Multi-organ dysfunction as a presentation of calcium channel blocker intoxication.

SummaryWe report the case of a 73-year-old woman who intentionally ingested 400 mg of amlodipine in a suicidal attempt who initially presented with hypotension which persisted despite aggressive therapy with fluid resuscitation, multiple pressor support, high-dose insulin therapy and calcium infusion. Her haemodynamic instability evolved to include bradycardia requiring atropine and transcutaneous pacing. Eventually she required salvage therapy with intravenous lipid emulsion (ILE) therapy . Despite all aggressive therapy, she developed multi-organ failure resulting in death. The literature on high-dose insulin euglycaemic therapy (HIET) and ILE therapy shows mixed results with some showing significant improvement in haemodynamic status. In our case, it had no significant positive impact on the outcome.

The use of double-pigtailed stents to relieve obstruction of a previous endoscopic gastrojejunal lumen-apposing metal stent.

Video 1EGD, which showed obstructed distal flange of the gastrojejunal lumen-apposing metal stent (LAMS) by the contralateral jejunal wall. Two double-pigtail stents were placed across the LAMS to relieve the obstruction.

Vulnerability to xylem cavitation of Hakea species (Proteaceae) from a range of biomes and life histories predicted by climatic niche.

BACKGROUND AND AIMS: Extreme drought conditions across the globe are impacting biodiversity, with serious implications for the persistence of native species. However, quantitative data on physiological tolerance are not available for diverse flora to inform conservation management. We quantified physiological resistance to cavitation in the diverse Hakea genus (Proteaceae) to test predictions based on climatic origin, life history and functional traits. METHODS: We sampled terminal branches of replicate plants of 16 species in a common garden. Xylem cavitation was induced in branches under varying water potentials (tension) in a centrifuge, and the tension generating 50 % loss of conductivity (stem P50) was characterized as a metric for cavitation resistance. The same branches were used to estimate plant functional traits, including wood density, specific leaf area and Huber value (sap flow area to leaf area ratio). KEY RESULTS: There was significant variation in stem P50 among species, which was negatively associated with the species climate origin (rainfall and aridity). Cavitation resistance did not differ among life histories; however, a drought avoidance strategy with terete leaf form and greater Huber value may be important for species to colonize and persist in the arid biome. CONCLUSIONS: This study highlights climate (rainfall and aridity), rather than life history and functional traits, as the key predictor of variation in cavitation resistance (stem P50). Rainfall for species origin was the best predictor of cavitation resistance, explaining variation in stem P50, which appears to be a major determinant of species distribution. This study also indicates that stem P50 is an adaptive trait, genetically determined, and hence reliable and robust for predicting species vulnerability to climate change. Our findings will contribute to future prediction of species vulnerability to drought and adaptive management under climate change.

Occurrence of honey bee-associated pathogens in Varroa-free pollinator communities.

Australia remains the last significant land mass free of Varroa, a parasitic mite which has caused dramatic honey bee (Apis mellifera) colony losses across the globe, due to its association with the pathogenic deformed wing virus (DWV). As such, Australia continues to maintain relatively healthy honey bee populations, despite recent work showing apiaries harbor a surprisingly high prevalence of microbial pathogens. We sought to determine the prevalence of these microbial pathogens in honey bees and native pollinators actively co-foraging on mass flowering crops and to understand the extent to which they may be shared between taxa. We found high prevalences of black queen cell virus (BQCV) and sacbrood virus (SBV) in the honey bees (88% and 41% respectively), and correspondingly, these were the most common honey bee pathogens detected in native pollinator taxa, albeit at much lower prevalence; the maximum prevalence for any pathogen in a native pollinator group was 24% (BQCV in Halictidae spp.). The viral pathogens Israeli acute paralysis virus and Lake Sinai viruses 1 and 2, and the fungal parasites Nosema apis and Nosema ceranae, were only rarely detected. Phylogenetic analyses of the most common pathogens revealed similar genotypes circulating between species. Our data suggest that, in Australian orchards, pathogen prevalence in honey bees is a good predictor of pathogen prevalence in native pollinators, which raises concerns about how the viral landscape may change in native taxa if, or when, Varroa arrives.

An 80-Year-Old Man With a 24-Hour History of Epigastric Pain.

CASE PRESENTATION: An 80-year-old man was admitted to our hospital with 24 hours of epigastric pain. The pain was described as sharp, episodic, nonradiating, and without an identifiable provoking factor. Associated symptoms included nausea and nonbloody vomiting. He denied dyspnea, angina, fevers, chills, dysphagia, diarrhea, melena, or hematochezia. He had taken less than 2 g of acetaminophen earlier in the day without symptomatic relief. He had a 30-pack-year smoking history but quit over 25 years ago. He did not drink alcohol or use illicit drugs. He had a medical history of end-stage renal disease, for which he had undergone hemodialysis; hypertension; metastatic prostate cancer, for which he had received androgen deprivation therapy; and abdominal aortic aneurysm. His surgical history included a remote endovascular repair of the abdominal aortic aneurysm. His medications included amlodipine, losartan, carvedilol, sevelamer, and leuprolide.

Efficacy of duodenal bulb biopsy for diagnosis of celiac disease: a systematic review and meta-analysis.

Background and study aims Although duodenal biopsy is considered the "gold standard" for diagnosis of celiac disease, the optimal location of biopsy within the small bowel for diagnosis remains unclear. The primary aim of this study was to perform a structured systematic review and meta-analysis to evaluate the diagnostic utility of endoscopic duodenal bulb biopsy for celiac disease. Patients and methods Searches of PubMed, EMBASE, Web of Science, and Cochrane Library databases were performed from 2000 through December 2017. Review of titles/abstracts, full review of potentially relevant studies, and data abstraction was performed. Measured outcomes of adult and pediatric patients included location of biopsy, mean number of biopsies performed, and diagnosis of celiac disease as defined by the modified Marsh-Oberhuber classification. Results A total of 17 studies (n = 4050) were included. Seven studies evaluated adults and 11 studies assessed pediatric populations. Mean age of adults and pediatric patients was 46.70 ± 2.69 and 6.33 ± 1.26 years, respectively. Overall, sampling from the duodenal bulb demonstrated a 5 % (95 % CI 3 - 9; P  < 0.001) increase in the diagnostic yield of celiac disease. When stratified by pediatric and adult populations, duodenal bulb biopsy demonstrated a 4 % (95 % CI: 1 to 9; P  < 0.001) and 8 % (95 % CI: 6 to 10; P  < 0.001) increase in the diagnostic yield of celiac disease. Non-celiac histologic diagnoses including Brunner gland hyperplasia and peptic duodenitis were reported more commonly in the duodenal bulb as compared to the distal duodenum with an increase in diagnostic yield of 4 % (95 % CI 3 - 5; P  < 0.001) and 1 % (95 % CI 1 - 2; P  < 0.001), respectively. Conclusions Based upon our results, biopsy and histologic examination of duodenal bulb during routine upper endoscopy increases the diagnostic yield of celiac disease.