Objectives We assessed the methodological quality and prognostic accuracy of clinical decision rules (CDR) in emergency department (ED) syncope patients. Methods We searched 5 electronic databases, reviewed reference lists of included studies and contacted content experts to identify articles for review. Studies that derived or validated CDRs in ED syncope patients were included. Two reviewers independently screened records for relevance, selected studies for inclusion, assessed study quality and abstracted data. Random effects meta-analysis was used to pool diagnostic performance estimates across studies that derived or validated the same CDR. Between study heterogeneity was assessed with I-squared statistic (I2), and subgroup hypotheses were tested using a test of interaction. Results We identified 18 eligible studies. Deficiencies in outcome (blinding) and inter-rater reliability assessment were the most common methodological weaknesses. Meta-analysis of the San Francisco Syncope Rule (SFSR) [sensitivity 86% (95%CI 83-89); specificity 49% (95%CI 48-51)] and the Osservatorio Epidemiologico sulla Sincope nel Lazio (OESIL) risk score [sensitivity 95% (95%CI 88-98); specificity 31% (95%CI 29-34)]. Subgroup analysis identified study design [prospective, diagnostic odds ratio (DOR) 8.82 (95%CI 3.5-22) vs. retrospective, DOR 2.45 (95%CI 0.96-6.21)] and ECG determination [by evaluating physician, DOR 25.5 (95%CI 4.41-148) vs. researcher or cardiologist, DOR 4 (95%CI 2.15-7.55)] as potential explanations for the variability in SFSR performance. Conclusion The methodological quality and prognostic accuracy of CDRs for syncope is limited. Differences in study design and ECG interpretation may account for the variable prognostic performance of the SFSR when validated in different practice settings.

Hyperglycemia on presentation in non-diabetic patients is an independent predictor of early mortality and worse functional outcome in patients with intracerebral hemorrhage.

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Background The conventional treatment for idiopathic intracranial hypertension involves weight loss, steroids, diuretics, and/or serial lumbar punctures; however, if the symptoms persist or worsen, surgical intervention is recommended. Surgical options include cerebrospinal fluid diversion procedures, such as ventriculoperitoneal and lumboperitoneal shunts, and optic nerve decompression with nerve sheath fenestration. The latter can be carried out using an endoscopic approach, but the outcomes of this technique have not been firmly established. Methods This systematic review examined the outcomes of performing endoscopic optic nerve decompression (EOND) in patients with idiopathic intracranial hypertension (IIH). Six studies were included for a total of 34 patients. Results The patients presented with visual field disturbances [32 of 32 (100%)], visual acuity disruptions [33 of 34 (97.1%)], papilledema [26 of 34 (76.5%)], and persistent headache [30 of 33 (90.1%)]. The mean duration of the symptoms ranged from 7 to 32 months. Overall, the patients showed post-EOND improvement of the signs and symptoms associated with IIH, specifically visual field deficits (93.8%), visual acuity (85.3%), papilledema (81.4%), and headaches (81.8%). Interestingly, 11 cases showed postoperative improvement in their symptoms with bony decompression of the optic canal alone, without nerve sheath fenestration. The authors did not report any major adverse events or complications with this approach. Conclusion EOND appears to be a promising and safe surgical alternative for patients with IIH who fail to respond to medical treatment. Further studies are needed before we can attest to the clinical validity of this procedure.

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