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Determination of Syncope Etiology Can Be Costly--What Is Necessary?

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Determination of Syncope Etiology Can Be Costly--What Is Necessary? Determination of Syncope Etiology Can Be Costly--What Is Necessary? Yield of Diagnostic Tests in Evaluating Syncopal Episodes in Older Patients. Mendu ML, McAvay G, et al: Arch Intern Med 2009; 169 (July 27): 1299-1305 Despite extensive evaluation, the cause of syncope remains unknown in approximately 50% of older patients. Background: Syncope is common, accounting for 1% to 3% of emergency department visits and <6% of hospital admissions with estimated costs of $6 billion per year in the United States. Patients typically undergo extensive cardiac and neurological testing. Objective: To determine the frequency, yield, and costs of tests to evaluate syncope in older adults. Design: Retrospective review of patients' medical records. Participants: 1,920 patients (mean age, 79 years; 53% female) with 2,106 admissions were included. Only 6% had neurological deficits on examination. Results: The most frequently ordered tests were electrocardiogram (99% of admissions), telemetry (95%), and cardiac enzymes (95%), and head CT (63% of admissions). Only 2% of echocardiograms revealed findings reported to contribute to the etiology of syncope. Telemetry helped define the etiology in 5% of cases. Overall, results from cardiac enzymes, head CT, echocardiography, carotid ultrasonography, and electroencephalography all affected the diagnosis or management in <5% of cases and helped determine syncope etiology <2% of the time. The single test with the highest yield in determining the etiology of syncope (15% to 21%) was measurement of postural blood pressure (BP) changes. However, this was performed in only 38% of cases, with only 24% of patients having their blood pressure recorded while lying and then standing. The most commonly reported etiologies for syncope were vasovagal and orthostatic hypotension. For 47% of syncopal episodes, no etiology could be determined. Arrhythmia and other cardiac causes accounted for a total of 16% of cases. Applying the San Francisco Syncope Rule (congestive heart failure, shortness of breath, abnormal electrocardiogram, hematocrit <30%, or systolic BP <90 at presentation) selected outpatients were more likely to have a serious cause for syncope and a worse prognosis. The investigators examined the cost of various tests used to help establish the etiology of syncope. Overall, the cost of head CT to determine the etiology of 1 case of syncope was estimated at >$99,000, and the overall cost of electroencephalography to determine the etiology of 1 case of syncope was almost $66,000. In contrast, the overall cost of postural BP recording to help determine the etiology of 1 case of syncope was estimated at $23 to $33. Conclusions: Many unnecessary tests are obtained to evaluate syncope; selecting tests based on history and physical examination (including postural BP recording) could result in a more cost-effective approach to evaluating older patients with syncope. Reviewer's Comments: An editorial accompanies this article in which a cardiologist points out that many unnecessary tests are ordered because of patient expectations and the practice of defensive medicine. The American Heart Association and the American College of Cardiology have published guidelines that all patients with syncope should have a history and physical examination and an electrocardiogram. If cardiac disease is suggested, further cardiac testing is indicated. Clearly, electroencephalography and neuroimaging should be reserved for patients for whom a neurological disorder is suspected clinically. (Reviewer-W. Steven Metzer, MD). © 2009, Oakstone Medical Publishing Keywords: Syncope, Diagnosis, Diagnostic Tests, Postural Blood Pressure, Orthostasis Print Tag: Refer to original journal article Stroke Before or During First 4 Weeks in GCA Patients in VB Circulation Strokes at Time of Disease Diagnosis in a Series of 287 Patients With Biopsy-Proven Giant Cell Arteritis. Gonzalez-Gay MA, Vazquez-Rodriguez TR, et al: Medicine 2009; 88 (July): 227-235 Most strokes in giant cell arteritis are in the vertebrobasilar circulation. Objective: To ascertain, in a population served by a single referral center, the incidence of strokes in giant cell arteritis (GCA) at the time of diagnosis, and to explore factors that may predict the occurrence of stroke. Design: Population-based, retrospective review. Participants: 287 patients with biopsy-proven GCA seen at a regional referral center were included in the study. Methods: Biopsies were done for all patients with clinical manifestations of GCA or with isolated polymyalgia rheumatica (PMR) plus constitutional symptoms, and/or an erythrocyte sedimentation rate >80 mL/1st hour. The study focused on strokes as "presenting symptoms" of GCA, defined as occurring any time before, and up to 4 weeks after, biopsy, diagnosis, and commencement of glucocorticoid (GLC) therapy. Demographic information and risk factors, clinical findings (particularly those relevant to GCA), laboratory data, imaging, and treatment information were obtained. Both GLC and antithrombotic therapy were noted. Strokes were assigned to the vertebrobasilar (VB) or internal carotid artery (ICA) circulations based on neurological syndrome and imaging. Transient ischemic attacks were excluded. Statistical analysis was by stepwise logistic regression. Results: 8 of the 287 patients (2.8%) had strokes during the relevant time period, 7 in the VB circulation. Surprisingly, in 5 of these 8 patients, the stroke occurred after the initiation of GLC, usually in the first 10 days. The only factor more common in GCA stroke patients versus patients without stroke was smoking. Delay before diagnosis, age and gender, other stroke risk factors, atrial fibrillation, and antithrombotic therapy were not associated with altered stroke risk. No GCA disease manifestation predicted higher risk of stroke. The only laboratory abnormality differentiating stroke from nonstroke patients was a slightly lower hemoglobin in patients without stroke. In the multivariable analysis, hypertension and permanent visual loss increased the odds ratio of stroke, while female gender and lower hematocrit lowered the odds ratio. Conclusions: The incidence of stroke before and during the first 4 weeks after diagnosis of GCA is low (2.8%). In general, this follows what has been reported recently in other studies. Most strokes occurring in this time frame in GCA patients were in the VB circulation. Reviewer's Comments: This confirms the severe involvement of the VB circulation in strokes associated with GCA, which is in turn explained by the frequent involvement of the extracranial vertebral arteries, as observed in autopsy cases of GCA. This skewed distribution supports the idea that it is the vasculitic process (rather than other risk factors commonly contributing to stroke risk) that is the mechanism for stroke in these elderly patients with GCA. The observation that most of the strokes occurred in those who had already started GLC therapy underlines the fact that the arterial damage inflicted by the vasculitides may not rapidly or completely resolve with therapy, even though the inflammatory component is blunted. (Reviewer-James W. Schmidley, MD). © 2009, Oakstone Medical Publishing Keywords: Giant Cell Arteritis, Cerebral Infarction Print Tag: Refer to original journal article IV Levetiracetam Is Effective as Acute Tx in Children Role of Intravenous Levetiracetam in Acute Seizure Management of Children. Kirmani BF, Crisp ED, et al: Pediatr Neurol 2009; 41 (July): 37-39 An IV loading dose of LEV at 50 mg/kg is quite effective in the treatment of acute seizure emergencies in children, including refractory SE. Background: IV levetiracetam (LEV) is not approved by the Food and Drug Administration for the emergent treatment of seizures. It is typically given as a loading dose to initiate therapy or to replace oral doses, but it is also being used in the treatment of refractory status epilepticus (SE). If LEV is effective in the treatment of refractory SE or for repetitive seizures, it would be logical to evaluate it as potential primary therapy. Objective: To evaluate the safety and efficacy of IV LEV for the treatment of refractory SE and acute seizure exacerbations in children. Methods: An electronic medical record review at a single institution identified children who ranged in age from 2 months to 18 years of age who had received an IV loading dose of LEV. Documentation included patient demographics, reason for IV LEV administration, seizure type and characteristics, underlying diagnosis, loading and maintenance LEV dose, other antiepileptic drugs used, response to treatment, adverse effects, and ongoing maintenance therapy. Results: A total of 32 children (17 boys and 15 girls) were identified, who had received an IV loading dose of LEV. The indication for treatment was SE in 16 patients, acute exacerbation of seizures in 15, and increased intensity of infantile spasms in 1 patient. New onset seizures were present in 9 patients. LEV was given after unsuccessful initial therapy with IV lorazepam and a loading dose of fosphenytoin in approximately 60% of cases. The LEV loading dose ranged from 25 to 70 mg/kg, but the most commonly used dose was 50 mg/kg. The dose was typically infused over 15 minutes. The response to LEV was considered favorable and included cessation of SE in all patients. Clinical and electrographic improvement was typically seen within 30 minutes following IV LEV administration. An IV maintenance dose of LEV was then continued at 25 mg/kg every 12 hours. IV LEV
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