No abstract

A 22-year-old man presented to the hospital after a motor vehicle collision in which his head struck the windshield of a bus. Initial observations and the physical and neurologic examinations were normal, but the injury warranted computed tomographic (CT) scanning. A CT scan of the brain (Panel A) showed an incidental finding of grossly dilated occipital and temporal horns of the right lateral ventricle. Magnetic resonance imaging (Panel B) confirmed the presence of a large cystic lesion extending from the temporal and posterior horns of the right lateral ventricle (axial size, 11 cm by 7 cm), with a mild midline shift of the third ventricle, and compression of the midbrain and brain stem with thinning of the temporal and occipital cortexes. A large, asymptomatic, intraventricular arachnoid cyst was diagnosed. Arachnoid cysts -collections of cerebrospinal fluid within the layers of the arachnoid membrane -occur infrequently. Most are congenital, but they can also be acquired after trauma or infection through the entrapment of cerebrospinal fluid within arachnoid adhesions. Neurosurgery was recommended in this case, but the patient discharged himself from the hospital and there was no further follow-up.

Background and importance: Chest pain (CP) is one of the most frequent presentations to the emergency department (ED), a large proportion of which is non-cardiac chest pain (NCCP). Repeat attendances to ED are common and impose considerable burden to overstretched departments. Objective: Our aim was to determine drivers for repeat ED presentations using NCCP as the primary cause of index presentation. Design, setting and participants: This was a retrospective cohort study of 1066 consecutive presentations with NCCP to a major urban hospital ED in North England. Index of Multiple Deprivation (IMD), a postcode-derived validated index of deprivation, was computed. Charlson comorbidity index (CCI) was determined by reference to known comorbidity variables. Repeat presentation to ED to any national hospital was determined by a national linked database (population 53.5 million). Independent predictors of ED representation were computed using logistic regression analysis. Results: Median age was 43 (IQR 28–59), and 50.8% were male. Furthermore, 27.8%, 8.1% and 3.8% suffered from chronic obstructive pulmonary disease (COPD), hypertension and diabetes mellitus, respectively. The most frequent diagnoses, using ICD-10 coding, were non-cardiac chest pain (55.1%), followed by respiratory conditions (14.7%). One-year incidence of adjudicated myocardial infarction, urgent or emergency coronary revascularisation and all-cause death was 0.6%, 2% and 5.3%, respectively. There was a total of 4770 ED repeat presentations 1 year prior to or following index presentation with NCCP in this cohort. Independent (multivariate) predictors for frequent re-presentation (defined as ≥2 representations) were a history of COPD (OR [odds ratio] 2.06, p = 0.001), previous MI (OR3.6, p = 0.020) and a Charlson comorbidity index ≥1 (OR 1.51, p = 0.030). The frequency of previous MI was low as only 3% had sustained a previous MI. Conclusions: This analysis indicates that COPD and complex health care needs (represented by high CCI), but not socio-economic deprivation, should be health policy targets for lessening repeat ED presentations. What is already known on this topic: Repeat presentations with non-ischaemic chest pain are common, placing a considerable burden on emergency departments. What this study adds: COPD and complex health care needs, denoted by Charlson comorbidity index, are implicated as drivers for repeat presentation to accident and emergency department. Socio-economic deprivation was not an independent predictor of re-presentation. How might this study affect research, practice, or policy: Community-based support for COPD and complex health care needs may reduce frequency of ED attendance.