Effects of a modern exhibit design on captive tiger welfare.

Offering captive animals larger, more complex spaces are thought to benefit their welfare. To this end, some zoos use trail systems linked to several enclosures. Since little is known about the effects of such designs on the welfare of captive carnivores specifically, we timed the behaviors exhibited by four tigers (Panthera tigris [Linnaeus]) given access to three exhibit configurations: one exhibit only (E, baseline); one exhibit and approximately 19 m2 of trail (ET); and two exhibits connected by approximately 46 m2 of trail (E2T). Behaviors were recorded during 1-h AM, Noon, and PM periods in Phase I (2017), and 2-h AM and PM periods in Phase II (2018). Percentages of behavior occurrence were analyzed using generalized linear mixed models (GLMM), with treatment and time of day as fixed effects. Tigers were least active at noon (Phase I), while active behaviors were prevalent during mornings and afternoons in both Phases. In Phase II (E2T vs. E), active and exploratory behaviors such as sniffing increased, while pacing and inactivity decreased (all p ≤ .001). We also examined nocturnal tiger movement using infrared motion-activated cameras. In parallel with diurnal observations, tiger activity in E2T greatly exceeded that in E. Nocturnal movement was most pronounced from 1800 to 2200 and least frequent from 0100 to 0400, closely matching patterns observed in the wild. Results indicate that offering tigers voluntary access to larger and more complex spaces stimulates natural behaviors and decreases stereotypical behaviors.

Psuedo-Cor Triatriatum in an Elderly Patient With Dyspnea of Exertion: An Undescribed Condition Characterized by 3-Dimensional Transesophageal Echocardiography.

A 66-year-old gentleman with no prior cardiac history presented with dyspnea on exertion and chest pain for 1 month. His workup included a transthoracic echocardiogram, which demonstrated findings suggestive of cor triatriatum (C-TAT) with uncertain degree of hemodynamic obstruction. In addition, mild left ventricular systolic dysfunction and segmental wall motion abnormalities suggestive of coronary artery disease were noted. The patient then underwent transesophageal echocardiography (TEE) to define better the structural characteristics and hemodynamic significance of the C-TAT, left and right heart catheterization to assess pressure gradients between the upper and lower left atrial chambers by simultaneous measurement of pulmonary capillary wedge and left ventricular end-diastolic pressures, and coronary angiography. Multiplane 2-dimensional TEE demonstrated an atrial membrane extending from the inferior portion of the interatrial septum to the superior aspect of the lateral atrial wall. This membrane exhibited a medial large oval opening with bidirectional flow and a ≤2 mm Hg gradient. Three-dimensional TEE imaging re-demonstrated this obliquely oriented membrane; however, of most importance, it revealed that the membrane divided the atria into a medial funnel and C-shaped cavity with a large distal oval shape opening and an even larger lateral atrial cavity. These findings were inconsistent with a true C-TAT and rather demonstrated what we defined as a pseudo-C-TAT membrane. Simultaneous right and left heart catheterization confirmed a minimal gradient of 3 to 5 mm Hg and coronary angiography demonstrated severe 3-vessel coronary disease as the primary cause of the patient's clinical syndrome.

Effects of guest feeding programs on captive giraffe behavior.

Zoological institutions develop human-animal interaction opportunities for visitors to advance missions of conservation, education, and recreation; however, the animal welfare implications largely have yet to be evaluated. This behavioral study was the first to quantify impacts of guest feeding programs on captive giraffe behavior and welfare, by documenting giraffe time budgets that included both normal and stereotypic behaviors. Thirty giraffes from nine zoos (six zoos with varying guest feeding programs and three without) were observed using both instantaneous scan sampling and continuous behavioral sampling techniques. All data were collected during summer 2012 and analyzed using linear mixed models. The degree of individual giraffe participation in guest feeding programs was positively associated with increased time spent idle and marginally associated with reduced time spent ruminating. Time spent participating in guest feeding programs had no effect on performance of stereotypic behaviors. When time spent eating routine diets was combined with time spent participating in guest feeding programs, individuals that spent more time engaged in total feeding behaviors tended to perform less oral stereotypic behavior such as object-licking and tongue-rolling. By extending foraging time and complexity, guest feeding programs have the potential to act as environmental enrichment and alleviate unfulfilled foraging motivations that may underlie oral stereotypic behaviors observed in many captive giraffes. However, management strategies may need to be adjusted to mitigate idleness and other program consequences. Further studies, especially pre-and-post-program implementation comparisons, are needed to better understand the influence of human-animal interactions on zoo animal behavior and welfare.

Entrapped devices after PCI.

In contemporary practice, entrapped devices are rarely encountered during percutaneous coronary intervention (PCI) but can be associated with serious morbidity and mortality. We present a case of a 62 y/o male who presented with an acute coronary syndrome. Revascularization was performed and complicated by guide wire entrapment and fracture. Cardiologists should be aware of this complication and the treatment options available.

Aortic Atherosclerosis in Systemic Lupus Erythematosus.

Aortic atherosclerosis (AoA) defined as intima-media thickening or plaques and aortic stiffness (AoS) also considered an atherosclerotic process and defined as decreased vessel distensibility (higher pulse pressure to achieve similar degree of vessel distension) are common in patients with SLE. Immune-mediated inflammation, thrombogenesis, traditional atherogenic factors, and therapy-related metabolic abnormalities are the main pathogenic factors of AoA and AoS. Pathology of AoA and AoS suggests an initial subclinical endothelialitis or vasculitis, which is exacerbated by thrombogenesis and atherogenic factors and ultimately resulting in AoA and AoS. Computed tomography (CT) for detection of arterial wall calcifications and arterial tonometry for detection of increased arterial pulse wave velocity are the most common diagnostic methods for detecting AoA and AoS, respectively. MRI may become a more applicable and accurate technique than CT. Although transesophageal echocardiography accurately detects earlier and advanced stages of AoA and AoS, it is semi-invasive and cannot be used as a screening method. Although imaging techniques demonstrate highly variable prevalence rates, on average about one third of adult SLE patients may have AoA or AoS. Age at SLE diagnosis; SLE duration; activity and damage; corticosteroid therapy; metabolic syndrome; chronic kidney disease; and mitral annular calcification are common independent predictors of AoA and AoS. Also, AoA and AoS are highly associated with carotid and coronary atherosclerosis. Earlier stages of AoA and AoS are usually subclinical. However, earlier stages of disease may be causally related or contribute to peripheral or cerebral embolism, pre-hypertension and hypertension, and increased left ventricular afterload resulting in left ventricular hypertrophy and diastolic dysfunction. Later stages of disease predisposes to visceral ischemia, aortic aneurysms and aortic dissection. Even earlier stages of AoA and AoS have been associated with increased cardiovascular and cerebrovascular morbidity and mortality of SLE patients. Aggressive non-steroidal immunosuppressive therapy and non-pharmacologic and pharmacologic interventions for control of atherogenic risk factors may prevent the development or progression of AoA and AoS and may decrease cardiovascular and cerebrovascular morbidity and mortality in SLE.

Can serum procalcitonin levels help interpret indeterminate chest radiographs in patients hospitalized with acute respiratory illness?

BACKGROUND: Clinical diagnosis of pneumonia is difficult and chest radiographs often indeterminate, leading to incorrect diagnoses and antibiotic overuse. OBJECTIVE: To determine if serum procalcitonin (ProCT) could assist in managing patients with respiratory illness and indeterminate radiographs. DESIGN: Subjects were prospectively enrolled during 2 consecutive winters. SETTING: A 520-bed hospital in Rochester, NY. PATIENTS: Five hundred twenty-eight adults admitted with acute respiratory illness were enrolled. MEASUREMENTS: Serum ProCT, admission diagnoses, and chest radiographic findings were used to derive receiver operating characteristics curves to assess predictive accuracy of ProCT for the presence of infiltrates. RESULTS: Subjects with pneumonia had higher ProCT (median 0.27 ng/ml) than those with exacerbations of chronic obstructive pulmonary disease (0.08 ng/ml), acute bronchitis (0.09 ng/ml), or asthma (0.06 ng/ml). ProCT had moderate accuracy for the presence of infiltrates (area under curve [AUC] 0.72), when indeterminate radiographs were independently classified as infiltrates by a pulmonologist evaluating patients. CONCLUSIONS: ProCT may be useful in diagnosing pneumonia when chest radiographs are indeterminate.

Utility of serum procalcitonin values in patients with acute exacerbations of chronic obstructive pulmonary disease: a cautionary note.

BACKGROUND: Serum procalcitonin levels have been used as a biomarker of invasive bacterial infection and recently have been advocated to guide antibiotic therapy in patients with chronic obstructive pulmonary disease (COPD). However, rigorous studies correlating procalcitonin levels with microbiologic data are lacking. Acute exacerbations of COPD (AECOPD) have been linked to viral and bacterial infection as well as noninfectious causes. Therefore, we evaluated procalcitonin as a predictor of viral versus bacterial infection in patients hospitalized with AECOPD with and without evidence of pneumonia. METHODS: Adults hospitalized during the winter with symptoms consistent with AECOPD underwent extensive testing for viral, bacterial, and atypical pathogens. Serum procalcitonin levels were measured on day 1 (admission), day 2, and at one month. Clinical and laboratory features of subjects with viral and bacterial diagnoses were compared. RESULTS: In total, 224 subjects with COPD were admitted for 240 respiratory illnesses. Of these, 56 had pneumonia and 184 had AECOPD alone. A microbiologic diagnosis was made in 76 (56%) of 134 illnesses with reliable bacteriology (26 viral infection, 29 bacterial infection, and 21 mixed viral bacterial infection). Mean procalcitonin levels were significantly higher in patients with pneumonia compared with AECOPD. However, discrimination between viral and bacterial infection using a 0.25 ng/mL threshold for bacterial infection in patients with AECOPD was poor. CONCLUSION: Procalcitonin is useful in COPD patients for alerting clinicians to invasive bacterial infections such as pneumonia but it does not distinguish bacterial from viral and noninfectious causes of AECOPD.

Exogenous procalcitonin evokes a pro-inflammatory cytokine response.

OBJECTIVE AND DESIGN: Procalcitonin (ProCT) is increased in serum of septic patients and those with systemic inflammation. Endogenous levels of ProCT might influence the response of polymorphonuclear leukocytes (PMNs), independently of endotoxin, in clinical disease. SUBJECTS: Healthy human volunteers. TREATMENT: Recombinant human ProCT (rhProCT). METHODS: Whole blood and PMNs were exposed in vitro to exogenous rhProCT. Interleukin (IL)-6, IL-8, IL-10, IL-13, tumor necrosis factor-alpha (TNFα), IL-1ß, and macrophage inflammatory protein (MIP)-1ß (pg/ml) were measured by multiplex suspension bead-array immunoassay, and migration and phagocytosis were measured in PMNs. RESULTS: In a whole-blood model, a dose-dependent increase in IL-6, TNFα, and IL-1ß of the cell-free supernatant was noted. Pre-incubation with ProCT, at doses consistent with clinical sepsis, resulted in a decrease in PMN migration without alteration in phagocytosis of Staphylococcus aureus or indirect measurements of bacterial killing. CONCLUSION: Clinically relevant levels of ProCT influence immunologic responses that may contribute to systemic inflammatory response and septic shock.

Gut barrier dysfunction in critically ill surgical patients with abdominal compartment syndrome.

OBJECTIVES: This study investigated the effects of intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) on gut barrier function in critically ill surgical patients. METHODS: A prospective observational cohort study on patients with severe acute pancreatitis or abdominal sepsis admitted to an intensive care or high-dependency unit. Intra-abdominal pressure (IAP) and plasma levels of immunoglobulin G (IgG) and IgM antiendotoxin core antibodies (EndoCAb) and procalcitonin (ProCT) were measured serially. RESULTS: Among 32 recruited patients, 24 (75%) and 8 patients (25%) developed IAH and ACS, respectively. The state of ACS was associated with significant reductions in plasma IgG EndoCAb (P = 0.015) and IgM EndoCAb (P = 0.016) and higher concentrations of plasma ProCT (P = 0.056) compared with absence of ACS. Resolution of IAH and ACS was associated with significant recovery of plasma IgG EndoCAb (P = 0.003 and P = 0.009, respectively) and IgM EndoCAb (P = 0.002 and P = 0.003, respectively) and reduction in plasma ProCT concentration (P = 0.049 and P = 0.019, respectively). Negative correlations were observed between IAP and plasma IgG EndoCAb (P = 0.003) and IgM EndoCAb (P = 0.002). CONCLUSIONS: Intra-abdominal hypertension and ACS are associated with significantly higher endotoxin exposure and ProCT concentrations, suggestive of gut barrier dysfunction. Resolution of IAH and ACS is associated with evidence for recovery of gut barrier function.

Procalcitonin in sepsis and systemic inflammation: a harmful biomarker and a therapeutic target.

The worldwide yearly mortality from sepsis is substantial, greater than that of cancer of the lung and breast combined. Moreover, its incidence is increasing, and its response to therapy has not appreciably improved. In this condition, the secretion of procalcitonin (ProCT), the prohormone of calcitonin, is augmented greatly, attaining levels up to thousands of fold of normal. This hypersecretion emanates from multiple tissues throughout the body that are not traditionally viewed as being endocrine. The serum values of ProCT correlate with the severity of sepsis; they recede with its improvement and worsen with exacerbation. Accordingly, as highlighted in this review, serum ProCT has become useful as a biomarker to assist in the diagnosis of sepsis, as well as related infectious or inflammatory conditions. It is also a useful monitor of the clinical course and prognosis, and sensitive and specific assays have been developed for its measurement. Moreover, it has been demonstrated that the administration of ProCT to septic animals greatly increases mortality, and several toxic effects of ProCT have been elucidated by in vitro experimental studies. Antibodies have been developed that neutralize the harmful effects of ProCT, and their use markedly decreases the symptomatology and mortality of animals that harbour a highly virulent sepsis analogous to that occurring in humans. This therapy is facilitated by the long duration of serum ProCT elevation, which allows for a broad window of therapeutic opportunity. An experimental groundwork has been established that suggests a potential applicability of such therapy in septic humans.

Comparative analysis of knowledge gain between interpretive and fact-only presentations at an animal training session: an exploratory study.

Zoos and aquariums have recognized the importance of integrating living collections with personally delivered interpretation. One way for zoos to accomplish this is by conducting public animal training sessions accompanied by personal interpretation. Many institutions offer these types of interactions, but the term "interpretation" is used loosely and without clear definition. This exploratory study compared knowledge gain of individual students in three different fifth grade school groups visiting the Potter Park Zoo in Lansing, Michigan. Each group observed an animal training session, with two groups receiving two types of presentations and one group serving as a control group. Although hearing the same facts, the two treatment groups received different program types: an interpretive presentation and a fact-only presentation. The third group viewed the training session but received no presentation. Results showed that individuals who received the interpretive presentation retained more information immediately after the training session than individuals in either of the other two groups. This exploratory study suggests that using an interpretive presentation style is more effective in producing knowledge gain than fact-only presentations in informal learning environments such as zoos and aquariums.

Procalcitonin assay in systemic inflammation, infection, and sepsis: clinical utility and limitations.

OBJECTIVE: The use of procalcitonin (ProCT) as a marker of several clinical conditions, in particular, systemic inflammation, infection, and sepsis, will be clarified, and its current limitations will be delineated. In particular, the need for a more sensitive assay will be emphasized. For these purposes, the medical literature comprising clinical studies pertaining to the measurement of serum ProCT in various clinical settings was examined. DATA SOURCE AND SELECTION: A PubMed search (1965 through November 2007) was conducted, including manual cross-referencing. Pertinent complete publications were obtained using the MeSH terms procalcitonin, C-reactive protein, sepsis, and biological markers. Textbook chapters were also read and extracted. DATA EXTRACTION AND SYNTHESIS: Available clinical and other patient data from these sources were reviewed, including any data relating to precipitating factors, clinical findings, associated illnesses, and patient outcome. Published data concerning sensitivity, specificity, and reproducibility of ProCT assays were reviewed. CONCLUSIONS: Based on available data, the measurement of serum ProCT has definite utility as a marker of severe systemic inflammation, infection, and sepsis. However, publications concerning its diagnostic and prognostic utility are contradictory. In addition, patient characteristics and clinical settings vary markedly, and the data have been difficult to interpret and often extrapolated inappropriately to clinical usage. Furthermore, attempts at meta-analyses are greatly compromised by the divergent circumstances of reported studies and by the sparsity and different timing of the ProCT assays. Although a high ProCT commonly occurs in infection, it is also elevated in some noninfectious conditions. Thus, the test is not a specific indicator of either infection or sepsis. Moreover, in any individual patient, the precipitating cause of an illness, the clinical milieu, and complicating conditions may render tenuous any reliable estimations of severity or prognosis. It also is apparent that even a febrile septic patient with documented bacteremia may not necessarily have a serum ProCT that is elevated above the limit of functional sensitivity of the assay. In this regard, the most commonly applied assay (i.e., LUMItest) is insufficiently sensitive to detect potentially important mild elevations or trends. Clinical studies with a more sensitive ProCT assay that is capable of rapid and practicable day-to-day monitoring are needed and shortly may be available. In addition, investigations showing that ProCT and its related peptides may have mediator relevance point to the need for evaluating therapeutic countermeasures and studying the pathophysiologic effect of hyperprocalcitonemia in serious infection and sepsis.

Procalcitonin has bioactivity at calcitonin receptor family complexes: potential mediator implications in sepsis.

CONTEXT: Sepsis is a major cause of death in the United States and accounts for approximately 50% of the fatalities in intensive care units. Serum procalcitonin (ProCT) levels are markedly elevated in sepsis and correlate positively with severity of the illness and mortality, however, little is known about the biological activity of ProCT. OBJECTIVE: To explore the biological activity of purified human ProCT at the calcitonin (CT) family of receptors. DESIGN: Human ProCT was purified from the TT medullary thyroid carcinoma cell line. Human CTa receptor or human CT receptor-like receptor (CLR) was transiently expressed in COS-7 cells alone or together with individual receptor activity-modifying proteins (RAMPs) to generate the CTa (CT) receptor, the AMY1 (amylin) receptor, the CGRP1 (CT gene-related peptide) receptor, and the AM1 and AM2 (adrenomedullin) receptors. Biological activity of ProCT was assessed by measurement of cAMP accumulation. RESULTS: ProCT was effectively inert at CTa, AM1, and AM2 receptors. In contrast, it was a potent partial agonist (50-60% of the CGRP efficacy) of the CGRP1 receptor with an EC50 as high as 0.56 nM, although the potency was batch dependent. ProCT also displayed weak partial agonist activity at the AMY1 receptor with an EC50 of approximately 100 nM. Moreover, ProCT also robustly inhibited CGRP-dependent cyclic adenosine monophosphate responses at the CGRP1 receptor. CONCLUSIONS: Our data provide a potential molecular mechanism for the observation that ProCT appears to be toxic while CGRP treatment appears to be beneficial in animal models of sepsis.

Collembola of the grave: a cold case history involving arthropods 28 years after death.

This report describes a cold case in which a cadaver of a 28-year-old female was exhumed in February 2005 from a cemetery in Battle Creek, Michigan. She had sustained a gunshot wound to the head and was found dead in her home on November 15, 1977. The body of the victim was subsequently embalmed and then buried at a depth of 1.8 m in an unsealed casket that was placed inside an unsealed cement vault. The exhumation yielded thousands of live specimens of a single species of the order Collembola or spring tails, Sinella (Coecobrya) tenebricosa (Entomobryidae). This species is considered to be a "tramp" species, cosmopolitan in the United States and Canada. Due to the ideal environmental conditions at the site, the population of this species underwent growth and development inside the casket for a number of years. Collected with the Collembola were large numbers of Acarina (mites) of the Family Glycyphagidae, and fly puparia, Conicera tibialis Schmitz (Order: Diptera, Family: Phoridae), also known as coffin flies. These invertebrates are sometimes mentioned by forensic investigators as occurring on corpses in graves, but aspects of their life history are rarely described. The species of Collembola that was found surviving and reproducing on this corpse in a casket exhumed after 28 years was the oldest reported grave site occurrence for any collembolan species based on a survey of the literature back to 1898.

Quality management and volume-related outcomes in the cardiac catheterization laboratory.

The assessment of quality in the cardiac catheterization laboratory is a complex, ongoing process that requires a comprehensive analysis of the multiple elements of quality. Although clinical outcomes are a reflection of the quality process, they derive from a complex interaction of clinical, technical, and process-of-care components. Procedural volume is associated but not equated with clinical outcomes, although the magnitude of this association depends on numerous covariates, most notably the diminishing rate of adverse outcomes over time.

Ubiquitous variability in the prevalence of Trichobilharzia stagnicolae (Schistosomatidae) infecting Stagnicola emarginata in three northern Michigan lakes.

During 4 consecutive collecting seasons from 1998 through 2001, 77,326 common beach snails (Stagnicola emarginata, Lymnaeidae) were examined for infections by Trichobilharzia stagnicolae from multiple sites on Walloon Lake, Higgins Lake, and Lake Leelanau, located in the northern region of the lower peninsula of Michigan. Snails were examined for infections using the light-box technique (exposure to bright fluorescent light). The prevalence of infected snails varied significantly among lakes within a year, between years in a lake, at a site from year to year, and at a site over a collecting season. Overall annual prevalence ranged from 0.54% (1999) to 1.32% (2001) on Walloon Lake, from 0.56% (2001) to 1.06% (1998) on Higgins Lake, and 0.30% (2001) to 0.89% (2000) on Lake Leelanau. Generally, the peak in prevalence coincided in July on the lakes. Prevalence was found to increase with snail length in all lakes. A comparison of the light-box technique and crushing snails demonstrated that prevalence varied in magnitude by technique as much as 1.2 and 5.7 times.

Interleukin-6, interleukin-8, and a rapid and sensitive assay for calcitonin precursors for the determination of bacterial sepsis in febrile neutropenic children.

OBJECTIVE: Children with cancer often develop febrile illnesses after cytotoxic chemotherapy. Determining which children have serious bacterial infections in this vulnerable period would be valuable. We evaluated the ability of a rapid and sensitive assay for the concentration of calcitonin precursors (CTpr) as a sensitive diagnostic marker for bacterial sepsis in febrile, neutropenic children and determined the utility of measuring cytokines to improve the predictive value of this approach. DESIGN: Prospective cohort study. SETTING: Academic children's hospital. PATIENTS: Fifty-six children (aged 5 months to 17 yrs) with a known malignancy who presented with fever and neutropenia. INTERVENTIONS: Serial blood samples were obtained (admission, 24 hrs, and 48 hrs), and concentrations of CTpr, interleukin-6, and interleukin-8 were determined. Demographic and laboratory data from the patients were collected from the medical record. MEASUREMENTS AND MAIN RESULTS: Sixteen (29%) of the children met the criteria for bacterial sepsis. Plasma levels of CTpr and interleukin-8, but not interleukin-6, were increased at all time points in children with sepsis compared with those without sepsis. CTpr at 24 and 48 hrs after admission were reliable markers for sepsis (area under the curve = 0.92 and 0.908, respectively). Logistic regression using CTpr at 24 hrs in addition to interleukin-8 at 48 hrs produced the best-fit models associated with sepsis. Using cutoff values of CTpr >500 pg/mL and interleukin-8 >20 pg/mL produced a screening test for sepsis with 94% sensitivity and 90% specificity. CONCLUSIONS: Our data show the utility of a rapid and sensitive assay for CTpr combined with interleukin-8 as a highly sensitive and specific diagnostic marker of bacterial sepsis in febrile, neutropenic children. The use of these markers as a clinical tool may allow for better prognostication for clinicians and may eventually lead to more targeted therapies for this heterogeneous population.

The importance of the evolution of ST-T wave changes for differentiating acute pericarditis from myocardial ischemia.

A 28-year-old, moderately obese man with dyslipidemia (low-density lipoprotein 163 mg/dL, high-density lipoprotein 33 mg/dL), hypertension, active tobacco use (1 pack per day), and a family history for premature coronary artery disease (CAD) initially presented with burning, nonexertional chest discomfort exacerbated by deep inspiration. His initial electrocardiogram (ECG; Fig. 1A) was interpreted as pericarditis because of the diffuse mild ST-segment elevation and PR-segment depression. An echocardiogram demonstrated normal left ventricular systolic function and a trivial pericardial effusion. He was treated with nonsteroidal antiinflammatories and his symptoms resolved. Follow-up ECG performed the next morning (Fig. 1B) demonstrated sinus rhythm, persistent mild ST elevation, and biphasic T waves in leads V3-V4 as well as in leads III and aVF. Four months later, the patient returned with similar symptoms of chest discomfort and was admitted with the diagnosis of unstable angina. The admission ECG was unremarkable showing no persistent PR or ST-T abnormalities. He was ruled out for myocardial infarction by serial enzymes. An exercise myocardial perfusion imaging study was obtained. The patient exercised for 7 minutes 33 seconds on a standard Bruce protocol, obtained 9.4 METs, and reached 69% of maximum predicted heart rate. His exercise ECG revealed up to 2.5 mm of ST-segment elevation in leads V3-V5 accompanied by chest discomfort. The patient's chest pain resolved with cessation of exercise and 1 sublingual nitroglycerin. The ECG returned to baseline within 3 minutes of recovery. He was referred for coronary angiography and was found to have a proximal left anterior descending (LAD) stenosis and underwent percutaneous coronary intervention with stenting. He was discharged home on postprocedure day 3.