Association between Syncope and Tumarkin Attacks in Ménière's Disease.

OBJECTIVES: The aim of the current study was to further collect evidence that would confirm the hypothesis that vestibular drop attacks (VDAs) could cause syncope in patients with Ménière's disease (MD). MATERIALS AND METHODS: A cross-sectional survey design was employed in the present study. An Internet-based survey was administered on 602 individuals with MD. The mean age of the participants was 56.7 (25-75) years, and the mean duration of the disease was 12.4 (0.5-35) years. RESULTS: VDAs with varying severity were present among 307 (50.7%) patients and led to fall in 92 patients, and syncope occurred in 45 patients with VDA. The overall percentage of syncope due to MD was 4.7%. Factors, such as duration of disease, age, and gender of the patient, did not explain attacks of syncope. Migraine and headache were not associated with syncope. Syncope was witnessed in 23 and self-reported by 22 patients. Syncope was associated with frequent VDA, duration of VDA, and falls that occurred during VDA. Patients with syncope reported the experience as frightening, had reduced general health-related quality of life, had higher anxiousness scores, and suffered more from fatigue. They also experienced problems with work, employment, and social restrictions. CONCLUSION: Approximately 5% of patients with MD suffer from syncope, and syncope occurs among patients with VDA. In vestibular syncope, the sympathetic tone is lost, and baroreflex feedback is inhibited leading to fall and syncope. The consequences of vestibular syncope are severe, and patients face injuries and a significantly reduced quality of life.

Atypical Prodromal Symptoms Help to Distinguish Patients With Psychogenic Nonsyncopal Collapse Among Youth Referred for Fainting.

BACKGROUND: Distinguishing patients with psychogenic nonsyncopal collapse (PNSC), a conversion disorder that resembles syncope, can pose a difficult clinical challenge. Using the open-ended question "what does it feel like to faint?," the present study aimed to characterize how patients with PNSC perceive and communicate the prodromal symptoms associated with their attacks by comparing narratives between patients with PNSC and those with syncope. METHODS: During a 42-month database-type study of tilt-table diagnoses, all patients with a history of fainting were asked the open-ended question. Symptom descriptions were compared, qualitatively and quantitatively, between patients with PNSC and those with tilt-induced syncope (n = 121 in both cohorts). RESULTS: Twenty-nine patients (24%) diagnosed with PNSC and eight (6.6%) diagnosed with syncope either denied having any prodromal symptoms or could not recall any symptoms (P < 0.001). Among patients who reported prodromal symptoms, patient narratives led to the formation of 26 symptom categories. Symptom frequencies differed between cohorts in 19 of the symptom categories (each P value <0.05). Qualitative differences in the descriptions of symptoms were often present, even when symptom frequencies did not differ. More patients with PNSC described atypical symptoms than patients with syncope, 54 of 92 (58.7%) versus eight of 113 (7.1%), P < 0.001. CONCLUSIONS: Symptom narratives can help to distinguish patients with PNSC from those with syncope. The use of a single, open-ended question as a screening tool for conversion disorder has immediate clinical relevance because it can be instituted easily in a busy clinical setting.

Signs of autonomic arousal precede tilt-induced psychogenic nonsyncopal collapse among youth.

Characterizing the physiologic changes leading up to psychogenic nonsyncopal collapse (PNSC) may help to elucidate the processes that cause paroxysmal functional neurological symptom disorders and to clinically distinguish PNSC from syncope. Thus, we aimed to characterize preictal sweat rate, heart rate, and systolic blood pressure changes among patients with tilt-induced PNSC compared to patients with tilt-induced neurally mediated syncope. The presence of increased preictal sweating was compared between groups. Heart rates and systolic blood pressures were compared from the recumbent and tilted baselines to the periods 120 s and 30 s prior to PNSC and syncope. Patients with PNSC (n = 44) were more likely than patients with syncope (n = 44) to have preictal increases in sweating, n = 31 (70.5%) versus n = 21 (47.7%), p = 0.03, although all patients with syncope eventually developed a sweat response. Comparing the recumbent baseline to the period 30 s prior to PNSC, blood pressure (112 ±â€¯9 versus 129 ±â€¯13 mmHg, p < 0.001) and heart rate (76 ±â€¯12 versus 119 ±â€¯22 bpm, p < 0.001) increased. Similarly, comparing the tilted baseline to the period 30 s prior to PNSC, blood pressure (118 ±â€¯12 versus 129 ±â€¯13 mmHg, p < 0.001) and heart rate (95 ±â€¯15 versus 119 ±â€¯22 bpm, p < 0.001) increased. Preictal blood pressure and heart rate differed significantly between patients with PNSC and patients with syncope. In conclusion, signs of autonomic arousal (increased sweating, heart rate, and blood pressure) often precede tilt-induced PNSC. Sweating prior to fainting may not be useful in distinguishing PNSC from neurally mediated syncope.

Youth With Psychogenic Non-Syncopal Collapse Have More Somatic and Psychiatric Symptoms and Lower Perceptions of Peer Relationships Than Youth With Syncope.

BACKGROUND: Little is known about somatic and psychiatric symptoms and perceived peer relationships of patients with psychogenic nonsyncopal collapse. OBJECTIVE: This study aimed to compare somatic and psychiatric symptoms and other elements potentially related to functional neurological symptom disorders between youth with psychogenic nonsyncopal collapse and those with neurally mediated syncope. METHODS: Before testing, patients completed a structured interview and questionnaire addressing current symptoms, previous psychiatric diagnoses, referrals, diagnostic testing, prescribed medications, and patient self-ratings of anxiety, depression, and perceived peer relationships. RESULTS: Compared with patients with syncope (n = 60), patients with psychogenic nonsyncopal collapse (n = 60) had higher ratings for lightheadedness and vertigo, more abdominal pain, more chronic headaches, more fatigue, more sleep disturbances, more prescriptions for antidepressant medicines, more encephalograms performed, more referrals to psychiatry, and more psychiatric diagnoses including anxiety, depression, posttraumatic stress disorder, previous nonfainting conversion disorders, and eating disorders (all p < 0.05). Patients with psychogenic nonsyncopal collapse rated their anxiety (10.5 ± 7.7 versus 5.9 ± 5.8, p < 0.001) and depression (8.7 ± 8.3 versus 3.1 ± 5, p < 0.001) symptoms higher and their peer relationships (37 ± 12.3 versus 47.6 ± 7.9, p < 0.001) lower than patients with syncope. Peer relationships remained significantly lower (p = 0.001) when analyzed with anxiety and depression. CONCLUSION: Patients with psychogenic nonsyncopal collapse have more symptom complaints and perceptions of poorer peer social interactions than patients with syncope. These results broaden our understanding of the biopsychosocial profile that increases an individual's vulnerability to psychogenic nonsyncopal collapse specifically and to functional neurological symptom disorders in general.

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.

Razonamiento, diseño y metodología del estudio de identificación de los atributos físicos del síndrome de temor a caerse en ancianos (FISTAC) / Rationale, design and methodology of physical attributes identification of the fear of falling syndrome (FISTAC study)

Introducción. El objetivo del estudio es identificar los atributos físicos del síndrome de temor a caerse (STAC) en mayores con caídas previas. Metodología. Estudio observacional analítico sobre 183 sujetos mayores de 64 años que hayan sufrido al menos una caída en el último año, captados desde la consulta de geriatría del Complejo Hospitalario Universitario de Albacete. De ellos, 140 cumplían criterios de STAC, y los otros 43 no (grupo control). Como covariables se recogieron datos sociodemográficos, antropométricos, de comorbilidad y fármacos, situación funcional, función física, fragilidad, estado cognitivo y afectivo. Se determinó la masa muscular mediante bioimpedanciometría (BIA) y densitometría (DXA), la fuerza prensora mediante dinamómetro digital de JAMAR, la fuerza extensora (1RM) de miembros inferiores, la potencia muscular de miembros inferiores mediante el instrumento T-Force, la variabilidad de la marcha con el instrumento Gait-Rite, las alteraciones posturales mediante posturografía. Se analizará si el STAC se asocia con alteraciones físicas ajustado por las covariables de estudio. Resultados. Edad media 78,4 años, 147 mujeres. En 182 participantes se pudo realizar posturografía, en 146 se pudo determinar potencia muscular de piernas, en 117 se realizó DXA y en 165, BIA. El STAC se asoció a sexo femenino, estado de fragilidad, ánimo deprimido, riesgo social, fuerza y potencia muscular, función física, número de fármacos e hipotensión ortostática en la muestra global, pero al ajustar por sexo, solo la fragilidad, el ánimo deprimido y el consumo de fármacos se asociaron al STAC. Conclusiones. Se presenta el razonamiento, el diseño y la metodología del estudio FISTAC (AU)

Introduction. The aim of this study was to identify the physical determining factors of the Fear of Falling Syndrome (FoF) in older adults with a history of falls. Methods. An observational study was conducted on 183 subjects older than 64 years with a fall in the previous year, with data collected from the geriatrics outpatient clinic of the Complejo Hospitalario Universitario from Albacete, Spain. Sociodemographic and anthropometric data, as well as comorbidity, drugs usually taken, functional status, physical function, frailty, cognitive and affective status were collected. Muscle mass was measured using bioimpedancy meter (BIA), and densitometry (DXA), strength with digital hand-held JAMAR dynamometer and with a Leg-press machine, muscle potency with a T-Force instrument, gait variability with the Gait-Rite instrument, and postural stability with the Neurocom Balance Master posturograph were also determined. An analysis was performed to determine if the FoF is associated with physical impairments adjusted for the study covariates. Results. The study included 140 subjects with FoF, and 43 without it. The mean age was 78.4 years, and 147 were women. Posturography could be measured in 182 participants, DXA in 117, BIA in 165, and muscle potency in 146. FoF was associated with female sex, frailty, depressed mood, social risk, muscle strength and power, physical function, number of drugs used, and orthostatic hypotension in the overall sample. After adjusting for sex, only frailty, depressed mood, and number of drugs remained associated. Conclusions. Rationale, design, and methods of the FISTAC study are presented (AU)

Comparison of Specific Fainting Characteristics Between Youth With Tilt-Induced Psychogenic Nonsyncopal Collapse Versus Reflex Syncope.

Little is known about the predictive features of psychogenic nonsyncopal collapse (PNSC). The aim of the present study was to compare the self-reported fainting characteristics between young patients who were ultimately diagnosed with PNSC with those ultimately diagnosed with neurally mediated syncope and to determine which features were predictive of either diagnosis. A prospective study was conducted of sequential patients referred for fainting. All study data were obtained before testing or diagnosis. Several fainting characteristics were compared between cohorts including numbers of lifetime fainting episodes, fainting frequency the week before evaluation, fainting duration, numbers of fainting spells in a single day, presence of presyncope, types of prodromal symptoms, tearfulness with fainting, and the numbers of emergency department visits and hospital admission for fainting. During the study period, 52 patients were diagnosed with PNSC, producing a diagnostic rate of 18.9%. In univariate analyses, multiple features differed between patients with PNSC and those with syncope. After controlling for age and gender in a multivariate analysis, each of the following predicted PNSC: ≥20 lifetime fainting spells (p = 0.005), ≥2 fainting spells in a single day (p = 0.03), self-reported loss of consciousness ≥2 minutes (p = 0.01), and tearfulness associated with fainting (p = 0.022). Two or more typical prodromal symptoms (p = 0.004) predicted syncope. In conclusion, several characteristics related to fainting have predictive value in distinguishing PNSC from syncope, particularly among youth. Assessing these clinical features can help to inform appropriate testing and accurate diagnosis among patients who faint.

Long-term follow-up of psychogenic pseudosyncope.

OBJECTIVE: To determine the outcome of patients with psychogenic pseudosyncope (PPS) after communication of the diagnosis. METHODS: This was a retrospective cohort study of patients with PPS referred in 2007 to 2015 to a tertiary referral center for syncope. We reviewed patient records and studied attack frequency, factors affecting attack frequency, health care use, and quality of life using a questionnaire. We explored influences on attack freedom and attack frequency in the 6 months before follow-up for age, sex, education level, duration until diagnosis, probability of diagnosis, additional syncope, and acceptance of diagnosis. RESULTS: Forty-seven of 57 patients with PPS could be traced, of whom 35 (74%) participated. Twelve (34%) were attack-free for at least 6 months. The median time from diagnosis to follow-up was 50 months (range 6-103 months). Communicating and explaining the diagnosis resulted in immediate reduction of attack frequency (p = 0.007) from the month before diagnosis (median one attack, range 0-156) to the month after (median one attack, range 0-16). In the 6 months before follow-up, the number of admissions decreased from 19 of 35 to 0 of 35 (p = 0.002). The use of somatic and mental health care shifted toward the latter (p < 0.0001). Quality of life at follow-up (Short Form Health Survey 36) showed lower scores for 7 of 8 domains compared to matched Dutch control values; quality of life was not influenced by attack freedom. CONCLUSIONS: After communication of the diagnosis in PPS, attack frequency decreased and health care use shifted toward mental care. Low quality of life underlines that PPS is a serious condition.

Neurocardiovascular Instability and Cognition.

Neurocardiovascular instability (NCVI) refers to abnormal neural control of the cardiovascular system affecting blood pressure and heart rate behavior. Autonomic dysfunction and impaired cerebral autoregulation in aging contribute to this phenomenon characterized by hypotension and bradyarrhythmia. Ultimately, this increases the risk of falls and syncope in older people. NCVI is common in patients with neurodegenerative disorders including dementia. This review discusses the various syndromes that characterize NCVI icluding hypotension, carotid sinus hypersensitivity, postprandial hypotension and vasovagal syncope and how they may contribute to the aetiology of cognitive decline. Conversely, they may also be a consequence of a common neurodegenerative process. Regardless, recognition of their association is paramount in optimizing management of these patients.

Comparison of semiologies between tilt-induced psychogenic nonsyncopal collapse and psychogenic nonepileptic seizures.

We sought to characterize the clinical features of tilt-induced psychogenic nonsyncopal collapse (PNSC) from a cohort of young patients and to compare the semiologies between PNSC and EEG-confirmed psychogenic nonepileptic seizures (PNES). A PNSC diagnosis was made if a clinical event occurred during tilt-table testing that the patient regarded as fainting, but neither hypotension nor EEG changes were present. A diagnosis of PNSC was made in 17.6% of all patients referred during the 15-month study period. Cohorts with psychogenic nonsyncopal collapse (n=40) and PNES (n=40) did not differ in age (15.5±2.2 versus 14.6±2.7, p=.11) or female gender (80% versus 72.5%, p=.43). Psychogenic nonsyncopal collapse events were briefer than PNES events (median: 45 versus 201.5s, p<.001). Negative motor signs (head drop, body limpness) predominated in PNSC (85% versus 20%, p<.001), while the positive motor signs of convulsion occurred more often with PNES (90% versus 30%, p<.001). Behavioral arrest (25% versus 32.5%, p=.46) and eye closure (85% versus 72.5%, p=.21) did not differ between PNSC and PNES. Patients with PNSC were more likely to be tearful before (30% versus 7.5%, p=.02) and after (62.5% versus 7.5%, p<.001) an event. In conclusion, although overlap exists, the features of PNSC generally appear similar to neurally mediated syncope, while the features of PNES generally appear similar to epileptic seizures. Psychogenic nonsyncopal collapse and PNES likely represent similar disorders that differ primarily by clinical semiologies and referral patterns.

Medical Student Presyncope and Syncope in the Operating Room: A Mixed Methods Analysis.

OBJECTIVE: Medical students often feel faint (presyncopal) in the operating room (OR). Despite mandatory surgical rotations in clerkship, there is little formal training and acclimatization to the operating suite in the first 2 years of medical school. This study aimed to assess presyncope and syncope in the OR in first, second, third, and fourth year medical students at a large Canadian academic center. DESIGN: Following an extensive literature review, we developed a mixed methods survey de novo to assess medical students' experience in the OR and determine the frequency of presyncopal and syncopal events. RESULTS: A total of 180 students (106 females, 59%), evenly distributed among all 4 years of medical school, responded to the survey (response rate 40%, n = 180/454). In total, 75 students (42%) had experienced presyncope, and 10 students (6%) had experienced syncope in the OR. Female medical students were more likely to experience both presyncope (p < 0.001) and syncope (p = 0.011) relative to their male colleagues. They were also more likely to report that these experiences had an effect on their attitude toward the OR (p < 0.001) and their career choice (p < 0.001). Half of respondents believed that the undergraduate medical preclerkship curriculum did not provide adequate exposure to the OR. Students consistently expressed the desire for more preclinical OR exposure and formal instruction concerning OR etiquette. Only 28% of students reported receiving information on how to avoid syncope, and their classmates were the number one source (59%) for this advice. The most commonly employed preventative measures were eating before the OR and staying well hydrated. Presyncope had a negative effect on attitudes toward the OR in 28% of students. CONCLUSION: Although true loss of consciousness (syncope) among medical students in the OR is uncommon, presyncope is a highly prevalent phenomenon. It is most prevalent in female students, and may have a negative effect on overall student well-being. All students may benefit from normalization of this very common experience by staff surgeons or residents. Formal instruction regarding the common symptoms, triggers, and methods for preventing presyncope and syncope is an essential supplement to the current preclinical medical curriculum.

Gender differences in symptom predictors associated with acute coronary syndrome: A prospective observational study.

Signs and symptoms (typical and atypical symptoms) of acute coronary syndromes (ACS) differ between men and women. Identification of gender differences has implications for both health care providers and the general public. The aim of this study was to determine the symptom predictors of the acute coronary syndromes in men and women. In this prospective study, nurse data collectors directly observed 256 men and 182 women (N = 438) with symptoms suggestive of ACS in the Emergency Departments of eight hospitals in Tehran. ACS was eventually diagnosed in 183 (57.2%) men and 137 (42.8%) women on the basis of standard electrocardiogram and cardiac enzyme (CPK-MB) level. In men, chest symptoms (OR = 3.22, CI = 0.137-0.756, P = 0.009), dyspnea (OR = 2.65, CI = 1.78-4.123 P = 0.001) and diaphoresis (OR = 2.175, CI = 1.020-4.639, P = 0.044) were significantly associated with the diagnosis of ACS 3.78, 2.72 and 1.87 times more than in women having these symptoms, respectively. These results indicated that chest symptoms, diaphoresis and dyspnea were the more pronounced typical symptoms of ACS in men compared to women. Additionally, the numbers of typical symptoms can be considered as more predictive of ACS in men (OR = 1.673, CI = 1.211-2.224, P < 0.001) than women (OR = 1.271, CI = 1.157-2.331, P = 0.212). Therefore, clinicians need to take men showing typical symptoms into consideration carefully.

Tilt-induced vasovagal syncope and psychogenic pseudosyncope: Overlapping clinical entities.

OBJECTIVE: To describe the combination of tilt-induced vasovagal syncope (VVS) and psychogenic pseudosyncope (PPS) and aid its clinical recognition. METHODS: We identified people with tilt-induced VVS/PPS from 2 tertiary syncope referral centers. For each case, 3 controls with tilt-induced VVS were selected at random from the same center. Clinical characteristics were compared between both groups adjusting for multiple comparisons. RESULTS: Of 1,164 tilt-table tests, 23 (2%) resulted in VVS/PPS; these 23 cases were compared with 69 VVS controls. VVS and PPS coincided more often than chance would predict: 2% vs 0.6%, p < 0.001. Typical VVS prodromes and triggers were reported in all people with VVS/PPS and in controls with VVS. Attack frequency was significantly higher in the VVS/PPS (2 per month, range 0.1-60) than in the VVS group (0.25 per month, range 0.02-4; p < 0.001). Delayed recovery of consciousness was more frequently reported in the VVS/PPS group (likelihood ratio [+LR] 8.14, 95% confidence interval [CI] 3.94-16.84), as well as episodes without prodromes (+LR 5.57, 95% CI 2.53-12.26), atypical triggers (+LR 5.00, 95% CI 2.04-12.24), eye closure (+LR 3.75, 95% CI 1.68-8.35), and apparent loss of consciousness >1 minute (+LR 2.86, 95% CI 1.98-4.13). CONCLUSIONS: VVS/PPS presents with a complex phenotype. High attack frequency, delayed recovery of consciousness, apparent loss of consciousness >1 minute, ictal eye closure, atypical triggers, and the absence of prodromes may serve as indicators that PPS coincides with VVS.

Determinants of depression and somatisation symptoms in low back pain patients and its treatment: global burden of diseases.

OBJECTIVE: To determine the prevalence of Low Back Pain in primary care setting population and to examine its association with symptoms of depression and somatisation. METHODS: The cross-sectional study was conducted at 13 Primary Healthcare Centres (throughout Qatar from March to December, 2012. A General Health Questionnaire was used to identify the probable cases. A specially designed questionnaire with three parts was used for data collection: socio-demographic information of the studied subjects, modified version of the Roland-Morris scale for evaluating back-related functional disability, and Symptom Cheklist-90-Revised for depression and somatisation subscales. RESULTS: A representative sample of 2,600 patients was approached and 1,829(70.0%) of them participated in the study. The prevalence of low back pain in the study sample was 56.5%. There were statistically significant differences between subjects with and without low back pain in terms of body mass index (p< 0.025), gender (p< 0.003) and housing condition (p< 0.001). There was a significant difference between subjects with and without the pain in terms of all aspects of functional disability. Somatisation disorder in low back pain was 203 (19.6%) and depression disorder was 265 (25.4%). Most of the patients with LBP reported pain in the arms and legs (p< 0.001); shortness of breath (p< 0.028) palpitations (p=0.004); gastrointestinal complaints such as abdominal pain (p< 0.001), diarrhoea (p< 0.001) and vomiting (p< 0.001); feeling tired (p< 0.001); trouble with sleeping (p< 0.001); headache (p< 0.001) and fainting (p=0.043). The mode of treatment taken by the patients for relief were bed rest 695 (67.2%) followed by warm compression 480 (47.6%), physiotherapy 491 (47.5%), regular exercise 414 (40%), and back plasters 346 (33.5%). CONCLUSIONS: The present study showed that the symptoms of depression and somatisation were prevalent among low back pain patients. Functional disability was higher in the patients. Recognising this problem may lead to better patient-treatment matching and improved clinical outcomes.