Panic symptoms in transient loss of consciousness: Frequency and diagnostic value in psychogenic nonepileptic seizures, epilepsy and syncope.

PURPOSE: Previous studies suggest that ictal panic symptoms are common in patients with psychogenic nonepileptic seizures (PNES). This study investigates the frequency of panic symptoms in PNES and if panic symptoms, just before or during episodes, can help distinguish PNES from the other common causes of transient loss of consciousness (TLOC), syncope and epilepsy. METHODS: Patients with secure diagnoses of PNES (n=98), epilepsy (n=95) and syncope (n=100) were identified using clinical databases from three United Kingdom hospitals. Patients self-reported the frequency with which they experienced seven symptoms of panic disorder in association with their episodes. A composite panic symptom score was calculated on the basis of the frequency of symptoms. RESULTS: 8.2% of patients with PNES reported "never" experiencing any of the seven panic symptoms in their episodes of TLOC. Patients with PNES reported more frequent panic symptoms in their attacks than those with epilepsy (p<0.001) or syncope (p<0.001), however, patients with PNES were more likely "rarely" or "never" to report five of the seven-ictal panic symptoms than "frequently" or "always" (45-69% versus 13-29%). A receiver operating characteristic analysis demonstrated that the composite panic symptom score distinguished patients with PNES from the other groups (sensitivity 71.1%, specificity 71.2%), but not epilepsy from syncope. CONCLUSIONS: Patients with PNES report TLOC associated panic symptoms more commonly than those with epilepsy or syncope. Although panic symptoms are reported infrequently by most patients with PNES, a composite symptom score may contribute to the differentiation between PNES and the other two common causes of TLOC.

A survey of the management of transient loss of consciousness in the emergency department.

UNLABELLED: Transient loss of consciousness (TLoC) is a common presentation to the emergency department (ED). We sought to evaluate current practice in the management of patients with TLoC presenting to a large, city centre ED, against national standards. METHODS: The ED admissions database was searched to identify all patients attending with TLoC during October 2012. The clinical record of the attendance was reviewed to determine if the initial assessment met national standards. RESULTS: Ninety-one patients had a primary presentation with TLoC, representing 0.95% of ED attendances. Documentation of before/during/after the clinical event and clinical examination were done well. Notable aspects done less well included lying and standing blood pressure and recording of driving status. No patient was discharged from the ED with a copy of their 12-lead electrocardiogram (ECG). Sixty-five patients (71%) were discharged from the ED, with follow-up arranged for 11 (16%). Additional follow-up would have been appropriate in a further 15 cases (28%). CONCLUSION: Several aspects of the initial assessment of TLoC were done well. Areas for improvement include driving status documentation and advice, recording of postural blood pressures and ECG provision on discharge.

The older patient with syncope: practicalities and controversies.

The prevalence of syncope, in particular cardiac syncope, increases with advancing age and is associated with significant morbidity and mortality. Diagnosis of syncope within this population can be complex due to atypical presentations, amnesia for events and the overlap with falls. Thus, a lower threshold for investigation, preferably within a specialist syncope service, is necessary. Investigations for neurally mediated syncope, such as head-up tilt table testing, are well tolerated in the older patients, while advances in auto-activated cardiac monitoring devices have increased the diagnostic yield for cardiac syncope. The treatment of syncope ranges from simple conservative measures through to permanent cardiac pacing. This is a review of the existing literature highlighting the epidemiology, aetiology, clinical features, investigation and management strategies of syncope in the older population.

Home orthostatic training in chronic fatigue syndrome--a randomized, placebo-controlled feasibility study.

BACKGROUND: Orthostatic (Tilt)-training is an effective treatment for neurally mediated hypotension (NMH). NMH is a frequent finding in chronic fatigue syndrome (CFS). We evaluated home orthostatic training (HOT) in CFS in a randomized placebo-controlled feasibility study. METHODS: Thirty-eight patients with CFS (Fukuda Criteria) were randomly allocated to daily tilt training (n = 19) or sham training (n = 19) for 6 months. Haemodynamic responses to standing were performed in all subjects using continuous technology (Taskforce) at enrolment, week 1, 4 and 24. Symptom response and compliance were assessed using diaries. RESULTS: Two patients (one from each arm) withdrew from the study. Fourteen patients in each group complied completely or partially, and patients found the training manageable and achievable. Compared to the sham group, blood pressure while standing dropped to 8.0 mmHg less in the HOT group at 4 weeks (95% CI: 1.0 to 15.0, P = 0.03). At 4 weeks, the HOT group had higher total peripheral resistance compared to the sham group; mean difference 70.2, 95% CI: -371.4 to 511.8. Changes were maintained at 6 months. There was no significant difference in fatigue between groups at 4 weeks (mean difference 1.4, 95% CI: -13.5 to 16.2), but there was a trend towards improvement in fatigue at 6 months. Compliers had lower fatigue compared to non-compliers. CONCLUSIONS: A placebo-controlled study of HOT in CFS is feasible. HOT is well tolerated and generally complied with. A likely physiological rationale for HOT in CFS is related to reductions in orthostatic intolerance. An adequately powered study including strategies to enhance compliance is warranted.

Head-up Tilt Table Testing: a state-of-the-art review.

Vasovagal syncope (VVS) is the commonest cause of syncope accounting for up to 60% of all cases. The head-up tilt-table test (HUTT) was first described as a diagnostic test for VVS in 1986 and is now in widespread use as a research and diagnostic tool. Vasovagal syncope was previously thought to be confined to younger patients but with the introduction of HUTT, it is now being diagnosed with greater frequency in the elderly. Research into the physiological changes in susceptible individuals during HUTT has greatly increased our understanding of the pathophysiological processes underlying VVS; in particular, the hypotensive response during VVS is associated with sympathetic withdrawal rather than bradycardia alone. Various provocation agents, including nitrates, isoprotenerol and lower body negative pressure have been described to improve the diagnostic yield of the HUTT. Glyceryl trinitrate is now routinely administered during HUTTs. Individuals with typical presentations and infrequent episodes do not require investigation with HUTT as history alone is often diagnostic. The head-up tilt-table test is, however, required with atypical features, seizure activity, occupational issues, and is more likely to be required in older patients. The practicalities of conducting the HUTT and limitations of HUTTs are also discussed.

The intravenous adenosine test: a new test for the identification of bradycardia pacing indications? A pilot study in subjects with bradycardia pacing indications, vasovagal syncope and controls.

BACKGROUND: Intravenous adenosine has recently been used in the diagnosis of unexplained syncope, but there is no consensus as to the meaning of a 'positive' test. The objective is to determine the sensitivity and specificity of intravenous adenosine testing in the diagnosis of bradycardia-pacing indications [sinus node dysfunction(SND), atrio-ventricular block (AVB) and cardio-inhibitory carotid sinus syndrome (CSS)]. DESIGN: Pilot cohort study. METHODS: Patients-(i) Bradycardia-pacing group: Consecutive patients referred for pacing for SND, AVB and CSS; (ii) Consecutive head-up tilt (HUT)-positive VVS patients. Controls-(i) Simple controls (S-Con: normal examination/ECG) and (ii) Electrophysiology controls (EP-Con: consecutive subjects referred for accessory pathway ablation). Pacing referrals and EP-Con had electrophysiology studies to confirm referral diagnosis and exclude others. All subjects had bolus injection of 20 mg intravenous adenosine during continuous ECG and blood pressure monitoring (positive test: >or=6 s asystole, >or=10 s high-degree AVB post-injection). Sensitivity, specificity, safety and tolerability of the test were measured. RESULTS: Of 264 potential participants (4 SND, 8 AVB, 7 CSS, 10 VVS, 10 EP-Con and 11 S-Con) 50 were studied. All (100%) of the bradycardia-pacing group were adenosine test-positive, as were 6 (60%) VVS. None (0%) and 3 (27%) of the EP- and S-Con groups were positive. Adenosine testing was 100% sensitive and 86% specific for bradycardia-pacing indications, and 100% specific using the diagnostically 'clean' EP-Con results. There were no significant adverse or side effects. CONCLUSION: Adenosine testing reliably identified patients with definitive bradycardia-pacing indications in whom alternative diagnoses were excluded. Further work is needed to evaluate the role of this test in the diagnosis of unexplained syncope.

Pacing in elderly recurrent fallers with carotid sinus hypersensitivity: a randomised, double-blind, placebo controlled crossover trial.

OBJECTIVES: While carotid sinus syndrome (CSS) is traditionally defined by the association of carotid sinus hypersensitivity (CSH) with syncope, uncertainty remains over the role, if any, of complex pacing in patients with CSH and unexplained or recurrent falls. We sought to clarify the role of dual chamber pacing in this patient group in the first placebo-controlled study in CSH. DESIGN: Randomised, double-blind, crossover, placebo-controlled trial. SETTING: Specialist falls and syncope facility. PATIENTS: Consecutive subjects aged over 55 years with CSH as the sole attributable cause of three or more unexplained falls in the 6 months preceding enrolment. INTERVENTION: Dual-chamber permanent pacing with rate-drop response programming. The pacemaker was switched on (DDD/RDR) or off (ODO (placebo)) for 6 months, then crossed over to the alternate mode for a further 6 months, in randomised, double-blind fashion. MAIN OUTCOME MEASURE: The primary outcome measure was number of falls in paced and non-paced modes. RESULTS: Twenty-five of 34 subjects (mean 76.8 years (SD 9.0), 27 (79%) female) recruited completed the study. Pacing intervention had no effect on number of falls (4.04 (9.54) in DDD/RDR mode, 3.48 (7.22) in ODO; relative risk of falling in ODO mode 0.82, 95% CI 0.62 to 1.10). CONCLUSION: Permanent pacing intervention had no effect on fall rates in older patients with CSH. Further work is urgently needed to clarify the role, if any, of complex pacing in this patient group.

A case of nocturnal fainting: supine vasovagal syncope.

Supine loss of consciousness is a relatively rare occurrence prompting investigations for underlying causes as diverse as cardiac arrhythmia, hypoglycaemia and nocturnal epilepsy. Neurally mediated syncope is rarely implicated as the cause of symptoms in supine loss of consciousness because of the absence of orthostatic stress and gravitational relative preservation of cerebral perfusion, but we report here on a case of recurrent, atypical and troublesome vasovagal syncope occurring at night while supine. Diagnosis aided by head-up tilt table testing and conservative management brought about complete resolution of symptoms.

Calcaneal bone mineral density in older patients who have fallen.

BACKGROUND: Annually, 35-40% of those aged >65 years fall; up to 5% of such falls result in fracture. Fracture is determined both by propensity to fall and by bone fragility. AIM: To determine osteoporosis prevalence and predictors in patients who have fallen. DESIGN: Observational cross-sectional study. METHODS: We measured calcaneal BMD in 408 consecutive patients aged >50 years attending after falling. Fall number, fracture history, weight, height, and risk factors for falls and osteoporosis were recorded. T scores (SD above or below the mean for young adults) were derived in both sexes, and Z scores (SD above or below age-related normal score) in females. RESULTS: In females (n = 300, 74%), mean (SD) T score was -1.1(1.6), and mean Z score was 0(1.4); 127 (42%) had osteoporosis (T score < - 1.6). ROC curves confirmed significant relationships between osteoporosis and age, weight and height (all p < 0.0001). Incorporating fracture history, our model (fracture aged >50 years, age >83 years, weight <57 kg, height <153 cm as dichotomous variables) predicted osteoporosis with 91% sensitivity, 34% specificity. Of 108 male fallers, 36 (33%) had osteoporosis. Age, height and weight all predicted osteoporosis (p < 0.02). The resulting model (fracture aged >50 years, age > or =80 years, weight < or =68 kg, height < or =167 cm as dichotomous variables) predicted osteoporosis with 92% sensitivity, 30% specificity. DISCUSSION: Osteoporosis prevalence is not increased in female fallers compared to age-related norms; empirical use of osteoporosis treatment solely on the basis of falls thus appears inappropriate. In both sexes, the factors predicting osteoporosis were age, height and weight. Where BMD is not practical, possible or economical, our model may be a sensitive means of predicting fallers with osteoporosis.

Cerebral autoregulation is impaired in cardioinhibitory carotid sinus syndrome.

OBJECTIVES: To compare changes in cerebral autoregulation in response to controlled, lower body negative pressure-induced hypotension in patients with carotid sinus syndrome (CSS) and case controls. DESIGN: Prospective case controlled study. SETTING: Secondary and tertiary referral falls and syncope service. PATIENTS: 17 consecutive patients with CSS and 11 asymptomatic controls. INTERVENTIONS: Hypotension insufficient to cause syncope induced by lower body negative pressure (minimum 30 mm Hg fall in systolic blood pressure (SBP)) during concomitant transcranial Doppler ultrasonography. MAIN OUTCOME MEASURES: Cerebral autoregulation (systolic, diastolic and mean middle cerebral arterial blood flow velocities and cerebrovascular resistance) with continuous end-tidal carbon dioxide and haemodynamic monitoring. RESULTS: Cerebral autoregulatory indices differed significantly between patients with CSS and controls. Systolic, diastolic and middle cerebral arterial blood flow velocities were, respectively, 9.2 m/s (95% confidence interval (CI) 2.9 to 15.4 m/s), 4.7 m/s (95% CI 1.5 to 7.9 m/s) and 6.9 m/s (95% CI 2.5 to 11.4 m/s) slower in patients with CSS. Cerebrovascular resistance was significantly greater in patients with CSS than in controls at SBP nadir and suction release; differences were 0.9 mm Hg/m/s (95% CI 0.0 to 1.7 mm Hg/m/s) and 0.8 mm Hg/m/s (95% CI 0.0 to 1.7 mm Hg/m/s), respectively. End-tidal carbon dioxide and systemic haemodynamic variables were similar for patients and controls at baseline and during lower body negative pressure. CONCLUSIONS: Cerebral autoregulation is altered in patients with CSS. This difference may have aetiological implications in the differential presentation with falls and drop attacks rather than syncope.

Falls and confidence related quality of life outcome measures in an older British cohort.

Falls are common in older subjects and result in loss of confidence and independence. The Falls Efficacy Scale (FES) and the Activities-specific Balance Confidence scale (ABC) were developed in North America to quantify these entities, but contain idiom unfamiliar to an older British population. Neither has been validated in the UK. The FES and the ABC were modified for use within British culture and the internal consistency and test-retest reliability of the modified scales (FES-UK and ABC-UK) assessed. A total of 193 consecutive, ambulant, new, and return patients (n=119; 62%) and their friends and relatives ("visitors", n=74; 38%) were tested on both scales, while the last 60 subjects were retested within one week. Internal reliability was excellent for both scales (Cronbach's alpha 0.97 (FES-UK), and 0.98 (ABC-UK)). Test-retest reliability was good for both scales, though superior for the ABC-UK (intraclass correlation coefficient 0.58 (FES-UK), 0.89 (ABC-UK)). There was evidence to suggest that the ABC-UK was better than the FES-UK at distinguishing between older patients and younger patients ([t(ABC)] = 4.4; [t(FES)] = 2.3); and between fallers and non-fallers ([t(ABC)] = 8.7; [t(FES)] = 5.0) where the t statistics are based on the comparison of two independent samples. The ABC-UK and FES-UK are both reliable and valid measures for the assessment of falls and balance related confidence in older adults. However, better test-retest reliability and more robust differentiation of subgroups in whom falls related quality of life would be expected to be different make the ABC-UK the current instrument of choice in assessing this entity in older British subjects.

Carotid sinus syndrome masquerading as treatment resistant epilepsy.

A 65 year old woman had a 12 year history of frequent, recurrent seizure-like episodes labelled as treatment resistant epilepsy after neurological evaluation and follow up and treatment with multiple antiepileptic medications. Carotid sinus massage provoked 5.6 seconds asystole with symptom reproduction, and she has remained symptom-free after permanent pacemaker implantation for her carotid sinus syndrome and withdrawal of antiepileptic medications.