Evaluation and outcome of emergency room patients with transient loss of consciousness

The clinical and demographic features of dizziness related to general health among the Saudi population

[Purpose] The purpose of this study was to determine the validity, demographic features of the newly developed Amer Dizziness Diagnostic Scale (ADDS), provide differential diagnosis of the vestibular disorders, assist in the clinical research and practice activities of health workers as well as to understand the probability of the utilization of the ADDS as a first-line evaluation tool in general clinical practice. [Subjects and Methods] Two hundred subjects of various ages including both male and female patients with a history of vertigo and/or dizziness were included in the study and evaluated once using the ADDS. [Results] There were more female (59.5%) than male (49.5) patients in this study. Additionally, we found that most patients (64.4%) had a central mediated problem. In addition, the Amer Dizziness Diagnostic Scale has been found to have both a sensitivity and specificity of 96% that can adequately determine the possible diagnosis of vestibular disorders. [Conclusion] This study has demonstrated the validity of the ADDS scale, the predominance of female involvement related to supplementary medication, vitamin D deficiency, general lifestyle factors, and fluid retention, high sensitivity and specificity, provide differential diagnosis of vestibular disorders that could be used as a first-line evaluation tool in general clinics.

Bias in counseling of seizure patients following a transient impairment of consciousness: differential adherence to driver fitness guidelines

PURPOSE

To determine primary care physicians' counseling as well as patients' driving behaviors following seizure and non-seizure events impairing consciousness in the community.

METHODS

Patients attending a rapid-referral first seizure clinic were entered into the study if they were deemed medically-unfit to drive according to national guidelines for driving licensure: had experienced a seizure or an unexplained episode of lost consciousness, and had a valid driver's license at the time of their index event. Risk of physician counseling in the community regarding driving cessation in the interval between initial primary care assessment and neurological consultation was examined as a primary outcome, and patient driving cessation was examined as a secondary outcome.

RESULTS

106 of 192 (55%) patients attending clinic met guideline criteria requiring driver fitness counseling in the primary care community, and 89 patients (46%) were deemed medically-unfit to drive following the initial specialist consultation appointment. Among medically unfit driver cases, 73% were ultimately deemed to have experienced a seizure and 27% had experienced a non-seizure event (e.g. syncope, PNES). Driver fitness counseling was more likely for seizure than non-seizure cases (unadjusted odds ratio: 4.14, p<0.05), as was patient driving cessation (5.10, p<0.05).

CONCLUSION

Physician compliance with clinical practice guidelines appears strongly biased when counseling about driving following an episode of transient impairment in consciousness. The failure of the primary care medical community to apply driver fitness counseling equitably to both seizure and non-seizure drivers may have ramifications upon public safety or conversely disease-related quality-of-life.

Priorities for emergency department syncope research

STUDY OBJECTIVES

There is limited evidence to guide the emergency department (ED) evaluation and management of syncope. The First International Workshop on Syncope Risk Stratification in the Emergency Department identified key research questions and methodological standards essential to advancing the science of ED-based syncope research.

METHODS

We recruited a multinational panel of syncope experts. A preconference survey identified research priorities, which were refined during and after the conference through an iterative review process.

RESULTS

There were 31 participants from 7 countries who represented 10 clinical and methodological specialties. High-priority research recommendations were organized around a conceptual model of ED decisionmaking for syncope, and they address definition, cohort selection, risk stratification, and management.

CONCLUSION

We convened a multispecialty group of syncope experts to identify the most pressing knowledge gaps and defined a high-priority research agenda to improve the care of patients with syncope in the ED.

Risk stratification of adult emergency department syncope patients to predict short-term serious outcomes after discharge (RiSEDS) study

Background

While Canadian ED physicians discharge most syncope patients with no specific further follow-up, approximately 5% will suffer serious outcomes after ED discharge. The goal of this study is to prospectively identify risk factors and to derive a clinical decision tool to accurately predict those at risk for serious outcomes after ED discharge within 30 days.

Methods/Design

We will conduct a prospective cohort study at 6 Canadian EDs to include adults with syncope and exclude patients with loss of consciousness > 5 minutes, mental status changes from baseline, obvious witnessed seizure, or head trauma prior to syncope. Emergency physicians will collect standardized clinical variables including historical features, physical findings, and results of immediately available tests (blood, ECG, and ED cardiac monitoring) prior to ED discharge/hospital admission. A second emergency physician will evaluate approximately 10% of study patients for interobserver agreement calculation of predictor variables. The primary outcome will be a composite serious outcome occurring within 30 days of ED discharge and includes three distinct categories: serious adverse events (death, arrhythmia); identification of serious underlying disease (structural heart disease, aortic dissection, pulmonary embolism, severe pulmonary hypertension, subarachnoid hemorrhage, significant hemorrhage, myocardial infarction); or procedures to treat the cause of syncope. The secondary outcome will be any of the above serious outcomes either suspected or those occurring in the ED. A blinded Adjudication Committee will confirm all serious outcomes. Univariate analysis will be performed to compare the predictor variables in patients with and without primary outcome. Variables with p-values <0.2 and kappa values ≥0.60 will be selected for stepwise logistic regression to identify the risk factors and to develop the clinical decision tool. We will enroll 5,000 patients (with 125 positive for primary outcome) for robust identification of risk factors and clinical decision tool development.

Discussion

Once successfully developed, this tool will accurately risk-stratify adult syncope patients; however, validation and implementation will still be required. This program of research should lead to standardized care of syncope patients, and improve patient safety.

Natriuretic peptides in the evaluation of syncope in children and adolescents

INTRODUCTION

Natriuretic peptides have an increasing role in assessing cardiovascular conditions. The number of papers addressing their role in the evaluation of children with syncope of unclear etiology is sparse. The aim of this study was to determine whether measuring atrial natriuretic peptide (ANP) and the inactive form, N-terminal prohormone of brain natriuretic peptide (NT-proBNP) concentration in children admitted due to differential diagnosis of syncope can be helpful in establishing the most probable cause of this condition.

METHODS

The study included 88 patients between 9 and 18 years of age hospitalized due to syncope. The control group comprised 25 healthy children. In order to identify the cause of syncope, children with this condition were subjected to cardiologic and neurologic evaluation, and ANP and NT-proBNP concentrations were determined.

RESULTS

The syncope group and the controls did not differ significantly in terms of natriuretic peptides concentrations. Similarly, no significant intergroup differences in natriuretic peptide concentrations were documented between children representing various types of response to the tilt test, and between the subgroups of patients with syncope of various origins.

CONCLUSION

Analysis of natriuretic peptides concentrations in children with syncope does not result in unambiguous findings that would enable establishing accurate diagnosis.

Management of vasovagal syncope: 2004

Vasovagal syncope is a common disorder that affects at least 20% of people at some time in their lives. Probably half of these patients faint recurrently; for many this causes physical trauma, a substantial reduction in quality of life, and difficulties with driving, employment and education. The last 15 years have seen striking advances in diagnostic approaches and prognostic understanding. A number of physiological, pharmacological and electrical therapies have been developed and tested to various degrees in patients. These include counterpressure manoeuvres, salt and fluid recommendations, and attempted treatment with fludrocortisone, midodrine, beta-blockers, serotonin reuptake inhibitors, and permanent pacemakers. This review highlights the most important of these advances and suggests strategies for managing this often difficult problem.

The semiology of tilt-induced psychogenic pseudosyncope

OBJECTIVES

To provide a detailed semiology to aid the clinical recognition of psychogenic pseudosyncope (PPS), which concerns episodes of apparent transient loss of consciousness (TLOC) that mimic syncope.

METHODS

We analyzed all consecutive tilt-table tests from 2006 to 2012 showing proven PPS, i.e., apparent TLOC had occurred without EEG changes or a decrease in heart rate (HR) or blood pressure (BP). We analyzed baseline characteristics, video data, EEG, ECG, and continuous BP measurements on a 1-second time scale. Data were compared with those of 69 cases of tilt-induced vasovagal syncope (VVS).

RESULTS

Of 800 tilt-table tests, 43 (5.4%) resulted in PPS. The majority (74%) were women. The median duration of apparent TLOC was longer in PPS (44 seconds) than in VVS (20 seconds, p < 0.05). During the event, the eyes were closed in 97% in PPS but in only 7% in VVS (p < 0.0001). A sudden head drop or moving down the tilt table was more common in PPS than in VVS (p < 0.01), but jerking movements occurred more frequently in VVS (p < 0.0001). In PPS, both HR and BP increased before and during apparent TLOC (p < 0.0001).

CONCLUSIONS

PPS is clinically distinct from VVS and can be diagnosed accurately with tilt-table testing and simultaneous EEG monitoring. Compared with VVS, eye closure during the event, long periods of apparent TLOC, and high HR and BP are highly specific for PPS. Improved understanding of the semiology of PPS as a clinical entity is vital to ensure accurate diagnosis.

[Syncope unit: experience of a center using diagnostic flowcharts for syncope of uncertain etiology after initial assessment]

INTRODUCTION AND OBJECTIVES

Syncope is a common symptom that leads to 1% of admissions to hospital emergency departments, and is associated with high costs to the health system. The cardiology department of Faro Hospital has had a syncope unit since July 2007. The aim of this study is to analyze its results in terms of etiological diagnosis and treatment of syncope, using diagnostic flowcharts based on European Society of Cardiology (ESC) guidelines.

METHODS

We conducted a retrospective study of all patients referred to the syncope unit of Faro Hospital between July 2007 and August 2011. We analyzed demographic data, characteristics of syncopal episodes, diagnostic methods, etiology of syncope and treatment. The percentages of syncope of cardiac and uncertain etiology were compared with data from other international syncope units. Statistical analysis was performed using SPSS version 13.0.

RESULTS

Of the 304 patients referred to the syncope unit for loss of consciousness, 245 (80.7%) had syncope. Most had reflex syncope (52.2%), 20% had cardiac syncope, 15.6% had orthostatic hypotension, and in 12% of cases etiology remained undetermined. The percentages of cardiac and uncertain etiology were similar to data published by other syncope units.

CONCLUSIONS

The Faro Hospital syncope unit obtained similar results to those published by other international syncope units through application of diagnostic flowcharts for etiological diagnosis of syncope. The flowcharts presented can be of value for the proper application of ESC guidelines on syncope.

Selecting appropriate diagnostic tools for evaluating the patient with syncope/collapse

The investigation of syncope is challenging and physicians have an ever-increasing array of diagnostic tools at their disposal. There are two essential goals that drive investigation: risk stratification and identification of etiology. In this review, we outline our approach while providing a synopsis of the available supportive evidence. The key to syncope is in the story as told by the patient and a bystander, since this drives both risk assessment and diagnostic testing. All patients should initially be evaluated with a systematic history and physical examination as well as an ECG. The initial evaluation provides an estimation of risk and directs whether inpatient or outpatient evaluation is appropriate. In a substantial proportion of patients, the etiology will be evident after initial evaluation and no further investigation is required. In the remaining, targeted use of additional investigations in the form of cardiac imaging, provocative testing and/or ambulatory ECG monitoring should be performed. A thoughtful and systematic approach to the investigation of syncope optimizes the diagnostic yield but also ensures efficient usage of limited health care resources.

Low iron storage in children with tilt positive neurally mediated syncope

BACKGROUND

The mechanisms under neurally mediated syncope (NMS) are not fully understood. This study aimed to assess the level of storage iron in children with different hemodynamic patterns in head-up tilt test.

METHODS

Altogether 210 children (11.31±2.49 years) with syncope or pre-syncope treated between May 2008 and September 2010 were studied prospectively. Following history taking and physical examination, their levels of hemoglobin (Hb), hematocrit (Hct) and serum ferritin were measured.

RESULTS

In the 210 children, 162 (77.1%) had NMS and 48 (22.9%) had syncope due to other causes. In the 162 children with NMS, 98 children were subjected to positive tilt test. The level of serum ferritin was significantly lower in the 98 children with NMS (P<0.001). The comparison of levels of Hb, Hct and mean cell volume (MCV) displayed no significant difference between the two groups. Reduced iron storage (serum ferritin <25 ng/mL) was found to be more prevalent in children with NMS (63% vs. 20%, P<0.001). Prevalence of iron deficiency was also significantly higher in children with NMS than in children with syncope due to other causes (27% vs. 6%, P=0.003).

CONCLUSIONS

In head-up tilt test positive children with NMS, the level of serum ferritin should be evaluated. Low storage iron may be one of the underlying mechanisms of NMS.

Evaluation of the current prognostic role of cardiogenic syncope

Prior studies about the prognosis of syncopal patients shows that the 1-year mortality is consistently higher in cardiogenic than in non-cardiogenic or unexplained syncope. After 10 years, other studies have raised several concerns about this circumstantial evidence, showing that the risk of death is predicted by only the underlying heart disease and not from the syncope itself. This is a prospective cohort study aimed to compare the prognosis of cardiogenic and non-cardiogenic syncope. We studied 200 syncopal patients consecutively admitted to the Emergency Department Observation Unit of the University Hospital of Parma. At 1 month and 1 year after discharge, we compared the incidence of syncopal recurrences, major procedures, cardiovascular events and death for any reason in patients with cardiogenic versus non-cardiogenic syncope. Cardiogenic syncope was associated with the presence of at least one adverse event at short and long term. Despite the significant advances in the treatment of cardiovascular diseases over the past decades, cardiogenic syncope continues to be associated with a significantly worse prognosis when compared with non-cardiogenic syncope.

[Practical implementation and usefulness of guidelines for the management of syncope: a professional practice study]

AIMS

To assess the practical implementation of international guidelines and their impact on syncope management in a 500-bed general hospital.

PATIENTS AND METHODS

Three groups of 63 consecutive patients admitted for syncope to the emergency care unit (ECU) were studied: group 1, before the guidelines delivered to the practitioners, group 2 immediately after the diffusion of guidelines and group 3, one year later. The study evaluates the mean duration of stay (MDS) and the relevance of the diagnostic strategy.

RESULTS

In group 1 compared to group 2, MDS were respectively 6.8±5.5 and 5.4±2.8 days (P=0.07) and the unexplained syncope number respectively 22% and 24% (P=0.8). The search of orthostatic hypotension became more systematic (13% versus 86% in group 1 and 2 respectively, P<0.001). The agreement (kappa coefficient) between initial and final diagnostic increased in 0.34 to 0.44. One year later MDS in group 3 was 7.1±4.7 days (P=0.8 versus group 1 and P=0.015 versus group 2) with only 6.3% systematic search for orthostatic hypotension (P<0.001).

CONCLUSIONS

Guidelines optimize the syncope management in the ECU and the agreement between the emergency and discharge diagnostic without change of unexplained syncope and. MDS tend to be shorter when guidelines are actively implemented. Nevertheless, the positive impact of guidelines implementation is of limited duration.

I passed out: now what?: general approach to the patient with syncope

Syncope is the transient loss of consciousness and postural tone caused by transient cerebral hypoperfusion. It is a common problem that is often alarming to patients and their families. The differential diagnosis of the patient with transient loss of consciousness is broad and workup may be expensive. It is important to identify patients with life-threatening conditions and those with red flags indicating an increased risk of sudden death. An initial approach consisting of a careful history, physical examination, and electrocardiograms is essential. This review covers the general diagnostic approach to the patient with syncope.

Patterns and preexisting risk factors of 30-day mortality after a primary discharge diagnosis of syncope or near syncope

OBJECTIVES

The risk of short-term mortality after an emergency department (ED) visit for syncope is poorly understood, resulting in prognostic uncertainty and frequent hospital admission. The authors determined patterns and risk factors for short-term mortality after a diagnosis of syncope or near syncope to aid in medical decision-making.

METHODS

A retrospective cohort study was performed of adult members of Kaiser Permanente Southern California seen at 11 EDs from 2002 to 2006 with a primary discharge diagnosis of syncope or near syncope (International Classification of Diseases, Ninth Revision [ICD-9] 780.2). The outcome was 30-day mortality. Proportional hazards time-to-event regression models were used to identify risk factors.

RESULTS

There were 22,189 participants with 23,951 ED visits, resulting in 307 deaths by 30 days. A relatively lower risk of death was reached within 2 weeks for ages 18 to 59 years, but not until 3 months or more for ages 60 and older. Preexisting comorbidities associated with increased mortality included heart failure (hazard ratio [HR] = 14.3 in ages 18 to 59 years, HR = 3.09 in ages 60 to 79 years, HR = 2.34 in ages 80 years plus; all p < 0.001), diabetes (HR = 1.49, p = 0.002), seizure (HR = 1.65, p = 0.016), and dementia (HR = 1.41, p = 0.034). If the index visit followed one or more visits for syncope in the previous 30 days, it was associated with increased mortality (HR = 1.86, p = 0.024). Absolute risk of death at 30 days was under 0.2% in those under 60 years without heart failure and more than 2.5% across all ages in those with heart failure.

CONCLUSIONS

The low risk of death after an ED visit for syncope or near syncope in patients younger than 60 years old without heart failure may be helpful when deciding who to admit for inpatient evaluation. The presence of one or more comorbidities that predict death and a prior visit for syncope should be considered in clinical decisions and risk stratification tools for patients with syncope. Close clinical follow-up seems advisable in patients 60 years and older due to a prolonged risk of death.

The Implantable Loop Recorder—An Important Addition to the Armentarium in the Management of Unexplained Syncope

Introduction: Unexplained syncope is a common condition with a significant impact both on the patient and on healthcare expenditure. Often, the diagnosis is hampered due to the temporary sporadic nature of the symptoms. Conventional monitoring methods have a low yield for identifying an abnormality during a spontaneous event. The implantable loop recorder (ILR), often underutilised, is an important diagnostic device that may fill this void in the early assessment of patients presenting with syncope. Materials and Methods: This article begins with 2 case vignettes which highlight the clinical utility of ILRs in making a definitive diagnosis and guiding subsequent management. This is followed by a review of the existing evidence for ILRs, including the recent international guidelines, underpinning the role of ILRs in the present management algorithm of patients presenting with unexplained syncope. The technical aspects and cost implications will also be reviewed. Results: Present evidence-based international guidelines have recommended the early use of ILRs in the management of patients with unexplained syncope. Furthermore, there may also be an important role for ILR use in patients with presumed epilepsy refractory to treatment and in the neurally mediated syncope cohort with recurrent symptoms. Cost benefit analysis also demonstrates advantages with early ILR use. Conclusion: The early use of ILR in selected patients remains an accurate, cost-effective, high yield tool for diagnosis and management of patients with unexplained syncope. However, its use should not detract from the importance of taking a detailed medical history and physical examination in the initial assessment to facilitate identification of the aetiology and risk stratification of patients. Key words: Electrophysiological study, Epilepsy, External loop recorder, Holter, Tilt testing

Syncope during exercise: just another benign vasovagal event?

In general, syncope in children and adolescents is a benign event. Syncope during exercise may identify patients with a potentially fatal condition. Catecholaminergic polymorphic ventricular tachycardia is characterized by life-threatening ventricular arrhythmias, usually polymorphic ventricular tachycardia or ventricular fibrillation, occurring under conditions of exercise or emotional stress. Catecholaminergic polymorphic ventricular tachycardia is a familial condition that presents with exercise-induced syncope or sudden death in children or young adults. Detailed evaluation should be considered for patients who have syncope during exercise, injure themselves during the fall (i.e., unprotected faint with no antecedent warning prodrome), or who have a family history of syncope, early sudden cardiac death, myocardial disease, or arrhythmias.

Underlying diseases in syncope of children in China

Background

Syncope accounts for about 1–2% of emergency department visits, but the etiology in many patients with syncope is unclear. Recently, with the use of the head-up tilt test (HUT), the number of patients with unexplained syncope (UPS) has been decreasing; however, the spectrum of underlying diseases of syncope in children is unclear. This retrospective study aimed to analyze the spectrum of underlying diseases in children with syncope.

Material/Methods

This multi-center clinical study consisted of 888 children (417 males, 471 females, aged 5–18 yrs, median age 12.0±3.0 yrs) with syncope who came from Beijing city, Hunan province, Hubei province and Shanghai from August 1999 to March 2009. The clinical and laboratory data of children were studied and the spectrum of underlying diseases in children with syncope was analyzed.

Results

In 888 children with syncope, 175 (19.7%) had vasovagal syncope (VVS) with vasoinhibitory response, 35 (3.9%) had VVS with cardioinhibitory response, 73 (8.2%) had VVS with mixed response, 286 (32.2%) had postural orthostatic tachycardia syndrome (POTS), 19 (2.1%) had orthostatic hypotension, 7 (0.9%) had situational syncope, 13 (1.5%) had cardiogenic syncope, and 280 (31.5%) had unexplained syncope.

Conclusions

The data suggest that neurally-mediated syncope was the most common cause in children with syncope. POTS and VVS were the most common hemodynamic patterns of neurally-mediated syncope.

Mortality in carotid sinus hypersensitivity: a cohort study

Objective Carotid sinus hypersensitivity (CSH) is common in older people. The authors hypothesise that patients with CSH have a higher mortality than a geographically, age-matched older cohort. Design A retrospective cohort study compared to geographical and age-matched data from the Office of National Statistics. Setting Specialist clinic in tertiary centre. Patients 1504 patients with CSH were identified from a single syncope outpatient assessment service between 1990 and 2001. Interventions Vital status was confirmed, and death certificates were sought for all deceased patients up to 2003. Main outcome measures Kaplan-Meier survival curves were analysed within the cohort according to three different subtypes of CSH. Standardised mortality rates (SMRs) were determined using geographical and age-matched data from the Office of National Statistics. Results There was no difference between CSH patients and the general population in SMRs for all causes, or for cerebrovascular or cardiovascular deaths. There was no difference in survival between the three subtypes of CSH (p=0.2) within the study cohort. Conclusion CSH is not associated with a higher mortality than the general population, and there are no differences in mortality between the three subtypes of CSH. This confirms earlier findings and reinforces the neutral effect of CSH on mortality.

Do outcomes of near syncope parallel syncope?

BACKGROUND

Limited information on the evaluation of emergency department (ED) patients complaining of "near syncope" exists. Multiple studies of syncope exclude near syncope claiming near syncope is poorly defined and its definition is nonuniform.

OBJECTIVE

The aim of this study was to determine the incidence of critical interventions or adverse outcomes associated with near syncope and compare these outcomes with syncope.

METHODS

Prospective, observational study enrolling (August 2007-October 2008) consecutive ED patients (age, ≥18 years) presenting with near syncope was conducted. Near syncope was defined as an episode in which the patient felt they might lose consciousness but did not. Critical intervention/adverse outcome was defined as hemorrhage, cardiac ischemia/intervention, alteration in antidysrhythmics, pacemaker/defibrillator placement, sepsis, stroke, death, dysrhythmia, sepsis, pulmonary embolus, or carotid stenosis. Primary outcome was an adverse outcome or critical intervention in hospital or less than 30 days. Near syncope and syncope outcomes and admission rates were compared using the χ(2) test.

RESULTS

After 1870 patients were screened, 244 met the study definition. Of the 244 patients, follow-up was achieved in 242 (99%). Emergency department hospitalization or 30-day adverse outcomes occurred in 49 (20%) of 244 compared with 68 (23%) of 293 of patients with syncope (P = .40). The most common adverse outcomes/critical interventions were hemorrhage (n = 6), bradydysrhythmia (n = 6), alteration in antidysrhythmics (n = 6), and sepsis (n = 10). Of patients with near syncope, 49% were admitted compared with 69% with syncope (P = .001).

CONCLUSION

Patients with near syncope are as likely those with syncope to experience critical interventions or adverse outcomes; however, near-syncope patients are less likely to be admitted. Given similar risk of adverse outcomes for near syncope and syncope, future studies are warranted to improve the treatment of ED patients with near syncope.

The prevalence and cost of the faint and fall problem in the state of Utah

BACKGROUND

Understanding the frequency and economic impact of faint and fall is a prerequisite for the creation of cost-effective diagnostic approaches.

METHODS

We evaluated the total number of patients presenting with faint or fall to the University of Utah Health Care System between November 1, 2008, and October 31, 2009. Using these data, we estimated the prevalence and total cost of the faint and fall problem in the state of Utah.

RESULTS

A total of 1,936 and 6,043 patients presented with faint and fall resulting in a total number of visits equal to 2,701 and 8,163, respectively. The yearly prevalence of faints was 9.5 patients (13.2 visits) per 1,000 inhabitants and the yearly prevalence of falls was 29.8 patients (40.2 visits) per 1,000 inhabitants. The prevalence of faints and falls progressively increased with age, reaching the values of 40 and 115 per 1,000 inhabitants in subjects aged >80 years. In both patient populations, two-thirds of visits were outpatient evaluations. While the cardiovascular service was involved in the outpatient evaluation of faint visits in 24% of the cases, <1% of outpatient fall visits resulted in a cardiovascular consultation. The average payments received per faint and fall patient evaluations were $2,517 and $3,200, respectively, resulting in an estimated yearly cost equal to $90,901,958 and $351,959,040, respectively.

CONCLUSION

This study highlights the magnitude of the faint and fall problem in the state of Utah. Our results provide all stakeholders with a frame of reference for the creation of cost-effective diagnostic approaches.

Misdiagnosis of epileptic and non-epileptic seizures in a neurological intensive care unit

OBJECTIVE

The etiological misinterpretation of paroxysmal neurological symptoms frequently causes a delayed treatment or an inappropriate utilization of ICU-capacities.

METHODS

In this study, the data of 208 patients admitted to a neurological ICU because of acute transient neurological deficits, loss of consciousness or unclear motor phenomena were retrospectively analyzed. The initial emergency room diagnosis was compared to the final diagnosis and the rate of misdiagnosis was related to the patients' history and diagnostic data.

RESULTS

In 13.9%, the emergency room diagnosis of epileptic seizures turned out to be incorrect, whereas in 15.6%, the final diagnosis of epileptic seizures was missed in the emergency room. Factors that were significantly correlated to missing the seizure diagnosis were (i) no prior history of epilepsy, (ii) old age, (iii) multi-morbidity, (iv) pathologic CT-scans demonstrating cerebrovascular lesions, (v) seizure description by non-professionals, (vi) predominantly negative seizure phenomena (aphasia, loss of consciousness, paresis), (vii) lack of tongue-bite lesions.

Epidemiological characteristics and diagnostic approach in patients admitted to the emergency room for transient loss of consciousness: Group for Syncope Study in the Emergency Room (GESINUR) study

AIMS

To assess the clinical presentation and acute management of patients with transient loss of consciousness (T-LOC) in the emergency department (ED).

METHODS AND RESULTS

A multi-centre prospective observational study was carried out in 19 Spanish hospitals over 1 month. The patients included were > or =14 years old and were admitted to the ED because of an episode of T-LOC. Questionnaires and corresponding electrocardiograms (ECGs) were reviewed by a Steering Committee (SC) to unify diagnostic criteria, evaluate adherence to guidelines, and diagnose correctly the ECGs. We included 1419 patients (prevalence, 1.14%). ECG was performed in 1335 patients (94%) in the ED: 498 (37.3%) ECGs were classified as abnormal. The positive diagnostic yield ranged from 0% for the chest X-ray to 12% for the orthostatic test. In the ED, 1217 (86%) patients received a final diagnosis of syncope, whereas the remaining 202 (14%) were diagnosed of non-syncopal transient loss of consciousness (NST-LOC). After final review by the SC, 1080 patients (76%) were diagnosed of syncope, whereas 339 (24%) were diagnosed of NST-LOC (P < 0.001). Syncope was diagnosed correctly in 84% of patients. Only 25% of patients with T-LOC were admitted to hospitals.

CONCLUSION

Adherence to clinical guidelines for syncope management was low; many diagnostic tests were performed with low diagnostic yield. Important differences were observed between syncope diagnoses at the ED and by SC decision.

Differentiation of convulsive syncope from epilepsy with an implantable loop recorder

INTRODUCTION

Not all convulsive episodes are due to epilepsy and a number of these have a cardiovascular cause. Failure to identify these patients delays the provision of adequate therapy while at the same time exposes the individual to the risk of injury or death.

METHODS

We report on three patients who suffered from recurrent convulsive episodes, thought to be epileptic in origin, who were refractory to antiseizure therapy. Although each patient had undergone extensive evaluation, no other potential cause of his or her seizure like episodes had been uncovered. In each patient placement of an implantable loop recorder (ILR) demonstrated that their convulsive episodes were due to prolonged periods of cardiac asystole and/or complete heart block. In all patients their convulsive episodes were eliminated by permanent pacemaker implantation.

CONCLUSION

In patients with refractory "seizure' like episodes of convulsive activity of unknown etiology a potential cardiac rhythm disturbance should be considered and can be easily evaluated by ILR placement.