Article

Should weakness be subsumed to nonspecific complaints?—Correspondence in response to Bhalla et al.

722 Correspondence

References

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    Should weakness be subsumed to Nonspecific complaints?–Correspondence in response to Bhalla et al.

    To the Editor,

    Recently, Bhalla et al. [1] published their brief report on prevalence of weakness and fatigue (W&F) visits in older emergency department (ED) patients in the American Journal of Emergency Medicine. They com- pared demographics and resource use in W&F patients with controls and determined ED diagnoses and disposition in a large patient cohort. This effort must be applauded as Geriatric EMergency medicine experts agree that generating an age-specific differential diagnosis for general weakness is a core competence of emergency physicians [2]. Bhalla et al. confirm previous studies from different emergency settings show- ing that nonspecific complaints such as weakness belong to the top 5 Presenting complaints in the older ED population [3,4]. We performed an observational, prospective study of consecutive patients with a pre- senting symptom of weakness over a 4-week period. In that study [5], 65% of the patients complained of generalized weakness and 35% of lo- calized weakness. Most patients with localized weakness had a final di- agnosis of cerebral ischemia, transient ischemic attack, or intracerebral hemorrhage. The remainder was diagnosed with stroke mimics such

    as migraine or Todd’s paralysis. Localized weakness can therefore be called a specific symptom. The differential diagnosis of generalized weakness, however, comprised almost the whole International Classifi- cation of Diseases catalog. Similarly, in a recent study of patients with “decreased general condition”, a vast spectrum of diagnoses was found [6].

    In our opinion, the main question is whether to create a new entity for W&F patients or to keep the concept of nonspecific complaints, which is much broader and has certain obvious advantages [7]. First, all symptoms that are not part of the set of specific symptoms can be called nonspecific because it has been shown that the diagnostic spec- trum is extremely broad in this type of presentation. This definition by exclusion has a major advantage because there is an endless list of non- specific presenting complaints.

    Second, the outcome is similar when W&F patients are compared with all patients presenting with nonspecific complaints (Table). Research on nonspecific complaints revealed that acute morbidity (Serious condition) is present in roughly 60% of the cases and that this patient group’s differ- ential diagnosis is difficult and extremely broad because it encompasses the entire spectrum of International Classification of Diseases catalog cases as well [4,8]. The 30-day mortality rate was shown to be roughly 6% in 2 prospective studies and this ongoing prospective cohort (Table)[9,10].

    We agree with Bhalla et al. that weakness and fatigue are common in the ED. However, we believe that W&F patients should be subsumed to nonspecific complaints for 3 important reasons: they merely represent the largest subgroup; they do not substantially differ in demographics and underlying condition; and they share the same outcome, namely, a high burden of morbidity and mortality.

    C.H. Nickel, MD?

    A. Malinovska, MD

    R. Bingisser, MD Department of Emergency Medicine, University Hospital Basel Petersgraben 2, CH-4031 Basel, Switzerland

    ?Corresponding author. Tel.: +41 61 556 5315; fax: +41 61 265 58 31

    E-mails: [email protected], [email protected]

    [email protected]

    http://dx.doi.org/10.1016/j.ajem.2015.02.019

    Table

    Comparison of patients with NSC with patients complaining of “weakness” and/or “fatigue” (W&F) from the ongoing BANC study

    NSC patients

    W&F patients

    95% CI for differencesa

    Number, n

    Age, median (IQR), y

    1278

    0081 (74.0 to 87.0)

    855

    081 (73.0 to 87.0)

    -0.753 to 1.405

    Sex, n (%)

    0782 (61.2%) female

    526 (61.5%) female

    -0.039 to 0.043

    Serious condition, n (%)

    0742 (58.1%)

    521 (60.9%)

    -0.071 to 0.014

    30-day mortality, n (%)

    0084 (6.57%)

    055 (6.43%)

    -0.019 to 0.024

    Top 6 primary discharge diagnoses,

    197 (15.4%) I00-I99

    141 (16.5%) I00-I99

    -0.042 to 0.020

    ICD10 categories, n (%)

    195 (15.3%) F00-F99

    185 (14.5%) N00-N99

    146 (11.4%) E00-E90

    114 (8.92%) R00-R99

    101 (7.90%) J00-J99

    110 (12.9%) F00-F99

    129 (15.1%) N00-N99

    107 (12.5%) E00-E90

    064 (7.49%) R00-R99

    067 (7.84%) J00-J99

    -0.006 to 0.054

    -0.037 to 0.027

    -0.039 to 0.017

    -0.009 to 0.038

    -0.020 to 0.026

    340 (26.6%) others

    237 (27.7%) others

    -0.049 to 0.029

    The BANC study [4] includes adult nontrauma patients presenting to the ED of University Hospital of Basel, Switzerland, with NCS such as weakness and fatigue. Serious conditions are defined as any potentially life-threatening condition [4]. Table represents descriptive statistics (frequencies and median [first and third quartiles]).

    Primary discharge diagnosis according to ICD10 categories: malignant neoplasms (C00-C75); endocrine, nutritional, and metabolic diseases (E00-E90); mental and behavioural disorders (F00-F99); diseases of the nervous system (G00-99); diseases of the circulatory system (I00-I99); diseases of the respiratory system (J00-J99); diseases of the digestive system (K00-K93); diseases of the musculoskeletal system and connective tissue (M00-M99); diseases of the Genitourinary system (N00-N99); symptoms, signs, and abnormal clinical and laboratory find- ings, not elsewhere classified (R00-R99).

    Abbreviations: NCS, nonspecific complains; CI, confidence interval; IQR, interquartile range; ICD10, International Classification of Diseases, 10th Revision; BANC, Basel Non-Specific Com- plaints study.

    a Differences in mean values (for metric variables) or fractions (for categorical variables) between NSC and W&F were calculated using 95% bootstrap CIs. If 0 is included in the 95% bootstrap CI, then no significant differences between NSC and W&F can be inferred. The bootstrap method was chosen because the 2 populations were partly dependent; therefore, standard tests were not appropriate. All calculations were performed with the statistical package R version 3.0.1 (The R Foundation for Statistical Computing, Austria).

    Correspondence 723

    References

    Bhalla MC, Wilber ST, Stiffler KA, Ondrejka JE, Gerson LW. Weakness and fatigue in older ED patients in the United States. Am J Emerg Med 2014;32: 1395-1398.2.

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    The differential diagnosis of acute pulmonary embolism and ST-segment Inferior myocardial infarction

    To the Editor,

    Distinct from the scenario of Acute pulmonary embolism masquerading as inferior acute myocardial infarction (AMI) [1], and vice versa, the clinical scenario that also needs to be recognized is the one where the 2 entities are causally related [2-6]. For example, APE may oc- casionally give rise to AMI (with ST-segment elevation in leads II, III, and aVF) when APE-related dilatation of the pulmonary artery causes com- pression of the proximal portion of the right coronary artery. This was the case ina 55-year-old woman in whom the right coronary artery had an anomalous origin from the left coronary sinus [2]. Even in the absence of this rare anomaly, when APE is massive, that, in itself, may cause AMI (including inferior AMI) by generating a sudden increase in right ventricular overload, with consequent increase in myocardial oxygen demand. Right ventricular infarction occurs when this demand cannot be met. In 1 of the 6 cases with autopsy documentation of this phenomenon, an electrocardiogram recorded approximately 1 hour before death was reported as showing “inferior necrosis” (case 1) [3]. Par- adoxical embolism is yet another mechanism whereby APE can cause AMI, and this was the case in 2 separate case reports where angiographically validated Coronary embolism was associated with ST- segment elevation in leads II, III, and aVF. In both instances, the diagnosis of paradoxical embolism was validated by documentation of patent foramen ovale [4,5]. Conversely, AMI may be complicated by APE, as was the case in a 66-year-old man in whom “serial electrocardio- grams and enzyme studies….confirmed the diagnosis of inferior MI” [6]. In that patient, APE was attributable to embolization from a right ventric- ular thrombus [6]. Finally, in the differential diagnosis of inferior AMI vs APE, cognizance must also be taken of aortic dissection, given the fact that elevation in D-dimer levels is a marker, both for APE and aortic dissec- tion [7]. Aortic dissection may, in turn, sometimes be associated with ST- segment elevation in leads II, III, and aVF [8-10]. In 1 such case, angio- graphically proven APE was an associated feature [9]. In another case, (with ST segment elevation in leads II and AVF) the presenting feature was pleuritic chest pain in association with a D-dimer level of 3520 mcg/L (reference range, 0-275) [10], the latter association being a

    potential source of confusion with APE. Even in the absence of pleuritic chest pain, aortic dissection may simulate APE by causing hypoperfusion of the right lung when the dissecting hematoma compresses the Right pulmonary artery [11,12]. The resulting image, on pulmonary perfusion scintigraphy, is consistent with massive pulmonary embolism [12]. In conclusion, increasing recognition has to be made of the association of APE and AMI, especially when the 2 disorders are causally related.

    Oscar M.P. Jolobe, MB, ChB, DPhil Manchester Medical Society, Manchester M13 9PL, United Kingdom 1 Philip Godlee Lodge, 842 Wilmslow Road, Manchester M20 2DS

    Tel.: +44 161 448 9034

    E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2015.02.016

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    Correlation between acute pulmonary embolism and ST elevation inferior myocardial infarction

    To the Editor,

    Submassive to massive Acute pulmonary embolism without concomitant coronary artery disease or paradoxical coronary embolism can masquerade as inferior ST-segment elevation myocardial infarction [1,2]. We wanted to emphasize that the clinician should con- sider APE as a differential diagnosis in patients with ST-segment eleva- tion (STE) in the inferior leads along with right ventricular (RV) strain electrocardiographic patterns [1].

    We would like to thank the author [3] of a letter entitled “The dif- ferential diagnosis of acute pulmonary embolism and ST-segment elevation inferior myocardial infarction,” which will be published in this journal. The author commented that the 2 entities can also be causally related. Acute pulmonary embolism can cause concur- rent inferior STEMI via paradoxical coronary embolism or the com- pression of the anomalous origin right coronary artery from the left

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