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Obesity has reached epidemic proportions and is now considered a chronic disease by the National Institute of Health (NIH) in the West. Its impact on trauma outcomes is of particular interest with several studies presenting conflicting information. The present overview suggests a strong association between obesity and injury severity, hospital length of stay (LOS), intensive care unit (ICU) admission, pattern of injury, rate of complications and mortality. The nature of the observations may relate to an underlying physiological state of the obese patient and its associated comorbidities with a constant heightened inflammatory state aggravated by the second hit on an injury.

Levetiracetam (LEV) is a commonly prescribed anti-seizure medication for the prophylaxis and treatment of focal and generalized seizures. However, a few significant LEV-associated adverse effects have been reported in the literature. Here, we describe a case of significant thrombocytopenia within 24 hours of IV LEV administration for generalized seizures in an anticoagulated immunocompetent patient that completely resolved following discontinuation of the medication. Increased awareness of this uncommon thrombocytopenic side effect of LEV especially in the setting of anticoagulation is important for clinicians providing care to patients with a history of seizures due to the heightened risk of clinically significant bleeding.

This is a case of a 69-year-old male, with well-controlled rheumatoid arthritis and benign prostatic hyperplasia, who presented with fever and generalized weakness. He was found to have atrial fibrillation on his second emergency department visit and later diagnosed with human granulocytic anaplasmosis (HGA). Atrial fibrillation subsided with the commencement of HGA-specific treatment. This is the first case of HGA and atrial fibrillation reported in the English literature. It highlights the importance of being vigilant for unusual presentations of tick-borne diseases in the endemic areas.

Introduction Obstructive Sleep Apnea (OSA) is one of the strongest modifiable risk factors for Atrial Fibrillation (AF). Although, STOP-BANG questionnaire is a well-validated screening tool for OSA, its adoption and utility to screen newly diagnosed AF has not been reported in a large rural healthcare system. Our aim was to identify the characteristics in patients with AF, which led to screening and referral for a sleep study by providers. In addition, we identified the provider specialty types that had the highest rate of screening for OSA and sleep study referral. Methods We conducted a retrospective multicenter study that identified newly diagnosed patients with AF from January 2018- January 2020. STOP-BANG questionnaire, patient demographics, electrocardiogram, and sleep study data were collected. A logistic regression model was used to identify patient characteristics that were associated with increased screening. Using a chi-squared test, we compared differences in provider specialty that screened for OSA and referred patients for a sleep study. Results Among the study cohort (N=845), 136 (16.1 %) were female and 709 (83.9 %) were male. Only 82 patients (9.7%) had confirmed OSA screening by STOP-BANG questionnaire. Among higher risk patients for OSA (at least 3 of the following: age>50, male, hypertension, BMI>35), the screened patients were 5.8 years younger (95% CI: 3.7-7.9, p Conclusion Our findings revealed underutilization of STOP-BANG to screen for OSA in newly diagnosed AF patients. Screening pattern may be tilted towards patients with obvious and severe forms of OSA therefore missing on milder cases. This study could prompt systemic adoption of STOP-BANG questionnaire, education, and periodic evaluation of healthcare providers in a large rural healthcare system to improve outcomes in AF patients. Support (If Any)

Nutritionally acquired vitamin K deficiency is a rare condition in adults and can uncommonly present as hemorrhagic pleural effusion. We discuss the case of A 44-year-old apparently healthy man who presented with left-sided pleuritic chest pain two months after experiencing upper respiratory tract symptoms. Imaging revealed a loculated left-sided effusion, and a corresponding thoracentesis yielded exudative hemorrhagic fluid with no microbial growth. Laboratory work-up showed prolonged clotting time with low factors II, VII, and X activity, absence of clotting factor inhibitors, and very low serum vitamin K levels. A five-day course of oral vitamin K and nutritional optimization normalized the clotting profile. Acquired vitamin K deficiency from poor micronutrient intake is rare in adults and can result in hemorrhagic pleural effusion. Vitamin K supplementation can normalize the clotting profile while nutritional counseling helps prevent a recurrence. Malnutrition-induced vitamin K deficiency can occur in the setting of a major depressive disorder in adults. Thorough patient history and physical examination are necessary to promptly identify and reverse the coagulopathy.