Wellens' Syndrome: A Sign of Impending Myocardial Infarction.

Wellens' pattern is an electrocardiogram (EKG) finding of biphasic or deeply inverted T waves in leads V2 and V3 that is suggestive of anterior wall ischemia classically reflecting critical stenosis of the proximal left anterior descending artery (LAD). This pattern reflects a preinfarction state that can eventually progress to massive and fatal anterior wall myocardial infarction (MI). We describe a case of a 50-year-old male who presented with chest pain and hypertensive emergency. EKG revealed new biphasic T-waves in V2-V5. The patient's chest pain resolved with blood pressure control, however, the persistence of Wellens' pattern on EKG prompted further investigation. Emergent left heart catheterization (LHC) revealed severe multivessel coronary artery disease, most notably with critical stenosis of the mid-LAD. The patient underwent successful surgical revascularization. This case highlights a classic EKG pattern that can have serious morbidity and mortality if it is missed. This case also describes a unique anatomical correlation of Wellens' syndrome as the coronary lesion was identified in the mid-LAD, contrary to lesions typically identified in the proximal LAD. Prior knowledge about Wellens' pattern allowed us to consider the possibility of critical LAD stenosis, which allowed for timely intervention and prevention of a massive myocardial infarction and possibly death.

A Breathtaking Hernia: A Giant Hiatal Hernia Masquerading as Poorly Controlled Asthma.

A 93-year-old female presented with persistent shortness of breath and wheezing since the consumption of a meal. Her past medical history is significant for a clinical diagnosis of asthma at the age of 88 years, without pulmonary function testing, complicated by several prior visits to the emergency department (ED) for recurrent exacerbations. Multiple bronchodilators in the ED provided only minimal improvement in her symptoms. Chest imaging eventually revealed a giant, fluid-filled hiatal hernia exhibiting a compressive effect on the posterior aspect of the left atrium. The etiology of the patient's airway bronchoconstriction was likely multifactorial. We hypothesize that the extrinsic, dynamic compression of the bronchial tree by the peristaltic motion of the hiatal hernia, microaspiration from gastroesophageal reflux, and peribronchial edema from left atrial compression accounted for our patient's unique presentation. An outpatient methacholine challenge test eventually excluded bronchial asthma. Although she was considered a poor surgical candidate, she has had no further recurrences of her symptoms with counseling on conservative lifestyle changes. This case serves to highlight the heterogeneity in presentations of hiatal hernias, particularly in elderly females. Furthermore, it remains prudent to maintain a broad differential for wheezing, as evidenced by our patient who was previously managed for a number of years as poorly controlled asthma.

A Primary Care Approach to Constipation in Adults with Intellectual and Developmental Disabilities.

Constipation is a condition that is very prevalent and is reported in up to 40 percent of individuals with intellectual and developmental disabilities (IDD). Constipation in this patient population is most commonly secondary to neuromuscular abnormalities, immobility, suboptimal diet, and medication side effects. History taking is frequently limited in adults with IDD due to communication barriers, often leading to a missed diagnosis of constipation. Inadequately treated constipation may lead to adverse effects including behavioral disturbances, fecal impaction, intestinal obstruction, and even death from intestinal perforation and sepsis. As a result, a high index of suspicion must exist for this patient population. Treatment in these patients requires an individualized approach, to reduce the constipation and its associated health complications.

Alarming Eosinophilia From Dobutamine Infusion.

A 49-year-old male with a history of nonischemic heart failure with reduced ejection fraction, hypertension, diabetes was admitted for cardiogenic shock. Treatment started with a high dose of dobutamine infusion. While the patient's volume status improved, his clinical status declined as he became febrile and hypotensive. He was found to have severe dobutamine-induced eosinophilia, corrected only upon dobutamine cessation and steroid administration. A comprehensive investigation ruled out other potential etiologies. Peripheral eosinophilia is a rare adverse effect associated with dobutamine, leading to a significant deterioration in already decompensated patients.

Methicillin-resistant Staphylococcus aureus (MRSA) sepsis complicated by warm autoimmune haemolytic anaemia secondary to antimicrobial therapy.

A 61-year-old Caucasian woman presented to the emergency room complaining of left-sided chest pain and altered mentation for 3 days. Her medical history included liver cirrhosis and coronary artery disease. On admission, she was found to have methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia. Due to a decline in mental status, a lumbar puncture was performed and cerebrospinal fluid cultures grew MRSA. She was treated initially with vancomycin. Ceftaroline was later added, due to the high burden of disease and difficulty in clearing her infection. After initiation of ceftaroline, bacteraemia cleared and mental status improved, however, she developed haemolytic anaemia. Ceftaroline was stopped and vancomycin continued. Staphylococcal meningitis is a rare occurrence, estimated at a rate of only 1%-10% of all bacterial meningitis cases. Ceftaroline seems to be a suitable option for disseminated MRSA infection, including MRSA meningitis, when the clinical response to vancomycin is inadequate. Further studies are warranted in order to establish adequate dosing while avoiding adverse effects.

Long-term patterns in estuarine fish growth across two climatically divergent regions.

Long-term ecological datasets are vital for investigating how species respond to changes in their environment, yet there is a critical lack of such datasets from aquatic systems. We developed otolith growth 'chronologies' to reconstruct the growth history of a temperate estuarine fish species, black bream (Acanthopagrus butcheri). Chronologies represented two regions in south-east Australia: South Australia, characterised by a relatively warm, dry climate, and Tasmania, characterised by a relatively cool, wet climate. Using a mixed modelling approach, we related inter-annual growth variation to air temperature, rainfall, freshwater inflow (South Australia only), and El Niño-Southern Oscillation events. Otolith chronologies provided a continuous record of growth over a 13- and 21-year period for fish from South Australia and Tasmania, respectively. Even though fish from Tasmania were sourced across multiple estuaries, they showed higher levels of growth synchronicity across years, and greater year-to-year growth variation, than fish from South Australia, which were sourced from a single, large estuary. Growth in Tasmanian fish declined markedly over the time period studied and was negatively correlated to temperature. In contrast, growth in South Australian fish was positively correlated to both temperature and rainfall. The stark contrast between the two regions suggests that Tasmanian black bream populations are more responsive to regional scale environmental variation and may be more vulnerable to global warming. This study highlights the importance of examining species response to climate change at the intra-specific level and further validates the emerging use of growth chronologies for generating long-term ecological data in aquatic systems.

Partial migration: growth varies between resident and migratory fish.

Partial migration occurs in many taxa and ecosystems and may confer survival benefits. Here, we use otolith chemistry data to determine whether fish from a large estuarine system were resident or migratory, and then examine whether contingents display differences in modelled growth based on changes in width of otolith growth increments. Sixty-three per cent of fish were resident based on Ba : Ca of otoliths, with the remainder categorized as migratory, with both contingents distributed across most age/size classes and both sexes, suggesting population-level bet hedging. Migrant fish were in slightly better condition than resident fish based on Fulton's K condition index. Migration type (resident versus migratory) was 56 times more likely to explain variation in growth than a model just incorporating year- and age-related growth trends. While average growth only varied slightly between resident and migratory fish, year-to-year variation was significant. Such dynamism in growth rates likely drives persistence of both life-history types. The complex relationships in growth between contingents suggest that management of species exhibiting partial migration is challenging, especially in a world subject to a changing climate.

Strontium randomly substituting for calcium in fish otolith aragonite.

The chemistry of fish ear bones (otoliths) is used to address fundamental questions in fish ecology and fisheries science. It is assumed that strontium (Sr), the most important element used in otolith chemistry research, is bound within the aragonitic calcium carbonate lattice of otoliths via random chemical replacement of calcium; however, this has never been tested and three other alternatives exist with regard to how Sr may be incorporated. If any variation in the mode of incorporation occurs, otolith chemistry data may be misinterpreted, impacting how fish and fisheries are understood and managed. Using X-ray absorption spectroscopy (specifically, analysis of extended X-ray absorption fine structure or EXAFS), we investigated how Sr is incorporated within fish otoliths from seven species collected from a range of aquatic environments. For comparison, aragonitic structures from other aquatic taxa (cephalopods and coral) were also analyzed. The results consistently indicated for all samples that Sr randomly replaces Ca within the aragonite lattice. This research explicitly shows how Sr is bound within otoliths and validates a fundamental and long-held assumption in aquatic research.