Diaphragmatic Endometriosis Presenting as Recurrent Catamenial Pneumothorax: A Case Report.

Catamenial pneumothorax is one of the most common extra-pelvic presentations of endometriosis, with the gastrointestinal tract being the most common location. Catamenial pneumothorax is defined as spontaneous recurrent pneumothorax occurring in women of reproductive age in a temporal relationship with menses. Symptoms include dyspnea, sharp chest pain, and hypoxemia. A much rarer presentation is the involvement of endometriosis with the diaphragm. In this case, we present a 31-year-old female who presented with signs of pneumothorax. She has had multiple episodes leading to suspicion of catamenial pneumothorax. However, it wasn't until her surgery that the extent of diaphragmatic involvement, characterized by numerous holes secondary to endometriosis, was discovered. She was surgically treated, which led to a drastic improvement in symptoms and a reduction in subsequent episodes. We hope that this case can add to the current limited literature on diaphragmatic endometriosis cases. Since this patient presented with mainly catamenial pneumothorax symptoms, we urge clinicians to still consider diaphragmatic involvement as a primary cause in patients with recurrent episodes of pneumothorax.

Assessment of risk tolerance for adverse events in emergency department chest pain patients: a pilot study.

BACKGROUND: Emergency physicians commonly encounter low-probability/high-morbidity decisions, and chest pain is a prime example. Negative outcomes are improbable but feared, resulting in substantially more patients admitted for chest pain than have important disease. The literature gives little guidance on patient preferences for decision-making when the negative outcomes are unlikely but potentially severe. OBJECTIVES: The objective of this pilot study was to assess the tolerance of Emergency Department (ED) patients with chest pain for adverse events occurring within 2 weeks of the episode. METHOD: We recruited a convenience sample of patients with a chief complaint of chest pain from the ED of an urban tertiary-care referral center. Each subject was interviewed to determine demographic information, perceived health status, insurance status, and tolerance for adverse events related to chest pain. Adverse events were defined loosely but were suggested to be heart attack, the need for emergency cardiac surgery, or death. The risk tolerance question was framed by describing a specific numeric risk and determining at what risk the patient switched from desiring hospital admission to desiring discharge; we termed this the decision threshold. RESULTS: Sixty-eight (68) subjects were included. Fifty-four percent of subjects were male, 60% were African-American, and 35% were white; 40% of the subjects classified themselves as being of average health. Of the 31 subjects who had prior heart trouble, 48% (n = 15) stated they had a prior heart attack and 19% (n = 6) an irregular heartbeat. The median decision threshold, or the acceptable personal risk of an adverse event for a person to forego admission to hospital, was 6.5% (interquartile range 0.5-22.9%). The mode was 0.5%, and 44% (30/68) of subjects had a decision threshold of 2% or less. There was no obvious pattern for most of these explanatory variables, though there was a suggestion that race may affect patients' risk tolerance. CONCLUSIONS: There is substantial variation in patients' reported tolerance for adverse events from ED chest pain. Further investigation of this phenomenon may lead to better decision-making.

Hyperperfusion syndrome following carotid artery stenting: the largest single-operator series to date.

BACKGROUND: Cerebral hyperperfusion syndrome (HPS) results from autoregulatory failure of cerebral blood flow following carotid endarterectomy (CEA) or carotid artery stenting (CAS) and encompasses a range of neurological findings including headache, seizure, intracranial hemorrhage (ICH), altered mental status and focal neurological changes. This report is the largest single-operator series evaluating the incidence and predictors of HPS following CAS. METHODS: A retrospective review was conducted on 482 consecutive patients who underwent CAS between August 1999 and December 2007 at Baptist Medical Center--Princeton, Birmingham, Alabama. All interventions were performed by a single operator (FM). The mean patient age was 70.4 +/- 10.3 years and 36% were symptomatic. All patients were high-risk for CEA. After cerebral protection catheters were routinely available, they were used in all but 6 cases (98.1%) where the anatomy precluded delivery. Brain computed tomography (CT) was performed immediately for any neurological change or significant headache following CAS. After neurological consultation and imaging, HPS was diagnosed if: 1) a neurological change occurred (not simply a headache); 2) CT revealed ipsilateral sulcal effacement/cerebral edema; and 3) stroke or transient ischemic attack (TIA) was excluded. RESULTS: Seven patients (1.45%) developed HPS following CAS. All patients achieved complete neurological recovery 6-24 hours following the procedure. Patients who developed HPS were significantly more likely to have had recent transient ischemic attack (TIA) symptoms than patients without HPS (p = 0.04). Unlike previous reports, there were no significant differences in procedural details, lesion characteristics and post-procedure blood pressure between the HPS and non-HPS patients, although the number of cases was small. Overall, the HPS cohort had a higher prevalence of comorbidities, though these differences did not reach statistical significance. Hypertension was present in all 7 HPS patients. Other complications in the series were death (0.83%), stroke (1.87%) and TIA (1.45%). CONCLUSIONS: The incidence of HPS is low (1.45%) following CAS, but it is an important complication to distinguish from stroke and TIA. Patients with a recent TIA may be predisposed to HPS. This report may underestimate the incidence of HPS, since patients with an isolated headache did not meet our diagnostic criteria and routine post-procedure brain CT imaging was not performed. The clinical predictors of HPS and its optimum management remain to be determined.