Patient: Female, 78Final Diagnosis: Takotsubo cardiomyopathySymptoms: Chest discomfort, chest pain, dyspnea, short of breathMedication: —Clinical Procedure: —Specialty: CardiologyObjective:Unusual or unexpected effect of treatmentBackground:Takotsubo cardiomyopathy is an increasingly recognized cardiac condition that usually results from an acute stressor. Some medications are becoming recognized as possible stressors. Albuterol is widely used in general medicine. We report an unusual link between Takotsubo cardiomyopathy and albuterol.Case Report:A 78-year-old woman presented to our emergency department for chest pain of 2-day duration. The patient had been taking albuterol inhaler therapy for worsening shortness of breath followed by chest pain. Her albuterol use was excessive. There were no other acute stressors. The electrocardiogram showed ST-elevations in the anterior and inferior leads. Emergent coronary angiography showed noncritical coronary artery disease and left ventriculography showed apical ballooning.Conclusions:When patients taking albuterol present with acute chest pain in the absence of other etiologies, beta-agonist-induced Takotsubo cardiomyopathy should be considered.

Background and study aims  Many people with celiac disease are undiagnosed and there is evidence that insufficient duodenal samples may contribute to underdiagnosis. The aims of this study were to investigate whether more samples leads to a greater likelihood of a diagnosis of celiac disease and to elucidate factors that influence the number of samples collected. Patients and methods  We identified patients from two community hospitals who were undergoing duodenal biopsy for indications (as identified by International Classification of Diseases code) compatible with possible celiac disease. Three cohorts were evaluated: no celiac disease (NCD, normal villi), celiac disease (villous atrophy, Marsh score 3), and possible celiac disease (PCD, Marsh score < 3). Endoscopic features, indication, setting, trainee presence, and patient demographic details were evaluated for their role in sample collection. Results  5997 patients met the inclusion criteria. Patients with a final diagnosis of celiac disease had a median of 4 specimens collected. The percentage of patients diagnosed with celiac disease with one sample was 0.3 % compared with 12.8 % of those with six samples ( P  = 0.001). Patient factors that positively correlated with the number of samples collected were endoscopic features, demographic details, and indication ( P  = 0.001). Endoscopist factors that positively correlated with the number of samples collected were absence of a trainee, pediatric gastroenterologist, and outpatient setting ( P  < 0.001). Conclusions  Histological diagnosis of celiac disease significantly increased with six samples. Multiple factors influenced whether adequate biopsies were taken. Adherence to guidelines may increase the diagnosis rate of celiac disease.

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