Defecation syncope. A symptom with multiple etiologies.

To our knowledge, there is no previous clinical description in the literature of patients with defecation syncope. We evaluated 20 patients with this disorder who were a subgroup of a larger, prospective study of syncope, 13 women and seven men, with a mean age of 59 years. Eleven patients had had one episode and nine had experienced multiple episodes. Fourteen patients were recumbent before the urge to defecate, nine of these asleep. The diagnostic evaluation disclosed that two patients had gastrointestinal tract problems, three had cardiac diseases, and one had transient ischemic attacks. Three additional patients had marked orthostatic hypotension. No identifiable cause for defecation syncope was found in 11 patients, but new medical problems were noted in four of those patients. In follow-up at two years, syncope had recurred in ten patients, but the majority of recurrences were unassociated with defecation. Seven patients died during the follow-up period of underlying chronic diseases. We conclude that defecation syncope is not a single distinct clinical entity. Multiple pathologic abnormalities in association with physiologic changes during sleep and defecation may contribute to syncope. Patients with defecation syncope should undergo a careful evaluation for diagnosis of underlying illness causing syncope.

Do symptoms predict cardiac arrhythmias and mortality in patients with syncope?

BACKGROUND: Patients with syncope frequently present with multitude of other symptoms but their significance in predicting morbidity or mortality has not been previously studied. OBJECTIVE: To determine if certain symptoms can be used to identify syncope patients at risk for cardiac arrhythmias, mortality, or recurrence of syncope. PATIENTS AND METHODS: From August 1987 to February 1991, we prospectively evaluated patients with syncope from outpatient, inpatient, and emergency department services of a university medical center. These patients were interviewed, charts were reviewed, and detailed information on 19 symptoms and comorbidities was obtained. A cause of syncope was assigned using standardized diagnostic criteria. All patients were followed up at 3-month intervals for at least 1 year for recurrence of syncope and mortality. Patients in whom the cause of syncope was determined by medical history and physical examination alone were not included in our analysis. RESULTS: History and physical examination led to the cause of syncope in 222 of 497 patients enrolled. In the remaining 275 patients, the absence of nausea and vomiting before syncope (odds ratio, 7.1) and electrocardiographic abnormalities (odds ratio, 23.5) were predictors of arrhythmic syncope. Underlying cardiac disease was the only predictor of 1-year mortality. No symptom remained as independent predictor for 1-year mortality or syncope recurrence. CONCLUSIONS: Symptoms, although important in assigning many noncardiac causes, are not useful in risk-stratifying patients whose cause of syncope cannot be identified by other history and physical examination. Triage decisions and management plans should be based on pre-existing cardiac disease or electrocardiographic abnormalities, which are important predictors of arrhythmic syncope and mortality.

The duration of Holter monitoring in patients with syncope. Is 24 hours enough?

To determine the incremental yield of ambulatory monitoring in the evaluation of syncope, three serial 24-hour Holter recordings were obtained in a consecutive series of 95 patients with syncope, the cause of which was not explained by history, physical examination, or 12-lead electrocardiogram. The mean age of patients was 61 years and 41% were men. Major electrocardiographic abnormalities were found in 26 patients (27%), including unsustained ventricular tachycardia (19 patients), pauses of at least 2 seconds (8 patients), profound bradycardia (1 patient), and complete heart block (1 patient). The first 24-hour Holter recording had at least one major abnormality in 14 patients (15%) (95% confidence interval, 8.3% to 23.4%). Of the 81 patients without a major abnormality on the first Holter recording, the second Holter recording had major abnormalities in 9 (11%) (95% confidence interval, 5.1% to 20.0%). Of the 72 patients without a major abnormality on the first two Holter recordings, only 3 patients (4.2%) had a major abnormality on the third Holter recording (95% confidence interval, 0.8% to 11.7%). Four factors were significantly associated with an increased likelihood of a major abnormality on 72 hours of monitoring: age above 65 years (relative risk, 2.2), male gender (relative risk, 2.0), history of heart disease (relative risk, 2.2), and an initial nonsinus rhythm (relative risk, 3.5). These results suggest that 24 hours of Holter monitoring is not enough to identify all potentially important arrhythmias in patients with syncope. Monitoring may need to be extended to 48 hours if the first 24-hour Holter recording is normal.

Efficacy of pneumococcal vaccination in adults. A meta-analysis of randomized controlled trials.

BACKGROUND: Because of the prevalence of pneumococcal pneumonia, the substantial morbidity and mortality associated with many pneumococcal infections, and an increase in the incidence of antibiotic resistance among pneumococcal isolates, considerable efforts for disease prevention have been made using a polyvalent polysaccharide pneumococcal vaccine. Despite numerous clinical trials of the vaccine, its efficacy in the prevention of pneumococcal infections and other clinically relevant medical outcomes in adults remains uncertain. METHODS: To assess quantitatively the efficacy of pneumococcal vaccination, a MEDLINE literature search, manual reviews of article bibliographies, and communications with pneumococcal vaccine investigators were used to identify randomized controlled trials of the pneumococcal vaccine. Independent review of 594 articles revealed nine randomized trials with 12 vaccine and control study groups that evaluated clinically relevant outcomes in adults. To estimate a summary effect size for all outcomes, Mantel-Haenszel odds ratios (ORs) and Dersimonian and Laird rate differences (RDs) and their associated 95% confidence intervals (CIs) were computed. RESULTS: Summary ORs demonstrated a statistically significant protective effect of the vaccine for four pneumococcal infection-related outcomes: definitive pneumococcal pneumonia (OR = 0.34; 95% CI = 0.24 to 0.48), definitive pneumococcal pneumonia for vaccine-containing pneumococcal antigen types only (vaccine types only) (OR = 0.17; 95% CI = 0.09 to 0.33), presumptive pneumococcal pneumonia (OR = 0.47; 95% CI = 0.35 to 0.63), and presumptive pneumococcal pneumonia (vaccine types only) (OR = 0.39; 95% CI = 0.26 to 0.59). The summary RDs, which account for heterogeneity among studies, confirmed a statistically significant protective effect for two of these same outcomes: definitive pneumococcal pneumonia (RD = 4/1000; 95% CI = 0/1000 to 7/1000) and definitive pneumococcal pneumonia (vaccine types only) (RD = 8/1000; 95% CI = 1/1000 to 16/1000). Summary ORs and RDs failed to demonstrate a protective effect for pneumonia (all causes), bronchitis, and mortality (all causes) or mortality due to pneumonia or pneumococcal infection. Subgroup analyses showed that for all four pneumococcal infection-related outcomes, vaccine efficacy differed for high- and low-risk subjects, demonstrating efficacy for low-risk subjects and lack of efficacy for high-risk subjects. CONCLUSIONS: Pneumococcal vaccination appears efficacious in reducing bacteremic pneumococcal pneumonia in low-risk adults. However, evidence from randomized controlled trials fails to demonstrate vaccine efficacy for pneumococcal infection-related or other medical outcomes in the heterogeneous group of subjects currently labeled as high risk.

The electronic medical record. A randomized trial of its impact on primary care physicians' initial management of major depression [corrected].

BACKGROUND: Inadequate treatments are reported for depressed patients cared for by primary care physicians (PCPs). Providing feedback and evidence-based treatment recommendations for depression to PCPs via electronic medical record improves the quality of interventions. METHODS: Patients presenting to an urban academically affiliated primary care practice were screened for major depression with the Primary Care Evaluation of Mental Disorders (PRIME-MD). During 20-month period, 212 patients met protocol-eligibility criteria and completed a baseline interview. They were cared for by 16 board-certified internists, who were electronically informed of their patients' diagnoses, and randomized to 1 of 3 methods of exposure to guideline-based advice for treating depression (active, passive, and usual care). Ensuing treatment patterns were assessed by medical chart review and by patient self-report at baseline and 3 months. RESULTS: Median time for PCP response to the electronic message regarding the patient's depression diagnosis was 1 day (range, 1-95 days). Three days after notification, 120 (65%) of 186 PCP responses indicated agreement with the diagnosis, 24 (13%) indicated disagreement, and 42 (23%) indicated uncertainty. Primary care physicians who agreed with the diagnoses sooner were more likely to make a medical chart notation of depression, begin antidepressant medication therapy, or refer to a mental health specialist (P<.001). There were no differences in the agreement rate or treatments provided across guideline exposure conditions. CONCLUSIONS: Electronic feedback of the diagnosis of major depression can affect PCP initial management of the disorder. Further study is necessary to determine whether this strategy, combined with delivery of treatment recommendations, can improve clinical outcomes in routine practice.

Influence of age on symptoms at presentation in patients with community-acquired pneumonia.

BACKGROUND: Advanced age has become a well-recognized risk factor for death in patients with pneumonia. It may also be associated with reduced symptom reporting, raising the possibility that diagnosis and treatment may be delayed in older patients. OBJECTIVE: To evaluate the association between age and the presenting symptoms in patients with community-acquired pneumonia. METHODS: This study was conducted at inpatient and outpatient facilities at 3 university hospitals, 1 community hospital, and 1 staff-model health maintenance organization. Patients included adults (age > or = 18 years) with clinical and radiographic evidence of pneumonia, who were able to complete a baseline interview. The presence of 5 respiratory symptoms and 13 nonrespiratory symptoms were recorded during a baseline patient interview. A summary symptom score was computed as the total number of symptoms at presentation. RESULTS: The 1812 eligible study patients were categorized into 4 age groups: 18 through 44 years (43%), 45 through 64 years (25%), 65 through 74 years (17%), and 75 years or older (15%). For 17 of the 18 symptoms, there were significant decreases in reported prevalence with increasing age (P < .01). In a linear regression analysis, controlling for patient demographics, comorbidity, and severity of illness at presentation, older age remained associated with lower symptom scores (P < .001). CONCLUSIONS: Respiratory and nonrespiratory symptoms are less commonly reported by older patients with pneumonia, even after controlling for the increased comorbidity and illness severity in these older patients. Recognition of this phenomenon by clinicians and patients is essential given the increased mortality in elderly patients with pneumonia.

The hospital discharge decision for patients with community-acquired pneumonia. Results from the Pneumonia Patient Outcomes Research Team cohort study.

BACKGROUND: The hospital discharge decision directly influences the length of stay in patients with community-acquired pneumonia, yet no information exists on how physicians make this decision. OBJECTIVES: To identify the factors physicians considered the factors responsible for extending length of hospital stay in clinically stable patients, and the outpatient medical services that would allow earlier hospital discharge for patients with community-acquired pneumonia. METHODS: Physicians responsible for the hospital discharge decision of patients with community-acquired pneumonia were asked to identify the factors responsible for extending stay in patients hospitalized beyond stability, and the medical services that could have allowed earlier hospital discharge to occur. RESULTS: For the 418 eligible patients with community-acquired pneumonia identified during the study, 332 questionnaires (79%) were completed by 168 physicians. Physicians believed 71 patients (22%) were discharged from the hospital 1 day or more (median, 2.5 days) after reaching clinical stability. The most common factors rated as being "very important" in delaying discharge were diagnostic evaluation or treatment of comorbid illness (56%), completion of a "standard course" of antimicrobials (15%), and delays with arrangements for long-term care (14%). Among the 302 patients with available information on both length of hospital stay and stability at discharge, median length of stay was 7.0 days for the 29 low-risk patients hospitalized beyond reaching clinical stability and 5.0 days for the remaining 128 low-risk patients (P < .005); median length of stay was 12.5 days for the 42 medium- and high-risk patients hospitalized beyond reaching clinical stability and 8.0 days in the remaining 113 medium- and high-risk patients (P < .001). Frequently cited medical services that "probably" or "definitely" would have allowed earlier discharge to occur included availability of home intravenous antimicrobial infusion (26%) and home visits by nurses (20%). CONCLUSIONS: Physicians believed that diagnostic evaluation or treatment of comorbid illness, completion of a standard course of antimicrobial therapy, and delays with arrangements for long-term care delayed hospital discharge in clinically stable patients. Addressing the efficiency of these aspects of inpatient medical care, as well as providing home treatment programs, could decrease the length of hospital stay in patients with community-acquired pneumonia.

Do pulmonary radiographic findings at presentation predict mortality in patients with community-acquired pneumonia?

BACKGROUND: Previous studies have reported conflicting results on whether pulmonary radiographic findings predict mortality for patients with community-acquired pneumonia (CAP). OBJECTIVE: To determine whether pulmonary radiographic findings at presentation are independently associated with 30-day mortality in patients with suspected CAP. METHODS: This study was conducted as part of the Pneumonia Patient Outcomes Research Team multicenter, prospective cohort study of ambulatory and hospitalized patients with clinical and radiographic evidence of CAP. For each patient with CAP, a structured data form was completed by a panel of radiologists to evaluate the radiographic pattern of infiltrate, number of lobes involved, presence of pleural effusion, and 8 other radiographic characteristics. Cox proportional hazards models were used to evaluate the independent association between radiographic findings and 30-day mortality, while controlling for patient demographic, clinical, and laboratory characteristics with a known association with this outcome. RESULTS: Of 2287 patients enrolled in the Pneumonia Patient Outcomes Research Team cohort study, 1906 patients (83.3%) had a pulmonary radiographic infiltrate confirmed by the radiology panel. Overall, 30-day mortality in this cohort was 4.9%. Univariate regression analyses demonstrated the following radiographic characteristics to be significantly associated with 30-day mortality: (1) bilateral pleural effusions (risk ratio [RR], 7.0; 95% confidence interval [CI], 3.9-12.6); (2) a pleural effusion of moderate or greater size (RR, 3.4; 95% CI, 1.4-8.4); (3) 2 or more lobes involved with infiltrate (RR, 2.5; 95% CI, 1.6-3.8); (4) bilateral infiltrate (RR, 2.8; 95% CI, 1.9-4.2); (5) bronchopneumonia (RR, 1.6; 95% CI, 1.0-2.7); and (6) air bronchograms (RR, 0.5; 95% CI, 0.2-0.9). Multivariate analysis of radiographic features and other clinical characteristics showed the presence of bilateral pleural effusions (RR, 2.8; 95% CI, 1.4-5.8) was independently associated with mortality. CONCLUSIONS: In patients with CAP, the presence of bilateral pleural effusions is an independent predictor of short-term mortality. This finding, which is available at presentation, can help guide physicians' assessment of prognosis in CAP.

Preferences for home vs hospital care among low-risk patients with community-acquired pneumonia.

OBJECTIVE: To measure preferences for initial outpatient vs hospital care among low-risk patients who were being actively treated for community-acquired pneumonia (CAP). METHODS: Study patients included 159 patients with CAP, 57 (36%) initially hospitalized, who were identified as being at low risk for early mortality using a validated prediction model. Subjects were enrolled from university and community health care facilities located in Boston, Mass, Halifax, Nova Scotia, and Pittsburgh, Pa, participating in the Pneumonia Patient Outcome Research Team prospective cohort study of CAP. Three utility assessment techniques (category scaling, standard gamble, and willingness to pay) were used to measure the strength of patient preferences for the site of care for low-risk CAP. At the time of initial therapy or during the early recuperative period, patient preferences were assessed across a spectrum of potential clinical outcomes using 7 standardized pneumonia clinical vignettes. RESULTS: Responses to the 7 pneumonia scenarios indicated that most patients consistently preferred outpatient-based therapy. This pattern was observed regardless of whether patients had actually been treated initially at home or in a hospital. Patients (74%) who stated that they generally preferred home care for low-risk CAP were willing to pay a mean of 24% of 1 month's household income to be assured of this preference. Preference for home care, as measured by the category scaling and the willingness to pay, persisted after adjustment for sociodemographic and baseline health status covariates. Sixty nine percent of interviewed patients said that their physician alone determined whether they would be treated in the hospital or at home. Only 11% recalled being asked if they had a preference for either site of care. CONCLUSIONS: Most patients, even those treated initially in a hospital, who were at low risk for mortality from CAP prefer outpatient treatment. However, most physicians appear not to involve patients in the site-of-care decision. More explicit discussion of patient preferences for the location of care would likely yield more highly valued care by patients as well as less costly treatment for CAP.

The hospital admission decision for patients with community-acquired pneumonia. Results from the pneumonia Patient Outcomes Research Team cohort study.

BACKGROUND: The hospital admission decision directly influences the magnitude of resource use in patients with community-acquired pneumonia, yet little information exists on how medical practitioners make this decision. OBJECTIVES: To determine which factors medical practitioners consider in making the hospital admission decision and which health care services they believe would allow ambulatory treatment of low-risk hospitalized patients with community-acquired pneumonia. METHODS: Medical practitioners responsible for the hospital admission decision for low-risk patients with community-acquired pneumonia were asked to describe patient characteristics at initial examination that influenced the hospitalization decision, and to identify the health care services that would have allowed initial outpatient treatment of hospitalized patients. RESULTS: A total of 292 medical practitioners completed questionnaires for 472 (76%) of the 624 low-risk patients eligible for this study. Although all patients had a predicted probability of death of less than 4%, practitioners estimated that 5% of outpatients and 41% of inpatients had an expected 30-day risk of death of more than 5%. Univariate analyses identified 3 practitioner-rated factors that were nearly universally associated with hospitalization: hypoxemia (odds ratio, 173.3; 95% confidence interval, 23.8-1265.0), inability to maintain oral intake (odds ratio, 53.3; 95% confidence interval, 12.8-222.5), and lack of patient home care support (odds ratio, 54.4; 95% confidence interval, 7.3-402.6). In patients without these 3 factors, logistic regression analysis demonstrated that practitioner-estimated risk of death of more than 5% had a strong independent association with hospitalization (odds ratio, 18.4; 95% confidence interval, 6.1-55.7). Practitioners identified home intravenous antibiotic therapy and home nursing observation as services that would have allowed outpatient treatment of more than half (68% and 59%, respectively) of the patients initially hospitalized for treatment. CONCLUSIONS: Practitioners' survey responses suggest that the availability of outpatient intravenous antimicrobial therapy and home nursing care would allow outpatient care for a large proportion of low-risk patients who are hospitalized for community-acquired pneumonia. These data also suggest that methods to improve practitioners' identification of low-risk patients with community-acquired pneumonia could decrease the hospitalization of such patients. Future studies are required to help physicians identify which low-risk patients could safely be treated in the outpatient setting on the basis of clinical information readily available at presentation.

Processes and outcomes of care for patients with community-acquired pneumonia: results from the Pneumonia Patient Outcomes Research Team (PORT) cohort study.

BACKGROUND: Although understanding the processes of care and medical outcomes for patients with community-acquired pneumonia is instrumental to improving the quality and cost-effectiveness of care for this illness, limited information is available on how physicians manage patients with this illness or on medical outcomes other than short-term mortality. OBJECTIVES: To describe the processes of care and to assess a broad range of medical outcomes for ambulatory and hospitalized patients with community-acquired pneumonia. METHODS: This prospective, observational study was conducted at 4 hospitals and 1 health maintenance organization in Pittsburgh, Pa, Boston, Mass, and Halifax, Nova Scotia. Data were collected via patient interviews and reviews of medical records for 944 outpatients and 1343 inpatients with clinical and radiographic evidence of community-acquired pneumonia. Processes of care and medical outcomes were assessed 30 days after presentation. RESULTS: Only 29.7% of outpatients had 1 or more microbiologic tests performed, and only 5.7% had an assigned microbiologic cause. Although 95.7% of inpatients had 1 or more microbiologic tests performed, a cause was established in only 29.6%. Six outpatients (0.6%) died, and 3 of these deaths were pneumonia related. Of surviving outpatients, 8.0% had 1 or more medical complications. At 30 days, 88.9% (nonemployed) to 95.6% (employed) of the surviving outpatients had returned to usual activities, yet 76.0% of outpatients had 1 or more persisting pneumonia-related symptoms. Overall, 107 inpatients (8.0%) died, and 81 of these deaths were pneumonia related. Most surviving inpatients (69.0%) had 1 or more medical complications. At 30 days, 57.3% (non-employed) to 82.0% (employed) of surviving inpatients had returned to usual activities, and 86.1% had 1 or more persisting pneumonia-related symptoms. CONCLUSIONS: In this study, conducted primarily at hospital sites with affiliated medical education training programs, virtually all outpatients and most inpatients had pneumonia of unknown cause. Although outpatients had an excellent prognosis, pneumonia-related symptoms often persisted at 30 days. Inpatients had substantial mortality, morbidity, and pneumonia-related symptoms at 30 days.

Evaluation and outcome of patients with syncope.

We studied 433 patients with syncope to derive insights into the diagnostic evaluation and outcome of patients with this common problem. This study shows that the etiology of syncope was not found in approximately 41% of patients. When a cause of syncope was determined, it was most frequently established on the basis of initial history, physical examination and an electrocardiogram (EKG). Furthermore, many of the other entities (e.g., aortic stenosis, subclavian steal) were suggested by findings on the history and physical examinations that required directed diagnostic testing. Initial EKG was abnormal in 50% of patients but led to a cause of syncope infrequently (less than 7%). Prolonged electrocardiographic monitoring, which has assumed a central role in the evaluation of syncope, led to a specific cause in only 22% of patients. Other tests were less often helpful in assigning a cause of syncope. At 5 years, the mortality of 50.5% in patients with a cardiac cause of syncope was significantly higher than the 30% mortality in patients with a noncardiac cause or 24.1% in patients with an unknown cause. At 5 years, a mortality of 50.5% in patients with a cardiac cause of syncope was noted. There were 54 actual deaths in this group as compared to 10.7 expected deaths based on 1980-86 mortality data from Allegheny County, PA (standardized mortality ratio = 5.02). At 5 years, a 33.1% incidence of sudden death was noted in patients with cardiac cause of syncope, as compared with 4.9% in patients with a noncardiac cause and 8.5% in patients with an unknown cause. Mortality and sudden death remained significant for the first 3 years after which the survival curves were parallel. A cardiac cause of syncope was an independent predictor of sudden death and mortality. Recurrences were common but were not associated with an increased risk of mortality or sudden death. Major vascular events were also more frequent in patients with cardiac causes of syncope. The results of this study will be helpful in designing future studies to evaluate the usefulness of newer diagnostic techniques. Furthermore, short- and long-term outcome data will be useful in planning intervention strategies in these patients.

Diagnostic evaluation of syncope.

Syncope is a common medical problem and is caused by a wide variety of diseases ranging from physiologic derangements with few consequences to conditions that may be immediately life-threatening. Because of the large differential diagnosis, many diagnostic tests are available for its evaluation. However, a cause of syncope is not established in 38% to 47% of patients despite these tests. In those patients in whom a diagnosis can be assigned, the history and physical examination identify a potential cause in 49% to 85%. Furthermore, in 8% of additional patients, history and physical examination are suggestive of causes that need confirmation by specific tests. Routine blood tests rarely yield diagnostically helpful information. In those patients in whom a potential cause for syncope is identified, arrhythmias are diagnosed by electrocardiogram in 2% to 11% of patients, cardiac monitoring in 3% to 27% (telemetry or Holter), stress test in less than 1%, carotid massage in less than 1%, and electrophysiologic studies in less than 3%. Diagnosis of arrhythmias as a cause of syncope is problematic because symptomatic correlation during electrocardiographic monitoring is rarely found (approximately 4%), and as a result, there is no uniform agreement on diagnostic criteria for abnormalities. Similar problems exist in the use of electrophysiologic studies. Upright tilt testing and psychiatric examination may be useful in evaluation of recurrent syncope of unknown cause in patients without organic heart disease. Based on the results of recent studies, strategies for evaluation of patients with syncope are possible that utilize selective and goal-directed diagnostic testing.

Evaluation and outcomes of patients with palpitations.

PURPOSE: To determine: (1) the etiologies of palpitations, (2) the usefulness of diagnostic tests in determining the etiologies of palpitations, and (3) the outcomes of patients with palpitations. PATIENTS AND METHODS: One hundred and ninety consecutive patients presenting with a complaint of palpitations at a university medical center were enrolled in this prospective cohort study. Patients underwent a structured clinical interview and psychiatric screening. The charts were abstracted for results of the physical exam and tests ordered by the primary physician. Assignment of an etiology of palpitations was based on strict adherence to predetermined criteria and achieved by consensus of the two physician investigators. One-year follow-up was obtained in 96% of the patients. RESULTS: An etiology of palpitations was determined in 84% of the patients. The etiology of palpitations was cardiac in 43%, psychiatric in 31%, miscellaneous in 10%, and unknown in 16%. Forty percent of the etiologies could be determined with the history and physical examination, an electrocardiogram, and/or laboratory data. The 1-year mortality rate was 1.6% (95% confidence interval [CI] 0% to 3.4%) and the 1-year stroke rate was 1.1% (95% CI 0% to 2.6%). Within the first year, 75% of the patients experienced recurrent palpitations. At 1-year follow-up, 89% reported that their health was the same or improved compared to that at enrollment, 19% reported that their work performance was impaired, 12% reported that workdays were missed, and 33% reported accomplishing less than usual work at home. CONCLUSIONS: The etiology of palpitations can often be diagnosed with a simple initial evaluation. Psychiatric illness accounts for the etiology in nearly one third of all patients. The short-term prognosis of patients with palpitations is excellent with low rates of death and stroke at 1 year, but there is a high rate of recurrence of symptoms and a moderate impact on productivity.

Is syncope a risk factor for poor outcomes? Comparison of patients with and without syncope.

OBJECTIVE: To determine whether syncope, independent of underlying comorbidities, is associated with increased mortality or other cardiovascular outcomes. PATIENTS AND METHODS: A prospective cohort study of patients with syncope and a group of patients without syncope matched with respect to age, gender, site of care (inpatient/ outpatient) and a cardiac disease index at an urban university medical center. Overall mortality, cardiac mortality, cardiovascular outcomes, and occurrence of syncope within 1 year of study enrollment were compared between the groups with Kaplan-Meier rates and Mantel-Cox statistics. RESULTS: The characteristics of 470 patients with syncope and the matched patients without syncope were similar except that the patients without syncope had more cardiac diseases than those with syncope (P = 0.002). Patients with and without syncope had similar rates of 1-year overall mortality (9% versus 11%, P = 0.29) and cardiac mortality (3% versus 6%, P = 0.08). In multivariate analyses, syncope was not a significant predictor of overall or cardiac mortality, but male gender, age > 55 years, and congestive heart failure were. One-year rates for other cardiovascular outcomes (myocardial infarction, congestive heart failure, cardiac arrest with survival, and cerebrovascular events) in patients with syncope were similar to those in patients without syncope (P > or = 0.2 for all comparisons). Patients with syncope had a 20.2% recurrence rate in 1 year as compared with a 2.1% rate for new syncope in patients without prior syncope (P < 0.00001). CONCLUSIONS: Syncope itself is not a risk factor for increased overall and cardiac mortality or cardiovascular events. Underlying heart diseases are risk factors for mortality regardless of whether the patient has syncope or not. The major focus of the evaluation of patients with syncope should be to identify and treat underlying heart diseases.

Diagnostic and prognostic implications of recurrences in patients with syncope.

The incidence and the diagnostic and prognostic implications of recurrences in 433 patients enrolled in a prospective syncope study are reported. Over a mean follow-up of 30 months, 146 patients had recurrent syncope. Patients with an initial diagnosis of a cardiovascular cause of syncope had a recurrence rate of 31 percent, patients with a noncardiovascular cause had a recurrence rate of 36 percent, and patients with syncope of unknown origin had a recurrence rate of 43 percent at three years (these differences were not significant; the minimum for any two-way comparison was p greater than or equal to 0.11). In eight of the 191 patients in whom a cause of syncope could not be found on initial evaluation, a diagnosis was assigned in follow-up after recurrent syncope. Recurrences led to major morbidity in eight of 146 patients (5 percent) and minor trauma in 10 patients (7 percent). Using recurrence as a time-dependent variable in the Cox models, it was found that this variable was not a significant predictor of overall mortality or sudden death. It is concluded that recurrences are common in patients with syncope, but new diagnosis are rarely established on the basis of evaluation of recurrences. Recurrences are not predictors of mortality or sudden death.

Upright tilt testing in evaluating syncope: a comprehensive literature review.

BACKGROUND: Upright tilt testing is widely utilized for the evaluation of syncope. Recently, there have been concerns about the specificity and the lack of standard methodology for this test. The purpose of this study was to summarize the methodologies of upright tilt testing in patients with syncope of unknown origin, the responses in control subjects, and the reproducibility and selection of therapy. METHODS: We used MEDLINE to search English language articles from 1966 to June 30, 1992. Studies were included for content review if they met our inclusion criteria. Data were extracted from each article by two trained reviewers using a predesigned data collection instrument. RESULTS: Thirty-three articles were included for review. There was considerable variability in the methodologies of tilt testing. Overall positive responses were reported in 49% of patients in passive-only studies as compared with 66% of patients in studies using isoproterenol with tilt testing. The percentage of positive responses increased with increasing angle of testing for studies using isoproterenol. There was no relationship between the percentage of positive responses and the maximum dose of isoproterenol. When we compared the results of passive studies that tested patients for 60 minutes at 60 degrees with the results of isoproterenol studies that tested patients at 60 degrees, the positive rate for passive-only studies was 54% as compared with 52% for the isoproterenol studies. The percentage of positive response in control subjects with passive studies was 8.9% (range 0% to 100%), and with isoproterenol 27% (range 0% to 65%). Other groups of patients showed a wide range of positive responses (range 0% to 83%). Reproducibility ranged from 71% to 87%. Upon retesting while the patient was receiving therapy, 90% of 115 positive patients were negative. Eighty-nine percent of 105 positive patients who were receiving therapy and followed for a mean time of 12 months were free of syncope. CONCLUSIONS: This review strongly suggests that isoproterenol may not have an effect on stimulating vasovagal syncope during upright tilt testing. We recommend protocols of passive tilt testing procedures at 60 degrees for 45 to 60 minutes since the overall specificity is higher with this method. The use of isoproterenol during tilt testing adds to the cost and complexity of the test, is associated with a higher rate of false-positive responses, leads to potential complications, and, thus, should be avoided.

Psychiatric illnesses in patients with syncope.

PURPOSE: To determine the prevalence of psychiatric disorders among patients with syncope; the relationship between psychiatric disorders and the cause of syncope; and the outcome of syncope patients with psychiatric disorders. PATIENTS AND METHODS: In a prospective cohort study in a university-affiliated medical center, hospitalized and ambulatory patients with syncope underwent a standardized medical and psychiatric evaluation consisting of the Diagnostic Interview Schedule (DIS) sections for somatization, panic, generalized anxiety, major depression disorders, and drug and alcohol dependence and abuse disorders. RESULTS: Of 414 patients who completed the DIS, 82 (20%) met the criteria for at least one of the psychiatric disorders or alcohol/drug disorders. Patients with at least one of the four major psychiatric disorders (n = 58) were more likely to report > or = 4 syncopal events in the past year (odds ratio (OR) 2.5, P < 0.04); and to have prodromal symptoms prior to syncopal events (OR 2.4, P < 0.04) than were patients without psychiatric disorders. Syncope patients with only alcohol/drug disorders (n = 24) were more likely to be male (OR 7.7, P < 0.001) and younger than 65 years old (OR 4.5, P < 0.001) than patients without alcohol/drug disorders. One-year recurrence rate for syncope in patients with any psychiatric diagnosis was 35%, compared to 15% in those without a psychiatric disorder (P < 0.0001). Physicians were able to recognize potential psychiatric or alcohol/drug disorders in 70% of patients with more than one psychiatric disorder, but failed to note or treat 60% of the patients with only one of the assessed disorders. CONCLUSIONS: We recommend screening for psychiatric disorders in patients with unexplained syncope, especially in individuals with recurrent syncope and multiple physical symptoms, or for males who are under 65 years of age.

Fever of nosocomial origin: etiology, risk factors, and outcomes.

OBJECTIVES: To identify the etiologies and risk factors associated with fever of nosocomial origin and compare the outcomes of patients with and without nosocomial fever. DESIGN: A prospective study with a case-control component. SETTING: The three medical services of a university hospital. PATIENTS AND METHODS: We evaluated 100 patients with fever of nosocomial origin. Etiologies were assigned by the consensus of three independent reviewers using Centers for Disease Control guidelines. Predictors of bacterial etiology were identified using logistic regression methods. Controls matched for age (+/- 5 years), sex, and comorbidity were identified for 65 of the nosocomial fever cases. Cases and controls were compared with conditional logistic regression to identify risk factors for fever of nosocomial origin. Cases and controls were followed at 1 month to compare length of stay, mortality, and hospital readmission rates. MEASUREMENTS AND MAIN RESULTS: An etiology was assigned in 81 cases: 51 had bacterial infection, 5 had nonbacterial infection, and 25 had a noninfectious etiology. Multivariate predictors of bacterial infection were the presence of diabetes mellitus (odds ratio [OR] = 5.74; 95% confidence interval of the odds ratio [CI] = 1.61 to 20.40), length of stay to fever onset after admission greater than 10 days (OR = 3.98, CI = 1.04 to 15.22), maximum temperature greater than 38.7 degrees C (OR = 3.37, CI = 1.28 to 8.88), and white blood cell count greater than 10 x 10(9)/L (OR = 4.64, CI = 1.68 to 12.77). Comparison of cases and controls indicated that patients with nosocomial fever had more invasive procedures in the 72 hours preceding enrollment in the study than controls (OR = 1.46, CI = 1.03 to 2.08). Although cases were hospitalized almost twice as long as controls (21.5 versus 12.5 days; p < 0.0001), neither 30-day mortality nor hospital readmission rates differed between cases and controls. CONCLUSION: Nosocomial fever often does not represent nosocomial infection and may constitute a wide variety of other conditions. Since bacterial etiology of fever is a major concern, clinical and laboratory findings can be used to predict patients at high risk for an infectious process. A reduction in the number of invasive procedures may decrease the incidence of nosocomial fever. New-onset nosocomial fever leads to an increase in length of hospital stay but is not a significant predictor of mortality.

Prolonged electrocardiographic monitoring in patients with syncope. Importance of frequent or repetitive ventricular ectopy.

The purposes of this study were to document the findings on prolonged electrocardiographic monitoring in patients with syncope, correlate these findings with symptoms during monitoring, and define the prognostic importance of these findings. A total of 235 patients with syncope in whom a cause was not assigned or suggested by the initial history, physical examination, and electrocardiography were studied. Although a variety of arrhythmias were documented during monitoring, the vast majority of arrhythmias were of short duration and did not produce symptoms. At two years, the patients with frequent or paired premature ventricular contractions (PVCs) when compared with patients with rare PVCs, had a higher incidence of sudden death (18.2 percent versus 4.0 percent; p less than 0.001) and higher overall mortality (28.3 percent versus 10.8 percent; p less than 0.003). Similarly, patients with ventricular tachycardia, when compared with patients with rare PVCs, had a higher incidence of sudden death (18.7 percent versus 4.0 percent; p less than 0.0001) and higher overall mortality (36.5 percent versus 10.8 percent; p less than 0.00001). Cox regression analyses revealed that frequent or repetitive PVCs and sinus pauses were independent electrocardiographic predictors of sudden death and mortality in patients presenting with syncope. Therefore, patients with syncope and frequent or repetitive ventricular ectopy or sinus pauses constitute a high-risk subgroup and may be candidates for more extensive diagnostic evaluation.