Reuniting overnutrition and undernutrition, macronutrients, and micronutrients.

Over-nutrition and its late consequences are a dominant theme in medicine today. In addition to the health hazards brought on by over-nutrition, the medical community has recently accumulated a roster of health benefits with obesity, grouped under "obesity paradox." Throughout the world and throughout history until the 20th century, under-nutrition was a dominant evolutionary force. Under-nutrition brings with it a mix of benefits and detriments that are opposite to and continuous with those of over-nutrition. This continuum yields J-shaped or U-shaped curves relating body mass index to mortality. The overweight have an elevated risk of dying in middle age of degenerative diseases while the underweight are at increased risk of premature death from infectious conditions. Micronutrient deficiencies, major concerns of nutritional science in the 20th century, are being neglected. This "hidden hunger" is now surprisingly prevalent in all weight groups, even among the overweight. Because micronutrient replacement is safe, inexpensive, and predictably effective, it is now an exceptionally attractive target for therapy across the spectrum of weight and age. Nutrition-related conditions worthy of special attention from caregivers include excess vitamin A, excess vitamin D, and deficiency of magnesium.

Is metformin poised for a second career as an antimicrobial?

Metformin, a widely used antihyperglycaemic, has a good safety profile, reasonably manageable side-effects, is inexpensive, and causes a desirable amount of weight loss. In 4 studies of patients with tuberculosis (1 prospective and 3 retrospective), metformin administration resulted in better outcomes. In mice with several models of endotoxemia, metformin diminished levels of proinflammatory cytokines and improved survival. Laboratory studies showed effectiveness of the drug on multiple pathogens, including Trichinella spiralis, Staphylococcus aureus, Pseudomonas aeruginosa, hepatitis B virus, hepatitis C virus, and human immunodeficiency virus. Metformin administration in humans and mice produced major changes in the composition of the gut microbiota. These recently discovered microbe-modulating properties of the drug have led investigators to predict wide therapeutic utility for metformin. The recent easing in United States Food and Drug Administration (FDA) guidelines regarding administration of metformin to patients with kidney disease, and reduced anxiety about patient safety in terms of lactic acidosis, increase the probability of broadening of metformin's usage as a treatment of infectious agents. In this text we review articles pertinent to metformin's effects on microorganisms, both pathogens and commensals. We highlight the possible role of metformin in a wide range of infectious diseases and a possible expansion of its therapeutic profile in this field. A systematic review was done of PubMed indexed articles that examined the effects of metformin on a wide range of pathogens. Metformin was found to have efficacy as an antimicrobial agent in patients with tuberculosis. Mice infected with Trypanosomiasis cruzi had higher survival when also treated with metformin. The drug in vitro was active against T. spiralis, S. aureus, P. aeruginosa, and hepatitis B virus. In addition there is emerging literature on its role in sepsis. We conclude that metformin may have a potential role in the therapy for multiple infectious diseases. Metformin, in addition to its traditional effects on glucose metabolism, provides anti-microbial benefits in patients with tuberculosis and in a very wide range of other infections encounters in vitro and in vivo.

Obesity paradox, obesity orthodox, and the metabolic syndrome: An approach to unity.

Obesity and the accompanying metabolic syndrome are strongly associated with heightened morbidity and mortality in older adults. In our review of more than 20 epidemiologic studies of major infectious diseases, including leaders such as tuberculosis, community-acquired pneumonia, and sepsis, obesity was associated with better outcomes. A cause-and-effect relationship between over-nutrition and survival with infection is suggested by results of two preliminary studies of infections in mice, where high fat feeding for 8-10 weeks provided much better outcomes. The better outcomes of infections with obesity are reminiscent of many recent studies of "sterile" non-infectious medical and surgical conditions where outcomes for obese patients are better than for their thinner counterparts --- and given the tag "obesity paradox". Turning to the history of medicine and biological evolution, we hypothesize that the metabolic syndrome has very ancient origins and is part of a lifelong metabolic program. While part of that program (the metabolic syndrome) promotes morbidity and mortality with aging, it helps infants and children as well as adults in their fight against infections and recovery from injuries, key roles in the hundreds of centuries before the public health advances of the 20th century. We conclude with speculation on how understanding the biological elements that protect obese patients with infections or injuries might be applied advantageously to thin patients with the same medical challenges.

Enhancing Procedure Documentation in Neonatal Intensive Care Unit (NICU): A Quality Improvement Initiative at a Tertiary Neonatal Hospital.

Background Accurate and comprehensive procedure documentation in Electronic Medical Records (EMR) is crucial for high-quality patient care, especially in high-acuity settings like Neonatal Intensive Care Units (NICU). Gaps in documentation at Corniche Hospital's NICU that were affecting patient safety and continuity of care were identified and addressed by following a pre and post-intervention design in the research. The process involved the initial audit, educational sessions with healthcare providers, and follow-up audits to measure improvements. Results post-intervention showed a significant increase in compliance with documentation standards, pointing out the effectiveness of educational interventions in improving EMR documentation practices. The local problem is demonstrated through the observation of incomplete and inconsistent procedure documentation in the NICU, hindering effective patient management and multi-disciplinary team communication. Methods A Quality Improvement Project (QIP) was implemented, including a baseline audit, educational interventions targeting healthcare providers, and subsequent re-audits to assess improvement. The project involved tailored educational sessions focused on correct EMR usage, adherence to documentation standards, and practical aspects of documenting procedures. Results Post-intervention, there was a significant increase in documentation compliance. The percentage of compliance in procedure encounter placement in EMR increased from 81% to 100%, and nursing documentation compliance improved from 11 (52.4%) to 18 (85.7%). However, a slight decrease in the completeness of physician documentation was noted. Conclusions The QIP effectively improved procedure documentation in the NICU. Continuous education and periodic review are essential for maintaining and further enhancing documentation standards. This initiative underscores the importance of targeted training and consistent audits in improving clinical documentation in healthcare settings.

Checkpoint Inhibitor-Related Capillary Leak Syndrome (CLS).

Immune checkpoint inhibitors (ICIs) are now being widely used for the treatment of various malignancies, but they have a distinctive set of side effects due to the overactivation of the immune system, which is important to recognize. Capillary leak syndrome (CLS) is a rare but potentially life-threatening side effect of ICIs that causes a significant increase in the permeability of capillaries, leading to the leakage of plasma-containing proteins from these small vessels. This condition results in several clinical features, including edema, hypotension, hypoalbuminemia, and hemoconcentration. Timely recognition and discontinuation of the offending immunotherapy can optimize outcomes. Treatment is focused on supportive care and prompt initiation of immunosuppressants, such as steroids.

A Rare Case of Pulmonary Cavitary Disease Caused by Mycobacterium xenopi.

Mycobacterium xenopi is a slow-growing, acid-fast, non-tuberculous mycobacterium (NTM). It is often considered to be a saprophyte or an environmental contaminant. Mycobacterium xenopi has low pathogenicity and is usually seen in patients with pre-existing chronic lung diseases and immunocompromised patients. We present a case of Mycobacterium xenopi causing a cavitary lesion in a patient with chronic obstructive pulmonary disease (COPD) that was discovered incidentally during the low-dose CT scan done for lung cancer screening in a patient with COPD. The initial workup was negative for NTM. An Interventional-guided (IR) core needle biopsy was done given the high suspicion for NTM and revealed a positive culture for Mycobacterium xenopi.  Our case highlights the importance of considering NTM in the differential diagnosis of at-risk patients and pursuing invasive testing if there is a high clinical suspicion.

Tick-Borne Rhabdomyolysis: A Rare Case of Rhabdomyolysis and Acute Kidney Injury Due to Anaplasmosis.

Anaplasmosis is a tick-borne illness commonly seen in the northeastern states of the United States. The most common presenting signs are fever, malaise, and body aches accompanied by leukopenia, thrombocytopenia, and transaminitis. Rhabdomyolysis and acute kidney injury are rare presentations that can lead to significant morbidity.  We present the case of a patient who presented with non-specific symptoms of malaise, fatigue, and body aches and was found to have rhabdomyolysis and acute kidney injury on laboratory workup. A presumptive diagnosis of anaplasmosis was made, and the patient was started on treatment for the same. The patient recovered successfully. Our case highlights the rare presentation of anaplasmosis with rhabdomyolysis and acute kidney injury. Physician awareness is needed for early diagnosis and preventing morbidity.

Large Cutaneous Squamous Cell Carcinoma: A Consequence of Elective Surgery Deferment During the COVID-19 Pandemic.

Cutaneous squamous cell carcinoma (cSCC) is a common skin cancer that can be treated effectively with limited morbidity if caught and treated early with elective surgical procedures. The COVID-19 pandemic caused most healthcare facilities to delay or defer elective surgeries as they allocated workforce and resources to treating significant increases of critically ill patients. This care delay has increased morbidity and mortality of many conditions treated with surgery. A few case reports exist on delayed elective surgeries' effects on patients and healthcare facilities. We report a case of cSCC enlarging and locally spreading due to elective surgery delay during the COVID-19 pandemic.

A Case of JAK2V617F-Negative Myeloproliferative Neoplasm in a Young Female Presenting With Extreme Thrombocytosis.

Thrombocytosis is a commonly observed condition in clinical practice and typically results from various pathophysiological factors, such as iron deficiency, blood loss, infection, medications, rheumatologic conditions, malignancy, asplenia, post-splenectomy, or familial factors. However, extreme thrombocytosis, defined as a platelet count > 10,000 K/UL (equal or greater than a million), is a rare occurrence. In this report, we present a compelling case of severe thrombocytosis attributed to underlying chronic myelogenous leukemia (CML), further complicated by coexisting iron deficiency. It is essential to emphasize that not all instances of extreme thrombocytosis are indicative of essential thrombocythemia. Hence, maintaining a high level of suspicion for non-ET myeloproliferative neoplasms (MPNs) such as CML, as well as other underlying conditions like iron deficiency anemia, is crucial for accurate diagnosis and timely management.

Secondary Hypertension Due to Underlying Takayasu Arteritis.

A young female patient in her early 20s of Hispanic descent presented to the hospital with new-onset chest pain and uncontrolled hypertension. She was found to have blood pressure in the 200s/100s. She was evaluated for causes of secondary hypertension and underwent computed tomography angiography (CTA) of her abdomen to rule out fibromuscular dysplasia, which showed abnormal thickening of lower thoracic and abdominal aorta extending into both renal arteries causing stenosis. This finding led to further investigations, and she was found to have elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). Magnetic resonance angiography (MRA) was done, which confirmed the findings of periaortitis in the vessels as described above. A diagnosis of Takayasu arteritis (TA) was made, and the patient was treated with high-dose steroids with significant improvement in her symptoms.

Metastatic Rectal Small Cell Carcinoma: A Case Report.

We report a case of metastatic small cell carcinoma presenting as a rectal mass in an 80-year-old male with a history of change in bowel movement and rectal pain for six months. A computed tomography (CT) scan of the abdomen and pelvis was done, which showed a large rectal mass with many liver metastases. He had a diagnostic colonoscopy, which showed a large obstructing rectal mass, and the biopsy result came back as small cell carcinoma. He underwent palliative diverting colostomy without complications. Initially, there was a plan to treat the patient with systemic chemotherapy with etoposide and carboplatin, but given the acute kidney injury, there was a delay in treatment. After the first cycle of chemotherapy, the patient had severe nausea and vomiting. After a discussion with the patient and his family, he decided on hospice care and passed away in a few weeks.

Systemic Air Embolism Following Computed Tomography-Guided Lung Biopsy.

A 61-year-old male with a history of poorly differentiated squamous cell carcinoma of tongue who completed chemo-radiation was found to have bilateral lung nodules on follow-up positron emission tomography (PET) scan. He underwent computed tomography (CT)-guided lung biopsy. Sequential chest scans done during the procedure showed air-fluid level in the left ventricle, suggestive of air embolism. He was hemodynamically stable during the procedure, however at the end of the procedure he developed right-sided face and arm weakness with aphasia. Emergent CT scans including angiography of head and neck were done which did not show any bleed and was also negative for any air in intracranial vasculature. Patient was treated with 100% oxygen. His neurological symptoms resolved in 30 minutes and he was subsequently admitted to intensive care unit (ICU) for further management. Six hours later, repeat CT of chest was done which showed resolution of air embolism.