Elevated Reading Research Articles

Inverse linear association between blood haemoglobin and oxygen saturation accuracy measured by pulse oximetry: a cross-sectional analysis in individuals with COVID-19 infection

BackgroundPulse oximetry measures oxygen saturation non-invasively by using differential absorption of infrared signals which are dependent on the oxyhaemoglobin:deoxyhaemoglobin ratio. We tested the hypothesis that pulse oximetry error in measurements...

More hypertensive crises in women than in men in a single emergency department

Abstract Introduction Hypertensive crises are a common presenting complaint in the emergency department. A hypertensive crisis includes hypertensive urgencies defined as a systolic and/or diastolic blood pressure greater than 180/120 mmHg and hypertensive emergencies with additional hypertension-mediated organ damage (HMOD). In the literature there is very little data regarding the distribution between men and women in hypertensive crises. Most data suggest a balanced distribution or a higher frequency in men, especially compared to premenopausal women. Methods We retrospectively analysed patient data in our hospital information system from 2022 using ICD-10 diagnoses at discharge. We included inpatient as well as outpatient cases that presented to our emergency department between 01/01/2022 and 31/12/2022 with one of the following ICD-diagnoses at discharge: - I10.01, Benign essential hypertension With mention of hypertensive urgency - I10.91, Essential hypertension, unspecified With mention of hypertensive urgency - I11.01, Hypertensive heart disease with (congestive) heart failure With mention of hypertensive urgency - I11.91, Hypertensive heart disease without (congestive) heart failure With mention of hypertensive urgency - R03.0, Elevated blood-pressure reading, without diagnosis of hypertension Then we compared the difference of the median age at presentation between men and women using the independent t-test. Results We identified 397 patients with a hypertensive crisis in the year of 2022. Overall the percentage of women in the collective of patients with any type of hypertensive crisis diagnosis was 73.0 % and thus a lot higher than the percentage of men. Women were on average 7.7 years older at presentation (p < 0.0001). Discussion: On the basis of the available data the causes for the distribution between men and women in hypertensive crises can only be speculated. On the one hand women may measure their blood pressure more frequently than men and the urge to call an ambulance or seek medical attention may be higher. On the other hand it could be possible that arterial hypertension in general has differences in the course and underlying mechanism with a higher frequency in blood pressure peaks, symptoms at lower blood pressure values and antihypertensive medication could be less effective depending on the type of drug. Also arterial hypertension may be underdiagnosed in women. The difference in the age at presentation is probably due to a later hormonal adjustment after the menopause as shown in the literature. The findings of this small observational study should be further investigated in larger trials.

Hypertensive Crisis: Believe It and Treat It

This evidence-based project aims to improve and standardize management of severe hypertension in intrapartum patients. Hypertension complications are a leading cause of maternal morbidity and mortality. Severe complications from a hypertensive crisis during intrapartum are almost completely preventable with proper identification and management in a hospital setting. Three goals were established for the evidence-based project: first, timely identification and notification of primary providers about a hypertensive crisis, which is defined as systolic blood pressure more than 160 or diastolic blood pressure more than 110 for two measurements within 15 minutes; second, treatment initiation within 60 minutes of a second elevated reading; and third, use of standard first-line drugs.

A Case of Complete Heart Block Presenting as Resistant Hypertensive Emergency

The nationally accepted guideline for hypertension is an elevated systolic and diastolic reading of >130/80. Unmanaged hypertension could eventually lead to hypertensive urgency if a patient’s blood pressure is >180/100 with no signs of organ damage, or hypertensive emergency if their blood pressure is >180/100 and there are signs of organ damage occurring. When a patient presents with hypertensive emergency that is difficult to control despite multiple antihypertensives, this is known as resistant hypertension. Persistently resistant hypertension can also be described as refractory hypertension. Here, we have an African-American gentleman who presented with bradycardia and hypertensive emergency that was refractory to medical therapies. Subsequently, it was found that he was in complete heart block. His blood pressure only improved two weeks after pacemaker implantation and required multiple antihypertensives.

Evaluation of online Spanish and English health materials for preventive mastectomy. are we providing adequate information?

Breast cancer remains the leading cause of cancer-related death in US Hispanic women. When present, lower health literacy levels potentially within this patient population require tailored materials to address health disparities. We aim to evaluate and compare Spanish and English online health care informative resources on preventive mastectomy. A Google web search using "preventive mastectomy" and "mastectomía preventiva" was conducted. The first ten institutional/organizational websites in each language were selected. Assessment of mean reading grade level, cultural sensitivity, understandability, and actionability was carried out utilizing validated tools. The mean reading grade level for English materials was 14.69 compared with 11.3 for Spanish, both exceeding the recommended grade level established by the AMA and NIH. The mean cultural sensitivity score for English information was 2.20 compared with 1.88 for Spanish information, both below the acceptability benchmark of 2.5. English webpages scored 65% and 35% for understandability and actionability, respectively, while Spanish webpages scored 47% and 18%. Online English and Spanish preventive mastectomy materials were written at an elevated reading level and lacked cultural sensitivity. Spanish language information demonstrated inferior understandability, actionability, and cultural sensitivity. Addressing these issues provides an opportunity to help resolve health literature disparities regarding preventive mastectomy for US Hispanic women.

High blood pressure readings on in-store machines: a qualitative study of the perspective of pharmacy staff

ObjectivesEmergency department (ED) visits for high blood pressure are on the rise. Yet the majority of these patients are discharged home after their ED evaluation, particularly those who present following an elevated reading on an in-store pharmacy machine. We aimed to gain insight on the practice and referral patterns of pharmacy staff who encounter a patient with an elevated in-store blood pressure (BP) reading.MethodsWe conducted a qualitative study using semi-structured interviews with pharmacy staff (pharmacists and pharmacy technicians/assistants) from California, United States and Ontario, Canada. Interview questions were designed to examine the practice and referral patterns of pharmacy staff for patients with elevated in-store BP readings. Standard descriptive content analysis techniques were used to analyze the data and to develop themes for current practice and referral patterns.ResultsTwenty-four interviews were completed: six with pharmacy technicians/assistants and 18 with pharmacists. Canadian pharmacy staff (83%) reported being approached frequently (defined as from weekly up to multiple times per day) by patients concerned about an elevated BP reading on an in-store machine, versus 50% reported by American participants. Participant definition of an elevated BP varied, with systolic values ranging from 120 to 150 mmHg and diastolic values from 60 to 90 mmHg. Participants emphasized the need to converse with and assess their patients prior to providing advice. The most frequently reported advice was to seek referral from an outside health care provider: ED, urgent care, or a primary care practitioner. Severity of the BP reading and symptomatology were reported as determining factors for referring patients to the ED. Pharmacists (92%) reported a lack of corporate and/or governing body policy for managing patients with in-store markedly elevated BP readings.ConclusionsManaging patients with an elevated BP reading in the community pharmacy setting is complex and not standardized. Referral to an external health care provider, including the ED, was a common theme. The development of a pharmacy referral tool/algorithm may be helpful to refer in-store patients with elevated BP readings to the most appropriate healthcare resources.

A Multimetric Health Literacy Analysis of Online Information for Gluteal Augmentation With Fat Grafting.

According to the American Society of Plastic Surgeons the number of gluteal augmentations with fat grafting, colloquially known as the "Brazilian buttock lift" (BBL), doubled from 2014 to 2018. Recent studies have demonstrated that gluteal augmentation with fat grafting has a higher mortality rate when compared with other esthetic surgeries. We hypothesize that online patient-directed information for gluteal augmentation are overly complex, written at an elevated reading grade level, with incomplete or no information regarding associated surgical risks. To perform an objective appraisal of the most popular online patient education materials for gluteal augmentation surgery and explore potential interventions for improving material quality. An online Google search using the term "Brazilian butt lift" was performed and the top 10 websites providing relevant information were identified. Readability for each website was determined using Readability Studio. Understandability, actionability and cultural sensitivity was assessed with validated tools by 2 independent raters. The top 10 websites were written at a mean reading grade level of 13.0, appropriate for a high school graduate. No website was written at the American Medical Association and the National Institutes of Health recommended 6th to 8th grade reading level. Mean understandability and actionability scores of 51% and 18.9%, respectively, suggest significant room for improvement. The average cultural sensitivity assessment tool score was 2.30, below the recommended threshold for acceptability of 2.5. Ninety percent of all websites did not meet the threshold for cultural acceptability. Online patient education materials for gluteal augmentation with fat grafting were written at an inappropriately elevated reading grade level and were overly complex, did not promote reader action, and were not sensitive to the needs of the target demographic.

Ocular biometric parameters are associated with non-contact tonometry measured intraocular pressure in non-pathologic myopic patients.

This research aimed to investigate effects and risk factors on non-contact tonometer (NCT) readings in healthy myopic subjects by employing cross-sectional study design. Totally, sixty otherwise healthy myopic volunteers (mean 28.4years old) with 90% female were recruited in ophthalmic clinic. The routine ophthalmic tests, refractive evaluation, examination central corneal thickness (CCT), depth of anterior chamber, axial length, corneal curvature, white-to-white and NCT were assessed at baseline. The linear-mixed model was utilized to evaluate correlation between the readings and ocular biometric parameters. For population in this study, mean spherical equivalents were - 4.85 ± 1.79 diopters in right eyes and - 4.63 ± 1.95 diopters in left eyes. Meanwhile, 28.3% of the eyes had a refractive error exceeding - 6.0 diopters. The mean NCT reading was 15.02 ± 3.02mmHg in left eyes and 15.33 ± 2.96mmHg in right eyes. Among the factors analyzed, CCT was the most significant parameter associated with NCT readings. After adjusting for the other factors, per one standard deviation increase of central corneal thickness (36.11μm) was associated a 1.14 (95% confidence interval 0.53-1.77) mmHg elevated NCT reading. The average central corneal curvature, age and spherical equivalence were also significantly and independently associated with NCT readings. Central corneal thickness, age, corneal curvature and degree of myopia were independently associated with NCT measured intraocular pressure. Central corneal thickness is one of the most influential factors.

A Multimetric Evaluation of Online Spanish Health Resources for Lymphedema

Breast cancer is a leading cause of death in US Hispanic females. This demographic is more likely to present with later-stage disease and require more extensive surgical treatment, including axillary lymph node dissection, which increases risk of lymphedema. The Spanish-speaking Hispanic population has a lower health literacy level and requires materials contoured to their unique needs. The aim of this study was to evaluate online Spanish lymphedema resources. A web search using the Spanish term "linfedema" was performed, and the top 10 websites were identified. Each was analyzed using validated metrics to assess readability, understandability, actionability, and cultural sensitivity using the SOL (Simplified Measure of Gobbledygook, Spanish), Patient Education and Materials Assessment for Understandability and Actionability (Patient Education and Assessment Tool), and Cultural Sensitivity and Assessment Tool (CSAT), respectively. Online materials were assessed by 2 independent evaluators, and interrater reliability was determined. Online lymphedema material in Spanish had a mean reading grade level of 9.8 (SOL). Average understandability and actionability scores were low at 52% and 36%, respectively. The mean CSAT was 2.27, below the recommended value of 2.5. Cohen κ for interrater reliability was greater than 0.81 for the Patient Education and Assessment Tool and CSAT, suggesting excellent agreement between raters. Available online Spanish lymphedema resources are written at an elevated reading level and are inappropriate for a population with lower health literacy levels. As patients continue to use the internet as their primary source for health information, health care entities must improve the quality of provided Spanish resources in order to optimize patient comprehension.

Risk Perceptions After Receiving Multiple Risk Feedback.

How do people respond to multiple risk feedback in a real-life context? Based on theoretical assumptions, three different predictions for risk perceptions were tested: (a) relative accuracy in risk perceptions, (b) self-defensive responses according to self-affirmation theory, and (c) compensatory responses according to the compensatory health belief model. Participants of a community health screening ( N = 725) received multiple risk indicator feedback for actual blood pressure, blood glucose, and blood lipid levels. Consistent multiple risk feedback profiles encompassed three consistent readings (three normal or three elevated readings). Mixed risk profiles included one elevated and two normal readings. Results indicate relative accuracy in responses: an elevated reading triggered higher risk perception of the respective risk factor. Importantly, the effect was not modulated by the presence of normal readings as assumed by the self-defensive or compensatory response perspective, indicating that people accurately integrate multiple risk indicator feedback as it is often provided in real life.

Prevalence and pattern of cardiovascular risk factors in a population in India

BackgroundCardiovascular disease is the leading cause of mortality in India. Since it is largely driven by risk factors such as hypertension, diabetes and smoking, it is important to study the...

Follow-up with primary care providers for elevated glycated haemoglobin identified at the dental visit.

This study examined patient experiences after receiving elevated diabetes screening values using blood collected at a dental clinic. It explores patients' reactions to screening, whether or not they sought recommended medical follow-up, and facilitating factors and barriers to obtaining follow-up care. At the comprehensive care clinics at a large, urban College of Dentistry in the United States, haemoglobin A1C (HbA1C) values were obtained from 379 study participants who had not been previously diagnosed with diabetes. In all, 169 (44.6%) had elevated HbA1C values. We analysed quantitative and qualitative data concerning these patients' follow-up with primary care providers (PCPs). We were able to contact 112 (66.3%) of the 169 study participants who had an elevated HbA1C reading. Of that group, 61 (54.5%) received recommended follow-up care from a PCP within 3 months, and an additional 28 (25.0%) said they intended to seek such care. Qualitative themes included the following: the screening letter - opportunity or burden, appreciation for the 3-month follow-up call and barriers to medical follow-up that included the following: lack of knowledge about diabetes, not understanding the importance of follow-up, busyness, financial concerns, fear and denial. Quantitative and qualitative data demonstrate that dentists, dental hygienists and nurses are well poised to discover and translate new models of patient-centred, comprehensive care to patients with oral and systemic illness.

Alcohol consumption decreases lactate clearance in acutely injured patients

IntroductionAlcohol, a common risk factor for injury, has direct toxic effects on the liver. The use of lactate clearance has been well described as an indicator of the adequacy of resuscitation in injured patients. We investigated whether acutely injured patients with positive blood alcohol content (+BAC) had less lactate clearance than sober patients. MethodsWe conducted a retrospective cohort study of acutely injured patients treated at an urban Level 1 trauma centre between January 2010 and December 2012. Blood alcohol and venous lactate levels were measured on all patients at the time of arrival. Study subjects were patients transported directly from the scene of injury, who had an elevated lactate concentration on arrival (≥3.0mmol/L) and at least one subsequent lactate measurement within 24h after admission. Lactate clearance ([Lactate1−Lactate2]/Lactate1) was calculated for all patients. Chi-squared tests were used to compare values from sober and intoxicated subjects. Lactate clearance was plotted against alcohol levels and stratified by age and Injury Severity Score (ISS). ResultsSerial lactate concentration measurements were obtained in 3910 patients; 1674 of them had +BAC. Patients with +BAC were younger (mean age: 36.6 [SD 14.7] vs 41.0 [SD 19.9] years [p=0.0001]), were more often male (83.4% vs 75.9% [p=0.0001]), had more minor injuries (ISS<9) (33.8% vs 27.1% [p=0.0001]), had a lower in-hospital mortality rate (1.4% vs 3.9% [p=0.0001]), but also had lower average lactate clearance (37.8% vs 47.6% [p=0.0001]). The lactate clearance of the sober patients (47.6 [SD 33.5]) was twice that of those with +BAC >400 (23.5 [SD 6.5]). Lactate clearance decreased with increasing BAC irrespective of age and ISS. ConclusionsIn a large group of acutely injured patients, a dose-dependent decrease in lactate clearance was seen in those with elevated BAC. This relationship will cause a falsely elevated lactate reading or prolong lactate clearance and should be taken into account when evaluating patients with +BAC.

Abstract MP71: Undetected Disease and Low Medication Adherence are Major Determinants of Poor Cardiovascular Risk Factor Control in Rural India

Background: Cardiovascular disease is the leading cause of mortality in India. Since it is largely driven by risk factors such as hypertension, diabetes and smoking it is important to study diagnosis, treatment and control patterns for these conditions, and identify areas for improvement. Methods: Project SEHAT (ClinicalTrials.gov number, NCT02115711) is a cluster RCT with a long term goal of improving the control of cardiovascular risk factors in a rural community in West Bengal, India. For the baseline data, 3575 adults, between the ages of 35 and 70, were screened for hypertension, diabetes and smoking. For hypertension and diabetes, an elevated reading was confirmed on a repeat visit. Results: Risk factors were common, with hypertension, diabetes and smoking evident in 18.3% (654 of 3575), 9.0% (321 of 3575) and 15.1% (540 of 3575) of adults, respectively. Overall, 34.5% (1233 of 3575) of adults had at least one risk factor. There was a huge burden of undetected disease, with only 45.2% (296 of 654) of hypertensives and 59.8% (192 of 321) of diabetics previously aware of their disease. Linkage to care was high with 72.0% (213 of 296) of previously diagnosed hypertensives and 86.0% (165 of 192) of previously diagnosed diabetics on treatment. Control rates were, however, low with 8.2% (54 of 654) of hypertensives controlled (BP &lt;140/90 mmHg) and 13.7% (44 of 321) of diabetics controlled (fasting blood sugar &lt;126 mg/dl). This may be partly explained by a low medication adherence rate, with the adherence (medium and high) being 35.5% (76 of 213) in hypertensives and 20.6% (34 of 165) in diabetics, as measured by the Morisky Medication Adherence Scale-8. Conclusions: In our population in rural India, 1 in 3 adults have a major cardiovascular risk factor, with abysmal control rates. Barriers to risk factor control primarily exist at the points of diagnosis and medication adherence. Over the next 2 years, a community health worker led intervention, with an aim to improve the control of hypertension, diabetes and smoking will be tested in this cohort.

Effect of indocyanine green dye administration on cerebral oxygen saturation.

Sir, Near-infrared spectroscopy (NIRS) is a non-invasive continuous method of measuring regional cerebral oxygen tissue saturation (SctO2).[1] It uses a technique similar to pulse oximetry where light absorption in wavelength 600–900 nm is used. Indocyanine green (ICG) is a water soluble and iodide containing dye that fluoresces when exposed to infrared light. This property of ICG is used for the intra-operative assessment of blood flow during aneurysm surgery. Safety of ICG usage in clinical settings has been demonstrated for determining cardiac output, hepatic function and liver blood flow and for ophthalmic angiography.[2] There have been hypotension, urticarial reaction or anaphylaxis and falsely low pulse oximetry recording during or following use of ICG.[3,4] Contrary to falsely low pulse oximetry recordings, ICG administration has been shown to increase SctO2.[4] Here, we are describing the effect of ICG administration on SctO2. A 65-year-old male patient was scheduled to undergo clipping of right supraclinoid internal carotid artery aneurysm under general anaesthesia. Apart from the routine monitoring, we placed bilateral NIRS sensors over the forehead of the patient. After administration of 10 mg of ICG, the SctO2 on both the sides suddenly increased to 100 from a baseline of about 65–75% and gradually decreased to the baseline value after about 15 min [Figure 1]. There were no associated haemodynamic changes. Figure 1 Snap shot of near infrared spectroscopy monitor showing the graphical trend of the cerebral oxygen saturation. Furthermore, clearly seen is the sudden acute increase in saturation after injection of indocyanine green at two different time points and gradual ... This sudden increase in SctO2 following administration of ICG can be explained by the principle applied in NIRS sensors. NIRS uses wavelengths between 700 and 850 nm to determine regional cerebral oxygen SctO2 by differentiating oxyhaemoglobin from reduced haemoglobin in the frontal lobe. Thus, any substances that absorb infrared light of the same wavelength produced by the light-emitting diodes may affect the absorption of light as they traverse the blood and tissues.[5] ICG has a characteristic absorption peak at around 805 nm and this is likely to reduce the amount of detected light in the 810 nm wavelength of the NIRS device, which would be interpreted as an increased oxyhaemoglobin concentration leading to falsely elevated SctO2 reading.[6] The effect of this falsely elevated SctO2 on the clinical outcome of the patients is not known. Despite these changes, the remaining of the surgical procedure was uneventful or did the patient develop any new neurological deficits and patient's trachea was successfully extubated at the end of the procedure. The anaesthesiologists and neurosurgeons must be aware of this interaction of ICG and cerebral oxygen SctO2 in the intra-operative period. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Sensitivity to verb-argument anomalies in aphasia is driven by event knowledge

Sensitivity to verb-argument anomalies in aphasia is driven by event knowledge

UNRECOGNIZED ELEVATED BLOOD PRESSURE IN THE 3-18 YEAR OLD POPULATION IN THE PRIMARY CARE SETTING

Objective – This study was done to assess the incidence of missed elevated blood pressure readings at two large outpatient clinics. Methods – We randomly selected 250 charts from all pediatric well child visits seen at the two sites during 2014. Recognized elevated blood pressure was the primary outcome. We reviewed the charts to determine if systolic and/or diastolic blood pressure was greater than the 90th percentile for age, gender and height or greater than 120/80 mmHg in patients without a previous history of elevated blood pressure. The charts were then reviewed to see if the practitioners in any way recognized the elevated blood pressure reading, either by repeating the reading, a clinic note documenting the high reading, a plan to recheck in the future, relevant lab work, imaging, or a referral to a pediatric cardiologist or nephrologist. Results – There were 72 (28.8%) children with elevated blood pressure readings. Twenty nine (40.3%) of these children were recognized as having elevated readings based on the criteria listed above. Twelve of these 29 children had other interventions taken. Forty three of these 72 children (59.7%) were not recognized and no intervention was taken. Conclusion – Almost 60% of children with elevated blood pressure readings taken as part of the well child visit were not recognized in provider documentation. Practitioners should be aware of this common pediatric diagnostic error. Appropriate measures such as training, use of a blood pressure simplified charts, or electronic alerts should be taken to reduce the amount of missed diagnoses.

Blood Pressure Visit Intensification Study in Treatment: Trial design

There is a presumption that, for patients with uncontrolled blood pressure (BP), early follow-up, that is, within 4 weeks of an elevated reading, improves BP control. However, data are lacking regarding effective interventions for increasing clinician frequency of follow-up visits and whether such interventions improve BP control. Blood Pressure Visit Intensification Study in Treatment involves a multimodal approach to improving intensity of follow-up in 12 community health centers using a stepped wedge study design. The study will inform effective interventions for increasing frequency of follow-up visits among patients with uncontrolled BP and determine whether increasing follow-up frequency is associated with better BP control.

PTH-219 Prevalence of intestinal failure-associated liver disease within a home parenteral nutrition service

Introduction Intestinal failure-associated liver disease (IFALD) is a potentially life-threatening and historically common complication of long-term parenteral nutrition. In the past two decades advances in catheter sepsis prevention and the development of novel lipid formulations have reduced the prevalence of IFALD. We examined the point prevalence of surrogate markers of IFALD within the home parenteral nutrition (HPN) service at the Royal Berkshire Hospital. Method The records of the HPN service were examined to identify patients receiving HPN between January 2012 and December 2014. Clinic notes, electronic patient records and imaging results were used to extract clinical information. Results Twenty-four patients (13 male; mean age 60 years, range 21–83 years) received long-term home parenteral nutrition during the study period for a mean duration of 25 months (range 3–54 months). Underlying causes of intestinal failure included inflammatory bowel disease (7, 29%), vascular causes (5, 21%), surgical complications including fistulae, sepsis and adhesions (5, 21%), malignancy (4, 17%) and dysmotility (3, 12%). Most patients received a tailor-made PN bag 3–7 days a week (median 5 days a week) with a lipid emulsion (SMOF) bag twice a week. In this cohort 16 patients had persistently abnormal liver biochemistry (raised ALT and/or ALP greater than the reference range for longer than six months). Two patients had mildly elevated bilirubin (1–2 x upper limit of normal). There were no clinical presentations of decompensated liver disease. Nineteen patients had hepatic imaging (ultrasound or CT) during the study period. One patient had splenomegaly secondary to portal vein thrombosis and one patient had ascites related to Budd-Chiari syndrome. No other patients had radiological signs of portal hypertension or cirrhosis on imaging. Three patients underwent transient elastography measurement (Fibroscan ® ) one of which had an elevated reading (10.7kPa, IQR 1.5). Conclusion These results show that two thirds of patients on long-term parenteral nutrition had persistent abnormalities in liver biochemistry which may indicate steatohepatitis. No patients showed signs of cirrhosis on imaging or presented with decompensated liver disease during the three-year study period. Whilst this is a relatively short follow-up period to detect the development of chronic liver disease, previous studies have reported a prevalence of complicated liver disease of 26% after two years of PN. 1 We plan to prospectively monitor liver biochemistry, abdominal imaging and transient elastography in our HPN cohort to assess the natural history of IFALD. Disclosure of interest None Declared. Reference Cavicchi M et al . Prevalence of liver disease and contributing factors in patients receiving home parenteral nutrition for permanent intestinal failure. Ann Intern Med. 2000;132:525–532

From Bradycardia to Tachycardia: Complete Heart Block

Syncope in the setting of heart block is usually, but not invariably, due to bradycardia. This point was underscored when a patient's telemetry data proved surprising. The patient, a 74-year-old man with no history of cardiac disease, initially presented to an urgent care facility after noting an elevated reading on his home blood pressure monitor. He described a 4-week history of dyspnea on exertion and poor exercise tolerance but denied dizziness, syncope, chest pain, orthopnea, lower-extremity edema, or other symptoms.