Incidence and risk factors for non-cardiac syncope in a cohort of patients addressing an accredited Arterial Hypertension Center: the Innocent Study.

BACKGROUND: Hypotensive susceptibility in hypertensive patients could facilitate orthostatic hypotension, syncope and fall. The aim of this study was to identify incidence, clinical form, complications and risk factors for non-cardiac syncope in a cohort of hypertensive patients. METHODS: This is an observational, case-controlled, retrospective study carried out on 168 patients, evaluated at the Hypertension Center of the University Hospital of Parma (Italy). Based on the presence of episodes of syncope during the six months prior to enrolment, we identified cases and controls and then we compared them to personal data, comorbidities, current drug regimens, presence of orthostatic hypotension, office and ambulatory blood pressure monitoring (ABPM) blood pressure (BP) values. RESULTS: In patients with previous syncopal episodes (29.8% of total), we more frequently found female gender, comorbidities associated with autonomic dysfunction, diuretics and non-CV drugs potentially associated with hypotension in their current drug regimen, orthostatic hypotension and lower office and ABPM BP values. CONCLUSIONS: To identify hypertensive patients at higher risk for syncope and falls, physicians should focus on comorbidities and current drug regimens, systematically perform an active standing test to identify orthostatic hypotension, employ ABPM to compare BP values with the pre-established target and highlight systolic BP drops and abnormalities suggesting concomitant autonomic dysfunction. The modulation of antihypertensive therapy is an effective tool to counteract the risk of non-cardiac syncope, with possible trauma or other negative influences.

Current ED syncope management in Italian hospitals and prospects for optimization: a national survey.

To investigate current ED management of patients with syncope in Italy and opportunities for optimization, we carried out a questionnaire survey involving 102 directors of ED facilities in our country, of any complexity level, with 55.9% located in the North, 97% equipped with an ED Observation Unit (EDOU), and 21.8% with an outpatient Syncope Unit (SU). 43.6% of EDs management is not standardized. Clinical judgment and monitoring are the main factors leading management while old age and neuropsychic comorbidities the most hindering it. More than one third of ED facilities treats fewer than half of patients in EDOU. Most of respondents (73.7%) reported an admission rate within 20%, primarily in cardiology, in the case of an established or suspected cardiac etiology of syncope. In most centers, the referral to the general practitioner is the priority path at discharge from ED. Nearly 50% of participants rated syncope management in their own center as sub-optimal. To optimize it, 98% of them believe that is appropriate to implement a standardized approach, with and a large majority focusing on increasing diagnostic yield and safety; other priorities include application of guidelines, implementation of care pathways, enhancement of the role of EDOU, and direct path to the SU. This study highlights that the management of syncope patients in our country requires a further improvement, especially through standardization of pathways and adoption of innovative organizational solutions. Admissions appear to be lower than reported in the literature but this finding must be confirmed by a multicentric study based on direct collection of data.

Incidence and predictive factors of acute diseases in patients with syncope: the ESCAPE study.

According to the 2018 ESC guidelines, emergency physicians shall primarily aim to identify syncopal episodes associated with an underlying acute principal disease. Therefore, in this study, we aimed to assess the incidence of syncope associated with acute principal diseases (APDs) and to identify predictive factors reflecting the presence of these underlying conditions. We retrospectively evaluated all patients presenting with syncope during a 6-month period to the local emergency department, collecting incidence of syncopal cases associated with APDs, personal information, clinical features, and laboratory abnormalities, which were compared between syncopal patients with or without APDs. A syncope-associated APD could be diagnosed in 346/1279 patients (27.1%). In the majority of cases, the cause was a non-cardiovascular acute condition (67%), mostly non-life-threatening such as infectious diseases (34.4%) and acute diseases with pain, fluid loss or hypotension (23.7%). Severe acute cardiovascular conditions were less frequent (4.2%). Cardiogenic syncope, no previous history of syncopal episodes, not full agreement with typical clinical features of syncope, alterations of vital parameters, and laboratory abnormalities were also found to be independently associated with syncope-associated APDs. Syncope may be frequently associated with APDs of varying severity, though mostly non-clinically threatening, thus confirming that this condition shall be considered a symptom and not a disease. Emergency physicians should hence be first engaged in troubleshooting an underlying pathology when facing patients with syncope, for timely identifying patients at higher risk of short-term adverse events and reducing inappropriate admissions and diagnostic investigations, especially in the presence of hypotensive syncope elicited by non-severe concurrent conditions.

How to simplify the implementation of Syncope ESC Guidelines in the Emergency Department and get on the road to achieve "zero inappropriate admissions".

According to 2018 ESC Guidelines for syncope, the first aim in ED evaluation is to identify patients with underlying acute diseases, at higher risk of short-term adverse events; in the meantime, emergency physicians should also identify cases of hypotensive syncope elicited by non-severe concurrent conditions, as they mostly do not require hospitalization. After excluding these cases, ESC GL state that patients should be managed with initial evaluation and risk stratification, providing several tables and flow-charts to do it. To optimize ED management, we propose to combine these two phases, as in the clinical practice they occur at the same, with the following simplified paths: patients with only clinical features suggestive of reflex syncope should be discharged, with a fast-track to an outpatient Syncope Unit only in case of severe syncope; patients with orthostatic syncope could be discharged with measures to prevent recurrences or be managed in an ED Observation Unit (EDOU) in case of fluid loss or other causes of volume depletion; patients with major clinical or ECG criteria suggestive of cardiogenic syncope should be admitted, for diagnostic or therapeutic purposes; patients with undetermined syncope or minor clinical or ECG criteria suggestive of cardiogenic syncope should be managed in an EDOU. ESC GL give focus to this novel care pathway, but they do not provide clear details on the organizational aspects; accordingly, this document proposes resources and protocols for managing patients in EDOU, as a first part of the functional path of the outpatient Syncope Unit.

Syncope Time Frames for Adverse Events after Emergency Department Presentation: An Individual Patient Data Meta-Analysis.

Background and Objectives: Knowledge of the incidence and time frames of the adverse events of patients presenting syncope at the ED is essential for developing effective management strategies. The aim of the present study was to perform a meta-analysis of the incidence and time frames of adverse events of syncope patients. Materials and Methods: We combined individual patients' data from prospective observational studies including adult patients who presented syncope at the ED. We assessed the pooled rate of adverse events at 24 h, 72 h, 7-10 days, 1 month and 1 year after ED evaluation. Results: We included nine studies that enrolled 12,269 patients. The mean age varied between 53 and 73 years, with 42% to 57% females. The pooled rate of adverse events was 5.1% (95% CI 3.4% to 7.7%) at 24 h, 7.0% (95% CI 4.9% to 9.9%) at 72 h, 8.4% (95% CI 6.2% to 11.3%) at 7-10 days, 10.3% (95% CI 7.8% to 13.3%) at 1 month and 21.3% (95% CI 15.8% to 28.0%) at 1 year. The pooled death rate was 0.2% (95% CI 0.1% to 0.5%) at 24 h, 0.3% (95% CI 0.1% to 0.7%) at 72 h, 0.5% (95% CI 0.3% to 0.9%) at 7-10 days, 1% (95% CI 0.6% to 1.7%) at 1 month and 5.9% (95% CI 4.5% to 7.7%) at 1 year. The most common adverse event was arrhythmia, for which its rate was 3.1% (95% CI 2.0% to 4.9%) at 24 h, 4.8% (95% CI 3.5% to 6.7%) at 72 h, 5.8% (95% CI 4.2% to 7.9%) at 7-10 days, 6.9% (95% CI 5.3% to 9.1%) at 1 month and 9.9% (95% CI 5.5% to 17) at 1 year. Ventricular arrhythmia was rare. Conclusions: The risk of death or life-threatening adverse event is rare in patients presenting syncope at the ED. The most common adverse events are brady and supraventricular arrhythmias, which occur during the first 3 days. Prolonged ECG monitoring in the ED in a short stay unit with ECG monitoring facilities may, therefore, be beneficial.

Emergency department management of patients with syncope according to the 2018 ESC guidelines: Main innovations and aspect deserving a further improvement.

The approach suggested by the 2018 ESC GL is the main road for achieving the ambitious goal "zero admission for syncope". This document has in fact introduced a clear-cut distinction between syncope associated with a definite diagnosis, which shall be managed according to the underlying condition, and the really undetermined cases, which shall be managed with prognostic stratification. ESC GL also emphasize the pivotal importance of managing patients in facilities such as ED observation syncope units or outpatient syncope clinics, as a safe alternative to admission. Moreover, they provide a table of non-syncopal causes of TLOC to be excluded, indicating the clinical features distinguishing them from syncope, clearly define the indications for additional examinations to be made after the initial evaluation and include a detailed table contains features for stratifying patients as being at high- and low-risk. However, we believe that this approach could be further improved, by especially defining criteria to identify patient neither high nor low risk, to be called at "intermediate-risk", making the prognostic stratification table easier to remember and use, by clarifying the role of laboratory tests to support the clinical judgment and by defining protocol for managing patients ED observation unit.

Analysis of Temporal and Causal Relationship Between Syncope and 30-Day Events in a Cohort of Emergency Department Patients to Identify the True Rate of Short-term Outcomes.

BACKGROUND: There are a limited number of studies on the short-term prognosis of syncopal patients, and those available are heterogeneous and often have considered events without a clear relationship with the syncopal episode as serious outcomes. OBJECTIVE: The aim of this study was to identify the incidence of short-term true outcomes of a syncopal episode, only considering those occurring after a reasonable period of time, with a plausible causal relationship with index syncope as well as syncopal recurrences causing major trauma. METHODS: In this retrospective, observational study, we assessed all patients managed in the emergency department (ED) during a 6-month period, with 30 days of follow-up. RESULTS: The study population consisted of 982 consecutive syncopal patients. We observed short-term serious events, in a broad sense, in 154 patients (15.7%), the most frequent being dysrhythmias (20.8%), cerebrovascular accidents (18.2%), major traumatic injuries (16.2%), death (13%), and myocardial infarction (9.7%). Most of these events (63.6%) could be identified within 72 h, mainly in the ED. Only 19 patients (2.2% of the sample), experienced a true short-term outcome (7 deaths, 1 myocardial infarction, 9 dysrhythmias, 1 major bleeding event, and 1 traumatic syncopal recurrence). CONCLUSIONS: The incidence of short-term true outcomes of syncope is extremely low. Distinguishing true outcomes from other events has a crucial significance for understanding the real prognostic role of syncope and for planning ED management. Once patients with syncope as a direct consequence of an acute disease needing admission by itself are excluded, most patients with unexplained syncope could be safely discharged after primary evaluation and brief ED monitoring.

Syncope: current knowledge, uncertainties and strategies for management optimisation in the emergency department.

Admission rates and expenditures for syncope remain high. This unsatisfactory management could be due to several factors, including lack of evidence-based strategy, poor accuracy of clinical decision rules, difficulty in disseminating guidelines, as well as uncertainties concerning management of intermediate-risk patients and role of observation protocols and syncope units. To optimise management, it has been proposed to adopt a pragmatic, symptoms-based definition of syncope and a classification related to the underlying mechanism rather than suspected aetiology. It has also been emphasised the importance of identifying patients at intermediate risk as they can be safely discharged after an intensive emergency department evaluation. A further improvement might result from a research implementation to validate the role of observation protocols and to select patients amenable to be sent to outpatient syncope units. Finally, future studies on prognostic significance of syncope should be performed with a more careful selection of outcomes and a greater uniformity.

Role of emergency department observation units in the management of patients with unexplained syncope: a critical review and meta-analysis.

This meta-analysis aimed to establish the role of standardized emergency department (ED) observation protocols in the management of syncopal patients as an alternative to ordinary admission. A systematic electronic literature search was performed to identify randomized controlled trials or observational studies evaluating syncopal patients managed in ED observation units. Data regarding mean length of stay, rate of etiological diagnosis, admission rate, and incidence of short-term serious outcomes were extracted. Six mostly single-center, small sized studies characterized by high heterogeneity, were included. A total of 458 patients were included with a balanced sex distribution (male 50.2%), a mean age of 60.1 years, and a considerable prevalence of heart disease (32.4%). Pooled analysis of the outcomes showed a mean stay of 28.2 hours, an etiological diagnosis rate of 67.3%, an admission rate of 18.5%, and a very low incidence of short-term serious outcomes (2.8%). Due to elevated diagnostic yield and low incidence of short-term adverse events, ED observation units-based management strategy seems ideal for patients with syncope. Nevertheless, further research is needed to identify criteria for selecting patients to be managed with this approach, define evaluation protocols, and confirm the safety of this strategy.

Short-term Prognosis and Current Management of Syncopal Patients at Intermediate Risk: Results from the IRiS (Intermediate-Risk Syncope) Study.

OBJECTIVES: Despite guidelines, admission rates and expenditures for syncope remain high. This may be caused by an imprecise definition of cardiovascular disease considered at risk and an overestimation of the role of comorbidities and advanced age. In a cohort of patients with undetermined syncope, we prospectively compared the short-term prognosis of patients at intermediate risk (i.e., with stable heart diseases or comorbidities, of any age) versus those at high risk for cardiogenic syncope and identified factors associated with serious events. Secondarily, we analyzed the current management of intermediate-risk patients. METHODS: In a cohort of patients with undetermined syncope, we analyzed personal data, the presence of stable heart diseases or comorbidities, destination, length of hospitalization, incidence of serious events at 30 days, and costs. RESULTS: In a 6-month period, 347 patients (185 male and 162 female, age 72.8 years) with undetermined syncope were enrolled, 250 at intermediate risk and 97 at high risk. Intermediate-risk patients were younger, with less frequent comorbidities and with a drastically lower incidence of serious events (0.8% vs. 27.8%, p < 0.001). Risk factors for cardiogenic syncope were the unique variable associated with serious events. Intermediate-risk patients were mostly admitted (62.8%) in an ordinary ward or into an emergency department observation unit; in the case of ordinary admission we observed a mean prolonged hospitalization (8.8 days), elevated costs ($270,183), and a high rate of unexplained syncope (51%). CONCLUSIONS: According to the results of this study, the authors believe that intermediate-risk patients could be safely discharged, with potentially significant costs saving. In prognostic stratification, priority is to seek risk factors for cardiogenic syncope while advanced age, stable heart diseases, or comorbidities likely lead to inappropriate hospitalization.

Emergency physician's perception of cultural and linguistic barriers in immigrant care: results of a multiple-choice questionnaire in a large Italian urban emergency department.

BACKGROUND: A poor communication with immigrants can lead to inappropriate use of healthcare services, greater risk of misdiagnosis, and lower compliance with treatment. As precise information about communication between emergency physicians (EPs) and immigrants is lacking, we analyzed difficulties in communicating with immigrants in the emergency department (ED) and their possible associations with demographic data, geographical origin and clinical characteristics. METHODS: In an ED with approximately 85 000 visits per year, a multiple-choice questionnaire was given to the EPs 4 months after discharge of each immigrant in 2011. RESULTS: Linguistic comprehension was optimal or partial in the majority of patients. Significant barriers were noted in nearly one fourth of patients, for only half of them compatriots who were able to translate. Linguistic barriers were mainly found in older and sicker patients; they were also frequently seen in patients coming from western Africa and southern Europe. Non-linguistic barriers were perceived by EPs in a minority of patients, more frequently in the elderly and frequent attenders. Factors independently associated with a poor final comprehension led to linguistic barriers, non-linguistic obstacles, the absence of intermediaries, and the presence of patient's fear and hostility. The latter probably is a consequence, not the cause, of a poor comprehension. CONCLUSION: Linguistic and non-linguistic barriers, although quite infrequent, are the main factors that compromise communication with immigrants in the ED, with negative effects especially on elderly and more seriously ill patients as well as on physician satisfaction and appropriateness in using services.

Emergency physician's perception of cultural and linguistic barriers in immigrant care: results of a multiple-choice questionnaire in a large Italian urban emergency department / 世界急诊医学杂志（英文）

@#BACKGROUND: A poor communication with immigrants can lead to inappropriate use of healthcare services, greater risk of misdiagnosis, and lower compliance with treatment. As precise information about communication between emergency physicians (EPs) and immigrants is lacking, we analyzed difficulties in communicating with immigrants in the emergency department (ED) and their possible associations with demographic data, geographical origin and clinical characteristics. METHODS: In an ED with approximately 85000 visits per year, a multiple-choice questionnaire was given to the EPs 4 months after discharge of each immigrant in 2011. RESULTS: Linguistic comprehension was optimal or partial in the majority of patients. Significant barriers were noted in nearly one fourth of patients, for only half of them compatriots who were able to translate. Linguistic barriers were mainly found in older and sicker patients; they were also frequently seen in patients coming from western Africa and southern Europe. Non-linguistic barriers were perceived by EPs in a minority of patients, more frequently in the elderly and frequent attenders. Factors independently associated with a poor final comprehension led to linguistic barriers, non-linguistic obstacles, the absence of intermediaries, and the presence of patient's fear and hostility. The latter probably is a consequence, not the cause, of a poor comprehension. CONCLUSION: Linguistic and non-linguistic barriers, although quite infrequent, are the main factors that compromise communication with immigrants in the ED, with negative effects especially on elderly and more seriously ill patients as well as on physician satisfaction and appropriateness in using services.

Thirty and ninety days mortality predictive value of admission and in-hospital procalcitonin and mid-regional pro-adrenomedullin testing in patients with dyspnea. Results from the VERyfing DYspnea trial.

INTRODUCTION: Mid-regional pro-atrial natriuretic peptide (MR-proANP), procalcitonin (PCT), and mid-regional pro-adrenomedullin (MR-proADM) demonstrated usefulness for management of emergency department patients with dyspnea. METHODS: To evaluate in patients with dyspnea, the prognostic value for 30 and 90 days mortality and readmission of PCT, MR-proADM, and MR-proANP, a multicenter prospective study was performed evaluating biomarkers at admission, 24 and 72 hours after admission. Based on final diagnosis, patients were divided into acute heart failure (AHF), primary lung diseases, or both (AHF + NO AHF). RESULTS: Five hundred one patients were enrolled. Procalcitonin and MR-proADM values at admission and at 72 hours were significantly (P < .001) predictive for 30-day mortality: baseline PCT with an area under the curve (AUC) of 0.70 and PCT at 72 hours with an AUC of 0.61; baseline MR-proADM with an AUC of 0.62 and MR-proADM at 72 hours with an AUC of 0.68. As for 90-day mortality, both PCT and MR-proADM baseline and 72 hours values showed a significant (P < .0001) predictive ability: baseline PCT with an AUC of 0.73 and 72 hours PCT with an AUC of 0.64; baseline MR-proADM with an AUC of 0.66 and 72 hours MR-proADM with an AUC of 0.71. In AHF, group biomarkers predicted rehospitalization and mortality at 90 days, whereas in AHF + NO AHF group, they predict mortality at 30 and 90 days. CONCLUSIONS: In patients admitted for dyspnea, assessment of PCT plus MR-proADM improves risk stratification and management. Combined use of biomarkers is able to predict in the total cohort both rehospitalization and death at 30 and 90 days.

Evaluation of the current prognostic role of heart diseases in the history of patients with syncope.

AIMS: Pivotal studies showed that the 1-year mortality was consistently higher in cardiogenic than in non-cardiogenic syncope 10 years later, further studies questioned these evidences, showing that the risk of death was only predicted by underlying heart disease and not from the syncope itself. Accordingly, nearly all the prognostic scales now include cardiovascular variables, but their definition is often neither unique nor precise and it might lead to an excessive hospitalization. METHODS AND RESULTS: This is a prospective cohort study aimed to compare the prognosis of syncopal patients with vs. without heart diseases, considered both in a broad (all cardiovascular diseases) and limited sense (only high-risk diseases, that is coronary heart diseases, heart failure, severe aortic stenosis, cardiomyopathies, and primarily arrhythmic diseases). We studied 200 patients consecutively admitted to the emergency department of the University Hospital of Parma. At 1 month and 1 year after discharge, we compared the incidence of syncopal recurrences with trauma, major procedures, cardiovascular events, and death for any reason in patients with vs. without heart diseases, considered both in a broad and limited sense. The presence of heart diseases in a broad sense was not associated with the endpoints, both at short and long term. Conversely, high-risk heart diseases were strongly associated with the presence of serious outcomes at short time. CONCLUSION: We recommend that emergency department physicians adopt a strict definition of heart diseases considered at risk to promptly identify all patients at risk for serious events, while avoiding an excessive hospitalization.

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.

The significance of protein S-100B testing in cardiac arrest patients.

Cardiac arrest often represents the first expression of an underlying cardiac disease. Despite advances in neurocritical care, the neurological assessment of cardiac arrest patients relies on clinical, instrumental and biochemical parameters. The clinical significance of S-100 calcium binding protein B (S-100B) has substantially increased throughout several areas of clinical neuroscience, but reliable evidences attest it can be used as a reliable and early predictor of poor physiological and cognitive neurological outcomes after cardiac arrest.

Syncope in the emergency department of a large northern Italian hospital: incidence, efficacy of a short-stay observation ward and validation of the OESIL risk score.

OBJECTIVE: Syncope causes 1-3% of all emergency department (ED) visits, a high percentage of hospitalisations and prolonged hospital stay; nevertheless, many cases remain unexplained. METHODS: This study analysed the incidence of syncope at the ED of the University Hospital of Parma in the first half of 2008; then a sample of 200 patients admitted later for syncope into the ED ward was studied, in order to evaluate the efficacy of a brief observation unit and to validate the Osservatorio Epidemiologico della Sincope nel Lazio (OESIL) risk score as a tool to identify cardiogenic syncopes. RESULTS AND CONCLUSIONS: As reported in the literature, syncope accounts for 2.3% of ED consultations and for 4.2% of total hospital admissions. A brief observation ward in the ED seems to have the necessary characteristics for managing most cases of syncope quickly (3.5 days). The final diagnosis was certain in 60%, suspected in 33% and unexplained in 7% of patients. The commonest forms of syncope were non-cardiogenic. Factors associated with cardiogenic syncope were previous syncopal events, lack of prodromal symptoms and a high OESIL risk score.

The increase in plasma PAI-1 associated with insulin resistance may be mediated by the presence of hepatic steatosis.

OBJECTIVE: Recent evidence suggests that plasminogen-activator inhibitor-1 (PAI-1) is abundantly produced by the fatty liver, but it is unclear whether hepatic steatosis (HS) can mediate the increase in plasma PAI-1 induced by insulin resistance/compensatory hyperinsulinemia (IR/CH). METHODS AND RESULTS: To address this issue, we cross-sectionally evaluated IR/CH as area under the curve of plasma insulin (AUC-PI) concentrations during OGTT, metabolic profile, and ultrasound degree of HS in 235 healthy volunteers (132M, age: 60+/-7 years) with normal transaminase concentrations. Circulating PAI-1 was increased in subjects with classical features of IR/CH (overweight, high fasting and post-OGTT insulin and glucose, high triglycerides (TG), and low HDL-cholesterol), and significantly correlated to prevalence and degree of HS, but not to alcohol intake. In a multivariate model, AUC-PI, TG and degree of HS were independent predictors of plasma PAI-1 (R(2)=0.32). However, AUC-PI was significantly correlated to PAI-1 only in subjects with HS, suggesting an interaction between AUC-PI and HS. In addition, in the presence of HS and IR/CH, PAI-1 concentrations were increased to a similar extent both in heavy and moderate drinkers, suggesting that metabolic and alcoholic steatosis have a similar effect on the relationship between IR/CH and PAI-1. CONCLUSION: These results support the hypothesis that HS has a major impact on the relationship between IR/CH and plasma PAI-1 concentrations, and this effect seems to be unaffected by the etiology of the HS.

Prevalence and significance of hypoalbuminemia in an internal medicine department.

BACKGROUND: Serum albumin is commonly measured in hospitalized patients. It has habitually been included among the parameters used for nutritional assessment, and recently its use has become even more widespread. Yet, no data are available in the literature about the prevalence and clinical significance of hypoalbuminemia in patients hospitalized in an internal medicine ward. The aim of this study was to investigate the prevalence and clinical significance of hypoalbuminemia in in-hospital internal medicine patients. METHODS: We retrospectively evaluated the albumin level of patients admitted to the Department of Internal Medicine and Biomedical Sciences of the University of Parma during the year 2000. We then evaluated sex, age, nutritional status, some laboratory parameters, associated diseases, and length of hospitalization in hypoalbuminemic patients in comparison with a group of patients without hypoalbuminemia. RESULTS: Hypoalbuminemics (46.5% of patients) were older, more frequently anemic, and had a higher erythrocyte sedimentation rate (ESR) and longer hospitalization; they were mostly normal weight or overweight. These patients also had chronic liver (18.6% vs. 4.5%), onco-hematological (33.8% vs. 12%), and infectious diseases (13.4% vs. 2.3%) and nephropathies (6.3% vs. 2%) more often than patients without hypoalbuminemia. The presence of onco-hematological diseases was related to anemia (O.R.=5.73; 95% CI: 3.184-10.310), lymphopenia (O.R.=2.76; 95% CI: 1.584-4.801), and hypoalbuminemia (O.R.=2.5; 95% CI: 1.178-5.307). CONCLUSIONS: Hypoalbuminemia is very frequent in an internal medicine ward. In this setting, serum albumin is related to the length of hospitalization and to other parameters with a well-known prognostic value (age, hemoglobin) and clinical usefulness (ESR). It may also play a role in the evaluation of the possible association of onco-hematological diseases.