Gastrointestinal (GI) associated symptoms are among the most common medical concerns resulting in visits to primary and specialty care. Especially challenging is the wide range of causative disorders and exposures associated with symptoms ranging from mild to life threatening - from within the GI tract as well as extra-gastrointestinal. Some of these are well described, and common, including infections, while others are newly emerging, such as cannabinoid hyperemesis syndrome. Others are well known but clinical success can remain elusive, such as food associated GI disorders - lactose intolerance and related. Although entire references have been written to address gastrointestinal diseases, in this edition of Disease a Month we will address some of the more challenging GI disorders; some of which are common but often difficult to control - food associated for example, and emerging GI illnesses such as radiation or cannabinoid hyperemesis, that lead patients to the Emergency Department, primary care clinician or specialty referral. What follows is a discussion of diverse but clinically important GI disorders, and the newer therapeutic strategies to help patients better manage their symptoms, and improve their quality of life.

BackgroundIn the last several years another mosquito-borne pathogen-Chikungunya virus (CHIKV) has evolved into a significant public health threat, from a relatively unknown and geographically isolated pathogen.2][3][4][5][6][7][8][9] By December 2013 the first local transmission of Chikungunya virus was reported in the Western Hemisphere; likely first with autochthonous cases in St. Martin. 9,10As of 08/08/14 over 500,000 suspected/laboratory confirmed cases have been reported in the Americas.Local transmission has been reported extensively throughout the Americas, including the United States and US territories in the Caribbean.As the vector is highly adaptable to a variety of geographic regions, further spread is to be expected, especially as the CDC cautions there is a risk the virus will be imported to new areas by infected travelers. 8hikungunya virus (CHIKV), the causative agent for Chikungunya fever (CHIKF) is a singlestranded RNA virus, member of the genus Alphavirus, and family Togaviridae.2,4,6,10,11,13 Its name is derived from the Kimakonde language and means "to become contorted" 7 as patients often experience severe arthralgias.Other translations, from a dialect found in the Madoke language of Tanzania, means "the one bowing.3 " CHIKV was initially isolated over 60 years during an epidemic in Tanzania; interestingly the illnesses were first thought to be Dengue.That notwithstanding, the actual timeline of CHIKV may go back into the 18th century.Typically infection resulted from enzootic and local outbreaks in Africa, and Asia, but the epidemiology has changed as a result of demographic shifts, overcrowding, travel, and the ability of vectors to adapt. 14,15 Large-scle epidemics affecting millions in Africa, Asia, Europe, and the Pacific regions have occurred, such that more than 45 countries, including ones in the Americas are at risk from CHIKF.Not surprisingly the risk of CHIKV can both influence and be influenced by tourism and travel.16 It is a mosquito-borne disease transmitted to humans by the ubiquitous Aedes mosquitoes, including A aegypti (Fig. 1) and A albopictus. 1,6,9,17,18 In Africa other mosquitoes may be involved in disease transmission, such as A. furcifer-taylori, and A. luteocephalus.Because of a mutation in an African lineage of CHIKV, it became adaptable to A. albopictus, increasing the spread and geographic

This work presents a generic optimization framework to address the problem of the optimal design and operational scheduling of energy microgrids. The problem to be solved is formulated as a mixed-integer linear programming (MILP) model whose objective function concerns the total cost minimization of the energy microgrid. The energy generating units to be installed consist of technologies using fuel (natural gas) as a raw material (microturbines, fuel cells etc.), and renewable energy sources (wind and solar). The microgrid is divided into a certain number of zones, each of which is characterized by a given amount of electricity demand to be satisfied, while the system can exchange electrical energy with the main power grid by acquiring from and selling energy to the grid. The efficiency and applicability of the proposed model is illustrated using three case studies. The maximum allowable level of CO2 emissions, the price of electricity purchased from the main grid, and the price of electricity sold to the main grid constitute the parameters whose influences on the economic variables of the microgrid, on the quantities and the capacities of the installed technologies, as well as on the energy balance of the microgrid are investigated. The proposed model provides a systematic and analytical methodological framework for a detailed planning and scheduling of energy microgrids, highlighting potential risks and appropriate price signals on critical energy projects undertaken by investors and/or designed by policy makers at a national and/or regional level under realistic operating conditions.

TB is the second most common cause of infection-related death in the world, resulting in 3–4 million deaths annually. It is estimated that there are 8 million new cases a year. Of concern, TB organisms resistant to the wide array of anti-tuberculosis therapeutics are widespread and prevalent worldwide. Of note, TB drug-resistant strains can spread person to person much the same as TB sensitive to chemotherapeutics. It is also the most common opportunistic pathogen associated with HIV. TB is not just a global threat, but one that the US continues to face. While TB can be a challenge to treat, often requiring multiple antimicrobial agents, drug-resistant (DR), multi-drug-resistant (MDR), and extensively drug-resistant (XDR) TB continue to be significant public health concerns. MDR-TB is caused by mycobacterium that is resistant to the most effective anti-TB drugs, isoniazid and rifampin, for example, and can result from either infection with organisms which are already drug resistant or develop it in the course of treatment. This often occurs with inadequate initial treatment. XDR-TB is a growing global concern and is caused by organisms resistant to isoniazid, rifampin (MDR-TB), and any fluoroquinolone and any of the second-line anti-TB injectable medicines (amikacin, kanamycin, and capreomycin). Neither MDR-TB nor XDR-TB respond to the standard 6-month treatment with first-line anti-TB drugs and can take upwards of 2 years of treatment. The WHO estimated about 500,000 new MDR-TB cases in 2011, of which 60% of these occurred in Brazil, China, India, the Russian Federation, and South Africa; 50% were in China and India alone. In 2008, 440,000 people had MDR-TB, and the WHO estimates onethird died. In Africa, little data are available, and most cases of MDR and XDR-TB go undiagnosed. Worrisome is the fact that the drugs used to treat resistant TB (MDR and XDR) are less potent, more toxic, and expensive than first-line drugs. Of note, 48% of patients with MDR-TB enrolled for treatment in 2009 were reported to have been successfully treated. There is an increase in the detection of MDR-TB patients due to the availability of rapid diagnostics. The Xpert MTB/RIF assay has been deployed in 77 countries in 2012, allowing better treatment. Ideally patients who are initially diagnosed with TB will be adequately treated; this includes emphasizing the critical

Peritonitis is an important cause of morbidity in patients undergoing peritoneal dialysis. Rothia mucilaginosa has been reported as an unusual cause of peritoneal dialysis associated peritonitis. Difficulty in the management of this microorganism lies in the absence of uniform recommendations for anti-microbial therapy directed against this pathogen. The current report describes the clinical course of an episode of peritoneal dialysis associated peritonitis caused by Rothia mucilaginosa. Treatment options for this organism are summarized.

Mycobacterium abscessus complex pulmonary disease is notoriously difficult to treat by medication alone. We report our experience with resectional surgery combined with preoperative and postoperative multidrug chemotherapy for the treatment of patients with M. abscessus complex pulmonary disease.This is a retrospective review of 33 patients undergoing lung resection for M. abscessus complex pulmonary disease at a single center in Japan between January 2008 and December 2019.The median age of patients was 54.0 (interquartile range [IQR], 49.0-66.0) years; 27 (81.8%) were female. Nodular-bronchiectatic was the most common disease type (n = 24, 72.7%). Disease was limited in 18 (54.5%) patients and extensive in 15 (45.5%). The median duration of preoperative multidrug chemotherapy employing oral and parenteral antibiotics was 10.0 (IQR, 3.0-18.0) months. A total of 34 anatomical lung resections were performed as follows: 22 lobectomies, 5 segmentectomies, 4 combined resections, 2 bilobectomies, and 1 pneumonectomy. No operative mortalities and 4 (13.3%) morbidities occurred. The median duration of multidrug chemotherapy after the surgery was 18.0 (IQR, 12.0-31.0) months. Postoperative sputum-negative status was achieved in 31 (93.9%) patients; all 23 patients obtaining preoperative negative conversion remained negative, and 8 (80.0%) of 10 patients with preoperative positive sputum became negative postoperatively. Recurrence was observed in 2 (6.5%) patients. The recurrence-free probabilities were 96.3%, 96.3%, and 80.2% at 1 year, 3 years, and 5 years, respectively.Combined with preoperative and postoperative multidrug chemotherapy, resectional surgery can be performed safely and achieve favorable outcomes for patients with M. abscessus complex pulmonary disease.

Smoked salmon is a highly appreciated delicatessen product. Nevertheless, this ready-to-eat (RTE) product is considered at risk for Listeria monocytogenes, due to both the prevalence and growth potential of this bacteria on the product. Biopreservation may be considered a mild and natural effective strategy for minimizing this risk. In this study, we evaluated the following three potential bioprotective lactic acid bacterial strains against L. monocytogenes in three smoked salmon types with different physicochemical characteristics, primarily fat, moisture, phenol and acid acetic content: two bacteriocin-like producers that were isolated from smoked salmon and identified as Lactobacillus curvatus and Carnobacterium maltaromaticum and a recognized bioprotective bacteriocin producer from meat origin, Lactobacillus sakei CTC494. L. sakei CTC494 inhibited the growth of L. monocytogenes after 21 days of storage at 8 °C in all the products tested, whereas L. curvatus CTC1742 only limited the growth of the pathogen (<2 log increase). The effectiveness of C. maltaromaticum CTC1741 was dependent on the product type; this strain limited the growth of the pathogen in only one smoked salmon type.These results suggest that the meat-borne starter culture, L. sakei CTC494, may potentially be used as a bioprotective culture to improve the food safety of cold-smoked salmon.

From 1900 to the end of the 20th century, and into the present, there has been a significant shift in the top ten causes of death in the United States (Tables 1 and 2). Where once infectious diseases were leading health care concerns, these have been largely replaced by cardiovascular disease and cancer. Unfortunately for a large proportion of the planet, infectious diseases remain the leading causes of death, disability, in some cases preventable blindness, and other serious sequelae. Because of our location, significant public health and medical infrastructure, and widespread immunizations against a wide array of pathogens, the US has been fortunately isolated from many infectious diseases, with the notable exception of tuberculosis (TB), HIV/AIDS, Lyme, West Nile, pneumonia, and influenza-related illness, as well as hospital-acquired infections. Of note, West Nile virus infections in the United States resulted in more than 140 deaths in 2006. Unfortunately most of the world still bears an enormous burden related to infections. Instead of recognizing that billions of people worldwide are exposed to important and emerging infectious diseases, our training has relegated this topic mostly to “tropical medicine” or public health or labeled the threat as a “zebra” item. While most of us remember from our early medical training the old adage “If you hear hoof beats, think horses, not zebras,” the US, and our attention, including medical training, can no longer afford to follow this adage or relegate these so-called “zebras” to the dismissed column, as many of them are important global health concerns. The world has come to our country as much as we have traveled to the world. And by extension—the world's diseases have come to our clinics, emergency departments, and health care facilities. Globalization, population shifts, and the changing ecology, including encroachment of previously unexplored regions, have altered the longstanding epidemiology of infectious diseases, causing spread where once continents and oceans contained the pathogen. New pathogens are occurring—some through unknown means and others through natural adaptation. It has long been recognized that influenza viruses exchange genetic material, either emerging as a new strain, as we continue to see with H5N1, H1N1, and now the latest H7N9. But this likely holds true for other viruses, as recently demonstrated with a novel coronavirus, most recently referred to as Middle East respiratory syndrome (MERS CoV). Social determinants of health—poverty, overcrowding, lack of infrastructure in many developing nations and in our own cities, which leads to poor sanitation, inadequate clean water, under-immunization and lack of health care access, environmental changes resulting in

An article about emerging pathogens would be remiss in not discussing travel-related illness (TAI). As of 2010 it was estimated that nearly 940 million tourists arrived at international destinations, which is twice that of 1990. Of note, journeys to developing regions represented 47% of travel in 2010 compared to 31% in 1990. Given that the burden of disease, especially infectious diseases, remains high in the often impoverished developing world, it is not surprising that more than half of international travelers to developing countries become ill during their trip according to a study, and approximately 8% seek medical care for TAI during or after their journey. Not unexpectedly, there are changes in the type of TAI reflective of the changing destinations—from tourism to work and destination-based travel, and the local, endemic illnesses found therein. The most common sites for contracting malarial illness, the most common TAI in a study, were sub-Saharan Africa (77%) and Oceania (6%). Giardiasis and dengue fever were the second and third most commonly diagnosed TAI, respectively. Of note, gastrointestinal illness represented 25% of diseases, and febrile or viral syndrome caused about 10% with respiratory syndromes affecting about 5% of TAI patients. These data are not unexpected given travelers often spend upward of 7–17 h in close proximity during airline travel. Even with improved ventilation and air turnover in modern jet travel, the small distance between and prolonged exposure to people make travelers vulnerable to respiratory and other infections. Financial considerations impact airlines; it is obvious to any frequent flier there remains a lack of proper between-flight cleaning of surfaces (seatback trays, lavatories, and arm rests), which increases the likelihood of disease transmission. Frequent hand washing, avoiding touching nose, mouth, and eyelids are important basic approaches travelers can take to reduce risk, as well as proper vaccination. Adding to the challenge of characterizing and quantifying the extent of and patterns associated with TAI is the lack of data. Studies about travel-associated illness, including the medical response to TAI, are limited. Nevertheless, some disturbing results have been published. Data suggest that among patients who presented to an ED with symptoms consistent with a potential TAI, and who were eventually diagnosed as such, less than 10% were asked about travel at their first presentation to the HCF, resulting in delayed diagnosis, delayed treatment, and unnecessary patient discomfort. We can do better. One of the few, recent, and large-scale TAI studies involved over 40,000 ill travelers. It revealed the most common destinations were sub-Saharan Africa (26%), Southeast Asia (17%), South-central Asia (15%), and South America (10%). And noted increases in enteric fever and dengue TAI.

We present the case of a 26-year-old Asian woman with a past medical history of idiopathic thrombocytopenia purpura who presented to the Emergency Department (ED) after ingesting a tea concocted from approximately 16 herbs that her traditional Chinese medical doctor (omd) prescribed. Fifteen minutes after ingesting the homemade tea, the patient reported that she felt her tongue was becoming numb. Thinking that she simply burned her tongue, the patient continued to drink the tea. Over the next 15 min, the patient experienced perioral numbness followed by numbness in the hands that traveled proximal toward the shoulders, and finally numbness in the feet that traveled proximal to the knees.