The pandemic of coronavirus disease 2019 has emerged in late 2019 infecting millions of people worldwide. Diabetes mellitus (DM) has been associated with severe illness and mortality mainly due to acute respiratory distress syndrome. We report a case of a middle-aged man with DM and COVID-19 who developed seizure and altered mental status, found to have diabetic ketoacidosis (DKA), acute kidney injury, hypovolemic shock, and hyperammonemia all contributing to metabolic encephalopathy. He was admitted to the ICU and subsequently intubated for airway protection; with appropriate management his condition improved and was successfully extubated. The patient had no lung involvement throughout the illness. We report this case to highlight that COVID-19 can lead to multi-organ failure in patients with DM even in the absence of lung involvement which all physicians should be mindful of.

Deep vein thrombosis (DVT) is a relatively common clinical entity with significant morbidity and mortality. Acute pulmonary embolism (PE) is the most significant complication of DVT and warrants immediate attention. The location of the DVT has a substantial impact on its ability to break off and travel to the pulmonary vasculature, causing a PE. Proximal DVT is more likely to cause a PE than a distal DVT. The widely accepted management for proximal DVT is anticoagulation. However, the management of distal DVT is unclear. This review article discusses factors that increase the risk of PE in patients with distal DVT, guidance on how to categorize patients into high and low-risk categories, and the recommended management for each category.

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Patients with primary and metastatic brain tumors are predisposed to thromboembolism. This review of the literature explores the high prevalence of venous thromboembolism and its negative impact on patients with brain cancer. It outlines the recommended prophylactic strategies to prevent venous thrombosis and analyzes the benefit versus risk of anticoagulation in this population, with a focus on the risk of intracranial bleeding associated with it. Additionally, it explores the exceedingly high prevalence of venous thromboembolism in the setting of brain cancer surgeries and provides guidance on the best methods used for prophylaxis in this setting and discusses the safety of each method perioperatively. Lastly, this review article provides guidance on how to manage venous thromboembolism in patients with brain cancer and discusses the use of vena cava filters in this population.

Malnutrition is extremely common in hospitalized patients. It can lead to various complications and increase mortality. However, it remains poorly recognized and many health care systems do not require nutritional assessment during the hospital stay. This most likely due to lack of awareness and inadequate coordination between health care workers. Physicians can utilize many different methods when performing malnutrition screening, and there is also a lack of global clear-cut recommendations on criteria used to diagnose malnutrition. This article aims to increase malnutrition awareness among health care providers, and provide a guide on screening, diagnosis, and management of malnutrition.

Neuroendocrine tumors (NETs) are epithelial neoplasms with predominant neuroendocrine differentiation and the ability to synthesize and secrete variable hormones and monoamines. They are relatively rare, accounting for 2% of all malignancy cases in the United States. The most common system affected by NETs is the gastrointestinal tract. Clinical presentation depends on the organ being involved and the hormone being secreted. It can be variable from asymptomatic incidental findings on imaging to intestinal obstruction, or carcinoid syndrome (CS). Several biochemical testings are developed to help with the diagnosis of NETs including 5-hydroxyindoleacetic acid (5-HIAA) and chromogranin A (CgA). Computerized tomography (CT) scans and magnetic resonance imaging (MRI) are the most commonly used modalities to localize the primary tumor and evaluate for metastasis. However, radionuclide imaging using somatostatin receptor-based imaging techniques has improved accuracy to detect smaller neoplasm. Surgical removal is the mainstay of treatment for locoregional tumors. Several medical managements are available for non-respectable NETs which include SSAs, peptide receptor radionuclide therapy (PRRT), and platinum-based chemotherapy agents.

INTRODUCTION: Proponents of coffee enemas advocate for its role in cancer treatment, where it is believed to detoxify via vasodilation and toxin excretion. However, there is no science-based evidence to verify these claims, and its use is associated with harmful effects, including electrolyte imbalances and death. We present a case of coffee-enema induced proctocolitis (PC). CASE DESCRIPTION/METHODS: A 40-year-old woman presented with acute abdominal pain, bloody diarrhea, and tenesmus. She denied recent travel or sick contacts. She had mixed-type IBS, but denied ever experiencing symptoms this severe. Her brother had ulcerative colitis (UC) and aunts had Crohn’s Disease. CT showed severe PC from rectum to descending colon. WBC 21.8, CRP 23, FLA was positive; however, C. Diff, shiga toxin, stool culture, lipase, LFTs were unremarkable. On day 2, she admitted to using 500mL of room temperature coffee enema to treat gallstones, hours prior to symptom onset, which “never came back out.” Flexible sigmoidoscopy displayed severe rectal inflammation, extending to 60cm depth. She was empirically started on Solu-Medrol. Biopsy revealed necrotic mucosa and purulent exudate, suggesting ischemic colitis (IC), but no crypt abscesses. Repeat sigmoidoscopy on day 10 showed improvement of damage, extending to 30cm depth. Clinical improvement was slow, and she was finally discharged on day 13. DISCUSSION: A few South Korean reports of coffee enema induced PC exist in literature. Our patient presented similarly to those cases, suggesting a consistent process through which it achieves its damage. PC occurs in UC, but our patient’s biopsy was more suggestive of IC. IC usually spares rectum due to rich blood supply; our patient’s rectum was not spared. Caffeine may decrease blood flow through a variety of mechanisms (e.g., blocking cGMP formation) and could lead to ischemia. Additionally, it blocks adenosine A2 receptors (AA2Rs). In animal models, AA2R activation attenuates intestinal inflammation, so inhibition may lead to inflammation. Our patient’s PC was likely due to direct contact injury, as well as damage from activation of inflammation and blood flow alteration. Our patient planned to follow up with her naturopathic doctor who recommended the enema. She blamed herself for using too much coffee and could not be persuaded that coffee enemas pose more risk than benefit. It is imperative we educate on risks of “natural” remedies and work to develop trusting relationships with patients so they accept evidence-based practice.

Atrial fibrillation (AF) is a relatively common clinical entity with significant morbidity and mortality, particularly in the elderly. Stroke is one of the most significant complications of AF, which can be prevented with the use of anticoagulation. Elder population are at an increased risk of falls and the use of anticoagulation in this group can lead to intracranial hemorrhage. Therefore, it is unclear whether patients at high risk of falls should be anticoagulated. This review article discusses the epidemiology of AF and falls in the elder population, and whether the benefit of anticoagulation outweighs the risks in this group.