2012年 · 第125卷第20期

In the last decade,the 2000,2005 and 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care were issued based on an increasing amount of basic and clinical research.The issue and promotion of the new guidelines have caused worldwide discussion,as well as controversy.These guidelines have greatly changed clinicians' understanding of CPR and also promoted further research and development of CPR in China。

Abstract：Background The influences of intrathoracic pressure (ITP) to hemodynamic and respiratory parameters during cardiopulmonary resuscitation (CPR) are confusing.In this research,we investigated the phasic changes of ITP during CPR and reveal the relationships among the hemodynamics,respiratory parameters,and ITP.Methods After 8 minutes of untreated ventricular fibrillation,which was induced in twenty intubated male domestic pigs,12 minutes of 30:2 CPR was performed.Continuous respiratory variables,hemodynamics,ITP and blood gas analysis were measured during CPR.After that,defibrillation was done and prognostic indicators after CPR was recorded.Results Average ITP at baseline was -(14.1±1.6) mmHg (1 mmHg=0.133 kPa).When gasping inspirations were going on,it decreased sharply to near -50 mmHg.ITP fluctuated up and down quickly from near -20 mmHg to 20 mmHg when compressions were performed.These phasic changes became mild as the CPR was performed,the contrast of high and low ITP decreased to (12.95±2.91) mmHg at the end of 12 minutes of CPR.Total alveolus minute volume decreased too,because of the decrease of compression and gasp related ventilations.Curve correlation was found between the tidal volume of compression and ITP:ITP=607.33/(1+3134×e-0.58×TV),(e:natural constant,R2=0.895).Negative correlations were found between the right atrial diastolic pressure and ITP (r=-0.753,P ＜0.01); and positive correlations were found between the coronary perfusion pressure and ITP (r=-0.626,P＜0.01 ).Conclusions ITP is one of the key factors which can influence the prognosis of CPR.Correlations were found between the changes of ITP and the tidal volumes of compressions,right atrial diastolic pressure and coronary perfusion pressure during CPR.More positive ITP during compression and more negative during decompression were good to ventilation and perfusion。

Abstract：Background Respiratory failure is the main cause of death in acute organophosphorus pesticide poisoning.In this study,a pulse-induced contour cardiac output monitor was used to evaluate the respiratory status in a pig model of acute dichlorvos poisoning.Methods Twenty female pigs were randomly allocated to dichlorvos (n=7),atropine (n=7),and control (n=6) groups.In the dichlorvos group,pigs were administered 80％ emulsifiable dichlorvos (100 mg/kg) via a gastric tube.In the atropine group,pigs were similarly administered dichlorvos,and 0.5 hours later,atropine was injected to attain and maintain atropinization.The control group was administered saline solution.Arterial blood gas was measured at 0,0.5,1,2,4,and 6 hours post-injection.The extravascular lung water index and pulmonary vascular permeability index were recorded by the pulse-induced contour cardiac output monitor.At termination of the study,the animals were euthanized,the lung wet-to-dry weight ratio was determined,and histopathology was observed.Results In the dichlorvos group,the extravascular lung water index and pulmonary vascular permeability index were substantially increased from 0.5 hours and were particularly high within 1 hour.In the atropine group,these indices increased initially,but decreased from the 1-hour mark.The control group exhibited no obvious changes.In both the dichlorvos and atropine groups,the extravascular lung water index was negatively correlated with partial pressure of oxygen/fraction of inspiration oxygen (PO2/FiO2) and positively correlated with the pulmonary vascular permeability index.Compared with the control group,the lung wet-to-dry weight ratio markedly increased and the histopathological findings obviously changed in the dichlorvos group,but only mildly increased and changed,respectively,in the atropine group.Conclusion The extravascular lung water index is an appropriate and valuable parameter for assessment of respiratory function in acute dichlorvos poisoning。

Abstract：Background In recent years,the incidence of unexplained sudden death has risen significantly across the world.However,it occurred suddenly,often in young apparently healthy individuals and almost 50％ of the patients did not have any warning signals or symptoms.Therefore,the prodromal symptoms before the incident are extremely important for early prediction of sudden death.In this article,we aimed to explore the value of prodromal symptoms for unexplained sudden death and whether the prodromal symptoms have a predictive function to unexplained sudden death (USD)without underlying diseases.Methods A total of 208 sudden death cases were selected for the survey in the Emergency Department of Peking University Third Hospital from January 2006 to December 2009 and their medical records were reviewed.The patients were divided into two groups,65 patients had underlying diseases while 143 had not underlying diseases.In the meantime,their prodromal symptoms were collected and compared,prodromal symptoms including chest distress,dyspnea,syncope,fever,headache,vomiting,etc.Results Patients with underlying diseases were compared to those without underlying diseases associated with sudden death; there was no significant difference in gender and age distribution.Among the 208 cases,39 cases (18.75％) had prodromal symptoms,patients with underlying diseases had prodromal symptoms in 12 cases (18.46％),while patients without underlying diseases had prodromal symptoms in 27 cases (18.88％).The difference between the two groups with prodromal symptoms was not statistically significant(P＞0.05).Conclusions Prodromal symptoms are extremely important warning signals in the occurrence of USD.It has equally important predictive value for patients both with and without underlying diseases,especially in predicting sudden death caused by cardiopulmonary and neurological diseases。

Abstract：Background The European System for Cardiac Operative Risk Evaluation (EuroSCORE) is one of the most widely used risk models for the predicting mortality after cardiac surgery.The aim of this study was to validate the EuroSCORE model for predicting operative mortality in heart valve surgery on a Chinese multicenter database and comparing the performance of EuroSCORE with our new risk stratification system,the Sino System for Coronary Operative Risk Evaluation (SinoSCORE).Methods Data from patients undergoing heart valve surgery between January 2007 and December 2008 were retrospectively collected,from 43 hospitals in China.The EuroSCORE and the SinoSCORE were calculated for each patient.Mortality was defined as any in-hospital death.Area under the receiver operating characteristics curve (AUG)was used to study the discriminatory abilities of the models.The Hosmer-Lemeshow (H-L) goodness-of-fit test was used to study the calibration of the predictive models.Results A total of 15 367 patients were analyzed.For the entire cohort,the observed mortality was 2.34％,the predicted mortality was 3.71％ (additive),3.19％ (logistic) and 3.66％ (SinoSCORE).AUC was 0.747 for SinoSCORE,0.699 additive and 0.696 for logistic EuroSCORE.Calibration of SinoSCORE and additive EuroSCORE was good (H-L:P=0.250 and P=0.051,respectively),but the logistic EuroSCORE model had a poor calibration (H-L:P＜0.05).The discriminatory ability and calibration of the SinoSCORE were good in low- and high-risk patients.However,the discriminatory ability of the EuroSCORE model was poor in all risk deciles.Conclusions The EuroSCORE does not accurately predict mortality in Chinese patients with heart valve surgery,and the SinoSCORE is superior to the EuroSCORE at predicting in-hospital mortality in Chinese heart valve surgery patients。

Abstract：Background Neural respiratory drive is usually measured during inspiration,even in patients with chronic obstructive pulmonary disease (COPD) in whom the primary physiological deficit is expiratory flow limitation.The purpose of the study was to test the hypothesis that inspiratory muscle neural respiratory drive could be used to assess expiratory load.Methods Ten healthy young men,(26±4) years old,were asked to expire through a tube immersed in water where an expiratory load was required.The load was judged by the depth of the tube in water and the different loads (0 cmH2O,10 cmH2O,20 cmH2O and 30 cmH2O) were randomly introduced.Each expiratory load lasted for 3-5 minutes and inspiration was unimpeded throughout.Diaphragm electromyogram (EMG) and transdiaphragmatic pressure were recorded by a catheter with 10 metal coils and two balloons.Incremental cycle exercise with and without an expiratory load at 30 cmH2O was also performed.Results Neural drive during expiratory loaded breathing was larger than during unloaded breathing but neural drive did not increase proportionally with increasing expiratory load; neural drive during expiratory loading at 0,10,20 and 30 cmH2O was (10.1±3.1) μV,(16.7±7.3) μV,(18.4±10.7) μV and (22.9±13.2) μV,respectively.Neural drive as a percentage of maximum at the end of exercise with or without load was similar ((57.4±11.0)％ max vs.(62.7±16.4)％ max,P ＞0.05).Conclusion Neural respiratory drive measured at inspiration does not accurately quantify expiratory load either at rest or during exercise。

Abstract：Background Parapharyngeal lymph node (PPLN) metastasis from thyroid carcinoma is rare.We describe the clinical features,diagnosis,and surgical treatment of this condition.Methods Twenty-five patients with PPLN metastasis from thyroid carcinoma were treated at our institution from January 1999 to December 2010,including 22 patients with papillary carcinoma,two with medullary carcinoma,and one with follicular carcinoma.Of these,16 had a history of surgical treatment prior to PPLN metastasis.Of the nine patients without a history of surgical treatment,five had widespread cervical lymph node metastases and four had occult papillary thyroid carcinoma.PPLN metastasis was diagnosed by enhanced computed tomography in 22 cases.Results Resection of metastases was performed via a transcervical approach in 23 patients and a transmandibular approach in two patients.After a median follow-up time of 31 months (range:6-130 months),nine patients developed distant metastases,and six of these died of their disease.The 5-year survival rate was 63.8％.Conclusions PPLN metastasis from thyroid carcinoma may occur in patients:with previous neck dissection,with widespread metastases to cervical lymph nodes prior to initial treatment,and with occult thyroid carcinoma.Enhanced computed tomography is helpful for diagnosis in the first two presentations.Surgical resection remains the mainstay of treatment for this disease.PPLN metastasis has a tendency to be associated with distant metastases and a poor prognosis。

Abstract：Background Hepatic arterial infusion chemotherapy for liver metastases is under evaluation because of the high target dose and low general toxicity.To investigate the efficacy and safety of a Folfox4 regimen administered through a combined hepatic arterial and systemic infusion for the first-line treatment of colorectal cancer (CRC) with unresectable liver metastases.Methods Twenty-seven CRC patients with unresectable hepatic metastases and no prior chemotherapy were enrolled into the study They received a Folfox4 regimen; 1st day:HA(I) of oxaliplatin 85 mg/m2 and L-folinic acid 200 mg/m2,followed by a bolus hepatic arterial injection of 5-fluorouracil 400 mg/m2,then continuous HAl of 5-FU 600 mg/m2; 2nd day:infusion of L-folinic acid 200 mg/m2 i.v.followed by an intravenous bolus injection of 5-Fluorouracil 400 mg/m2,then　continuous infusion of 5-fluorouracil 600 mg/m2 i.v.The patients received HA(I) during the odd cycles,and the intravenous administration of the same Folfox4 regimen during the even cycles.Results A total of 236 treatment cycles were given with a median of 10 cycles.The therapy generated the following results after six treatment cycles:complete response (CR) 1/27 (3.7％),partial response (PR) 17/27 (63.0％),stable disease (SD) 6/27 (22.2％),and progress disease (PD) 3/27 (11.1％).Five patients had hepatectomy.The serum levels of both carcinoembryonic antigen (CEA) and CA19-9 were significantly reduced (P＜0.05).A median time to progression of 11 months and a median overall survival of 24 months were documented.The major adverse events included grade 1/2 nausea/vomiting,upper abdominal pain,peripheral neuropathy,and neutropenia/thrombocytopenia.Conclusions The Folfox4 regimen administered through combined hepatic arterial and systemic infusions is efficacious and safe for the treatment of CRC with unresectable liver metastases,and it facilitates the control of local lesions。

Abstract：Background Estrogen deficiency results in loss of bone mass.Phytoestrogens are plant-derived non-steroidal compounds with estrogen-like activity that bind to estrogen receptors.The main aim of this study was to investigate the effect of the phytoestrogen puerarin on adult mouse osteoblasts.Methods Osteoblast cells were harvested from 8-month old female imprinting control region (ICR) mice.The effects of puerarin stimulation on the proliferation,differentiation and maturation of osteoblasts were examined.The production of nitric oxide (NO) and the expression of bone morphogenetic protein-2 (BMP-2),SMAD4,mitogen-activated protein kinases (MAPK),core binding factor α1/runt-related transcription factor 2 (Cbfa1/Runx2),osteoprotegerin (OPG),and receptor activator of NF-kB ligand (RANKL) genes were analyzed.The activation of signal pathways was further confirmed by specific pathway inhibitors.Results The osteoblast viability reached its maximum at 10-8 mol/L puerarin.At this concentration,puerarin increases the proliferation and matrix mineralization of osteoblasts and promotes NO synthesis.With 10-8 mol/L puerarin treatment,BMP-2,SMAD4,Cbfa1/Runx2,and OPG gene expression were up-regulated,while the RANKL gene expression is down-regulated.Concurrent treatment involving the (bone morphogenetic protein) BMP antagonist Noggin or the NOS inhibitor L-NAME diminishes puerarin induced cell proliferation,Alkaline phosphatase (ALP) activity,NO production,as well as the BMP-2,SMAD4,Cbfa1/Runx2,OPG,and RANKL gene expression.Conclusions In this in vitro study,we demonstrate that puerarin is a bone anabolic agent that exerts its osteogenic effects through the induction of BMP-2 and NO synthesis,subsequently regulating Cbfa1/Runx2,OPG,and RANKL gene expression.This effect may contribute to its induction of osteoblast proliferation and differentiation,resulting in bone formation。

Abstract：Background The control of blindness in children is a high priority within the VISION 2020 initiative.To determine the causes of severe visual impairment and blindness in children from Shanghai Blind Children School (SBCS) can provide useful information on childhood blindness in Shanghai.Methods A cross-sectional investigation of students in SBCS was conducted in May 2010.The World Health Organization/Prevention of Blindness (WHO/PBL) eye examination record system for children with low vision and blindness was used.The results were further compared with the findings of two previous investigation studies conducted in 1986 and 2004,respectively in SBCS.Results Of the 146 children observed,80 children (54.8％) were blind (best corrected best visual acuity less than 0.05),27 children (18.5％) had severe visual impairment (best corrected visual acuity less than 0.1 but better than or equal to 0.05),and 34 children (23.3％) had moderate visual impairment (best corrected visual acuity less than 0.3 but better than or equal to 0.1).The major affected anatomic sites in the 107 children with severe visual impairment and blindness (SVI/BL) were retina (47.7％),whole globe (16.8％),optic nerve (13.1％) and lens (9.3％).The leading causes of SVI/BL were retinopathy of prematurity (ROP,25.2％),followed by retinal dystrophy (15.9％),optic nerve atrophy (9.3％) and microphthalmos (9.3％).The two leading etiologic categories of SVI/BL were perinatal/neonatal (36.4％) and congenital/hereditary groups (29.0％).The leading cause of moderate visual impairment was aphakia after cataract surgery (congenital cataract,44.1％).Compared with the findings in two previous investigations in SBCS,the proportion of ROP in visual impairing diseases increased,while the proportion of disorders of the lens (cataract and aphakia)significantly decreased.Conclusions The leading cause of childhood blindness in SBCS nowadays is ROP.It is projected that without improvement in perinatal medical care that ROP will continue to be a major cause of childhood blindness。

Abstract：Background Clinical practice guidelines (CPGs) play an important role in healthcare in China as well as in the world.However,the current status and trends of Chinese CPGs are unknown.The aim of this study was to systematically review the present situation and the quality of Chinese CPGs published in the peer-reviewed medical literature.Methods To identify Chinese CPGs,a systematic search of relevant literature databases (CBM,WANFANG,VIP,and CNKI) was performed for the period January 1978 to December 2010.We used the AGREE Ⅱ instrument to assess the quality of the included guidelines.Results We evaluated 269 guidelines published in 115 medical journals from 1993 to 2010 and produced by 256different developers.Only four guidelines (1％) described the systematic methods for searching and selecting the evidence,14 (5％) guidelines indicated an explicit link between the supporting evidence and the recommendations,only one guideline used the Grading of Recommendations Assessment,Development and Evaluation (GRADE) system.Thirty-one guidelines (12％) mentioned updates and the average frequency of update was 5.5 years; none described a procedure for updating the guideline.From the assessment with the Appraisal of Guidelines for Research and Ecaluation Ⅱ (AGREE Ⅱ),the mean scores were low for the domains "scope and purpose" (19％) and "clarity of presentation" (26％)and very low for the other domains ("rigour of development" 7％,"stakeholder involvement" 8％,"applicability" 6％ and "editorial independence" 2％).Conclusions Compared with other studies on the quality of guidelines assessed with the AGREE instrument in other countries,Chinese CPGs received lower scores,which indicates a relatively poor quality of the guidelines.However,there was some increase over time。

Abstract：Background The recurrence of pterygium after surgery is high.A variety of adjunctive treatment approaches have been developed to improve the clinical efficacy and many related articles have been published.This study aimed to determine the risk for postoperative pterygium recurrence comparing autologous conjunctival transplantation (ACT)versus mitomycin C (MMC).Methods Relevant literature published until December 2010 in Medline,Embase,Cochrane,Cochrane library,Science Citation Index,and Google Scholar were searched.Qualified random clinical trial (RCT) studies on the comparison of recurrence rate of pterygium after ACT and MMC treatment were included in this study.Results Eight RCTs with 663 eyes entered the final analysis.The recurrent rate of pterygium was 8.7％ (30/343) for ACT and 18.75％ (60/320) for MMC.Using fixed-effect meta analysis,we found that the recurrence was significantly lower after ACT than MMC treatment (odds ratio (OR)=0.40,95％ confidence index (CI),0.25-0.63,P ＜0.0001).In sensitivity analyses,we employed random-effects model and excluded studies of low quality or studies in which MMC was administrated after the operation.All the sensitivity analyses confirmed that ACT led to lower recurrence rates than MMC.Sub-group analysis revealed that the recurrence rate was 20.2％ (20/99) and 27.65％ (26/94) for conjunctival autograft (CA) and MMC respectively,and no significant difference in the recurrence rate was detected (OR=0.65,95％CI 0.33-1.28,P=0.22).However,we found that conjunctival limbal autograft (CLA) had lower recurrence rate than MMC (OR=0.26,95％ CI 0.14-0.48,P=0.0001).Conclusion CLA has better therapy efficacy against the recurrence of pterygium than MMC。

Abstract：Objective This article aimed to review the biological characteristics of enhancer of zests homolog 2 (EZH2),and the transcriptional repression mechanism of action of EZH2 in tumors,particularly in the progression of lymphoma.Data sources The data cited in this review were mainly obtained from the articles listed in PubMed and HighWare that were published from March 2004 to April 2012.The search terms were "enhancer of zests homolog 2","polycomb group",and "lymphoma".Study selection Articles regarding the mechanism of EZH2 in post-transcriptional modification,functions of polycomb group proteins,and the roles of EZH2 in lymphoma were selected.Results EZH2 acts as oncogene and involved in many kinds of tumors.Moreover,it plays an important role in tumorigenesis and lymphomagenesis by promoting the proliferation and aggressiveness of neoplastic cells,facilitating malignant tumor cell diffusion,and mediating transcriptional silencing.Conclusion EZH2 mediated transcriptional repression through its methyltransferase activity at the chromatin level has certain influence on lymphoma,and there might exist a therapeutic window for the development of new agents and identification of novel diagnostic markers based on EZH2。

Abstract：Background There is no consensus regarding the performance for endorectal ultrasonography (ERUS) at every stage of rectal cancer.Thus,the purpose of our study was to further assess the value of ERUS in the preoperative staging of rectal cancer.Methods A retrospective study was performed with 44 consecutive patients (mean age:(63.3±10.2) years) who underwent surgical treatment for endorectal carcinoma and were preoperatively evaluated using Biplane ERUS between September 2008 and December 2010.We compared the ERUS staging with the pathological findings based on surgical specimens.Results ERUS staging agreed with the histologic staging in 39 of the 44 (88.6％) patients:the agreement on the depth of transmural invasion was good (k=0.73; 95％ CI:0.60-0.86,P =0000).The detection sensitivities of rectal cancer with FRUS were as follows:T1 85.7％,T2 87.5％,T3 88.9％,and T4 100.0％ with specificity values of T1 97.3％,T2 92.9％,T3 96.2％,and T4 97.6％.ERUS correctly staged patients with T1 95.5％,T2 90.9％,T3 70.5 ％,and T4 97.7％ The positive predictive value of ERUS was lowest for T4 (75％),but highest for T3 (94.1％) followed by T2 (87.5％) and T1(85.7％); the negative predictive values of ERUS from high to low were ordered as T4 (100％),T1 (97.3％),T2 (92.9％),and T3 (92.6％).The percentage of total over-staged cases was 4.5％ and the under-staged cases was 6.8％.The extent of perirectal lymph node metastases was determined with a sensitivity of 68.4％ (13/19),specificity of 80.0％ (20/25),and diagnostic accuracy of 75.0％ (33/44).Conclusion Biplane ERUS has a high diagnostic accuracy for tumoral invasion of the rectal wall at every T stage,but relatively low diagnostic accuracy for lymph node metastases。

Abstract：Background Appendectomy is the traditional surgical procedure for correcting torsion of the adnexa.Although it prevents pulmonary embolism,ovarian necrosis,and secondary infection,it can have cdtical adverse effects on the ovanan function.Methods We performed surgery for adnexal torsion in 12 patients,using high ligation of the ovarian vein,followed by removal of the ovarian tumor.Results Blood flow in the residual ovary gradually returned to normal within 1-3 months,and a dominant follicle could be seen in the residual ovary within 2-6 months post-surgery in all the 12 cases.Menstruation recovered in these three cases within 2-3 months.Postoperative intrauterine pregnancies occurred in two cases,with a corpus luteum graviditatis in the residual ovary in one case,while the other patient underwent labor after 13 months and a normal ovary on the affected side was seen at cesarean section.Conclusions This new surgical technique involving high ligation of the ovarian vein for adnexal torsion allowed successful preservation of the residual ovary and ovarian blood distribution,and can thus be used for the treatment of primary diseases of the ovary.The surgical procedure is simple,safe,and effective,and warrants extensive application in clinical practice。

Abstract：Currently,pediatric emergency medicine (PEM) as practiced in many developed countries is different from ours in China.Chinese pediatric emergency medicine is just children's internal medicine and does not include general surgery,ear-nose-throat,etc.If children have an emergency condition that require specialized treatments they need to go to different departments.However in Canada,the pediatric emergency physicians will first treat the patients whatever the condition,then,if it is a complicated sub specialty problem,they will consult the specialist or let the patient see the specialist later.In addition,resuscitation is done in the pediatric intensive care unit (PICU) in China,but it is done in the emergency room in Canada.This article compares the differences in the pediatric emergency systems in Canada and China and also introduces the international standard system of pediatric triage。

Abstract：We report a case of severe hyponatremia related to duloxetine and ziprasidone.A 50-year-old woman on duloxetine and ziprasidone treatment for major depressive disorder developed polydipsia,polyuria,and two episodes of seizures,followed by admission to the emergency department on the 10th day of treatment.Laboratory investigations revealed elevated creatine kinase (CK) as well as hyponatremia,hypo-osmolality,and increased urine sodium.Syndrome of Inappropriate Antidiuretic Hormone (SIADH) was considered,although urine osmolality was not measured.Duloxetine and ziprasidone were discontinued and the CK gradually normalized after correction of hyponatremia Clinicians should be aware of the possibility of antipsychotic-induced hyponatremia,particularly in patients with symptoms of polydipsia。

Abstract：A patient presented with a large pericardial tumor of uncertain etiology.Five years earlier,she had been treated for myxoid liposarcoma of the thigh.For pre-surgical evaluation,conventional radiography,positron emission tomography/computed tomography (PET/CT),magnetic resonance imaging (MRI),CT of the heart,transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) were performed.The final histopathologic diagnosis was metastatic liposarcoma.Each of the imaging modalities used had advantages and disadvantages,and their coordination was necessary for optimal evaluation。

A 58-year old male patient was admitted to our hospital with repeated coughing,expectoration with blood in the sputum for more than 10 months,bilateral wrists and ankles with pain and afternoon low fever,chest tightness and shortness of breath in the latest one month.The patient had a history of joint pain for more than 3years without special treatment.He had a smoking history for more than 30 years with 10 cigarettes a day.He had no family tumor history.Physical examination:T 38.5℃,P 100/min,R 22/min,blood pressure (BP) 107/77 mmHg;the double upper fingers visible clubbing,bilateral supraclavicular lymph node not feelable,left inferior pulmonary respiratory sounds disappeared,and wet and dry sounds not heard。

Dengue is an important mosquito-borne disease,caused by one of the four serotypes of dengue virus.According to the reports from the World Health Organization,every year 50 to 100 million infections occur,including 500 000 dengue hemorrhagic fever cases and 22 000 deaths,mostly among children.1 The main features of severe infection are hypotension,fluid leak and shock.Management of dengue shock syndrome and its pathophysiology are not fully understood.We reported two patients with dengue who developed hypotension without considerable fluid accumulation in the third space and explaining an alternative cause for hypotension in these patients。

Coats' disease is characterized by the formation of telangiectatic and microaneurysms changes of the retinal vessels and a large amount of yellowish subretinal exudates but without appreciable signs of retinal or vitreal traction.1 It usually occurs unilaterally and mainly in young males.According to the appearance of the fundus,Coats' disease has been classified as stage 1-5.2 The age at diagnosis has been as young as 3 months in one case,3who was a premature and low-birth-weight infant and suffered from stage 2 Coats' disease。