coarctation. A right parasternal approach enables better visualization of the ascending aorta. Fundamental echochocardiographic scanning allows approximate yet useful diagnosis of hypotension and shock.

Let the surgeon sleep: trauma team activation for severe hypotension.

BACKGROUND: Trauma centers must balance the need to bring the full resources of the trauma center to the sickest patients emphasizing a need for personnel resource allocation. Our level I academic trauma center changed the systolic blood pressure (SBP) requirement for trauma team activation (TTA) from 90 mm Hg to 80 mm Hg. This investigation was undertaken to determine the effects of such change. METHODS: The hospital's trauma registry identified patients for two 18-month periods, pre and post the change in TTA criteria. Data elements included team activation level, emergency department length of stay, emergency department to operating room (OR) times, delay to OR, and Injury Severity Score. RESULTS: Full TTA decreased as did the percentage of cases with TTA. Eleven patients were identified in the SBP <80 mm Hg group who would have had TTA before the change. All 11 had timely trauma surgery consults. No delays to OR were related to TTA. The percentage of cases with laparotomy occurring >2 hours after arrival was unchanged. One hundred ninety fewer TTA were called in an 18-month period. Inpatient mortality between the two groups was not significantly changed. CONCLUSIONS: Changing criteria for TTA from SBP 90 mm Hg to <80 mm Hg preserves personnel without patient harm. Lowering the SBP for TTA is one method of preserving trauma surgery manpower.

Impacto do treinamento de força em circuito na pressão arterial de jovens / Impact of circuit strength training on blood pressure in adolescents

As investigações do comportamento cardiovascular após o treinamento de força são escassas em jovens...

Hypotension begins at 110 mm Hg: redefining "hypotension" with data.

BACKGROUND: Clinicians routinely refer to hypotension as a systolic blood pressure (SBP) < or =90 mm Hg. However, few data exist to support the rigid adherence to this arbitrary cutoff. We hypothesized that the physiologic hypoperfusion and mortality outcomes classically associated with hypotension were manifest at higher SBPs. METHODS: A total of 870,634 patient records from the National Trauma Data Bank with emergency department SBP and mortality data were analyzed. Patients (140,898) with severe head injuries, a Glasgow Coma Score < or =8, and base deficit (BD) <5, or missing data items were excluded from analysis. Admission BD, as a measure of metabolic hypoperfusion, was evaluated in 81,134 patients and mortality was plotted against SBP. RESULTS: Baseline mortality was <2.5%. However, at 110 mm Hg, the slope of the mortality curve increased such that mortality was 4.8% greater for every 10-mm Hg decrement in SBP. This effect was consistent to a maximum of 26% mortality at a SBP of 60 mm Hg. Hypoperfusion (change in the slope of BD curve) began to increase above baseline of 4.5 at a SBP 118 mm Hg. CONCLUSION: Taking the BD and mortality measurements together, this analysis shows that a SBP < or =110 mm Hg is a more clinically relevant definition of hypotension and hypoperfusion than is 90 mm Hg. This analysis will also be useful for developing appropriately powered studies of hemorrhagic shock.

Influence of definition and location of hypotension on outcome following severe pediatric traumatic brain injury.

OBJECTIVE: To examine the influence of definition and location (field, emergency department, or pediatric intensive care unit) of hypotension on outcome following severe pediatric traumatic brain injury. DESIGN: Retrospective cohort study. SETTING: Harborview Medical Center (level I pediatric trauma center), Seattle, WA, over a 5-yr period between 1998 and 2003. PATIENTS: Ninety-three children <14 yrs of age with traumatic brain injury following injury, head Abbreviated Injury Score > or = 3, and pediatric intensive care unit admission Glasgow Coma Scale score <9 formed the analytic sample. Data sources included the Harborview Trauma Registry and hospital records. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The relationship between hypotension and outcome was examined comparing two definitions of hypotension: a) systolic blood pressure <5th percentile for age; and b) systolic blood pressure <90 mm Hg. Hospital discharge Glasgow Outcome Score <4 or disposition of either death or discharge to a skilled nursing facility was considered a poor outcome. Pediatric intensive care unit and hospital length of stay were also examined. Systolic blood pressure <5th percentile for age was more highly associated with poor hospital discharge Glasgow Outcome Score (p = .001), poor disposition (p = .02), pediatric intensive care unit length of stay (rate ratio 9.5; 95% confidence interval 6.7-12.3), and hospital length of stay (rate ratio 18.8; 95% confidence interval 14.0-23.5) than systolic blood pressure <90 mm Hg. Hypotension occurring in either the field or emergency department, but not in the pediatric intensive care unit, was associated with poor Glasgow Outcome Score (p = .008), poor disposition (p = .03), and hospital length of stay (rate ratio 18.7; 95% confidence interval 13.1-24.2). CONCLUSIONS: Early hypotension, defined as systolic blood pressure <5th percentile for age in the field and/or emergency department, was a better predictor of poor outcome than delayed hypotension or the use of systolic blood pressure <90 mm Hg.

Crisis de Cianosis / Cyanosis of crisis

La crisis de cianosis son eventos hallados casi exclusivamente en la tetralogía de Fallot. Se caracterizan por irritabilidad, cianosis aguda y taquipnea. En situaciones más graves puede llevar a la hipotonía, pérdida de conocimiento, convulsiones, accidente cerebrovascular y muerte. Es el evento más grave de laTetralogía de Fallot. Se observa en 30 por ciento de estos pacientes, mayormente entre los 3 y 5 meses de edad. Se basa fisiopatológicamente en una disminución brusca del flujo pulmonar (generalmente por espasmos infundibular) y aumento del cortocircuito derecha izquierda, con paso de la sangre insaturada al circuito sistémico. Puede ser desencadenado por disminución de la resistencia vascular periférica (hipotensiónarterial, deshidratación), irritación, aumento de la presión pulmonar, etc

Crisis de Cianosis / Cyanosis of crisis

La crisis de cianosis son eventos hallados casi exclusivamente en la tetralogía de Fallot. Se caracterizan por irritabilidad, cianosis aguda y taquipnea. En situaciones más graves puede llevar a la hipotonía, pérdida de conocimiento, convulsiones, accidente cerebrovascular y muerte. Es el evento más grave de laTetralogía de Fallot. Se observa en 30 por ciento de estos pacientes, mayormente entre los 3 y 5 meses de edad. Se basa fisiopatológicamente en una disminución brusca del flujo pulmonar (generalmente por espasmos infundibular) y aumento del cortocircuito derecha izquierda, con paso de la sangre insaturada al circuito sistémico. Puede ser desencadenado por disminución de la resistencia vascular periférica (hipotensiónarterial, deshidratación), irritación, aumento de la presión pulmonar, etc

Low blood pressure and the risk of dementia in very old individuals.

BACKGROUND: The role of blood pressure (BP) as a risk factor for dementia is complex and may be age dependent. In very old individuals, low BP might increase risk for dementia, perhaps by reducing cerebral perfusion pressure. METHODS: The association between BP and dementia was examined in the Bronx Aging Study, a prospective study of 488 community-dwelling elderly individuals over age 75, dementia-free at baseline (1980 to 1983) and followed at 12- to 18-month intervals. Subjects with baseline BP and with at least one follow-up visit were included (n = 406). Incident dementia was diagnosed using the criteria of the Diagnostic and Statistical Manual of Mental Disorders (3rd rev. ed.). RESULTS: Over 21 years (median 6.7 years), 122 subjects developed dementia (65 Alzheimer's disease [AD], 28 vascular dementia, 29 other dementias). Relative risk of dementia increased for each 10-mm Hg decrement in diastolic (hazard ratio [HR] 1.20, 95% CI 1.03 to 1.40) and mean arterial (HR 1.16, 95% CI 1.02 to 1.32) pressure, adjusted for age, sex, and education. Low diastolic BP significantly influenced risk of developing AD but not vascular dementia. Upon examination of groups defined by BP, mildly to moderately raised systolic BP (140 to 179 mm Hg) was associated with reduced risk for AD (HR vs normal systolic BP group 0.55, 95% CI 0.32 to 0.96), whereas low diastolic BP (

Influencia de la aplicación de un protocolo de actuación en el tratamiento de los traumatismos abdominales cerrados / Influence of the application of a management protocol in the treatment of blunt abdominal trauma

Introducción. El manejo del traumatismo abdominal cerrado ha variado mucho en los últimos años. Material y métodos. Estudiamos la aplicación de un protocolo prospectivo a los pacientes con traumatismo abdominal cerrado durante un año, con el objetivo de evaluar la utilidad del tratamiento no operatorio y su influencia en la morbimortalidad. Todos los pacientes atendidos siguiendo dicho protocolo fueron comparados con un grupo de pacientes previo. Resultados. Durante el período de estudio prospectivo, 65 pacientes fueron ingresados con traumatismo abdominal cerrado (grupo prospectivo [P]). Durante el período previo fueron atendidos 77 pacientes (grupo retrospectivo [R]). No hubo diferencias significativas entre ambos grupos en cuanto al sexo, la edad, la escala HIS (Haemodynamic Injury Scale) o el mecanismo de lesión. El 55 por ciento de los pacientes del grupo R fue intervenido, mientras que en el grupo P se intervino al 25 por ciento (p = 0,0005). Entre los pacientes con lesión esplénica, en el grupo R fue intervenido el 85 por ciento, mientras que en el grupo P sólo el 50 por ciento (p = 0,03). Entre los pacientes con lesiones hepáticas fue intervenido el 70 por ciento en el período R y sólo el 16 por ciento en el período P (p = 0,05). No hubo diferencias significativas entre los grupos R y P en la estancia hospitalaria, la estancia en UCI, la transfusión y la mortalidad hospitalaria. Conclusiones. La aplicación de un protocolo de manejo de los pacientes con traumatismo abdominal cerrado permite el tratamiento no operatorio en la mayoría de los casos sin aumentar la morbimortalidad, la estancia hospitalaria o los requerimientos transfusionales, evitando la morbilidad ocasionada por la propia cirugía. (AU)

Near-drowning and drowning classification: a proposal to stratify mortality based on the analysis of 1,831 cases.

STUDY OBJECTIVE: To establish an updated classification for near-drowning and drowning (ND/D) according to severity, based on mortality rate of the subgroups. MATERIALS AND METHODS: We reviewed 41,279 cases of predominantly sea water rescues from the coastal area of Rio de Janeiro City, Brazil, from 1972 to 1991. Of this total, 2,304 cases (5.5%) were referred to the Near-Drowning Recuperation Center, and this group was used as the study database. At the accident site, the following clinical parameters were recorded: presence of breathing, arterial pulse, pulmonary auscultation, and arterial BP. Cases lacking records of clinical parameters were not studied. The ND/D were classified in six subgroups: grade 1--normal pulmonary auscultation with coughing; grade 2--abnormal pulmonary auscultation with rales in some pulmonary fields; grade 3--pulmonary auscultation of acute pulmonary edema without arterial hypotension; grade 4--pulmonary auscultation of acute pulmonary edema with arterial hypotension; grade 5--isolated respiratory arrest; and grade 6--cardiopulmonary arrest. RESULTS: From 2,304 cases in the database, 1,831 cases presented all clinical parameters recorded and were selected for classification. From these 1,831 cases, 1,189 (65%) were classified as grade 1 (mortality=0%); 338 (18.4%) as grade 2 (mortality=0.6%); 58 (3.2%) as grade 3 (mortality=5.2%); 36 (2%) as grade 4 (mortality=19.4%); 25 (1.4%) as grade 5 (mortality=44%); and 185 (10%) as grade 6 (mortality=93%) (p<0.000001). CONCLUSION: The study revealed that it is possible to establish six subgroups based on mortality rate by applying clinical criteria obtained from first-aid observations. These subgroups constitute the basis of a new classification.

[The problem of the rational correction of arterial dystonia]. / Problema ratsional'noi korrektsii arterial'noi distonii.

An original classification is suggested of arterial dystonia, based on comparison of systolic to diastolic pressure ratios. There has been performed an analysis of effects of different drug preparations (including trace elements and vegetable drugs) tried separately on maximum and minimum arterial pressure.