Unexplained Syncope: Clinical Management

The management of unexplained syncope begins with the patient's history and physical examination, which are oriented to help separate benign from serious causes. Malignant etiologies are more likely to occur with exertional syncope. Cardiac causes should be considered, particularly cardiomyopathy, postoperative congenital heart disease, right ventricular dysplasia, anomalous coronary artery, pulmonary artery hypertension, myocarditis, long QT syndrome, and Wolff-Parkinson-White syndrome. Neurological and metabolic disorders may underlie a syncope episode. After malignant causes of syncope have been excluded and the diagnosis of neurocardiac syncope has been established, treatment strategies include behavior modification, salt and increased fluids, and pharmacological agents. Efficacious agents include β-blockers, dysopyramide, fludrocortisones, and alpha agents. Yet, behavior modification alone may be as effective as salt or pharmacological therapy. Because the natural history of neurocardiac syncope in children is spontaneous resolution, it is appropriate to try the simple measures before introducing drug therapy.     

FIBRINOLYSIS AND OBESITY: THE EFFECT OF WEIGHT REDUCTION

In eight obese subjects the initially low level of fibrinolytic activity increased after significant weight reduction. Reduction to a normal weight resulted in normal fibrinolytic activity, which was maintained when an isocaloric diet was resumed. Subsequent weight gain in two subjects caused a return of fibrinolytic activity to its initially low level. Overall, the ultimate level of fibrinolysis achieved was closely related to the degree of obesity. The changes in fibrinolysis appeared to be unrelated to changes in plasma levels of fibrinogen, triglyceride, cholesterol, free fatty acids and glucose.     

Good Grief: Coming to Terms with the Childbirth Experience

The practical application of what is known about the grieving process is discussed in connection not only with obvious grief-laden situations, but also with situations in which the grief content is more subtle. It is proposed that learning to identify the less traumatic situations in which an expression of grief can help obstetric patients and their families cope with the childbirth experience is also a part of optimum nursing care.     

A scoring technique for computerized patient management problems

A scoring technique was developed for computerized patient management problems, based on an external criterion group of practising paediatricians. The technique was used successfully to score the 1974 computerized patient management problems examination, taken by paediatric candidates as part of the certification process required by the Royal College of Physicians and Surgeons of Canada. Statistical analysis indicated there was significant agreement between practising paediatricians' and candidates' responses. Comparison of responses of both groups suggested that differences between candidates and practising paediatricians were due to different approaches to the content of the problem, rather than a defect of scoring. The technique will be revised as computerized examinations are increasingly adopted by other medical specialties.